Pulmonary edema: symptoms, emergency care. Providing emergency care for pulmonary edema Pulmonary edema symptoms emergency

When pulmonary edema can develop, causes, clinical picture, tactics, help - this information is very important, because a person’s life can often depend on it. First aid for pulmonary edema is a very urgent and necessary procedure; it consists, first of all, of calling an ambulance team, because outside a medical institution it is unlikely that the necessary equipment and medications will be found. But while specialists are awaiting the arrival, people close to the patient must take measures.

The essence of the problem

Pulmonary edema is acute pulmonary failure. It is associated with infiltration of the alveoli with an acute and sudden disruption of the exchange of gases in the lungs. When at rest, the patient feels tightness in the chest, suffocation, bubbling breathing, coughing, accompanied by sputum with blood and foam.

The disease is very serious and quite dangerous, and if the patient is not provided with emergency care in a timely manner, the death rate is high. Provided that all measures were carried out correctly and in the shortest possible time, the patient’s condition will soon improve significantly, and his life will not be in danger.

Causes of pulmonary edema

Pulmonary edema can be caused by cardiac diseases, severe bronchitis, lobar pneumonia, asthma, and tuberculosis. Edema can be caused by complications after various infectious diseases - measles, whooping cough, poliomelitis, influenza and ARVI.

In newborns, acute pulmonary edema can be caused by hypoxia, bronchopulmonary dysplasia, and prematurity. With laryngitis, adenoids, foreign bodies entering the respiratory tract, a similar condition can also be observed, as with mechanical suffocation - drowning or hanging.

Acute kidney diseases, tumors, hemorrhages, cirrhosis of the liver, and brain surgery can also cause edema. It can develop during acute allergic reactions, poisoning with chemicals, drugs, and extensive burns. In pregnant women, this can occur with eclampsia.

Classification of pulmonary edema:

Interstitial - the pulmonary parenchyma is saturated with fluid, but transudate does not leak into the lumen of the alveoli.
Alveolar - plasma enters the lumen of the alveoli.

In fact, these are not types of edema, but 2 stages of the same process.

Clinical picture

Most often, pulmonary edema occurs at night. Suddenly the patient begins to choke and cough dryly and jerkily. Choking appears, a similar condition forces a person to sit down or stand up - these are signs of early left ventricular failure. Next, shortness of breath appears, breathing becomes bubbling, and foamy sputum is released. The tips of the fingers and lips turn blue, the pulse and breathing quicken. The patient is very nervous, he is excited, and is terrified of death.

The transition from interstitial edema to the next (alveolar) stage is signaled by a sharp transition from panic excitation to an inhibited state, while shortness of breath increases and the pulse becomes threadlike. Bubbling breathing can already be heard in the distance. An urgent call to the doctor is necessary - it is important to stop the pathology as early as possible, because it is easier to do this at the interstitial stage than when alveolar edema develops.

According to the course of edema, one can distinguish:

Acute edema - most often it is accompanied by myocardial infarction, heart disease or anaphylactic shock. Duration less than 4 hours.
Subacute - lasts up to 12 hours and is caused by liver or kidney failure.
Protracted - lasts up to several days and can be observed with renal failure and chronic lung pathologies.
Lightning - lasts only a few minutes and is almost always fatal.

What to do first?

Emergency care for pulmonary edema is as follows:

Immediately call an ambulance.
The patient must be seated and his legs lowered.
Open a vent or window and provide air flow.
Remove items from the patient that are obstructing breathing.
Take your pulse and monitor your breathing all the time.
Measure your blood pressure.
Place the patient's feet in hot water.
Do alcohol inhalation.
apply a tourniquet to the thigh for half an hour (first on one, then on the other).
If the patient's blood pressure is above 90 mm Hg, place nitroglycerin under the tongue.
If the patient can drink and swallow, give Furosemide or Lasix to drink.

For pulmonary edema, first aid is very important. After the ambulance arrives, the patient is provided with emergency medical care:

A narcotic analgesic (Promedol or Morphine) is administered intravenously, then Nitroglycerin and Lasix. After which the patient must be hospitalized.
While the patient is being transported, the doctor should, if necessary, perform artificial ventilation of the lungs and possibly perform tracheal intubation.
To eliminate foam, you need to carry out a procedure with an inhalation mixture that contains antifoam agents. To prevent the patient from choking on foam, foam pumps are used.
If necessary, you need to reduce blood pressure and eliminate signs of bronchospasm.
If thromboembolism is present, Heparin or other anticoagulants should be used.
Administer Atropine if the pulse is thready.
For atrial fibrillation, cardiac glycosides are used.

