Neurogenic Pulmonary Edema

Neurogenic Pulmonary Edema

1. Neurogenic Pulmonary edema Ade Wijaya, MD – October 2018

2. Outline: Introduction Etiology Pathophysiology Clinical presentation Clinical course Differential diagnosis Treatment & prognosis Summary

3. Introduction Pulmonary compromise during an acute neurologic illness that can not be explained by cardiovascular or pulmonary factors C an be considered as a form of ARDS Prevalence: 2-8 % Busl KM, Bleck TP. Neurogenic pulmonary edema. Critical care medicine. 2015 Aug 1;43(8):1710-5.

4. Etiology Subarachnoid hemorrhage (SAH) Intracranial hemorrhage (ICH) Traumatic brain injury Stroke Acute hydrocephalus Seizures and status epilepticus Meningitis Subdural hemorrhage Cervical medulla injury Cerebral thrombosis Cerebral gas embolism Medication overdose Multiple sclerosis Arteriovenous malformation Busl KM, Bleck TP. Neurogenic pulmonary edema. Critical care medicine. 2015 Aug 1;43(8):1710-5.

5. Pathophysiology Central sympathetic discharge The hemodynamic theory is based on systemic and pulmonary vasoconstriction following the sudden increase in circulating catecholamines This vasoconstriction and hypertension may cause increased pulmonary blood volume through a shift of blood from the systemic to the pulmonary circulation Busl KM, Bleck TP. Neurogenic pulmonary edema. Critical care medicine. 2015 Aug 1;43(8):1710-5.

6. CLINICAL PRESENTATION S igns of oxygenation failure , such as dyspnea, tachypnea, tachycardia, cyanosis, pink frothy sputum, and crackles and rales on auscultation. Hypoxia is reflected by low PaO2 and a PaO2/FiO2 ratio below 200 Chest radiograph (CXR) usually shows features of pulmonary edema with bilateral diffuse alveolar infiltrates Weisman SJ: Edema and congestion of the lungs resulting from intracranial hemorrhage . Surgery 1939; 6:722–729

7. Clinical course Early: minutes to hours after CNS insult (in most cases: 30-60 minutes) Delayed: 12-24 hours after CNS insult Symptoms usually resolve within 48–72 hours after onset, but may subside as rapidly as they developed Weisman SJ: Edema and congestion of the lungs resulting from intracranial hemorrhage . Surgery 1939; 6:722–729 Davison DL, Chawla LS, Selassie L, et al: Neurogenic pulmonary edema: Successful treatment with IV phentolamine. Chest 2012 ; 141:793–795 Tan CK, Lai CC: Neurogenic pulmonary edema. CMAJ 2007;177:249–250

8. Differential diagnosis Cardiogenic pulmonary edema Aspiration pneumonia Transfusion-related lung injury Sepsis P ostairway obstruction edema, V entilator-associated pneumonia Ventilation-induced lung injury Baumann A, Audibert G, McDonnell J, et al: Neurogenic pulmonary edema . Acta Anaesthesiol Scand 2007; 51:447–455 Davison DL, Terek M, Chawla LS: Neurogenic pulmonary edema. Crit Care 2012; 16:212 Fontes RB, Aguiar PH, Zanetti MV, et al: Acute neurogenic pulmonary edema : Case reports and literature review. J Neurosurg Anesthesiol 2003 ; 15:144–150 Davidyuk G, Soriano SG, Goumnerova L, et al: Acute intraoperative neurogenic pulmonary edema during endoscopic ventriculoperitoneal shunt revision. Anesth Analg 2010; 110:594–595

9. Treatment & prognosis Treatment of the underlying neurologic condition focused on reduction of ICP in order to halt the sympathetic discharge that is presumed to be the culprit for the lung injury Supportive treatment for pulmonary edema. (volume management, ventilation strategies) Mortality: 50-100 % Busl KM, Bleck TP. Neurogenic pulmonary edema. Critical care medicine. 2015 Aug 1;43(8):1710-5.

10. Summary NPE occurs as a complication of acute neurologic illness and may mimic acute lung injury of other etiology Central sympathetic role Treatment strategies are mainly supportive and must target both the neurologic condition and NPE .

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