Pulmonary Edema

Definition
Your lungs contain millions of small, elastic air sacs. With each breath, the air sacs
take in oxygen and release carbon dioxide. Normally, the exchange of gases takes
place without problems. But sometimes increased pressure in the blood vessels in
your lungs forces fluid into the air sacs, preventing them from absorbing oxygen — a
condition called pulmonary edema.

In most cases, heart problems cause pulmonary edema. But fluid can accumulate for
other reasons, including pneumonia, exposure to certain toxins and medications, and
exercising or living at high elevations.

Acute pulmonary edema is a medical emergency requiring immediate care. Although

pulmonary edema can sometimes prove fatal, the outlook is often good when you
receive prompt treatment for pulmonary edema along with therapy for the underlying
problem.

Symptoms
Depending on the cause, pulmonary edema symptoms may appear suddenly or
develop slowly over weeks or months.

Signs and symptoms that come on suddenly are usually severe and may include:

 Extreme shortness of breath or difficulty breathing

 A feeling of suffocating or drowning
 Wheezing or gasping for breath
 Anxiety, restlessness, a sense of apprehension
 A cough that produces frothy sputum that may be tinged with blood
 Excessive sweating
 Pale skin
 Chest pain when pulmonary edema is caused by coronary artery disease

If you develop any of these signs or symptoms, call 911 or emergency medical
assistance right away. Pulmonary edema can be fatal if not treated.

Signs and symptoms that develop more gradually include:

 Difficulty breathing when you're lying flat as opposed to sitting up.

 Awakening at night with a breathless feeling.
 Having more shortness of breath than normal when you're physically active.
 Significant weight gain when pulmonary edema develops as a result of
congestive heart failure, a condition in which your heart pumps too little blood
to meet your body's needs. The weight gain is from accumulation of fluid in
your body, especially in your legs.
Airways and air sacs of the lungs

Chambers and valves of the heart

Causes
Two major airways (bronchi) carry air into your lungs. These airways subdivide into
smaller airways (bronchioles) that finally end in clusters of tiny air sacs called alveoli.
These air sacs inflate like miniature balloons every time you inhale.

Wrapped around each air sac are capillaries that connect the arteries and veins in your
lungs. The capillaries are so narrow that red blood cells have to pass through them in
single file. Each red blood cell absorbs oxygen, while the plasma — the fluid
containing the red blood cells — releases carbon dioxide as well as absorbs some of
the oxygen.

But in certain circumstances, the alveoli fill with fluid instead of air, preventing
oxygen from being absorbed into your bloodstream. A number of factors can cause
fluid to accumulate in your lungs, but most have to do with your heart (cardiac
pulmonary edema). Understanding the relationship between your heart and lungs can
help explain why.

How your heart works

Your heart is composed of two upper and two lower chambers. The upper chambers
(the right and left atria) receive incoming blood and pump it into the lower chambers.
The lower chambers, the more muscular right and left ventricles, pump blood out of
your heart. The heart valves — which keep blood flowing in the correct direction —
are gates at the chamber openings.

Normally, deoxygenated blood from your body enters the right atrium and flows into
the right ventricle, where it's pumped through large blood vessels (pulmonary arteries)
to your lungs. There, the blood releases carbon dioxide and picks up oxygen. The
oxygen-rich blood then returns to the left atrium through the pulmonary veins, flows
through the mitral valve into the left ventricle, and finally leaves your heart through
another large artery, the aorta. The aortic valve at the base of the aorta keeps the blood
from flowing backward into your heart. From the aorta, the blood travels to the rest of
your body.

What goes wrong

Cardiac pulmonary edema — also known as congestive heart failure — occurs when
the left ventricle isn't able to pump out enough of the blood it receives from your
lungs. As a result, pressure increases inside the left atrium and then in the pulmonary
veins and capillaries, causing fluid to be pushed through the capillary walls into the
air sacs.

Congestive heart failure can also occur when the right ventricle is unable to overcome
increased pressure in the pulmonary artery, which usually results from left heart
failure, chronic lung disease or high blood pressure in the pulmonary artery
(pulmonary hypertension).