Treatment in hospital

The patient is placed in the emergency department, where it is necessary to constantly monitor the pulse rate, blood pressure and breathing. Almost all drugs are injected into the subclavian catheter. Treatment is determined for each patient strictly individually, in accordance with the reasons that provoked the swelling.

These can be inhalations of oxygen and defoamers, drugs to eliminate bronchospasm, antipsychotics, narcotic analgesics. If necessary, the patient can be given anesthesia for a while. Also, for pulmonary edema, nitrates, tranquilizers, and loop diuretics are administered. If atrial fibrillation is diagnosed, cardiac glycosides are used. In order to remove fluid from the lungs, large doses of Ambroxol are administered.

The patient's blood pressure should be constantly measured; if it is high, it is reduced with ganglion blockers. If hypoproteinemia is observed, fresh frozen plasma must be administered.

Possible thrombus formation is monitored, and if there is a risk of its occurrence, Heparin is administered. If a secondary infection develops during the process, it is treated with antibiotics.

When treating pulmonary edema, the patient must follow a salt-free diet with limited fat and liquid. After discharge, the patient must continue treatment on an outpatient basis and is under the supervision of a physician.

Prevention of edema

Since pulmonary edema syndrome in most cases occurs in people with chronic diseases, timely treatment of these pathologies can significantly reduce the risk of edema. However, with heart defects, coronary disease, heart failure and long-term arrhythmias, its development cannot be completely excluded. But with careful monitoring by the doctor and strict implementation of all his recommendations, the patient can avoid complications of existing diseases, including pulmonary edema.

First aid for pulmonary edema is a necessary measure to maintain human life.

First aid is a set of measures aimed at eliminating acute symptoms and providing life support.

If pulmonary edema occurs, then first aid is to call an ambulance, since in out-of-hospital conditions all the necessary medications and equipment are rarely available. While waiting for qualified doctors, people around the patient must take the necessary measures.

Pulmonary edema: clinic and emergency care

Pulmonary edema is a condition when too much fluid accumulates in the lungs. This is due to the large difference in colloid osmotic and hydrostatic pressure in the capillaries of the lungs.

There are two types of pulmonary edema:

Membranogenic– occurs if capillary permeability has increased sharply. This type of pulmonary edema often occurs as an accompaniment to other syndromes.

Hydrostatic– develops due to diseases in which hydrostatic capillary pressure increases sharply, and the liquid part of the blood finds its way out in such quantities that it cannot be removed through the lymphatic tract.

Clinical manifestations

Patients with pulmonary edema complain of lack of air, have frequent shortness of breath and sometimes attacks of cardiac asthma that occur during sleep.

The skin is pale, and the nervous system may have inappropriate reactions in the form of confusion or depression.

With pulmonary edema, the patient develops cold sweat, and when listening to the lungs, wet rales are detected in the lungs.

First aid

At this time, it is very important to act quickly and accurately, since without support the situation can deteriorate sharply.

When the ambulance arrives, all specialists’ actions will be aimed at three goals:

reduce the excitability of the respiratory center;
relieve the load on the pulmonary circulation;
remove foaming.

In order to reduce the excitability of the respiratory center, the patient is administered morphine, which relieves not only pulmonary edema, but also an asthma attack. This substance is unsafe, but here it is a necessary measure - morphine selectively affects the brain centers responsible for breathing. Also, this medication makes the blood flow to the heart less intense and due to this, congestion in the lung tissue is reduced. The patient becomes much calmer.

This substance is administered either intravenously or subcutaneously, and its effect begins within 10 minutes. If the blood pressure is low, promedol is administered instead of morphine, which has a less pronounced but similar effect.

Strong diuretics (for example, furosemide) are also used to relieve pressure.

To relieve the pulmonary circulation, they resort to a dropper with nitroglycerin.

If there are symptoms of impaired consciousness, the patient is given a weak antipsychotic.

Along with these methods, oxygen therapy is indicated.

If the patient has persistent foam, this treatment will not give the desired effect, as it may block the airways. To avoid this, doctors give inhalation with 70% ethyl alcohol, which is passed through oxygen. Then specialists suck out excess fluid through the catheter.

Causes of pulmonary edema

Hydrostatic edema can occur due to:

Heart dysfunction.
Entry of air, blood clots, and fat into the vessels.
Bronchial asthma.
Lung tumors.

