Pulmonary Edema: Causes, Symptoms, and Treatment

• Pulmonary Edema

  • Occurs when the left ventricle fails to eject sufficient blood, leading to increased pressure in the lungs.
  • Increased pressure causes fluid leakage across pulmonary capillaries into the lung airways.

Manifestations of Pulmonary Edema

- Pink, frothy sputum
- Dyspnea (shortness of breath)
- Orthopnea (difficulty breathing when lying flat)
- Paroxysmal nocturnal dyspnea (sudden nighttime breathlessness)
- Cough with frothy, pink sputum
- Tachypnea (rapid breathing)
- Tachycardia (rapid heart rate)
- Cyanosis (bluish discoloration of the skin)
- Crackles (rales) on lung auscultation

Risk Factors for Pulmonary Edema

- Cardiogenic causes include left-sided heart failure, acute myocardial infarction, mitral valve disease, and hypertension.
- Non-cardiogenic causes include pneumonia, inhalation injury, sepsis, airway obstruction, and high altitude.

Medications for Pulmonary Edema

- Furosemide (Lasix) is used for diuresis.
- Nitroglycerin is used for vasodilation to lower high systolic blood pressure.
- Morphine is used for anxiety and vasodilation.
- ACE inhibitors or ARBs are used for heart failure management.

Treatment for Pulmonary Edema

- Oxygen therapy is administered to maintain adequate oxygen saturation.
- Diuretics are used to reduce fluid overload.
- Vasodilators are used to decrease afterload.
- Inotropic agents are used to improve cardiac output.
- Addressing the underlying cause (e.g., treating heart failure or infection) is crucial.
- Chest tube placement may be necessary.

Nursing Interventions for Pulmonary Edema

- Monitor vital signs and oxygen saturation.
- Assess lung sounds for crackles.
- Administer prescribed medications.
- Position the patient upright to facilitate breathing.
- Provide emotional support to reduce anxiety.

Safety and Nursing Care for Pulmonary Edema

- Implement fall precautions.
- Educate the patient on fluid and sodium restrictions.
- Monitor for signs of electrolyte imbalances.
- Encourage smoking cessation.

Pulmonary Embolism (PE)

- A collection of particulate matter enters venous circulation and lodges in pulmonary vessels.
- A blood clot is the most common cause, but fat emboli can occur with long bone breaks, indicated by petechiae.

Risk Factors for PE

- Prolonged immobility (e.g., bed rest, long flights)
- Recent surgery, especially orthopedic procedures
- Central venous catheter
- History of deep vein thrombosis (DVT)
- Cancer
- Smoking
- Obesity
- Use of estrogen-based contraceptives
- Pregnancy and postpartum period
- Age over 60

Clinical Manifestations of PE

- Sudden onset of dyspnea
- Pleuritic chest pain
- Hemoptysis (coughing up blood)
- Tachypnea
- Tachycardia
- Hypotension
- Anxiety

Treatments for PE

- Anticoagulation therapy (e.g., heparin, warfarin) is common.
- Thrombolytic therapy is used in severe cases.
- Surgical embolectomy may be indicated.
- Inferior vena cava (IVC) filter placement is used for recurrent PE.

Medications for PE

- Heparin is used for immediate anticoagulation; protamine sulfate is the antidote.
- Warfarin is used for long-term anticoagulation; vitamin K is the antidote.
- FFP (Fresh Frozen Plasma) is used in some cases.
- Direct oral anticoagulants (DOACs) are used as alternatives.
- Tissue plasminogen activator (tPA) is used for thrombolysis.

Nursing Interventions for PE

- Monitor for signs of bleeding.
- Assess respiratory status and oxygenation.
- Administer prescribed anticoagulants and thrombolytics.
- Educate the patient on medication adherence and bleeding precautions.

Labs for PE

- Low PACO2 on ABG, elevated troponin, BNP, and D-dimer (for clotting)

Safety and Basic Care for PE

- Implement fall precautions.
- Avoid invasive procedures that may cause bleeding.
- Encourage early ambulation to prevent DVT.
- Provide emotional support to reduce anxiety.

Chest Trauma

- Motor vehicle accidents often cause pulmonary contusion.

Risk Factors for Chest Trauma

- Blunt force to chest
- Pneumothorax, hemothorax, tension pneumothorax
- Rib fractures
- Flail chest
- Occupational accidents

Clinical Manifestations of Chest Trauma

- Chest pain
- Dyspnea
- Cyanosis
- Decreased breath sounds
- Hemorrhage and edema in alveoli
- Hypotension
- Tachycardia

Treatments for Chest Trauma

- Airway management (intubation if necessary)
- Oxygen therapy to maintain adequate oxygenation
- Chest tube insertion for pneumothorax or hemothorax
- Pain management to facilitate breathing and prevent complications
- Surgical repair for severe injuries (e.g., flail chest, major vessel injury)

Medications for Chest Trauma

- Analgesics (e.g., opioids, NSAIDs) for pain control
- Antibiotics if there is an open chest wound or risk of infection
- Sedatives or muscle relaxants if mechanical ventilation is required

Nursing Interventions for Chest Trauma

- Monitor respiratory status (rate, depth, breath sounds).
- Assess for signs of pneumothorax or hemothorax.
- Maintain chest tube drainage system (if present).
- Position the patient to optimize breathing (high Fowler’s position).
- Administer pain medications as prescribed.
- Provide emotional support and reassurance.