Medical conditions that can cause the left ventricle to become weak and eventually
fail include:
  Coronary artery disease. Over time, the arteries that supply blood to your
heart can become narrow from fatty deposits (plaques). A heart attack occurs
when a blood clot forms in one of these narrowed arteries, blocking blood
flow and damaging the portion of your heart muscle supplied by that artery.
The result is that the damaged heart muscle can no longer pump as well as it
should.

Although the rest of your heart tries to compensate for this loss, it's either
unable to do so effectively or it's weakened by the extra workload. When the
pumping action of your heart is weakened, blood backs up into your lungs,
forcing fluid in your blood to pass through the capillary walls into the air sacs.

 Cardiomyopathy. When your heart muscle is damaged by causes other than

blood flow problems, the condition is called cardiomyopathy. Often,
cardiomyopathy has no known cause, although it sometimes runs in families.
Less common causes include infections (myocarditis), alcohol abuse and the
toxic effects of drugs such as heroin and some types of chemotherapy.

Because cardiomyopathy weakens the left ventricle — your heart's main pump
— your heart may not be able to respond to conditions that require it to work
harder, such as a surge in blood pressure or infections. When the left ventricle
can't keep up with the demands placed on it, fluid backs up into your lungs.

 Heart valve problems. In mitral valve disease or aortic valve disease, the
valves that regulate blood flow either don't open wide enough (stenosis) or
don't close completely (insufficiency). This allows blood to flow backward
through the valve. When the valves are narrowed, blood can't flow freely into
your heart and pressure in the left ventricle builds up, causing the left ventricle
to work harder and harder with each contraction.

The increased pressure extends into the left atrium and then to the pulmonary
veins, causing fluid to accumulate in your lungs. On the other hand, if the
mitral valve leaks, some blood is backwashed toward your lung each time
your heart pumps. If the leakage develops suddenly, you may develop sudden
and severe pulmonary edema.

 High blood pressure (hypertension). Untreated or uncontrolled high blood pressure causes a
thickening of the left ventricular muscle, and accelerates coronary artery disease.

Noncardiac pulmonary edema

Not all pulmonary edema is the result of heart disease. Fluid may also leak from the
capillaries in your lungs' air sacs because the capillaries themselves become more
permeable or leaky, even without the buildup of back pressure from your heart. In that
case, the condition is known as noncardiac pulmonary edema because your heart isn't
the cause of the problem. Some factors that can cause increased capillary permeability
leading to noncardiac pulmonary edema are:

 Lung infections. When pulmonary edema results from lung infections, such as pneumonia,
the edema occurs only in the part of your lung that's inflamed.
 Exposure to certain toxins. These include toxins you inhale — such as chlorine, ammonia
or nitrogen dioxide — as well as those that may circulate within your own body. For
 example, women giving birth may develop pulmonary edema when amniotic fluid reaches
the lungs through the veins of the uterus (amniotic fluid embolism).
 Kidney disease. When your kidneys can't remove waste effectively, excess fluid can build
up, causing pulmonary edema.
 Smoke inhalation. Smoke contains chemicals that damage the membrane between the air
sacs and the capillaries, allowing fluid to enter your lungs.
 Adverse drug reaction. Many drugs — ranging from narcotics such as heroin to diabetes
medications and chemotherapy drugs — are known to cause noncardiac pulmonary edema.
 Acute respiratory distress syndrome (ARDS). This serious disorder occurs when your lungs
suddenly fill with fluid and inflammatory blood cells. Many conditions can cause ARDS,
including severe injuries (trauma), systemic infection (sepsis), pneumonia and shock.
ARDS sometimes develops after extensive surgery.
 High altitudes. Mountain climbers and people who live in or travel to high-
altitude locations run the risk of developing high-altitude pulmonary edema
(HAPE). This condition — which typically occurs at elevations above 8,000
feet — can also affect hikers or skiers who start exercising at higher altitudes
without first becoming acclimated. But even people who have hiked or skied
at high altitudes in the past aren't immune.