Membrane pulmonary edema can occur for the following reasons:

Kidney failure.
Chest injury.
Ingress of toxic vapors, gases, smoke, mercury vapor, etc.
Rejection of gastric contents into the respiratory tract or water.

Pulmonary edema occurs when the normal level of interstitial fluid in the lungs is exceeded. This condition is a serious complication of many heart diseases. Swelling can also be triggered by a severe allergic reaction, injury, as well as poisoning by various chemicals. In this case, the patient’s condition sharply worsens, the functioning of the heart and respiratory organs is noticeably impaired. The patient urgently needs the help of a doctor, otherwise the consequences will be very sad. The algorithm for providing emergency care for pulmonary edema includes various measures, but all of them are aimed at alleviating the patient’s condition.

Mechanism of edema development

Pulmonary edema occurs when fluid accumulates in the tissues instead of air.. Due to this, the blood circulation of the respiratory organs is disrupted, oxygen enters the cells in insufficient quantities, which ultimately leads to disruption of the functioning of the lungs and the entire body as a whole.

Doctors identify only two main mechanisms that can lead to swelling of the respiratory organ:

Exceeding the level of intercellular fluid due to increased pressure in the blood vessels of the respiratory organ. This type of edema is called hydrostatic.
Excess of intercellular fluid volume due to excessive filtration of plasma at absolutely stable pressure. This type of edema is called membrane edema.

Regardless of the pathogenesis of edema, the patient’s condition is extremely serious and requires immediate medical attention.

Causes

Membrane and hydrostatic edema have different causes. Therefore they are divided into groups.

Causes of hydrostatic pulmonary edema

The causes of such edema are various pathologies of the heart and respiratory system:

Heart defects at the stage of decompensation. Most often observed with mitral valve insufficiency and stenosis;
Blockage of large and small vessels of the lungs;
Deterioration of contractile functions of the heart. Most often, edema develops with left ventricular infarction and severe myocardial damage;
Pneumothorax;
Severe respiratory failure. This can happen with bronchial asthma, aspiration, or blockage of the airways by foreign objects.

Persistent arrhythmia can also cause hydrostatic edema. In this case, blood circulation in the heart is disrupted.

Causes of membranous pulmonary edema

Membrane edema occurs in diseases of a general nature, which include:

Non-inflammatory pathologies - respiratory syndrome, aspiration, prolonged inhalation of certain chemical components;
Inflammatory pathologies – pneumonia and sepsis.

First aid for pulmonary edema caused by various reasons is practically the same. The main task is to normalize the functioning of the heart and respiratory system.

Severe complications of pulmonary edema are suffocation and cardiogenic shock.

Clinical picture

It is not difficult to determine this condition if you know the main signs of manifestation. The speed of development determines fulminant, acute, subacute and prolonged edema.

Swelling can be triggered by active physical exercise, intense stress, or a sudden change in body position. In some cases, so-called precursors appear before this condition. This may include progressive shortness of breath, rapid breathing, regular coughing and moist rales in the lungs.

The first symptom of edema will be chest pain and a feeling of squeezing. After this, motor activity increases and shortness of breath increases. It is difficult for the patient not only to inhale, but also to exhale. A person lacks oxygen, his heartbeat is too rapid, and cold and sticky sweat appears on his skin. The skin becomes bluish. At the very beginning, the cough is dry, then it gradually turns into a wet one. In the end, the sputum becomes foamy and pinkish. In particularly severe cases, foam may be released from the nasal passages.

A clear symptom of changes in the lungs is loud and bubbling breathing, it is frequent and intermittent. The patient is very frightened. Consciousness may be confused. As the symptoms progress, the pressure drops significantly and the pulse is difficult to palpate.

It is very difficult for the patient to breathe, he takes a forced sitting position, this makes breathing much easier for him. Even an inexperienced person can notice the blueness of a patient’s lips. In some cases, moist rales can be heard even without a stethoscope.

In the fulminant form, all dangerous symptoms develop very quickly, literally in a matter of minutes. Due to the sudden development, it is very difficult to save a patient with this form.

With a protracted form of the pathology, symptoms increase gradually and the prognosis is much better than with a rapid and acute form.

