Neurogenic pulmonary edema: Difference between revisions
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{{CMG}}, {{AE}} {{SHH}} | {{CMG}}, {{AE}} {{SHH}} | ||
==Overview== | ==Overview== | ||
Neurogenic [[pulmonary edema]] usually appears within minutes to hours after a [[Brain|cerebral]] injury. It is an acute life-threatening [[Complication (medicine)|complication]] associated with many forms of [[central nervous system]] injury, such as [[brain]] or [[spinal cord]] [[Bleeding|hemorrhage]], [[Physical trauma|trauma]], [[Tumor|tumors]], [[epilepsy]] and [[Infection|infections]]. The pathogenetic factors for the its onset include increased [[intracranial pressure]] and severe over-activation of the [[sympathetic nervous system]]. Neurogenic [[pulmonary edema]] must be differentiated from other diseases with same symptoms, include [[aspiration pneumonia]], [[Pulmonary edema, cardiogenic|cardiogenic pulmonary edema]], [[angioedema]] and [[Asthma|asthma attack]]. NPE is characterized by [[dyspnea]], bilateral basal pulmonary [[Rales|crackles]] and the other signs and symptoms of [[pulmonary edema]], in the absence of cardiac failure. [[Arterial blood gas]] test shows [[hypoxemia]], [[hypercapnia]] and [[acidosis]]. In treatment of neurogenic [[pulmonary edema]], the main principle is supportive treatment and decreasing [[intracranial pressure]] as in [[acute respiratory distress syndrome]]. | |||
==Historical Perspective== | ==Historical Perspective== | ||
*In 1908, W. T. Shanahan noted acute pulmonary edema as an adverse effect of [[epileptic seizures]]. | *In 1908, W. T. Shanahan noted acute [[pulmonary edema]] as an adverse effect of [[epileptic seizures]]. | ||
*During WWI, francois Moutier noted the sudden onset of pulmonary edema among soldiers shot in the head.<ref name="pmid22429697">{{cite journal |vauthors=Davison DL, Terek M, Chawla LS |title=Neurogenic pulmonary edema |journal=Crit Care |volume=16 |issue=2 |pages=212 |date=December 2012 |pmid=22429697 |pmc=3681357 |doi=10.1186/cc11226 |url=}}</ref><ref name="pmid29123866">{{cite journal |vauthors=Izumida H, Homma K, Sasaki J, Hori S |title=Pulmonary edema following tonic-clonic seizure |journal=Acute Med Surg |volume=4 |issue=2 |pages=221–222 |date=April 2017 |pmid=29123866 |pmc=5667274 |doi=10.1002/ams2.251 |url=}}</ref> | *During WWI, francois Moutier noted the sudden onset of [[pulmonary edema]] among soldiers shot in the head.<ref name="pmid22429697">{{cite journal |vauthors=Davison DL, Terek M, Chawla LS |title=Neurogenic pulmonary edema |journal=Crit Care |volume=16 |issue=2 |pages=212 |date=December 2012 |pmid=22429697 |pmc=3681357 |doi=10.1186/cc11226 |url=}}</ref><ref name="pmid29123866">{{cite journal |vauthors=Izumida H, Homma K, Sasaki J, Hori S |title=Pulmonary edema following tonic-clonic seizure |journal=Acute Med Surg |volume=4 |issue=2 |pages=221–222 |date=April 2017 |pmid=29123866 |pmc=5667274 |doi=10.1002/ams2.251 |url=}}</ref> | ||
*In the Vietnam War, [[alveolar]] [[edema]] and [[hemorrhage]] seen in the lungs of soldiers dying after isolated bullet head wounds.<ref name="pmid5789529">{{cite journal |vauthors=Simmons RL, Heisterkamp CA, Collins JA, Genslar S, Martin AM |title=Respiratory insufficiency in combat casualties. 3. Arterial hypoxemia after wounding |journal=Ann. Surg. |volume=170 |issue=1 |pages=45–52 |date=July 1969 |pmid=5789529 |pmc=1387602 |doi= |url=}}</ref> | *In the Vietnam War, [[alveolar]] [[edema]] and [[hemorrhage]] seen in the [[Lung|lungs]] of soldiers dying after isolated bullet head wounds.<ref name="pmid5789529">{{cite journal |vauthors=Simmons RL, Heisterkamp CA, Collins JA, Genslar S, Martin AM |title=Respiratory insufficiency in combat casualties. 3. Arterial hypoxemia after wounding |journal=Ann. Surg. |volume=170 |issue=1 |pages=45–52 |date=July 1969 |pmid=5789529 |pmc=1387602 |doi= |url=}}</ref> | ||
==Pathophysiology== | ==Pathophysiology== | ||