Although the exact mechanism isn't completely understood, HAPE seems to

develop as a result of increased pressure from constriction of the pulmonary
capillaries. Symptoms include headaches, insomnia, fluid retention, cough and
shortness of breath. Without appropriate care, HAPE can be fatal.

When to seek medical advice

Acute pulmonary edema is life-threatening. Get emergency assistance if you have any
of the following acute signs and symptoms:

 Trouble breathing or a feeling of suffocating (dyspnea)

 A bubbly, wheezing or gasping sound when you breathe
 Pink, frothy sputum when you cough
 Breathing difficulty along with profuse sweating
 A blue or gray tone to your skin
 A severe drop in blood pressure

Acute pulmonary edema is likely to be incapacitating, so don't attempt to drive

yourself to the hospital. Instead, dial 911 or emergency medical care and wait for
help.

Tests and diagnosis

Because pulmonary edema requires prompt treatment, you'll initially be diagnosed on
the basis of your symptoms and a physical exam. You may also have blood drawn —
usually from an artery in your wrist — so that it can be checked for the amount of
oxygen and carbon dioxide it contains (arterial blood gas concentrations).

Once your condition is more stable, your doctor will ask about your medical history,
especially whether you have ever had cardiovascular or lung disease. You'll also
likely have a chest X-ray, which can help support a diagnosis of pulmonary edema.
And you may have further tests to determine why you developed fluid in your lungs.
These tests may include:

 Electrocardiography (ECG). This noninvasive test can reveal a wide range

of information about your heart. During an ECG, patches attached to your skin
receive electrical impulses from your heart. These are recorded in the form of
waves on graph paper or a monitor. The wave patterns show your heart rate
and rhythm, and whether areas of your heart show diminished blood flow.
 Echocardiography (diagnostic cardiac ultrasound exam). Another
noninvasive test, echocardiography uses a wand-shaped device called a
transducer to generate high-frequency sound waves that are reflected from the
tissues of your heart. The sound waves are then sent to a machine that uses
them to compose images of your heart on a monitor.

The test can help diagnose a number of heart problems, including valve
problems, abnormal motions of the ventricular walls, fluid around the heart
(pericardial effusion) and congenital heart defects. It also accurately measures
the amount of blood your left ventricle ejects with each heartbeat (ejection
fraction, or EF). Although a low EF often indicates a cardiac cause for
pulmonary edema, it's possible to have cardiac pulmonary edema with a
normal EF.

 Transesophageal echocardiography (TEE). In a traditional cardiac

ultrasound exam, the transducer remains outside your body on the chest wall.
But in TEE, a soft, flexible tube with a special transducer tip is inserted
through your mouth and into your esophagus — the passage leading to your
stomach. The esophagus lies immediately behind your heart, which allows for
a closer and more accurate picture of your heart and central pulmonary
arteries. You'll be given a sedative to make you more comfortable and prevent
gagging. You may have a sore throat for a few days after the procedure, and
there's a slight risk of perforation or bleeding from the esophagus.
 Pulmonary artery catheterization. If other tests don't reveal the reason for
your pulmonary edema, your doctor may suggest a procedure to measure the
pressure in your lung capillaries (wedge pressure). During this test, a small,
balloon-tipped catheter is inserted through a vein in your leg or arm into a
pulmonary artery. The catheter has two openings connected to pressure
transducers. The balloon is inflated and then deflated, giving pressure
readings.

Complications
If pulmonary edema persists, it can raise pressure in the pulmonary artery and
eventually the right ventricle begins to fail. The right ventricle has a much thinner
wall of muscle than does the left side. The increased pressure backs up into the right
atrium and then into various parts of your body, where it can cause:

 Leg swelling (edema)

 Abdominal swelling (ascites)
 Buildup of fluid in the membranes that surround your lungs (pleural effusion)
When not treated, acute pulmonary edema can be fatal. In some instances it may be
fatal even if you receive treatment. The outcome depends in part on the condition of
your heart and lungs before you developed edema and on the amount of fluid in your
lungs. Drug-induced pulmonary edema can be a cause of death in people who abuse
narcotics.