Urgent Care

Emergency care for pulmonary edema is provided in several successive stages. The person providing assistance must act decisively, but very carefully. It is necessary to adhere to the following algorithm of actions:

The patient is given a semi-sitting position; in this position of the body it is much easier to breathe. This is considered the optimal body position for pulmonary edema;
If necessary, mucus is removed from the upper respiratory tract. If a person is conscious, he can blow his nose; if the patient is unconscious, then they resort to suctioning out the mucus with a rubber syringe;
Inhalation of alcohol vapor is performed. It is necessary to take 70% medical alcohol;
Venous tourniquets are applied to the limbs;
According to the doctor's indications, Lasix solution is administered intravenously if the medication has no effect. Then after 20 minutes a higher dose is administered;
Eufillin and Prednisolone are administered.

Emergency care also includes the administration of nicotinic and ascorbic acid, as well as sodium bicarbonate solution.

If a person has symptoms of pulmonary edema, they can be given a nitroglycerin tablet as first aid. But such actions must be agreed with a doctor.

Nurse tactics

If there is a nurse near the patient, then the emergency tactics will be as follows:

The doctor is promptly notified;
The patient is seated comfortably, pillows are placed under his back, and his legs should hang down;
If a person is very nervous, the nurse should calm him down;
All compressive clothing is removed from the patient. These could be belts, ties, things with tight elastic bands and a bra;
If a person becomes ill in the house, then it is necessary to open the windows to provide fresh air.;
Before the doctor arrives, it is necessary to regularly monitor the patient’s condition. To do this, measure your pulse and blood pressure. It is better to write down the data so that you can show it to the doctor later;
The patient is placed under the tongue with a nitroglycerin tablet to improve myocardial nutrition;
A few minutes after taking nitroglycerin, the patient’s blood pressure is measured; if the systolic reading is high, then another tablet is given;
To relieve the pulmonary circulation, it is necessary to apply tourniquets to all limbs or only to the legs;

When applying tourniquets, care must be taken to ensure that they do not compress the arteries. The tourniquets are applied for no more than 15 minutes and removed from the limbs gradually.

If pulmonary edema is observed while the patient is in the hospital, he is immediately provided with inhalation of clean and humidified oxygen;
Treatment tactics are determined by the attending physician.

It is worth knowing that the first symptoms of pulmonary edema most often appear at night, so on-duty nurses need to be vigilant. The lives of patients depend on the attentiveness of these health workers.

You need to start providing first aid for pulmonary edema as early as possible. With timely treatment, the prognosis is very good. It takes a couple of weeks for the patient to fully recover. If the dangerous condition was not noticed in a timely manner and first aid was not provided, everything could end very sadly. Pulmonary edema often leads to the death of patients.

Pulmonary edema is a pathology in which intercellular fluid from blood vessels leaks into the lung tissue and alveoli. At the same time, gas exchange in the body is disrupted. Changes occur in the composition of the blood: the level of carbon dioxide increases. A person begins to experience oxygen starvation, and the functions of the nervous system are depressed. If medical assistance is not provided in time for pulmonary edema, death occurs.

This condition is divided into two types:

membranogenic, i.e. with a sharp increase in the level of permeability of blood vessels;
hydrostatic, i.e. associated with diseases that increase pressure in the capillaries.

Reasons for the development of edema

Edema, sometimes called cardiac asthma, may be due to the following:

diseases of the circulatory system, in which blood stagnates in the pulmonary circulation (any disease in the stage of decompensation);
overdose of drugs or narcotic substances;
formation of a blood clot in the pulmonary artery;
poisoning with toxic substances or toxic gases;
kidney pathologies, in which the level of protein in the blood decreases;
blood poisoning;
pneumonia;
hypertensive crisis;
stagnation of blood in the right circulation is usually associated with bronchial asthma, emphysema and other respiratory diseases;
shock caused by injury;
radiation sickness.

Symptoms of edema

Pulmonary edema can be triggered by excessive physical activity, sudden changes in body position, or severe stress. When the pathology is just beginning, a person feels shortness of breath and wheezing in the chest, and breathing quickens.

At the initial stage, fluid collects in the interstitium of the lungs. This condition is accompanied by the following symptoms:

squeezing feeling in the chest;
frequent nonproductive cough;
sudden pallor of the skin;
labored breathing;
tachypnea;
a feeling of anxiety and panic, possible confusion;
hypertension;
cardiopalmus;
increased sweating;
bronchospastic syndrome.

When fluid enters the alveoli, the second stage begins - alveolar pulmonary edema. The patient suddenly becomes worse. To reduce pain, the patient takes a sitting position, leaning on outstretched arms. This stage of edema is accompanied by the following symptoms:

wet and dry wheezing;
increasing shortness of breath;
bubbling breathing;
suffocation intensifies;
cyanosis of the skin;
swelling of the neck veins;
heart rate increases to 160 beats per minute;
consciousness is confused;
blood pressure drops;
the patient feels fear of death;
thready and hard to palpate pulse;
foamy pink sputum is produced;
in the absence of timely medical care - coma.