*Pulmonary edema may develop in the setting of a sudden neurologic event. Neurogenic pulmonary edema usually appears within minutes to hours after cerebral injury.<ref name="pmid9149590">{{cite journal |vauthors=Smith WS, Matthay MA |title=Evidence for a hydrostatic mechanism in human neurogenic pulmonary edema |journal=Chest |volume=111 |issue=5 |pages=1326–33 |date=May 1997 |pmid=9149590 |doi= |url=}}</ref><ref name="pmid231156932">{{cite journal |vauthors=Kim JE, Park JH, Lee SH, Lee Y |title=Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report- |journal=Korean J Anesthesiol |volume=63 |issue=4 |pages=368–71 |date=October 2012 |pmid=23115693 |pmc=3483499 |doi=10.4097/kjae.2012.63.4.368 |url=}}</ref> | *[[Pulmonary edema]] may develop in the setting of a sudden [[Neurology|neurologic]] event. Neurogenic [[pulmonary edema]] usually appears within minutes to hours after [[Brain|cerebral]] injury.<ref name="pmid9149590">{{cite journal |vauthors=Smith WS, Matthay MA |title=Evidence for a hydrostatic mechanism in human neurogenic pulmonary edema |journal=Chest |volume=111 |issue=5 |pages=1326–33 |date=May 1997 |pmid=9149590 |doi= |url=}}</ref><ref name="pmid231156932">{{cite journal |vauthors=Kim JE, Park JH, Lee SH, Lee Y |title=Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report- |journal=Korean J Anesthesiol |volume=63 |issue=4 |pages=368–71 |date=October 2012 |pmid=23115693 |pmc=3483499 |doi=10.4097/kjae.2012.63.4.368 |url=}}</ref> | ||
*Neurogenic pulmonary edema is an acute life-threatening complication associated with many forms of central nervous system injury, such as:<ref name="pmid231156932">{{cite journal |vauthors=Kim JE, Park JH, Lee SH, Lee Y |title=Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report- |journal=Korean J Anesthesiol |volume=63 |issue=4 |pages=368–71 |date=October 2012 |pmid=23115693 |pmc=3483499 |doi=10.4097/kjae.2012.63.4.368 |url=}}</ref> | *Neurogenic [[pulmonary edema]] is an acute life-threatening [[Complication (medicine)|complication]] associated with many forms of [[central nervous system]] injury, such as:<ref name="pmid231156932">{{cite journal |vauthors=Kim JE, Park JH, Lee SH, Lee Y |title=Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report- |journal=Korean J Anesthesiol |volume=63 |issue=4 |pages=368–71 |date=October 2012 |pmid=23115693 |pmc=3483499 |doi=10.4097/kjae.2012.63.4.368 |url=}}</ref> | ||
**Brain or spinal cord hemorrhage | **[[Brain]] or [[spinal cord]] hemorrhage | ||
**Trauma | **[[Physical trauma|Trauma]] | ||
**Tumors | **[[Tumor|Tumors]] | ||
**Epilepsy | **[[Epilepsy]] | ||
**Infections | **[[Infection|Infections]] | ||
*The pathogenetic factors for the onset of neurogenic pulmonary edema include:<ref name="pmid23115693">{{cite journal |vauthors=Kim JE, Park JH, Lee SH, Lee Y |title=Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report- |journal=Korean J Anesthesiol |volume=63 |issue=4 |pages=368–71 |date=October 2012 |pmid=23115693 |pmc=3483499 |doi=10.4097/kjae.2012.63.4.368 |url=}}</ref> | *The pathogenetic factors for the onset of neurogenic [[pulmonary edema]] include:<ref name="pmid23115693">{{cite journal |vauthors=Kim JE, Park JH, Lee SH, Lee Y |title=Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report- |journal=Korean J Anesthesiol |volume=63 |issue=4 |pages=368–71 |date=October 2012 |pmid=23115693 |pmc=3483499 |doi=10.4097/kjae.2012.63.4.368 |url=}}</ref> | ||
**Increased intracranial pressure | **Increased [[intracranial pressure]] | ||
**Severe over-activation of the sympathetic nervous system | **Severe over-activation of the [[sympathetic nervous system]] | ||
*Neurogenic pulmonary edema may develop as a result of activation of specific CNS trigger zones in the brainstem, leading to a rapid sympathetic discharge, rise in systemic blood pressure, baroreflex-induced bradycardia, and enhanced venous return. These cause pulmonary vascular congestion characterized by interstitial edema, intra-alveolar accumulation of transudate and hemorrhages.