Pulmonary edema - a complication of various diseases, which represents the excess propotevanie transudate in interstitial tissue and then in the pulmonary alveoli.The term pulmonary edema is used as a complex association clinical symptoms arising due to the accumulation of fluid in the pulmonary parenchyma.
Etiopatogenetichesky In principle distinguish two forms of pulmonary edema: hydrostatic (occurs as a complication of diseases accompanied by an increase in hydrostatic pressure in the lumen of blood vessels), and membranous (damaging effect occurs when toxins of different origin on the alveolar-capillary membrane).
Incidence hydrostatic pulmonary edema significantly larger due to the fact that the pathology of cardiovascular disease is prevalent in the general population.Risk groups for this disease are people over 40 years, but pulmonary edema can occur in children with congenital heart disease, accompanied by left ventricular failure.
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Pulmonary edema causes
Pulmonary edema is not an independent nosological form, but is a complication of diseases.
Among the main causes of pulmonary edema should be considered:
- acute intoxication syndrome, due to the ingestion of toxins of infectious and non-infectious origin (septic condition, while large bacterial pneumonia, excessive accumulation of drug poisoning substance poisons).Toxins have a damaging effect on the membrane and promote alveolokapillyarnye output transudate from pulmonary interstitium;
- acute left ventricular failure, which is a consequence of various pathologies of the cardiovascular system (acute myocardial infarction, mitral valvular heart disease, resistant hypertension, unstable angina, severe arrhythmias, cardiomyopathy, cardio);
- chronic lung disease (COPD, emphysema, bronchial asthma, pneumonia macrofocal, malignant tumors in the lung);
- pulmonary edema as a result of the rapid rise in the long distance (more than 3 km);
- unilateral pulmonary edema as a result of the rapid evacuation of liquid or air from the pleural cavity (with pleural effusion and pneumothorax);
- diseases associated with decreased oncotic pressure of the blood as a result of lowering of the protein (nephrotic syndrome, cirrhosis, chronic hemorrhagic syndrome);
- uncontrolled excessive infusion of liquid drugs by intravenous infusion in combination with impaired renal excretory function;
- traumatic injury of the chest, accompanied by pneumothorax;
- severe head injuries, accompanied by seizure activity;
- the occurrence of pulmonary edema in diseases occurring with increased intracranial pressure (acute ischemic stroke, tumor brain damage)
- prolonged mechanical ventilation with a high concentration of oxygen;
- aspiration syndrome drowning, foreign body, or vomit into the airway.
Depending on the root causes of pulmonary edema there is a classification that distinguishes cardiogenic and non-cardiogenic (neurogenic, nephrogenic, allergic, toxic) form of edema.
pathogenetic mechanisms of any form of pulmonary edema consist of several stages.Debut of interstitial pulmonary edema is the stage during which the accumulation of transudate in pulmonary interstitial.At this stage, symptoms of cardiac asthma.Then the movement of fluid containing a high percentage of protein to the alveoli and whipping it with the air, resulting in a viscous foam.Because of its thick consistency foam occlusive respiratory tract and acute respiratory failure occurs, which causes the accumulation of carbon dioxide in the tissues (hypercapnia), decompensated acidosis and hypoxia.All of these metabolic disorders can cause irreversible processes in vital organs and are fatal.
There are three pathological mechanism of pulmonary edema:
1. The sharp increase in hydrostatic pressure.
2. Reduced oncotic blood pressure.
3. Damage to the structure of the membrane protein located between the alveoli and alveolar capillary permeability and improvement.
When any form of pulmonary edema is a violation alveolokapillyarnoy wall, resulting from damage to the protein-polysaccharide complex membrane.When pulmonary edema resulting from anaphylactic shock, severe intoxication infectious nature, inhalation of toxic substances, and severe renal insufficiency, the pathogenetic mechanism is leading in the development of symptoms of pulmonary edema.
The combination of increased hydrostatic pressure reduced oncotic pressure created conditions for increasing the filtration pressure in the lumen of the pulmonary capillaries.The reason for this condition often becomes uncontrolled intravenous infusion hypo-osmotic solution without daily urine.In addition, when severe renal and hepatic failure there is a deficiency of the protein in the blood, thereby reducing the oncotic pressure.