An attack can disrupt the integrity of the respiratory tract and lead to the death of the victim.

A person with pulmonary edema needs emergency care. The following actions must be taken:

at the first symptoms of cardiac asthma, call emergency medical care;
help the patient take a semi-sitting or sitting position, while his legs should be lowered;
place the patient's feet in a basin of hot water;
open the windows, giving the victim access to fresh air, remove or unfasten tight clothing that interferes with breathing;
control breathing and pulse;
if you have a tonometer, measure your blood pressure;
if heart pressure is above 90, give the person one nitroglycerin tablet sublingually;
apply venous tourniquets to the legs to retain venous blood in them and reduce the load on the heart;
tourniquets are applied to the lower limbs one at a time and can be placed on them for no more than 20 minutes;
after normalization of pressure, administer intravenously to the victim (for example, Lasix) to reduce the amount of fluid in the lungs;
carry out inhalation with a 96% (for children 30%) aqueous solution of alcohol, which has an anti-foaming effect.

After the above manipulations, you need to wait for an ambulance, which will relieve pulmonary edema and take the patient to intensive care. There, doctors determine what caused the pathology, and further treatment is carried out by a doctor of the appropriate specialty.

Emergency medical care for swelling

Immediately after arrival, emergency doctors must inject a patient with pulmonary edema into a vein with a narcotic painkiller (Morphine, Promedol) to normalize hydrostatic pressure in the pulmonary circulation, a diuretic and nitroglycerin. When transporting to the hospital, the following actions are carried out:

the patient is positioned so that the upper half of the body is elevated;
in the absence of diuretics, tourniquets are applied to the lower extremities, the pulse in the arteries should be maintained;
oxygen therapy is performed (if required, a tube is inserted into the patient’s trachea and artificial ventilation is performed);
the solution for inhalation should include an antifoam (70–96% aqueous solution of ethyl alcohol), which reduces the tension of the exudate;
every 30–40 minutes of inhalation, the patient should breathe pure oxygen for 10 minutes;
an electric suction is used to remove foam from the upper respiratory tract;
if a blood clot has formed in the pulmonary artery, anticoagulants that thin the blood are used;
if the patient has atrial fibrillation, he is administered a drug from the group of cardiac glycosides;
In case of nausea, vomiting or ventricular tachycardia, glycosides should not be used;
if pulmonary edema is caused by a drug overdose, medications that reduce muscle tone are used;
when diastolic pressure is more than 100, 50 mcg of nitroglycerin is required intravenously;
for bronchospastic syndrome, the patient is given Methylprednisolone or;
if the heart rate is less than 50 beats per minute, use Eufillin in combination with Atropine;
if the victim has bronchial asthma, he is given a standard dose of pentamine or sodium nitroprusside.

Therapy for pulmonary edema

Further care for pulmonary edema should be carried out by doctors from the intensive care unit or intensive care unit. Monitoring of pulse, blood pressure and respiration should be carried out continuously. All medications are administered through a catheter inserted into the subclavian vein.

After the swelling is stopped, treatment of the pathology that caused it begins. To treat edema of any origin, antibiotics and antiviral therapy are needed.

Diseases of the respiratory system are treated with antibiotics from the group of macrolides and fluoroquinolones, which have an expectorant and anti-inflammatory effect. Penicillin is rarely used due to its low effectiveness. Together with antibiotics, immunomodulators are prescribed to affect the immune system and prevent recurrence of infection.

If the swelling is caused by intoxication, medications are prescribed to relieve symptoms and, if required, an antiemetic. After diuretics, it is also necessary to restore the water-salt balance of the body.

Severe forms of acute pancreatitis are treated with medications that inhibit the functioning of the pancreas. In addition to them, enzyme preparations and agents are prescribed that accelerate the healing of foci of necrosis.

Asthma attacks are relieved with glucocorticosteroids, bronchodilators, and phlegm thinners.

For liver cirrhosis, drugs to protect it and thioctic acid are prescribed.

If the cause of the pathology is myocardial infarction, beta-blockers, drugs that prevent the formation of blood clots, and angiotensin-converting enzyme inhibitors are required.

The prognosis after cardiac asthma is usually favorable, but the patient must be examined by the attending physician within a year.