<ref name="pmid25496372">{{cite journal |vauthors=Šedý J, Kuneš J, Zicha J |title=Pathogenetic Mechanisms of Neurogenic Pulmonary Edema |journal=J. Neurotrauma |volume=32 |issue=15 |pages=1135–45 |date=August 2015 |pmid=25496372 |doi=10.1089/neu.2014.3609 |url=}}</ref> | *Neurogenic [[pulmonary edema]] may develop as a result of activation of specific [[CNS]] trigger zones in the [[Brain stem|brainstem]], leading to a rapid [[Sympathetic control|sympathetic]] discharge, rise in systemic [[blood pressure]], [[baroreflex]]-induced [[bradycardia]], and enhanced [[venous return]]. These cause pulmonary vascular [[congestion]] characterized by [[interstitial edema]], intra-alveolar accumulation of [[transudate]] and [[Bleeding|hemorrhages]].<ref name="pmid25496372">{{cite journal |vauthors=Šedý J, Kuneš J, Zicha J |title=Pathogenetic Mechanisms of Neurogenic Pulmonary Edema |journal=J. Neurotrauma |volume=32 |issue=15 |pages=1135–45 |date=August 2015 |pmid=25496372 |doi=10.1089/neu.2014.3609 |url=}}</ref> | ||
*The initiating mechanism may be a marked, although brief, generalized vasoconstriction, followed by a shift of blood from the peripheral vascular bed to the pulmonary vascular bed.<ref name="pmid64378962">{{cite journal |vauthors=Piatti L, Locatelli V, Ferracini C, Sozzi G |title=[Neurogenic pulmonary edema. Description of a case occurring after an epileptic crisis] |language=Italian |journal=G Ital Cardiol |volume=14 |issue=8 |pages=602–5 |date=August 1984 |pmid=6437896 |doi= |url=}}</ref> | *The initiating mechanism may be a marked, although brief, generalized [[vasoconstriction]], followed by a shift of blood from the peripheral vascular bed to the pulmonary vascular bed.<ref name="pmid64378962">{{cite journal |vauthors=Piatti L, Locatelli V, Ferracini C, Sozzi G |title=[Neurogenic pulmonary edema. Description of a case occurring after an epileptic crisis] |language=Italian |journal=G Ital Cardiol |volume=14 |issue=8 |pages=602–5 |date=August 1984 |pmid=6437896 |doi= |url=}}</ref> | ||
==Differentiating neurogenic pulmonary edema from other Diseases== | ==Differentiating neurogenic pulmonary edema from other Diseases== | ||
*Neurogenic pulmonary edema must be differentiated from other diseases with same symptoms, include:<ref name="pmid1629591">{{cite journal |vauthors=Pender ES, Pollack CV |title=Neurogenic pulmonary edema: case reports and review |journal=J Emerg Med |volume=10 |issue=1 |pages=45–51 |date=1992 |pmid=1629591 |doi= |url=}}</ref> | *Neurogenic [[pulmonary edema]] must be differentiated from other diseases with same symptoms, include:<ref name="pmid1629591">{{cite journal |vauthors=Pender ES, Pollack CV |title=Neurogenic pulmonary edema: case reports and review |journal=J Emerg Med |volume=10 |issue=1 |pages=45–51 |date=1992 |pmid=1629591 |doi= |url=}}</ref> | ||
**Aspiration pneumonia | **[[Aspiration pneumonia]] | ||
**Cardiogenic pulmonary edema (such as acute heart failure and pericardial tamponade) | **[[Pulmonary edema, cardiogenic|Cardiogenic pulmonary edema]] (such as [[Heart failure resident survival guide|acute heart failure]] and [[Cardiac tamponade|pericardial tamponade]]) | ||
**Angioedema | **[[Angioedema]] | ||
**Anaphylaxis | **[[Anaphylaxis]] | ||
**Asthma attack | **[[Asthma|Asthma attack]] | ||
**Atelectasis | **[[Atelectasis]] | ||
**Bronchitis | **[[Bronchitis]] | ||
**COPD exacerbation | **[[Chronic obstructive pulmonary disease|COPD]] exacerbation | ||
**Pneumonia | **[[Pneumonia]] | ||
* For more information about differential diagnosis of pulmonary edema click '''''[[Pulmonary edema|here]]'''''. | * For more information about [[differential diagnosis]] of [[pulmonary edema]] click '''''[[Pulmonary edema|here]]'''''. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