Among the pathogenetic causes of acute cardiogenic pulmonary edema to the fore sharp increase in hydrostatic pressure in the pulmonary circulation, compounded by the fact that blood flow in the left side of the heart is difficult (myocardial infarction, mitral stenosis).
Pulmonary edema symptoms
Clinical manifestations of pulmonary edema depends on the stage of the disease and on the speed of transition from interstitial to alveolar form.In terms of limitations distinguished: acute pulmonary edema (symptoms of alveolar edema develops a maximum of 4 hours), lingering (symptoms of edema is increasing gradually and peak after a few days) and lightning, which is almost 100% of cases are fatal, due to the critical condition of the patient.
cause of acute pulmonary edema are transmural myocardial infarction and decompensated mitral stenosis.Subacute version of pulmonary edema occurs in renal failure, infection of the pulmonary parenchyma.Prolonged shape edema characteristic of chronic inflammatory disease localized in the lung tissue.
fulminant variant observed at cardiogenic pulmonary edema, which is accompanied by a common cardiac pathology (extensive myocardial infarction, anaphylactic shock).In subacute form of the first symptom of pulmonary edema is shortness of breath during physical activity, which gradually increases and is transformed into a gasp.
In practice, doctors ambulance used clinical classification of pulmonary edema, in which distinguished 4 stages: Stage dyspnea (massive dry rales throughout the lung fields and no wet wheezing) ortopnoeticheskaya stage (prevalence moist rales over dry) stage expressedorthopnea (crackles are heard at a distance without the use of phonendoscope), manifests, step (bubbling breath, pronounced cyanosis skin, copious frothy sputum).
peculiarity of interstitial pulmonary edema is its appearance at night on the background of well-being.Provoking factor may make excessive physical activity and psycho-emotional strain.The harbinger of edema is a cough at night.
Symptoms of interstitial pulmonary edema phase: shortness of breath with minimal physical activity and at rest, decreases in the sitting position of the patient, severe shortness of breath and inability to take a deep breath, dizziness and malaise.
In the primary visual inspection of the patient's attention is drawn to the sharp pallor and moisture of the skin, combined with cyanosis nasolabial triangle and the surface of the tongue, exophthalmos.Percussion light reveals the symptoms of acute emphysema in a box sound.
auscultation changes in the lungs - bronchial breath type with a mass of dry wheezing buzzing throughout the lung fields on both sides.Cardio-vascular changes observed palpitations, I relaxed tone at all points of auscultation, in the projection of the pulmonary trunk marked accent II tone.When X-ray visualized lack of structure and expansion of the roots of the lungs, lung picture blurred, uniform symmetrical pnevmotizatsii reduction and the availability of lines of Curly in the basal lateral segments of the lungs.
Symptoms of pulmonary alveolar edema phase growing very rapidly and suddenly so difficult tolerated.The patient rapidly growing shortness of breath until suffocation, respiratory rate increased to 40 per minute, appears noisy stridor and cough, with copious frothy sputum mixed with blood (in a short time the patient noted the allocation of up to 2 liters of frothy sputum).In contrast, interstitial edema, when patients choose a forced situation and try not to move, even in the alveolar edema phase the patient is very excited.At external examination indicated diffuse cyanosis, hyperhidrosis and facial skin and body, lowering blood pressure and increased heart rate low filling, swelling of the veins in the neck.Auscultation changes - weight mixed wet rales throughout the lung fields, tachycardia and tachypnea, heart sounds are not tapped due to noisy breathing.Radiological skialogiya: homogeneous bilateral extensive blackout in the root area with fuzzy rough contours and infiltrative changes in the lungs of different lengths and shapes.
In the acute period marked increased heart rate to 160 beats per minute and an increase in blood pressure, and if protracted course and build-up of hypoxia observed weakening pulse, decreased blood pressure and increased frequency of respiratory movements, despite the fact that breathing becomes shallow.
