Treatment of noncardiogenic pulmonary edema
Pulmonary edema (OL) - accumulation of fluid in the interstitialtissue and / or lung alveoli as a result of plasma transsudation from blood vessels of the small circulation. The pulmonary edema is divided into interstitial and alveolar, which must be considered as two stages of a single process. • Interstitial pulmonary edema is the edema of the interstitial lung tissue without exiting the transudate into the lumen of the alveoli. Clinically manifested as shortness of breath and cough without phlegm. With the progression of the process, alveolar edema arises. • Alveolar edema of the lungs is characterized by sweating plasma in the lumen of the alveoli. Patients have a cough with a separation of foamy sputum, suffocation, in the lungs first dry and then wet rales are heard.
Prevalent age - over 40 years of age.
Etiology • Cardiogenic AL with low cardiac output ••IM - large lesion area, rupture of the heart walls, acute mitral insufficiency •• Decompensation of chronic heart failure - inadequate treatment, arrhythmias, severe concomitant disease, severe anemia •• Arrhythmias (supraventricular and ventricular tachycardias, bradycardias) •• Obstruction in the path of blood flow - mitral or aortic stenosis, hypertrophic cardiomyopathy, tumors, thrombi •• Valvular insufficiency - mitral or aortic insufficiency •• Myocarditis •• Massive PE • • Leo heart disease •• Hypertensive crisis •• Cardiac tamponade •• Heart trauma • Cardiogenic OL with high cardiac output •• Anemia •• Thyrotoxicosis • Acute glomerulonephritis with arterial hypertension • Arteriovenous fistula • Noncardiogenic AL - see Adult respiratory distress syndrome.
Pathomorphology of cardiogenic AL • Intra-alveolar transudate in pink color •In the alveoli - microhemorrhagia and hemosiderin-containing macrophages • Brown lung induration, venous plethora • Hypostatic bronchopneumonia • At autopsy - heavy, enlarged light dough-like consistency, the liquid drains from the surface of the incision.
Clinical picture • Pronounced dyspnea (dyspnea)and respiratory depression (tachypnea), participation in the act of breathing auxiliary muscles: inspiratory zapping intercostal spaces and supraclavicular pits • Forced sitting position (orthopnea), anxiety, fear of death • Cyanotic cold skin, profuse sweating • Features of the clinical picture of interstitial AL (cardiac asthma) ) •• Noisy wheezing, difficulty breathing (stridor) •• Auscultatory - against a background of weakened breathing, dry, sometimes scanty small bubbling rales • Features of clinical pictures s of alveolar AL •• Cough with the departure of foamy sputum is usually pink in color •• In severe cases, the aperiodic breathing of Cheyne-Stokes •• Auscultation - moist finely bubbling wheezing, initially arising in the lower parts of the lungs and gradually spreading to the apex of the lungs • Changes from the CCC • Tachycardia •• Alternating pulse (inconstancy of the pulse wave amplitude) in severe left ventricular failure •• Pain in the heart area •• In the presence of heart defects - the presence of an appropriate cell nical symptoms.
Laboratory research • Hypoxemia (degree varies with backgroundoxygen therapy) • Hypokapnia (concomitant lung diseases may complicate the interpretation) • Respiratory alkalosis • Changes depending on the nature of the pathology causing AL (increased levels of MB-CK, troponins T and I in infarction, increased thyroid hormone concentration in thyrotoxicosis, etc.) .
Special researches • ECG - signs of hypertrophy of the leftventricle • Echocardiogram is informative for heart diseases • Introduction to the pulmonary artery of the Swan-Ganz catheter to determine the pulmonary artery wedge pressure (DZLA), which helps in differential diagnosis between cardiogenic and noncardiogenic AL. DZLA <15 mmHg is typical for adult respiratory distress syndrome, and DZLA> 25 mm Hg. - for heart failure • Chest X-ray •• Cardiogenic AL: cardiac enlargement, blood redistribution in the lungs, Curly line (linear striation due to increased pulmonary interstitial imaging) with interstitial AL or multiple small foci in alveolar AL, often pleural effusion •• Non-cardiogenic AL: the borders of the heart are not expanded, there is no redistribution of blood in the lungs, less pronounced effusion into the pleural cavity.
Differential diagnostics • Pneumonia • Bronchial asthma • PE • Hyperventilation syndrome.
TREATMENT. Emergency Activities • Making the patient sit with the boweddown (reducing the venous return of blood to the heart, which reduces preload) • Adequate oxygenation with a mask with 100% oxygen at a rate of 6-8 l / min (better with defoamers - ethyl alcohol, antifosilane). With the progression of pulmonary edema (determined by the coverage of all pulmonary fields with moist, large bubbling rales), intubation and mechanical ventilation under positive exhalation pressure are performed to increase intra-alveolar pressure and reduce the transudation. • Morphine administration at a dose of 2-5 mg IV for suppressing the excessive activity of the respiratory center Introduction of furosemide iv in a dose of 40-100 mg to reduce bcc, expand venous vessels, reduce venous return of blood to the heart • Introduction of cardiotonic drugs (dobutamine, dopamine) d To increase blood pressure (see Cardiogenic shock) • Reduction of postload with sodium nitroprusside at a dose of 20-30 μg / min (using a special dispenser) with a systolic blood pressure of more than 100 mm Hg. up to the resolution of pulmonary edema. Instead of sodium nitroprusside, intravenous administration of nitroglycerin is possible. • Use of aminophylline in a dose of 240-480 mg IV for reducing bronchoconstriction, increasing renal blood flow, increasing the release of sodium ions, increasing myocardial contractility. • Overlapping venous tourniquets to reduce the venous return to the heart. As venous tourniquets, you can use the sphygmomanometer cuffs imposed on the three limbs, except for the one where the intravenous drug is administered. The cuff is inflated to values average between systolic and diastolic BP, and every 10-20 minutes the pressure in the cuff should be reduced. Inflating cuffs and reducing the pressure in them must be carried out consistently on all three limbs. • The appropriateness of the appointment of cardiac glycosides is debated. • If there is pulmonary edema against the background of a hypertensive crisis, the administration of antihypertensive drugs is necessary. • Noncardiogenic edema - see Adult respiratory distress syndrome.
Additionally • Bed rest • Diet with a sharp restriction of table salt • Medical bleeding • Ultrafiltration of blood (also to reduce bcc) • Aspiration of foam in alveolar AL.
Complications • Ischemic lesions of internal organs • Pneumosclerosis, especially after non-cardiogenic AL.
Forecast • Depends on the underlying disease that caused AL • Lethality in cardiogenic AL is 15-20%.
Age-related features • Children: AL occurs more often with malformations of the pulmonary system and heart or as a result of trauma • Elderly: AL is one of the most common causes of death.
Pregnancy • The timing of the onset of AL: 24-36 weeks of gestation, during childbirth and in the early postpartum period • The method of delivery depends on the obstetric situation •• In the absence of conditions for delivery through natural birth canals - caesarean section •• When delivering through natural birth canals - the imposition of obstetric forceps absence of conditions for applying forceps - craniotomy. • Prevention of AL in pregnant women is important: timely resolution of the issue of the possibility of maintaining pregnancy, stabilization of heart pathology in pregnant women, dynamic observation state CCC.
Synonyms for cardiogenic AL: • Acute left ventricular failure • Cardiac asthma.
Abbreviations • OL - pulmonary edema • DZLA - pulmonary artery wedge pressure
ICD-10 • I50.1 Left ventricular failure • J81 Pulmonary edema.