Possible complications after pulmonary edema

If first aid for pulmonary edema is not provided correctly, a person’s condition can worsen and lead to complications:

the pathology can develop into a lightning-fast form, and doctors will not have time to provide assistance in time;
if too much foam is produced, it blocks the airways;
with swelling, breathing is suppressed;
pressing or squeezing pain behind the sternum can cause painful shock;
blood pressure drops with a significant amplitude, exposing blood vessels to enormous stress;
significant increase in heart rate, cessation of blood circulation.

ALGORITHM FOR PROVIDING EMERGENCY CARE. ACUTE LEFT VENTRICULAR FAILURE

Acute left ventricular failure (ALVF) manifests itself in the form of cardiac asthma and pulmonary edema. First, the fluid accumulates in the interstitial tissue of the lung (in the interstitial crevices) - cardiac asthma. and then the edematous fluid sweats into the alveoli - pulmonary edema. Thus, cardiac asthma and pulmonary edema are two successive phases of acute left ventricular failure.

Acute left ventricular failure may be caused by heart disease (cardiac ALV). It develops due to a decrease in the contractility of the left ventricular myocardium with ischemic heart disease, mitral stenosis, arrhythmias, aortic heart defects, cardiomyopathies, and severe myocarditis.

Extracardiac acute left ventricular failure occurs due to overload of the heart with increased blood volume and blood pressure in hypertension, symptomatic hypertension, and chronic renal failure.

Factors provoking an attack: 1. psycho-emotional stress, 2. inadequate physical activity, 3. weather change 4. geomagnetic disturbances, 5. excess salt in food, 6. drinking alcohol, 7. taking corticosteroids, anti-inflammatory non-steroids, sex hormones, 8. pregnancy, 9. premenstrual syndrome, 10. disturbance of urodynamics, 11. exacerbation of any chronic diseases, 12 withdrawal of cardiotonics, beta-blockers.

Clinic: paroxysm of cardiac asthma occurs more often at night or during the day in a lying position. Inspiratory shortness of breath appears (respiratory rate up to 30-40 per minute), turning into suffocation, which forces the patient to sit down or stand up. The face is pale, and then cyanotic, covered with sweat, distorted with fear. The attack is accompanied by a cough with copious liquid sputum. Speech is difficult due to cough. Hand tremors and hyperhidrosis are observed. On auscultation, there are moist rales over the entire surface of the lungs. The appearance of bubbling breathing and coughing with pink foamy sputum indicates the onset of pulmonary edema.

Complications: 1. cardiogenic shock, 2. asphyxia.

Differential diagnosis carried out with an attack of bronchial asthma and other variants of broncho-obstructive syndrome.

ALGORITHM FOR PROVIDING EMERGENCY CARE

Pulmonary edema, emergency care

Pulmonary edema- severe pathological condition caused by sweating of plasma, blood into the lung tissue. leads to respiratory failure.

It is observed in acute and chronic heart failure, pneumonia, coma, brain tumors, anaphylactic shock, Quincke's edema, poisoning, head and chest injuries, intracranial hemorrhages, plague and other infectious diseases.

Clinic

Shortness of breath, cough, bubbling breath, secretion of foamy sputum with blood, a feeling of compression and pain in the heart area, anxiety, agitation, pale skin, cold sticky sweat, cyanosis, auscultation - an abundance of moist rales in the lungs, dullness of percussion sound.

Urgent Care

1. Place the patient in a semi-sitting position.

2. Suction mucus from the upper respiratory tract.

3. Inhale vapors of 70% ethyl alcohol.

4. Apply a tourniquet to the lower extremities.

5. As prescribed by the doctor, administer: 1% Lasix solution - 4.0 intravenously or intramuscularly, if there is no effect, repeat after 20 minutes, increasing the dose, 2.4% aminophylline solution - 10 ml intravenous bolus, 0.05% strophanthin solution - 0 .5-1 ml of isotonic sodium chloride solution intravenously in a slow stream.

6. Prednisolone 60 mg intravenously.

7. 5% solution harp- 100 ml per 200 ml of isotonic solution slowly intravenously.

8. 0.25% droperidol solution - 2.0 in a 20% glucose solution intravenously.

9. 2.5% solution of aminazine mixture - 0.5 ml, 2.5% solution of pipolfen - 1.0 ml intravenous bolus in 20 ml of 40% glucose solution.

10. 5% solution of ascorbic acid - 4 ml, 1% solution of nicotinic acid - 1 ml.