*The incidence of neurogenic pulmonary edema is approximately 2000 to 42900 per 100,000 individuals in patients with [[subarachnoid hemorrhage]].<ref name="pmid126580012">{{cite journal |vauthors=Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ |title=Acute neurogenic pulmonary edema: case reports and literature review |journal=J Neurosurg Anesthesiol |volume=15 |issue=2 |pages=144–50 |date=April 2003 |pmid=12658001 |doi= |url=}}</ref><ref name="pmid7774210">{{cite journal |vauthors=Solenski NJ, Haley EC, Kassell NF, Kongable G, Germanson T, Truskowski L, Torner JC |title=Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study |journal=Crit. Care Med. |volume=23 |issue=6 |pages=1007–17 |date=June 1995 |pmid=7774210 |doi= |url=}}</ref> | *The [[incidence]] of neurogenic [[pulmonary edema]] is approximately 2000 to 42900 per 100,000 individuals in patients with [[subarachnoid hemorrhage]].<ref name="pmid126580012">{{cite journal |vauthors=Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ |title=Acute neurogenic pulmonary edema: case reports and literature review |journal=J Neurosurg Anesthesiol |volume=15 |issue=2 |pages=144–50 |date=April 2003 |pmid=12658001 |doi= |url=}}</ref><ref name="pmid7774210">{{cite journal |vauthors=Solenski NJ, Haley EC, Kassell NF, Kongable G, Germanson T, Truskowski L, Torner JC |title=Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study |journal=Crit. Care Med. |volume=23 |issue=6 |pages=1007–17 |date=June 1995 |pmid=7774210 |doi= |url=}}</ref> | ||
*The incidence of neurogenic pulmonary edema is approximately 20000 per 100,000 individuals in patients with traumatic brain injury.<ref name="pmid9092843">{{cite journal |vauthors=Bratton SL, Davis RL |title=Acute lung injury in isolated traumatic brain injury |journal=Neurosurgery |volume=40 |issue=4 |pages=707–12; discussion 712 |date=April 1997 |pmid=9092843 |doi= |url=}}</ref> | *The [[incidence]] of neurogenic [[pulmonary edema]] is approximately 20000 per 100,000 individuals in patients with [[traumatic brain injury]].<ref name="pmid9092843">{{cite journal |vauthors=Bratton SL, Davis RL |title=Acute lung injury in isolated traumatic brain injury |journal=Neurosurgery |volume=40 |issue=4 |pages=707–12; discussion 712 |date=April 1997 |pmid=9092843 |doi= |url=}}</ref> | ||
*Age, gender, race and other epidemiologic and demographic features are based on underlying neurologic problem. | *Age, gender, race and other [[Epidemiology|epidemiologic]] and [[Demographics|demographic]] features are based on underlying [[Neurology|neurologic]] problem. Overall [[pulmonary edema]] commonly affects individuals older than 65 years of age. | ||
==Risk Factors== | ==Risk Factors== | ||
*Severe brain damage represents a risk factor for developing | *Severe [[brain damage]] represents a risk factor for developing neurogenic [[pulmonary edema]], which include:<ref name="pmid23917719">{{cite journal |vauthors=Ridenti FA |title=Neurogenic pulmonary edema: a current literature review |journal=Rev Bras Ter Intensiva |volume=24 |issue=1 |pages=91–6 |date=March 2012 |pmid=23917719 |doi= |url=}}</ref> | ||
**Cerebral hemorrhage | **[[Cerebral hemorrhage]] | ||
**Subarachnoid hemorrhage | **[[Subarachnoid hemorrhage]] | ||
**Head injuries | **[[Head injury|Head injuries]] | ||
**Seizures | **[[Seizure|Seizures]] | ||
== Natural History, Complications and Prognosis== | == Natural History, Complications and Prognosis== | ||
*Misdiagnosis and inappropriate treatment may worsen cerebral damage because of hypoxemia or reduced cerebral perfusion pressure.<ref name="pmid23917719">{{cite journal |vauthors=Ridenti FA |title=Neurogenic pulmonary edema: a current literature review |journal=Rev Bras Ter Intensiva |volume=24 |issue=1 |pages=91–6 |date=March 2012 |pmid=23917719 |doi= |url=}}</ref> | *Misdiagnosis and inappropriate treatment may worsen [[Brain|cerebral]] damage because of [[hypoxemia]] or reduced [[cerebral perfusion pressure]].<ref name="pmid23917719">{{cite journal |vauthors=Ridenti FA |title=Neurogenic pulmonary edema: a current literature review |journal=Rev Bras Ter Intensiva |volume=24 |issue=1 |pages=91–6 |date=March 2012 |pmid=23917719 |doi= |url=}}</ref> | ||
*Common complications of neurogenic pulmonary edema are based on underlying neurological damage and pulmonary edema (include electrolyte disturbance, leg and/or abdominal swelling and respiratory arrest). | *Common [[Complication (medicine)|complications]] of neurogenic [[pulmonary edema]] are based on underlying [[Neurology|neurological]] damage and [[pulmonary edema]] (include [[electrolyte disturbance]], leg and/or [[Abdominal distension|abdominal swelling]] and [[respiratory arrest]]). | ||
