PULMONARY

EDEMA, PLEURAL
EFFUSION, ASTHMA
CARDIOGENIC PULMONARY
EDEMA
• CAUSES:
 Acute complication of MI & IHD.
 Exacerbation of pre-existing cardiac problems- HTN,
aortic/mitral valve disease.
 Arrhythmias.
 Failure of prosthetic valves.
 Ventricular septal defect.
 Cardiomyopathy.
 ß-Blockers.
 Acute myocarditis. Left Atrial myxoma.
 Pericardial disease.
• PATHOPHYSIOLOGY:

 Left heart failure results in ↑LV end-diastolic pressure causing

↑pulmonary capillary hydrostatic pressure → fluid collection
in the extravascular pulmonary tissues faster than the
lymphatics could clear it.

• HISTORY:

 Dyspnoea & distress.

 Time of onset & any associated chest pain.
 Check for current medications.
GRADES OF DYSPNEA
• Grade I – Minimal Dyspnea. Dyspnea on
running or on doing more than ordinary effort.

• Grade II – On doing ordinary effort.

• Grade III – Considerable Dyspnea. On doing

less than ordinary effort.

• Grade IV – Dyspnea at rest.

EXAMINATION:
• Tachypnoeic, tachycardic & anxious.

• Cyanosed, coughing out pink frothy sputum & unable to talk-

severe cases.

• Look for ↑JVP.

• Inspiratory crepitations.

• Wheeze may be more prominent.

• Cardiogenic pulmonary edema is associated with evidence of

decreased CO.
INVESTIGATIONS:
• ECG- Arrhythmias, LVH, LBBB, recent or evolving MI.
• Blood- U&E, glucose, FBC, Troponin.
• ABG if saturations are very low.
• CXR- Features in cardiogenic pulmonary edema:
 Upper lobe diversion- Distension of upper pulmonary veins.
 Cardiomegaly.
 Kerley A,B & C septal lines.
 Fluid in interlobar fissures.
 Peribronchial & perivascular cuffing.
 Pleural effusion.
 Bat’s wing Hilar Shadows.
TREATMENT
• Raise the head-end to sitting position.
• High flow O2 with tight fitting face mask.
• If SBP>90mmHg, give S/L Sorbitrate & then start
NTG.
• IV Furosemide 50-60mg. Higher doses for the once
already on Furosemide.
• Monitor urine output.
• Treat underlying cause.
• Non-Invasive ventilation- CPAP should be started.
• Invasive ventilation when CPAP doesn’t improve or
cardiovascular collapse takes place.
PROSTHETIC VALVE FAILURE
• Acute failure results in dramatic acute onset pulmonary
edema with loud murmurs.

• Resuscitation should be carried out as per protocol.

• Urgent help- ICU Team, Cardiologist & CT Surgeon.

• Confirmation- Transthoracic or transesophageal ECHO.

• Immediate valve replacement is the treatment of choice.

 NON-CARDIOGENIC PULMONARY OEDEMA
• This can occur in the absence of ↑ pulmonary venous pressure.
• Mechanisms:
 ↑ Capillary permeability.
 ↓ Plasma oncotic pressure.
 ↑ Lymphatic pressure.

• Causes:
 ARDS.
 IC Bleed.
 IVF overload.
 Hypoalbuminaemia.
 Drugs/Poisons/Chemical inhalation.
 Lymphangitis carcinoma.
 Smoke inhalation.
 Near drowning incidents.
 High altitude moutain sickness.
APPROACH
• To distinguish it from cardiogenic cause.

• Treatment should be initiated as per the

underlying cause.

• Primary management should be as per the

cardiogenic pulmonary edema protocol.
 PLEURAL EFFUSION
• Normal- 20ml in each pleural cavity.

• Exudate- If Pleural Fluid : Serum Protein >0.5

Pleural Fluid : Serum LDH >0.6

Fluid LDH >2/3 the upper limits of normal

serum LDH value.
 EXUDATES TRANSUDATES
• Pneumonia. • Cardiac failure.

• Malignancy.
• Nephrotic syndrome.
• TB.
• Hepatic failure.
• PE with pulmonary infarction.
• Ovarian hyper stimulation.
• Collagen vascular disease.

• Subphrenic abscess. • Ovarian fibroma.

• Amoebic liver abscess. • Peritoneal dialysis.

• Pancreatitis.
CLINICAL PRESENTATION
SYMPTOMS SIGNS
 Not apparent until >500ml
A mild dull ache & of fluid present.
dyspnea may be present  Dyspnoea.
in large effusion.  Stony dullness to
percussion.
Absent breath sounds.
H/O of vomiting
 ↓ Breath sounds.
followed by chest pain
Bronchial breathing.
→ ruptured esophagus.
Large unilateral Effusion→
Mediastinal Shift.
• INVESTIGATIONS:
 CXR- Only if ≥ 250mL.