Safety and Basic Care for Chest Trauma

- Prevent further injury by stabilizing the patient.
- Educate the patient on deep breathing exercises to prevent pneumonia.
- Monitor for complications such as infection or respiratory failure.
- Ensure proper chest tube management to avoid dislodgement.

Chest Tubes

- Inserted into the pleural space to drain fluid, blood, or air.
- Facilitate lung expansion.
- Reestablish a negative pressure and restore intrapleural pressure.
- Removed when the lungs have re-expanded or there is no more fluid drainage.

Chest Tube Systems

- A disposable three-chamber drainage system is most often used, the first chamber is for drainage collection 
- The second chamber is a water seal
- The third chamber is the suction control (can be wet or dry)

Indications for Chest Tubes

- Pneumothorax: Partial/complete lung collapse due to air in pleural space
- Hemothorax: Blood accumulation causing lung collapse
- Postoperative drainage following thoracotomy or open-heart surgery
- Pleural Effusion: Fluid accumulation in pleural space
- Pulmonary Empyema: Pus accumulation due to infection

Client Presentation with Chest Tubes

- Dyspnea
- Distended neck veins
- Hemodynamic instability
- Pleuritic chest pain
- Cough
- Absent or reduced breath sounds on the affected side
- Hyperresonance on percussion of affected side (pneumothorax)
- Dullness or flatness on percussion of the affected side (hemothorax, pleural effusion)
- Asymmetrical chest wall motion

Nursing Interventions for Chest Tubes

- Monitor the water seal chamber for continuous bubbling (air leak finding), locate the source of the air leak and tighten the connection or replace the system
- Check all connections
- Notify the provider if an air leak is noted, gently apply a padded clamp to determine the location of the air leak
- Instruct the client to exhale and cough to remove as much air as possible, if tubing separates
- Immerse the end of the chest tube in sterile water to provide a temporary water seal, if the chest tube drainage system is compromised
- Dress the area with dry, sterile gauze, if the chest tube is accidentally removed

Acute Respiratory Failure (ARF)

- Can result from a ventilation failure, oxygenation failure, or a combination with abnormalities shown on ABG
- Oxygenation failure: PaO2 < 60 mm Hg, with acidosis (low pH) and normal PaCO2.
- Ventilation failure: PaCO2 > 50 mm Hg, with acidosis (low pH) and normal PaO2.
- Combination: PaO2 < 60 mm Hg and PaCO2 > 50 mm Hg, with acidosis (low pH).

Types of Acute Respiratory Failure

- Oxygenation failure (type 1 ARF): O2 has difficulty moving into the blood from the lungs, decreased perfusion, caused by upper/lower obstruction, pneumonia, COVID-19, PE, pulmonary edema, shock, pneumothorax
- Ventilation failure (type 2 ARF): air movement is inadequate while blood movement remains normal, chest pressure doesn’t change enough to allow air in and out of the lungs, caused by myasthenia gravis, tetanus, stroke, meningitis, acities, COPD
- Combined failure: impaired gas exchange and lung perfusion, hypoventilation is always associated, caused by abnormal lungs, bronchitis, emphysema, or cystic fibrosis

Risk Factors for ARF

- Extremely young or advanced age
- Recent exposure to viral or bacterial infections
- Lack of immunizations
- Exposure to environmental contaminants (smoke, pollutants)
- Tobacco smoke
- Substance use (alcohol)
- Chronic lung disease
- Mechanical ventilation (ventilator-acquired pneumonia)

Clinical Manifestations of ARF

- Dyspnea is more intensive as respiratory failure progresses.
- Changes in respiratory rate
- Decreased O2 saturation
- Restlessness, irritability, agitation
- Tachycardia, tachypnea
- Confusion, fatigue
- Cyanosis (late sign)
- ABGs indicate hypoxia and hypercarbia.

Nursing Interventions / Treatment / Medications for ARF

- Nebulized or MDI bronchodilators or anti-inflammatory agents
- Corticosteroids are used if COVID-19 or COPD/Asthma.
- O2 therapy is used if acute hypoxemia; maintain PaO2 levels above 60 mmHg.

Supportive Care for ARF

- Reduce anxiety, position comfortably, conserve energy, encourage deep breathing.

Acute Respiratory Distress Syndrome (ARDS)

- ARDS is ARF with specific features including hypoxemia that persists even when 100% oxygen is given (refractory hypoxemia).
- Decreased pulmonary compliance with dyspnea, non-cardiac-associated bilateral pulmonary edema and dense pulmonary infiltrates on X-ray.
- Not primary diagnosis

Cause of ARDS

- Widespread inflammation leading to damage to alveolar-capillary membranes

Clinical Manifestations of ARDS

- Hyperpnea
- Tachypnea
- Hypoxemia
- Noisy respiration
- Cyanosis
- Pallor
- Retractions
- Hypotension
- Tachycardia
- Dysrhythmias

Diagnostic Assessment for ARDS

- Lowered partial pressure of arterial oxygen (PaO2) with a decreased P/F ratio