*Prognosis is generally poor and the associated mortality rate is high, but surviving patients usually recover very quickly.<ref name="pmid17378783">{{cite journal |vauthors=Baumann A, Audibert G, McDonnell J, Mertes PM |title=Neurogenic pulmonary edema |journal=Acta Anaesthesiol Scand |volume=51 |issue=4 |pages=447–55 |date=April 2007 |pmid=17378783 |doi=10.1111/j.1399-6576.2007.01276.x |url=}}</ref><ref name="pmid12658001">{{cite journal |vauthors=Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ |title=Acute neurogenic pulmonary edema: case reports and literature review |journal=J Neurosurg Anesthesiol |volume=15 |issue=2 |pages=144–50 |date=April 2003 |pmid=12658001 |doi= |url=}}</ref> | *[[Prognosis]] is generally poor and the associated [[mortality rate]] is high, but surviving patients usually recover very quickly.<ref name="pmid17378783">{{cite journal |vauthors=Baumann A, Audibert G, McDonnell J, Mertes PM |title=Neurogenic pulmonary edema |journal=Acta Anaesthesiol Scand |volume=51 |issue=4 |pages=447–55 |date=April 2007 |pmid=17378783 |doi=10.1111/j.1399-6576.2007.01276.x |url=}}</ref><ref name="pmid12658001">{{cite journal |vauthors=Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ |title=Acute neurogenic pulmonary edema: case reports and literature review |journal=J Neurosurg Anesthesiol |volume=15 |issue=2 |pages=144–50 |date=April 2003 |pmid=12658001 |doi= |url=}}</ref> | ||
== Diagnosis == | == Diagnosis == | ||
===Symptoms=== | ===Symptoms=== | ||
*NPE is characterized by dyspnea, bilateral basal pulmonary crackles and the other signs and symptoms of pulmonary edema, in the absence of cardiac failure.<ref name="pmid25820093">{{cite journal |vauthors=Tu YF, Lin CH, Lee HT, Yan JJ, Sze CI, Chou YP, Ho CJ, Huang CC |title=Elevated cerebrospinal fluid endothelin 1 associated with neurogenic pulmonary edema in children with enterovirus 71 encephalitis |journal=Int. J. Infect. Dis. |volume=34 |issue= |pages=105–11 |date=May 2015 |pmid=25820093 |doi=10.1016/j.ijid.2015.03.017 |url=}}</ref> | *NPE is characterized by [[dyspnea]], bilateral basal pulmonary [[Rales|crackles]] and the other signs and symptoms of [[pulmonary edema]], in the absence of [[Congestive heart failure|cardiac failure]].<ref name="pmid25820093">{{cite journal |vauthors=Tu YF, Lin CH, Lee HT, Yan JJ, Sze CI, Chou YP, Ho CJ, Huang CC |title=Elevated cerebrospinal fluid endothelin 1 associated with neurogenic pulmonary edema in children with enterovirus 71 encephalitis |journal=Int. J. Infect. Dis. |volume=34 |issue= |pages=105–11 |date=May 2015 |pmid=25820093 |doi=10.1016/j.ijid.2015.03.017 |url=}}</ref> | ||
*For more information about symptoms in pulmonary edema click '''''[[Pulmonary edema|here]]'''''. | *For more information about [[Symptom|symptoms]] in [[pulmonary edema]] click '''''[[Pulmonary edema|here]]'''''. | ||
=== Physical Examination === | === Physical Examination === | ||
*Patients with neurogenic pulmonary edema usually appear: | *Patients with neurogenic [[pulmonary edema]] usually appear: | ||
** [[Anxious]] | ** [[Anxious]] | ||
** Decrease in level of [[consciousness]] | ** Decrease in level of [[consciousness]] | ||
*Physical examination is remarkable for the signs of underlying neurologic damage and pulmonary edema, include: | *[[Physical examination]] is remarkable for the [[Medical sign|signs]] of underlying [[Neurology|neurologic]] damage and [[pulmonary edema]], include: | ||
** [[Wheezing]] | ** [[Wheezing]] | ||
** Prolonged expiratory phase | ** Prolonged expiratory phase | ||
| Line 70: | Line 69: | ||
** Use of [[accessory muscles of respiration]] | ** Use of [[accessory muscles of respiration]] | ||
**Nasal flaring | **Nasal flaring | ||
**Tachypnea | **[[Tachypnea]] | ||
**Bradycardia | **[[Bradycardia]] | ||
**High systemic blood pressure | **High systemic [[blood pressure]] | ||
=== Laboratory Findings === | === Laboratory Findings === | ||
| Line 85: | Line 84: | ||
* [[Acidosis]]: | * [[Acidosis]]: | ||