Pulmonary edema may have a fluctuating course, when the attack comes after the relief of recurrent clinical manifestations, so all patients in need of skilled care in a hospital.
toxic pulmonary edema accompanied by a fulminant and in most cases fatal.Signs of swelling increases for a few minutes, and acute respiratory failure ends with the complete cessation of breathing for poisoning by nitrogen oxides.And at the same time toxic pulmonary edema caused by uremia may have minor clinical symptoms and radiological picture bright.
Clinical manifestations of pulmonary edema can occur in other diseases, so it is necessary to conduct a thorough differential diagnosis with pathologies such as: pulmonary embolism, asthma status in bronchial asthma, acute coronary syndrome.In some cases there is a combination of pulmonary edema with the above diseases.
pulmonary edema in bedridden patients
pathogenetic mechanisms of occurrence of pulmonary edema in bed patient due to the fact that the horizontal tidal volume is much less than when breathing in a vertical position.By reducing the activity of the respiratory movements reduced lung capacity, reduced blood flow, and there are changes in pulmonary congestion interstitium.It creates the conditions for the accumulation of mucus containing inflammatory component.Expectoration is difficult, and therefore changes in the lung congestion worse.
Amid all these changes occur pathogenic congestive pneumonia, a complication of which is pulmonary edema in the absence of adequate therapy.
peculiarity of pulmonary edema in bedridden patients is the gradual emergence and growth of clinical symptoms.The primary complaint of patients is unmotivated and increasing shortness of breath shortness of breath, which patients describe as a feeling of lack of air.Because of the gradual increase in hypoxia occurs oxygen starvation of the brain, which manifests itself in the form of drowsiness, dizziness, weakness.Despite the paucity of clinical manifestations, with the objective investigation of violations observed in the presence of a large bubbling rale moist throughout the lung fields, with a maximum in the lower divisions, as well as blunting of pulmonary sound with percussion.
In order to prevent occurrence of pulmonary edema all bedridden patients is recommended to perform twice a day, breathing exercises - blowing air through the tube into a container of water, inflating balloons.
avoid congestion in the pulmonary circulation all bed-patients shows the position in bed with raised head end, so most stationary chambers equipped with special functional couches.
In bedridden patients possible accumulation of fluid not only in lung tissue, as evidence of pulmonary edema, but also in the pleural cavity (hydrothorax, pleural effusion).This situation illustrates the application of therapeutic puncture, after which most patients report significant improvement.
Pulmonary edema emergency
Relief pulmonary edema should occur in the prehospital and hospital in the intensive care unit should be performed after stabilization of the patient.In a situation where stabilize the patient's condition fails and the growing signs of respiratory and cardiac failure should be possible to deliver patient care in the hospital profile to provide more skilled care.The ambulance recommended conducting all resuscitation to stabilize the hemodynamic parameters.
to determine the urgent measures required to be taken into account not only the existing symptoms, but also a kind of edema of pathogenetic criteria.However, there is an algorithm of urgent measures that shall be followed in all cases of pulmonary edema.
Ensure supply of fresh air to the patient and give the patient Half-upright position.With the patient must remove all clothing compressing the upper half of the body.The most efficient and fastest way to reduce the pressure in the pulmonary circulation is bloodletting.Extracting recommended volume of 300 ml blood and significantly reduces congestion in the lungs.Contraindications to the use of this method is - hypotension and poorly pronounced veins.
bloodletting could serve as an alternative to the imposition of venous turnstiles for the "unloading" of the pulmonary circulation.If tourniquet should check the pulsation of the arteries below the tourniquet to stop arterial blood flow is not.Do not leave the venous tourniquet more than an hour, and I certainly 1 every 20 minutes.The absolute contraindication to tourniquet is thrombophlebitis.As a diversionary procedures used hot foot bath.
Immediate and medication assistance with pulmonary edema according to the following program:
- maintenance therapy through immediate adequate oxygenation, intubation, mechanical ventilation in the mode of 16-18 per minute and the volume of air insufflation 800-900 ml.Under oxygen therapy meant a constant inhalation of 100% humidified oxygen through a nasal cannula.