11. 4% sodium bicarbonate solution - 2 mg/kg intravenous bolus.

12. 7.5% potassium chloride solution - 15-20 ml intravenously.

Pulmonary edema

Pulmonary edema is excessive accumulation of fluid in the extravascular space of the lungs, accompanied by impaired gas exchange and acute respiratory failure.

Classification

Modern classification of pulmonary edema is based on differences in its pathogenesis. There are two main types:

cardiogenic or hydrostatic
non-cardiogenic, or edema due to increased permeability of the alveolar membrane
mixed forms of edema (usually neurogenic)
pulmonary edema due to other, rarer causes

Causes

Increased pulmonary capillary transmural pressure.

Left ventricular failure, acute or chronic.
Myocardial infarction or ischemia.
Severe hypertension.
Aortic stenosis or insufficiency.
Hypertrophic cardiomyopathy.
Myocarditis.
Mitral valve stenosis or severe mitral regurgitation.
Excessive infusion therapy.

Increased permeability of the pulmonary capillary endothelium.

Infection (bacteremia, sepsis).
Inflammation.
Disseminated intravascular coagulation.
Allergic reaction.
Iatrogenic damage (opiates, salicylates, chemotherapy, X-ray contrast agents).
ARDS.

Increased permeability of the alveolar epithelium.

Inhalation of toxic substances.
Allergic reaction.
Aspiration, drowning.
Surfactant deficiency.

Decrease in plasma oncotic pressure.

Hypoalbuminemia.
Nephrotic syndrome.
Liver failure.

Impaired plasma outflow.

Lymphangitis.
After lung transplantation.

Mixed mechanism.

Neurogenic pulmonary edema.
Altitude sickness.
Postoperative pulmonary edema.

Knowing the cause of pulmonary edema is important when choosing priority treatment options. Issues regarding the clinical physiology, diagnosis, and treatment of noncardiogenic pulmonary edema are similar to ARDS.

Clinical physiology of pulmonary edema

According to Starling's law, the movement of fluid from capillaries to the interstitium and back depends on the difference between hydrostatic and oncotic pressures on both sides of the vascular wall, as well as on the permeability of the wall itself.

Initially, when VOVL increases due to the interstitium of the lungs, hypoxia occurs without hypercapnia, which is easily eliminated by oxygen inhalation, since it is associated only with thickening of the alveolo-capillary membrane and impaired diffusion of gases through it. If, despite the inhalation of oxygen, hypoxemia persists, this means that this is due to the onset of alveolar shunting of the blood.

Due to swelling of the mucous membrane, the lumen of the respiratory tract narrows, and the bronchioles lose their elasticity, and an alveolar shunt develops, increasing respiratory failure.

In addition, increased muscle effort is required to open blood-filled, swollen lungs. At the same time, the work of the respiratory muscles increases and the oxygen price of breathing increases. Hypoxia intensifies, so the permeability of the alveolo-calillary membrane increases even more, and fluid transudation may occur, i.e. pulmonary edema. Catecholaminemia associated with hypoxemia blocks lymph flow - lung stiffness increases even more.

In all patients with decompensated left ventricular failure, functional studies reveal signs of obstructive and restrictive disorders:

static volumes of the lungs, including their total capacity, are reduced;
the volume of forced expiration is usually no more than half the required value;
the indicators of the “flow - maximum expiratory volume” curve are sharply reduced.

As pulmonary edema develops, plasma transudation occurs, and then the main mechanism of respiratory failure is the blocking of the airways with foam, which is formed when plasma foams in the atveoli. The same pricing serves as the main physiological mechanism of respiratory failure in ordinary (non-cardiogenic) pulmonary edema, although intensive care for these respiratory forms differs significantly.

Emergency diagnosis

Pulmonary edema can be caused by various causes, but differentiating them is difficult due to similar symptoms.

Symptoms of pulmonary edema are not specific. Most often, severe shortness of breath is noted as a manifestation of interstitial edema, tachypnea, cyanosis, participation of auxiliary muscles in inhalation, i.e. clinical signs of respiratory failure. At the first stage of pulmonary edema, auscultation reveals dry rales of narrowing of the airways against the background of peribronchial edema. As the edema develops, moist rales appear, more pronounced in the basal regions.

Chest X-ray should be performed for everyone with pulmonary edema; it allows us to identify the phases of interstitial and alveolar edema, and changes in the size of the heart.

