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!!!
