Neurogenic pulmonary edema: Difference between revisions
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*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 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> | ||
*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== | ||
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*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 epidemiologic and demographic features are based on underlying neurologic problem. Overall pulmonary edema commonly affects individuals older than 65 years of age. | ||
==Risk Factors== | ==Risk Factors== | ||
Revision as of 13:35, 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
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]
- Aspiration pneumonia
- Cardiogenic pulmonary edema (such as acute heart failure and pericardial tamponade)
- Angioedema
- Anaphylaxis
- Asthma attack
- Atelectasis
- Bronchitis
- COPD exacerbation
- Pneumonia
- 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]
- Cerebral hemorrhage
- Subarachnoid hemorrhage
- Head injuries
- Seizures
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 symptoms 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.