The diagnostic accuracy of chest radiography for pulmonary edema is limited for a number of reasons. First, the swelling may not be visible until the amount of fluid in the lungs increases by 30%. Secondly, many of the X-ray signs are not specific and may be characteristic of other pulmonary pathologies. Finally, technical difficulties cannot be ignored, including respiratory movements, patient positioning, and positive pressure ventilation.

Echocardiography evaluates myocardial function and the condition of the valves, helping to determine the cause of pulmonary edema. Doppler echocardiography allows you to assess diastolic pressure and identify diastolic dysfunction.

Diagnostic algorithm for pulmonary edema

We present a diagnostic algorithm for managing a patient with pulmonary edema in emergency pulmonology.

Stage I - History, objective examination, laboratory examination

Stage II - Chest X-ray

If the diagnosis is unclear

Stage III - Transthoracic or transesophageal echocardiography

Emergency treatment

Elimination of factors that cause pulmonary edema is an obligatory component of treatment tactics.

Eliminating feelings of fear and catecholaminemia with the help of antipsychotic drugs is an important universal intensive care measure for pulmonary edema.

Intensive care measures can be divided into the following groups:

defoaming;
elimination of plethora;
increased cardiac output;
stimulation of diuresis;
respiratory therapy.

Since pulmonary edema is a critical condition requiring urgent life support measures, the listed measures sometimes have to be performed against the background of mechanical ventilation and oxygen therapy.

Defoaming

If foaming in the lungs and respiratory tract is severe, defoaming is considered the most urgent measure. The most studied means for this purpose is inhalation of ethyl alcohol vapor.

Since ethyl alcohol can cause bronchiolospasm, oxygen is first given, which “bubbles” through 96% ethyl alcohol and is added through a catheter to the mixture inhaled by the patient. If no negative reaction occurs, you can try aerosol inhalation of 30-60% alcohol for 2-3 minutes, monitoring effectiveness after each session.

Defoaming can also be achieved by intravenous administration of 30-40% ethyl alcohol (15-30 ml). Alcohol is released into the alveoli and extinguishes the foam.

Eliminate pulmonary congestion and increase cardiac output

To do this, it is necessary to increase the output of the left ventricle: normalize the levels of plasma and cellular potassium, eliminate metabolic acidosis and, against this background, use cardiac glycosides.

Morphine is used, which reduces peripheral resistance. At the same time, the configuration of the left ventricle changes, which makes its contractions more effective, and the blood volume is redistributed from the pulmonary circulation to the large one. However, this effect of morphine occurs at significant doses, which depresses breathing.

In intensive care, the initial blood pressure level is of particular importance. The choice of inotropic support in patients with pulmonary edema directly depends on the level of blood pressure.

Blood pressure level serves as both an indicator of the effectiveness of treatment and a prognostic sign. When it is elevated, the effectiveness of treatment is high, and a positive result occurs quite quickly with infusion of sodium nitroprusside and other vasodilators. Baseline low blood pressure is an unfavorable prognostic sign, since the use of dopamine in these patients to maintain sufficient tissue perfusion may worsen left ventricular failure.

Stimulation of diuresis

Furosemide is used, which helps to reduce VOLV, which consolidates the beneficial effect of previous measures.

The lungs become less rigid, their opening requires less effort from the respiratory muscles, oxygen homeostasis improves, which means the permeability of the alveolo-capillary membrane and interstitial pulmonary edema decreases.

Respiratory therapy

The primary measure is oxygen inhalation in combination with spontaneous ventilation in PEEP mode. These modes increase intrapulmonary pressure, reduce pulmonary congestion and improve their compliance. The area of gas exchange increases, the evacuation of sputum is facilitated, i.e. the main mechanisms of respiratory failure are eliminated.

If the PEEP mode is ineffective during spontaneous ventilation for 30-60 minutes, mechanical ventilation should be performed. The PEEP level when performing mechanical ventilation for pulmonary edema should be at least 8 cm of water column.

Emergency care - algorithm

When foaming occurs in the lungs, inhalation of ethyl alcohol vapor is indicated, and if bronchiolospasm does not occur, short-term (2-3 minutes) inhalation of an aerosol of 30-60% ethyl alcohol is performed.

To reduce the congestion of the lungs, cardiac glycosides are indicated after normalization of the acid-base and electrolyte state, and dobutamine.

To reduce peripheral vascular resistance - morphine, nitrates under blood pressure control.

PEEP mode during spontaneous breathing - early non-invasive respiratory support.

If its effectiveness is insufficient, mechanical ventilation through an endotracheal tube in a moderate PEEP mode.