Pulmonary Edema

Critical Care Nursing (Theory)

7th LECTURE

2nd semester – 2018/2019

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 Pulmonary Edema

• Pulmonary edema is
defined as abnormal
accumulation of
fluid in the lung
tissue, the alveolar
space, or both. It is a
severe, life-
threatening
condition.

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 Pathophysiology
• Pulmonary edema most commonly occurs as a result of increased microvascular
pressure from abnormal cardiac function.
• The backup of blood into the pulmonary vasculature resulting from inadequate left
ventricular function causes an increased microvascular pressure, and fluid begins to
leak into the interstitial space and the alveoli. Other causes of pulmonary edema are
hypervolemia or a sudden increase in the intravascular pressure in the lung. One
example, which may occur in the patient who has undergone pneumonectomy, is
sometimes termed “flash” pulmonary edema.
• When one lung has been removed, all the cardiac output goes to the remaining lung.
If the patient’s fluid status is not monitored closely, pulmonary edema can quickly
develop in the postoperative period as the patient’s pulmonary vasculature attempts
to adapt. A second example is called re-expansion pulmonary edema.
• This may result from a rapid reinflation of the lung after removal of air from a
pneumothorax or evacuation of fluid from a large pleural effusion.
3
 Clinical Manifestations
• Increasing respiratory distress, characterized by dyspnea, air
hunger, and central cyanosis, is present.
• Patients are usually very anxious and often agitated.
• As the fluid leaks into the alveoli and mixes with air, a foam
or froth is formed.
• The patient coughs up (or the nurse suctions out) these
foamy, frothy, and often blood-tinged secretions. The patient
experiences acute respiratory distress and may become
confused
4
 Assessment and Diagnostic Findings
• Auscultation reveals crackles in the lung bases (especially in the posterior
bases) that rapidly progress toward the apices of the lungs.
• These crackles are caused by the movement of air through the alveolar fluid.
• The chest x-ray reveals increased interstitial markings.
• The patient may have tachycardia.
• Pulse oximetry values begin to fall, and arterial blood gas analysis
demonstrates worsening hypoxemia.

5
 Medical Management
• Management focuses on correcting the underlying disorder. If the pulmonary
edema is cardiac in origin, then improvement in left ventricular function is the
goal.
• Vasodilators, inotropic medications, afterload or preload agents, or
contractility medications may be administered.
• Additional cardiac measures (eg, intra-aortic balloon pump) may be indicated
if there is no response. If the problem is fluid overload, diuretics are
administered and fluids are restricted.
• Oxygen is administered to correct the hypoxemia; in some circumstances,
intubation and mechanical ventilation are necessary.
• The patient is extremely anxious, and morphine is prescribed to reduce
anxiety and control pain.
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Nursing Management

7
 Positioning the Patient to Promote Circulation

• Proper positioning can help reduce venous return to the heart.

• The patient is positioned upright, preferably with the legs dangling over the
side of the bed.
• This has the immediate effect of decreasing venous return, decreasing right
ventricular stroke volume, and decreasing lung congestion.

8
 Providing Psychological Support
• As the ability to breathe decreases, the patient’s fear and anxiety rise
proportionately, making the condition more severe.
• Reassuring the patient and providing skillful anticipatory nursing care are
integral parts of the therapy.
• Because the patient has an unstable condition, the nurse must remain with
the patient.
• The nurse gives the patient simple, concise information in a reassuring voice
about what is being done to treat the condition and the expected results.

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 Monitoring Medications
• The patient receiving morphine is observed for respiratory depression,
hypotension, and vomiting; a morphine antagonist, such as naloxone
hydrochloride (Narcan), is kept available and given to the patient who
exhibits serious respiratory depression.
• The patient receiving diuretic therapy may excrete a large volume of urine
within minutes after a potent diuretic is administered.
• A bedside commode may be used to decrease the energy required by the
patient and to reduce the resultant increase in cardiac workload induced by
getting on and off a bedpan. If necessary, an indwelling urinary catheter may
be inserted.
• The patient receiving continuous IV infusions of vasoactive medications
requires ECG monitoring and frequent measurement of vital signs.
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