** PH < 7.35 nEq/liter | ** PH < 7.35 nEq/liter | ||
** Early findings of pulmonary edema may be [[respiratory alkalosis]] because of [[hyperventilation]] | ** Early findings of [[pulmonary edema]] may be [[respiratory alkalosis]] because of [[hyperventilation]] | ||
===Imaging Findings=== | ===Imaging Findings=== | ||
*Imaging findings are remarkable for the pulmonary edema and underlying neurologic damage. | *[[Imaging]] findings are remarkable for the [[pulmonary edema]] and underlying [[Neurology|neurologic]] damage. | ||
*For more information about | *For more information about [[imaging]] findings in [[pulmonary edema]] click '''''[[Pulmonary edema|here]]'''''. | ||
== Treatment == | == Treatment == | ||
=== Medical Therapy === | === Medical Therapy === | ||
*In treatment of neurogenic pulmonary edema, the main principle is supportive treatment and decreasing intracranial pressure as in acute respiratory distress syndrome.<ref name="pmid26884694">{{cite journal |vauthors=Sarı MY, Yıldızdaş RD, Yükselmiş U, Horoz ÖÖ |title=Our patients followed up with a diagnosis of neurogenic pulmonary edema |journal=Turk Pediatri Ars |volume=50 |issue=4 |pages=241–4 |date=December 2015 |pmid=26884694 |pmc=4743867 |doi=10.5152/TurkPediatriArs.2015.1411 |url=}}</ref> | *In treatment of neurogenic [[pulmonary edema]], the main principle is supportive treatment and decreasing [[intracranial pressure]] as in [[acute respiratory distress syndrome]].<ref name="pmid26884694">{{cite journal |vauthors=Sarı MY, Yıldızdaş RD, Yükselmiş U, Horoz ÖÖ |title=Our patients followed up with a diagnosis of neurogenic pulmonary edema |journal=Turk Pediatri Ars |volume=50 |issue=4 |pages=241–4 |date=December 2015 |pmid=26884694 |pmc=4743867 |doi=10.5152/TurkPediatriArs.2015.1411 |url=}}</ref> | ||
*For more information about medical therapy in pulmonary edema click '''''[[Pulmonary edema|here]]'''''. | *For more information about medical therapy in [[pulmonary edema]] click '''''[[Pulmonary edema|here]]'''''. | ||
=== Surgery === | === Surgery === | ||
*The mainstay of treatment for pulmonary edema is medical therapy. Surgery may be reserved for underlying neurological damage. | *The mainstay of treatment for [[pulmonary edema]] is medical therapy. Surgery may be reserved for underlying [[Neurology|neurological]] damage. | ||
=== Prevention === | === Prevention === | ||
*Treating the | *Treating the underlying [[Neurology|neurologic]] disease is the only way of [[Prevention (medical)|preventing]] the recurrence of [[pulmonary edema]].<ref name="pmid6437896">{{cite journal |vauthors=Piatti L, Locatelli V, Ferracini C, Sozzi G |title=[Neurogenic pulmonary edema. Description of a case occurring after an epileptic crisis] |language=Italian |journal=G Ital Cardiol |volume=14 |issue=8 |pages=602–5 |date=August 1984 |pmid=6437896 |doi= |url=}}</ref> | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category: | [[Category:Medicine]] | ||
[[Category:Up-To-Date]] | |||
[[Category:Pulmonology]] | |||
{{WS}} | {{WS}} | ||
{{WH}} | {{WH}} | ||
Latest revision as of 18:28, 26 March 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]
Overview
Neurogenic pulmonary edema usually appears within minutes to hours after a cerebral injury. It is an acute life-threatening complication associated with many forms of central nervous system injury, such as brain or spinal cord hemorrhage, trauma, tumors, epilepsy and infections. The pathogenetic factors for the its onset include increased intracranial pressure and severe over-activation of the sympathetic nervous system. Neurogenic pulmonary edema must be differentiated from other diseases with same symptoms, include aspiration pneumonia, cardiogenic pulmonary edema, angioedema and asthma attack. NPE is characterized by dyspnea, bilateral basal pulmonary crackles and the other signs and symptoms of pulmonary edema, in the absence of cardiac failure. Arterial blood gas test shows hypoxemia, hypercapnia and acidosis. In treatment of neurogenic pulmonary edema, the main principle is supportive treatment and decreasing intracranial pressure as in acute respiratory distress syndrome.
