Acute Pulmonary Edema

in Acute Heart Failure

Tri Astiawati, MD, FIHA

Department of Cardiology and Vascular Medicine

Dr. Iskak General Hospital

 Introduction

• Acute Heart Failure (AHF)  clinical syndrome of new or

worsening signs and symptoms of HF (decompensated) often
leading to hospitalization to the Emergency dept.
• AHF represents a period of high risk for patients, with a 20% to
30% mortality rate within 6 months after admission
• It is a life-threatening medical condition requiring urgent
evaluation and treatment
• Most hospitalized patients have significant volume overload
(acute lung edema), and congestive symptoms predominate

1. ESCText book Intensive and Acute Cardiovascular Care, 2015: AHFepidemiology,classification

2. Meyer TE:Acute Heart Failure and Pulmonary Edema, in Cardiac Intensive Care 2010
Clinical classification of Acute HF Syndrome
Precipitant Factors of Acute Heart Failure
 Cardiac Pulmonary Edema

Defined as pulmonary edema due to

increased capillary hydrostatic pressure
secondary to elevated pulmonary venous
pressure
(Mc Murray JJ, 2012)

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 Acute Pulmonary
Edema
• AHF accompanied by severe respiratory distress,
with crackles over the lung and orthopnoe with
oxygen saturation usually < 90% on room air
prior to treatment; verified by chest-X-ray
• Life threatening
• Require immediate treatment
• Mortality rate : high

Guideline on Diagnosis and Treatment of Acute Heart Failure-ESC 2005

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 PATHOPHYSIOLOGY
• Pathophysiologic mechanisms:
– Imbalance of Starling forces - Ie, increased
pulmonary capillary pressure, decreased
plasma oncotic pressure, increased negative
interstitial pressure
– Damage to the alveolar-capillary barrier
– Lymphatic obstruction
– Idiopathic (unknown) mechanism

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Acute Pulmonary Edema, NEJM2005
PATHOPHYSIOLOGY ACUTE PULM0NARY
EDEMA
Clinical Presentation of AcuteHF

ESC2016 : Guidelines of Diagnosis and Treatment Chronic and Acute HF

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 Radiography
• Enlarged heart, Kerley lines, basilar edema,
pleural effusion (particularly bilateral and
symmetrical pleural effusions)

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 Echocardiography
• Establish the etiology of pulmonary edema
• Evaluate LV systolic and diastolic function, valvular
function, and pericardial disease.
• Non-invasive hemodynamic parameters appropriate
therapy

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 DIFFERENTIAL DIAGNOSIS
• Conditions to consider in the differential diagnosis of
CPE include the following :
– Pneumothorax
– Pulmonary embolism
– Respiratory failure
– Acute Respiratory Distress Syndrome
– Asthma
– Chronic Obstructive Pulmonary Disease

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Differentiation of Noncardiogenic from Cardiogenic
Pulmonary Edema Based on Clinical Data

Meyer TE:Acute Heart Failure and Pulmonary Edema, in Cardiac Intensive Care 2010
Differentiation Chest Radiographs from Patients with
Cardiogenic and Non-cardiogenic Pulmonary Edema.

ALO Cardiogenic ALO Non- Cardiogenic

Acute Pulmonary Edema, NEJM2005

 Pulmonary Arterial Catheter

• Helps in differentiating CPE from Non

Cardiogenic Pulmonary Edema (NCPE)
• A PCWP exceeding 18 mmHg indicates CPE
• Monitor hemodynamic condition

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Algorithm for management of acute pulmonary oedema/congestion

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 Medical treatment

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 Decrease venous tone (to optimize preload)
Vasodilators and arterial tone (decrease afterload)

ESC 2016
Intravenous vasodilators use to treat Acute Heart Failure

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 Diuretics

ESC- AHF guideline 2016

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 Opiates

• The effect was presumed to be secondary to

venodilatation → venus pooling → preload reduction
• May only be cautiously considered in patients with
severe dyspnea, mostly pulmonary edema
• Dose-dependent side effects include nause,
hypotension, bradycardia and respiratory depression
• Potentially increasing the need for invasive
ventilation

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 Recommendation inotropic and vasopressors

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 Oxygen therapy and ventilatory support in
acute heart failure

Conventional oxygen
therapy

Conventional
oxygen therapy

Mebazza et al European Journal of Heart Failure (2015) 17, 544–558

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 Ultrafiltration

Useful in patients with renal dysfunction and diuretic

resistance
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 Summary
• Acute pulmonary edema is a common clinical
presentation of AHF , life-threatening and require
immediate action
• Patients with acute cardiogenic pulmonary edema
require rapid assessment and therapy to prevent
progression to respiratory failure and cardiovascular
collapse.
• High mortality rate
• Management APE: Improve the patient's symptoms,
Improves fluid status, Identification of causal factors

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 Thank You

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Positive inotropes and/or vasopressors used to
treat acute heart failure
Treating Shock – Vasopressors