Acute Pulmonary Edema

ACUTE PULMONARY EDEMA: -- 2/2 Cardiogenic vs Noncardiogenic Etiogloy -- Rx -- according to etiology

Appreciate the difference in mechanism of Cardiogenic and Noncardiogenc Pulmonary Edema 
  • Mild elevations of left atrial pressure (18 to 25 mm Hg) cause edema in the perimicrovascular and peri- bronchovascular interstitial spaces. As left atrial pressure rises further (>25 mm Hg), edema fluid breaks through the lung epithelium, flooding the alveoli with protein-poor fluid.  
  • Patients with cardiogenic pulmonary edema often have an abnormal cardiac examination. Auscultation of an S3 gallop is relatively specific for elevated left ventricular end-diastolic pressure and left ventricular dysfunction  and suggests car- diogenic pulmonary edema . The specificity of this finding is high (90 to 97 percent), but its sensitivity is low (9 to 51 percent) 
  • Elevated neck veins, an enlarged and tender liver, and pe- ripheral edema suggest elevated central venous pressure. However, assessment of central venous pressure by physical examination in a critically ill patient can be difficult 
  • Patients with noncardiogenic edema often have warm extremities, even in the absence of sepsis, whereas patients with cardiogenic edema and poor cardiac output usually have cool extremities. 
  • In patients with congestive heart failure, plasma BNP levels corre- late with left ventricular end-diastolic pressure and pulmonary-artery occlusion pressure. According to a consensus panel, a BNP level below 100 pg per milliliter indicates that heart failure is unlikely (negative predictive value, >90 percent), whereas a BNP level greater than 500 pg per mil- liliter indicates that heart failure is likely (positive predictive value, >90 percent). However, BNP levels between 100 and 500 pg per milliliter provide inadequate diagnostic discrimination. BNP levels must be interpreted with caution in critically ill patients, since the predictive value of BNP levels is uncertain in this group. Some reports indicate that BNP levels can be elevated in criti- dally ill patients even in the absence of heart failure. In one report, all eight patients with sepsis with normal left ventricular function had BNP levels above 500 pg per milliliter. Thus, measuring BNP is most use- ful in critically ill patients if the level is below 100 pg per milliliter. BNP levels are also higher in patients with renal failure independent of heart failure, and a cutoff of below 200 pg per milliliter has been suggested to exclude heart failure when the estimated glomerular filtration rate is below 60 ml per minute. BNP is also secreted by RV, and moderate elevations have been reported in patients with acute pulmonary embolism, cor pulmonale, and pulmonary hypertension.  
Acute Pulmonary Edema NEJM 2005 

In a study of 45 patients with pulmonary edema in whom the cause was determined clinically and with the use of sampling of pulmonary edema fluid, a composite score based on the radiographic features in Table 1 correctly identified 87 percent of the patients who had cardiogenic edema and 60 percent of those who had noncar- diogenic edema. A measurement of the width of the vascular pedicle may improve the diagnostic accuracy of the chest radiograph, but its utility in distinguishing cardiogenic from noncardiogenic edema needs further evaluation 

Understanding negative pressure pulmonary edema Intensive Care Med 2014

Diffuse Pulmonary Haemorrhage
CXR Shows the following

CT Shows the following

What is the DDx

Patient is on Coumadin, and INR is 12. Platelet is normal.
Makes Anti-coag likely.
But, CRP, Procalcitonin is elevated? 
Makes SLE less likely. Cr is normal. 
Vasculitis is more likely. 
Infection is likely as well.