Edema pulmonar agudo

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

clinical practice

Acute Pulmonary Edema
Lorraine B. Ware, M.D., and Michael A. Matthay, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.

A 62-year-old man presents with a three-day history of progressive dyspnea, nonproductive cough, and low-grade fever. He had been hospitalized two years earlier for congestive heart failure. His blood pressure is 95/55 mm Hg, his heart rate 110 beats per minute, his temperature 37.9°C, and his oxygen saturation while breathing ambient air 86 percent. Chest auscultation reveals rales and rhonchi bilaterally. A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette. How should this patient be evaluated to establish the cause of the acute pulmonary edema and to determine appropriate therapy?

the clinical problem
From the Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville (L.B.W.); and the Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco (M.A.M.). Address reprint requests to Dr. Ware at the Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, 1161 21st Ave. S., T1218 MCN, Nashville, TN 37232-2650. N Engl J Med 2005;353:2788-96.
Copyright © 2005 Massachusetts Medical Society.

The following two fundamentally different types of pulmonary edema occur in humans: cardiogenic pulmonary edema (also termed hydrostatic or hemodynamic edema) and noncardiogenic pulmonary edema (also known as increased-permeability pulmonary edema, acute lung