Treatments and drugs

Administering oxygen is the first step in the treatment for pulmonary edema. You
usually receive oxygen through a face mask or nasal cannula — a flexible plastic tube
with two openings that deliver oxygen to each nostril. This should ease some of your
symptoms. Sometimes it may be necessary to assist your breathing with a machine.

Depending on your condition and the reason for your pulmonary edema, you may also
receive one or more of the following medications:

 Preload reducers. Doctors commonly use nitroglycerin and diuretics, such as

furosemide (Lasix), to treat pulmonary edema. These medications dilate the
veins in your lungs and elsewhere in your body, which decreases fluid
pressure going into your heart and lungs.
 Morphine (Astramorph, Roxanol). This narcotic, for years a mainstay in
treating cardiac pulmonary edema, may be used to relieve shortness of breath
and associated anxiety. But some doctors believe that the risks of morphine
may outweigh the benefits and are more apt to use other, more effective,
drugs.
 Afterload reducers. These drugs dilate the peripheral vessels and take a
pressure load off the left ventricle. Some examples of afterload reducer
medications include nitroprusside (Nitropress), enalapril (Vasotec) and
captopril (Capoten).
 Aspirin. Your doctor may recommend starting aspirin therapy if you're not
already taking it. Aspirin helps thin your blood so that it moves through your
small blood vessels more easily.
 Blood pressure medications. If you have high blood pressure when you
develop pulmonary edema, you'll be given medications to control it. On the
other hand, if your blood pressure is too low, you're likely to be given drugs to
raise it.

Treating high-altitude pulmonary edema (HAPE)

If you're climbing or traveling at high altitudes and experience mild symptoms of
HAPE, descending a few thousand feet should relieve your symptoms. Oxygen also is
helpful. When symptoms are more severe, you'll likely need help in your descent. A
helicopter rescue may be necessary for the most serious cases.

Sometimes, however, immediate rescue isn't possible. With this in mind, researchers
have devised several experimental therapies. In one, the distressed climber is placed
in an airtight bag known as a hyperbaric bag, which is then pumped with air,
simulating the air pressure at a lower altitude. A night's sleep in the bag seems to
relieve symptoms — at least temporarily.
Some climbers take the prescription medication acetazolamide (Diamox) to help treat
or prevent symptoms of HAPE. Diamox can occasionally have side effects —
including tingling or burning in the hands, feet and mouth, confusion, diarrhea,
nausea, and thirst.

Nursing Care
• Administer prescribed medications;
morphine, diuretics, …
• Bed rest
• Put the patient in upright position
• Check vital signs frequently
• Monitor intake and output
• Decrease anxiety

Prevention
Pulmonary edema often isn't preventable, but these measures can help reduce your
risk:

Preventing cardiovascular disease

Cardiovascular disease is the leading cause of pulmonary edema. You can reduce
your risk of many kinds of heart problems by following these suggestions:

 Control your blood pressure. High blood pressure (hypertension) can lead to
serious conditions such as stroke, cardiovascular disease and kidney failure.
Most adults should have their blood pressure checked at least once every two
years. This is a noninvasive and painless procedure using an inflatable cuff
that wraps around your upper arm. The test takes just a few minutes.

A resting blood pressure reading below 120/80 millimeters of mercury (mm

Hg) is considered normal. If your resting blood pressure is consistently 140/90
mm Hg or higher, you have high blood pressure. A reading in between these
levels places you in the prehypertensive category.
 In many cases, you can lower your blood pressure or maintain a healthy level
by getting regular exercise, eating a diet rich in fresh fruits, vegetables and
low-fat dairy products, and limiting alcohol and coffee.