Historical Perspective
- In 1908, W. T. Shanahan noted acute pulmonary edema as an adverse effect of epileptic seizures.
- During WWI, francois Moutier noted the sudden onset of pulmonary edema among soldiers shot in the head.[1][2]
- In the Vietnam War, alveolar edema and hemorrhage seen in the lungs of soldiers dying after isolated bullet head wounds.[3]
Pathophysiology
- Pulmonary edema may develop in the setting of a sudden neurologic event. Neurogenic pulmonary edema usually appears within minutes to hours after cerebral injury.[4][5]
- Neurogenic pulmonary edema is an acute life-threatening complication associated with many forms of central nervous system injury, such as:[5]
- Brain or spinal cord hemorrhage
- Trauma
- Tumors
- Epilepsy
- Infections
- The pathogenetic factors for the onset of neurogenic pulmonary edema include:[6]
- Increased intracranial pressure
- Severe over-activation of the sympathetic nervous system
- Neurogenic pulmonary edema may develop as a result of activation of specific CNS trigger zones in the brainstem, leading to a rapid sympathetic discharge, rise in systemic blood pressure, baroreflex-induced bradycardia, and enhanced venous return. These cause pulmonary vascular congestion characterized by interstitial edema, intra-alveolar accumulation of transudate and hemorrhages.[7]
- The initiating mechanism may be a marked, although brief, generalized vasoconstriction, followed by a shift of blood from the peripheral vascular bed to the pulmonary vascular bed.[8]
Differentiating neurogenic pulmonary edema from other Diseases
- Neurogenic pulmonary edema must be differentiated from other diseases with same symptoms, include:[9]
- For more information about differential diagnosis of pulmonary edema click here.
Epidemiology and Demographics
- The incidence of neurogenic pulmonary edema is approximately 2000 to 42900 per 100,000 individuals in patients with subarachnoid hemorrhage.[10][11]
- The incidence of neurogenic pulmonary edema is approximately 20000 per 100,000 individuals in patients with traumatic brain injury.[12]
- Age, gender, race and other epidemiologic and demographic features are based on underlying neurologic problem. Overall pulmonary edema commonly affects individuals older than 65 years of age.
Risk Factors
- Severe brain damage represents a risk factor for developing neurogenic pulmonary edema, which include:[13]
Natural History, Complications and Prognosis
- Misdiagnosis and inappropriate treatment may worsen cerebral damage because of hypoxemia or reduced cerebral perfusion pressure.[13]
- Common complications of neurogenic pulmonary edema are based on underlying neurological damage and pulmonary edema (include electrolyte disturbance, leg and/or abdominal swelling and respiratory arrest).
- Prognosis is generally poor and the associated mortality rate is high, but surviving patients usually recover very quickly.[14][15]
Diagnosis
Symptoms
- NPE is characterized by dyspnea, bilateral basal pulmonary crackles and the other signs and symptoms of pulmonary edema, in the absence of cardiac failure.[16]
- For more information about symptoms in pulmonary edema click here.
Physical Examination
- Patients with neurogenic pulmonary edema usually appear:
- Anxious
- Decrease in level of consciousness
- Physical examination is remarkable for the signs of underlying neurologic damage and pulmonary edema, include:
- Wheezing
- Prolonged expiratory phase
- Retraction of intercostal muscle
- Use of accessory muscles of respiration
- Nasal flaring
- Tachypnea
- Bradycardia
- High systemic blood pressure
Laboratory Findings
Arterial blood gas test:
- Hypoxia:
- Oxygen saturation < 90%
- PaO2 < 60 mm Hg
- Hypercapnia:
- CO2 > 45–55 mm Hg
- Acidosis:
- PH < 7.35 nEq/liter
- Early findings of pulmonary edema may be respiratory alkalosis because of hyperventilation
Imaging Findings
- Imaging findings are remarkable for the pulmonary edema and underlying neurologic damage.
- For more information about imaging findings in pulmonary edema click here.
Treatment
Medical Therapy
- In treatment of neurogenic pulmonary edema, the main principle is supportive treatment and decreasing intracranial pressure as in acute respiratory distress syndrome.[17]
- For more information about medical therapy in pulmonary edema click here.
Surgery
- The mainstay of treatment for pulmonary edema is medical therapy. Surgery may be reserved for underlying neurological damage.