• TREATMENT:
 Provide O2 if required.
 Emergency therapeutic pleural aspiration if severe respiratory
distress.
 Involve medical team.

BLUNTING OF
COSTOPHRENIC ANGLE
 ACUTE ASTHMA: ASSESSMENT
• Peak expiratory flow rate should be measured and be compared with
the expected rate!!

• MODERATE EXACERBATIOB OF ASTHMA:

 Increasing symptoms.
 Peak flow 50-75%.
 No features of acute severe asthma.

• ACUTE SEVERE ASTHMA:

 Inability to complete sentences in 1 breath.
 RR >25/min
 HR >110/min
 Peak flow 33-50%.
• LIFE-THREATENING ASTHMA:
 Cyanosis.
 Exhaustion, confusion, coma.
 Feeble respiratory effort.
 SpO2 <92%.
 Silent chest.
 Bradycardia, arrhythmia, hypotension.
 pO2 <60mmHg.
 Normal pCO2.
 Peak flow <33%.

• NEAR FATAL ASTHMA:

 ↑ pCO2 and may require mechanical ventilation.
• CLINICAL FEATURES THAT INCREASE
THE PROBABILITY OF ASTHMA:

 Diurnal variation in symptom severity.

 Symptoms in response to exercise, allergen exposure &

cold air.

 Px or family h/o atopic disorders.

 Peripheral blood eosinophilia.

 H/O improvement with treatment.

• INVESTIGATIONS:
 Peak expiratory flow rate.

 ABG if SpO2 <92% or Life threatening asthma.

 CXR if the following conditions are suspected.

 Suspected pneumomediastinum or pneumothorax.
 Suspected consolidation.
 Life-threatening asthma.
 Failure to respond to treatment as expected.
 Requirement for ventilation.
 ACUTE ASTHMA: MANAGEMENT
• High flow O2 to maintain saturations at 94-98%.
• Patient in sitting position.
• Check trachea & chest signs for pneumothorax.
• Salbutamol 5mg nebulization- consider continues nebulizations.
• Inj. Hydrocortisone 100mg IV.
• Add Ipratropium Bromide 500mcg to salbutamol nebulization.
• Inj. Magnesium Sulphate 1.2-2gm IV over 20min.
• Inj. Aminophylline 5mg/kg over 20min if never used before. If on
aminophylline, blood levels should be sent and then infusion @ 0.5-
0.7mg/kg/hr.
• Inj. Salbutamol 5mg in 500mL 5% Dextrose.
• Proper hydration.
• Avoid antibiotics.
• Repeat ABG within an hour.
• Watch out for Hypokalaemia.
• CRITERIA FOR ADMISSION:

 A life-threatening or near-fatal attack.

 Severe attack persisting after initial treatment.

• INTENSIVE CARE REFERRAL:

 Drowsiness, confusion.
 Exhaustion, feeble respiration.
 Coma or Respiratory arrest.
 Persisting or worsening hypoxia.
 Hypercapnoea.
 ABG showing ↓ pH.
 Deteriorating peak flow.
 DISCHARGE CRITERIA &
MANAGEMENT
• Consider discharge if peak flow is >75% or predicted 1hr
after initial treatment.

• Tab. Prednisolone 40-50mg for 5days if initial peak

inspiratory flow rate <50%.

• Adequate supply of Inhalers.

• Inhaler technique and PEFR monitoring should be reviewed.

• GP follow-up within 2 days.

CARDIAC ARREST IN ACUTE
ASTHMA
• Underlying rhythm is usually PEA.

• This may be because of prolonged severe hypoxia,

hypoxia-related arrhythmias or tension pneumothorax.

• ACLS Protocol to be followed.

• Tension pneumothorax to be relieved if present.

• Intubation early during resuscitation.

SOME ISSUES TO BE CONSIDERED
• Handover book to be completed daily.
• All procedures to be entered into the computer. Lately no one
is doing it!!!!
• 2DECHO to be done for all P1 cases from our side!!!
• Provisional diagnosis should be meaningful and sensible!!!
• You all should know the difference between comorbids n
provisional diagnosis.
• Please don’t act as duty doctors!!!
• Do not go away from our protocols.
• Px history to be taken properly and entered properly into the
initial assessments.
• Past medical treatment should be taken in detail n present
history to be correlated properly!!!
• Know your ATLS protocol properly and follow it!!!
• Log roll to be done for all P1 trauma cases without fail.
• When resuscitating a patient, follow your ACLS protocol
strictly!! Do not give bicarb, heparin and other nonsense!!!
• In Hypovolemic shock, always consider blood!!!
• If you don’t know or understand something, call me or the
registrar posted in the center!!!
• In respiratory distressed Px, always have NIV option on the
back of your mind!!
• Know our Sepsis Protocol thoroughly!!!
• Read your OHEM properly.
• Last but not least, you all r residents and you all have to learn a
lot. Please don’t forget that and concentrate on your work!!
Don’t get distracted with other stuff!!!