 Watch your blood cholesterol. Cholesterol is one of several types of fats

essential to good health. But too much cholesterol can be too much of a good
thing. Higher than normal cholesterol levels can cause fatty deposits to form in
your arteries, impeding blood flow and increasing your risk of vascular
disease. But lifestyle changes can often keep your cholesterol levels low. This
includes limiting fats — especially saturated fats — eating more fiber, fish,
and fresh fruits and vegetables, exercising regularly, stopping smoking, and
drinking in moderation.
 Don't smoke. If you smoke, the single most important thing you can do for
your heart and lung health is to stop. Continuing to smoke increases your risk
of a second heart attack or heart-related death and also increases your risk of
lung cancer and other lung problems such as emphysema. What's more, you're
at risk even if you don't smoke but live or work with someone who does.
Exposure to secondhand smoke is a contributing factor to coronary artery
disease. If you can't stop smoking by yourself, ask your doctor to prescribe a
treatment plan to help you quit.
 Eat a heart-healthy diet. Fish is one of the cornerstones of a heart-healthy
diet — it contains omega-3 fatty acids, which help improve blood cholesterol
levels and prevent blood clots. It's also important to eat plenty of fruits and
vegetables, which contain antioxidants, vitamins and minerals that help
prevent everyday wear and tear on your coronary arteries. Limit your intake of
all types of fats, especially animal (saturated) and trans fats (hydrogenated
oils).
 Limit salt. It's especially important to limit your salt intake if you have heart
disease. In some people with severely impaired left ventricular function,
excess salt — even in a single meal or a bag of chips — may be enough to
trigger congestive heart failure. If you're having a hard time cutting back on
salt, it may help to talk to a dietitian. He or she can help point out low-sodium
foods as well as offer tips for making a low-salt diet interesting and good
tasting.
 Exercise regularly. Exercise is vital for a healthy heart. Regular aerobic
exercise helps maintain a healthy weight, controls blood pressure and
cholesterol levels, helps prevent diabetes and maintains muscle tone. If you're
not used to exercise, start out slowly and build up gradually.
 Maintain a healthy weight. Being even slightly overweight increases your
risk of cardiovascular disease. On the other hand, losing only 10 percent of
your body weight can lower your blood pressure, cholesterol and reduce your
risk of diabetes.
 Get enough folic acid (folate). An essential B vitamin, folate may reduce
blood levels of homocysteine, an amino acid that builds and maintains tissues.
Too much homocysteine can promote the formation of plaques in your
arteries. To get 400 micrograms of folate a day, eat green, leafy vegetables,
citrus fruits, legumes, peanuts and cereal grains. If you're not sure how much
folate you're getting from your diet, talk to your doctor about a folic acid
supplement, or choose a multivitamin supplement that contains at least 400
micrograms of folic acid.
  Manage stress. To reduce your risk of heart problems, try to reduce your
stress levels. Rethink workaholic habits and find healthy ways to minimize or
deal with stressful events in your life.

Preventing HAPE
If you travel or climb at high altitudes, acclimate yourself slowly. Although
recommendations vary, most experts advise ascending no more than 1,000 or 2,000
feet a day once you reach 8,000 feet. In addition, it's important to drink plenty of
water to stay hydrated. The higher you ascend the more rapidly you breathe, which
means you lose larger amounts of water in the air you exhale from your lungs.
Finally, although being physically fit won't necessarily prevent HAPE, people in good
condition tend to be less stressed at high altitudes.

Lifestyle and home remedies

The following suggestions may speed your recovery from cardiac pulmonary edema
and help prevent a recurrence:

 Get plenty of sleep each night. Take a nap during the day if you feel tired.
 Listen to medical advice. Follow your doctor's advice about controlling any
underlying health problems, including advice about diet and exercise.
 Try to get at least 30 minutes of exercise on most days. If your exercise
plan seems too hard or too easy, talk to your doctor or a rehabilitation
therapist.
 Weigh yourself daily. Do so in the morning before breakfast and keep a
record of your daily weight. Call your doctor if you've gained 2 to 3 pounds in
a single day.
 Avoid drinking alcohol.Your lungs and heart work harder when you drink
alcohol.

If you've experienced noncardiac pulmonary edema — including some forms of

ARDS — take care to minimize any further damage to your lungs, and as far as
possible avoid the cause of your condition, such as drugs, allergens or high altitudes.