Prevention
- Treating the underlying neurologic disease is the only way of preventing the recurrence of pulmonary edema.[18]
References
- ↑ Davison DL, Terek M, Chawla LS (December 2012). "Neurogenic pulmonary edema". Crit Care. 16 (2): 212. doi:10.1186/cc11226. PMC 3681357. PMID 22429697.
- ↑ Izumida H, Homma K, Sasaki J, Hori S (April 2017). "Pulmonary edema following tonic-clonic seizure". Acute Med Surg. 4 (2): 221–222. doi:10.1002/ams2.251. PMC 5667274. PMID 29123866.
- ↑ Simmons RL, Heisterkamp CA, Collins JA, Genslar S, Martin AM (July 1969). "Respiratory insufficiency in combat casualties. 3. Arterial hypoxemia after wounding". Ann. Surg. 170 (1): 45–52. PMC 1387602. PMID 5789529.
- ↑ Smith WS, Matthay MA (May 1997). "Evidence for a hydrostatic mechanism in human neurogenic pulmonary edema". Chest. 111 (5): 1326–33. PMID 9149590.
- ↑ 5.0 5.1 Kim JE, Park JH, Lee SH, Lee Y (October 2012). "Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report-". Korean J Anesthesiol. 63 (4): 368–71. doi:10.4097/kjae.2012.63.4.368. PMC 3483499. PMID 23115693.
- ↑ Kim JE, Park JH, Lee SH, Lee Y (October 2012). "Neurogenic pulmonary edema following intracranial coil embolization for subarachnoid hemorrhage -A case report-". Korean J Anesthesiol. 63 (4): 368–71. doi:10.4097/kjae.2012.63.4.368. PMC 3483499. PMID 23115693.
- ↑ Šedý J, Kuneš J, Zicha J (August 2015). "Pathogenetic Mechanisms of Neurogenic Pulmonary Edema". J. Neurotrauma. 32 (15): 1135–45. doi:10.1089/neu.2014.3609. PMID 25496372.
- ↑ Piatti L, Locatelli V, Ferracini C, Sozzi G (August 1984). "[Neurogenic pulmonary edema. Description of a case occurring after an epileptic crisis]". G Ital Cardiol (in Italian). 14 (8): 602–5. PMID 6437896.
- ↑ Pender ES, Pollack CV (1992). "Neurogenic pulmonary edema: case reports and review". J Emerg Med. 10 (1): 45–51. PMID 1629591.
- ↑ Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ (April 2003). "Acute neurogenic pulmonary edema: case reports and literature review". J Neurosurg Anesthesiol. 15 (2): 144–50. PMID 12658001.
- ↑ Solenski NJ, Haley EC, Kassell NF, Kongable G, Germanson T, Truskowski L, Torner JC (June 1995). "Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study". Crit. Care Med. 23 (6): 1007–17. PMID 7774210.
- ↑ Bratton SL, Davis RL (April 1997). "Acute lung injury in isolated traumatic brain injury". Neurosurgery. 40 (4): 707–12, discussion 712. PMID 9092843.
- ↑ 13.0 13.1 Ridenti FA (March 2012). "Neurogenic pulmonary edema: a current literature review". Rev Bras Ter Intensiva. 24 (1): 91–6. PMID 23917719.
- ↑ Baumann A, Audibert G, McDonnell J, Mertes PM (April 2007). "Neurogenic pulmonary edema". Acta Anaesthesiol Scand. 51 (4): 447–55. doi:10.1111/j.1399-6576.2007.01276.x. PMID 17378783.
- ↑ Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ (April 2003). "Acute neurogenic pulmonary edema: case reports and literature review". J Neurosurg Anesthesiol. 15 (2): 144–50. PMID 12658001.
- ↑ Tu YF, Lin CH, Lee HT, Yan JJ, Sze CI, Chou YP, Ho CJ, Huang CC (May 2015). "Elevated cerebrospinal fluid endothelin 1 associated with neurogenic pulmonary edema in children with enterovirus 71 encephalitis". Int. J. Infect. Dis. 34: 105–11. doi:10.1016/j.ijid.2015.03.017. PMID 25820093.
- ↑ Sarı MY, Yıldızdaş RD, Yükselmiş U, Horoz ÖÖ (December 2015). "Our patients followed up with a diagnosis of neurogenic pulmonary edema". Turk Pediatri Ars. 50 (4): 241–4. doi:10.5152/TurkPediatriArs.2015.1411. PMC 4743867. PMID 26884694.
- ↑ Piatti L, Locatelli V, Ferracini C, Sozzi G (August 1984). "[Neurogenic pulmonary edema. Description of a case occurring after an epileptic crisis]". G Ital Cardiol (in Italian). 14 (8): 602–5. PMID 6437896.