Pulmonary Oedema Nursing Care of the Critically Ill Patient

Pulmonary Oedema refers to an accumulation of fluid in the interstitial spaces of the lungs that diffuses into the alveoli. This accumulation causes severe hypoxia. Thus, in pulmonary oedema nursing care, the patient’s oxygenation needs are prioritised.

Pulmonary Circulation VS Systemic Circulation

Pulmonary Oedema Pathophysiology

  1. excess vascular water fills the interstitium
  2. interstitial lymphatics situated within the pulmonary system are unable to drain excess water
  3. alveolar spaces flood and become unable to perform gas exchange due to ventilation/perfusion (V/Q) mismatch

RIGHT SIDE Heart Failure = Peripheral Oedema

LEFT SIDE Heart Failure = Pulmonary Oedema

Retrieved from https://www.otsuka.co.jp/en/health-and-illness/heart-failure/symptoms/ on 19th December 2022

Cardiogenic Pulmonary Oedema VS Non-Cardiogenic Pulmonary Oedema

Pulmonary oedema can be Cardiogenic Pulmonary Oedema a.k.a. Hydrostatic (pressure-related), Non-Cardiogenic Pulmonary Oedema (increased permeability), or a combination of both.

Cardiogenic Pulmonary Oedema a.k.a. Hydrostatic Oedema happens due to increased left ventricular filling pressure.

Non-Cardiogenic Pulmonary Oedema happens in the absence of elevated left ventricular pressure.

Pulmonary Oedema Signs & Symptoms + Radiographic Features

Pulmonary Oedema signs and symptoms onset is usually sudden, requiring immediate medical attention, usually due to intense dyspnoea resulting from the sudden V/Q Mismatch (happens when part of the lung receives oxygen without blood flow or blood flow without oxygen – respiratory reserve can help continue/preserve perfusion in V/Q mismatch, but only for a limited time), which leads to the patient becoming anxious and scared. Noisy respirations are also present due to secretions within the larynx and trachea. The patient’s skin becomes moist, cold and clammy – signs of shock.

Cyanosis develops rapidly in the late stage of respiratory failure. The patient develops a cough with copious frothy blood-stained sputum. Crepitations are heard throughout the chest on auscultation. A chest x-ray typically features a bat-like picture of the lungs. Note that a chest x-ray featuring pneumonia is very similar to one featuring pulmonary oedema, thus, in critical care it is important to distinguish between the two.

Full list of signs & symptoms of pulmonary oedema includes:

  • restlessness
  • anxiety
  • breathlessness
  • sense of suffocation
  • cyanotic nail beds
  • greyish skin tone
  • cold and moist hands
  • weak and rapid pulse
  • jugular vein distension
  • coughing
  • increasing foamy sputum
  • confusion and stuporous (as pulmonary oedema progresses)
  • rapid noisy moist-sounding breathing
  • significant decrease in oxygen saturation level
  • assessment includes crackles on auscultation
Retrieved from https://twitter.com/onsquares/status/1346344297214447616 on 18th December 2022

Cardiogenic Pulmonary Oedema Causes

  • Congestive Heart Failure (CHF) – the heart muscle doesn’t pump enough blood as it should, causing blood to back up, leading to fluid build-up in the lungs
  • Mitral Stenosis – narrowing of the valve between the two left heart chambers which reduces or blocks the blood flow into the heart’s left ventricle, leading to left-sided heart failure
  • Cor Pulmonale – a condition that causes the right side of the heart to fail
  • Myocardial Infarction a.k.a. heart attack – when blood flow to the heart muscle is blocked

Non-Cardiogenic Pulmonary Oedema Causes

  • Acute Respiratory Distress Syndrome – ARDS occurs when fluid builds up in the alveoli, keeping the lungs from filling with enough air; less oxygen reaches the bloodstream, depriving the organs of much needed oxygen to function adequately
  • Smoke Inhalation Burns

Pulmonary Oedema Nursing Care

  • record and monitor vital signs
  • administer high oxygen concentration to relieve cyanosis
  • position patient in an upright position or with legs and feet down or ideally dangling over the side of bed to promote better circulation – correct positioning increases the vital capacity of the patient’s lungs
  • reassure patient to reduce anxiety – do not leave patient alone
  • morphine can be administered to help further with the reduction of anxiety, as well as dilating peripheral circulation leading to a reduction in left ventricular pressure during diastole; IMPORTANT – morphine can depress the respiratory system, so never leave patient unattended
  • administer diuretics – monitor for medication effects including patient’s fluid and electrolyte levels; diuretics, especially if loop diuretics are administered, waste potassium and sodium; potassium administration may be required
  • bronchodilators can be used to relieve bronchospasm and facilitate bronchial toilet a.k.a. toilet bronchoscopy – a potentially therapeutic intervention to aspirate retained secretions within the endotracheal tube and airways and revert atelectasis; aspiration of airway secretions is the most common indication to perform a therapeutic bronchoscopy in the intensive care unit (ICU)
  • patients with pulmonary oedema are at times electively ventilated so that through PEEP,t further water leakage into the alveoli may be prevented
  • identify and treat primary cause eg. need for mitral valve prosthesis, opening blocked arteries etc.

NOTE: intubation and mechanical ventilation may be required if the patient’s condition worsens; haemodynamic monitoring (BP and PAWP) and ABGs act as guidance in artificial ventilation management.

NOTE: PAWP refers to Pulmonary Artery Wedge Pressure which is the pressure within the pulmonary arterial system that occurs when catheter tip ‘wedges’ in the tapering branch of one of the pulmonary arteries.


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Respiratory Conditions

In this blogpost we will be going through some respiratory conditions, namely Pulmonary Embolism (PE), Pneumothorax, Empyema, Pleurisy, Pulmonary Oedema and Pleural Effusion.

Pulmonary Embolism (PE)

Pulmonary Embolism (PE), which is a life threatening emergency, is the result of an obstruction of the pulmonary artery or one of its branches caused by a thrombus, which starts anywhere within the venous system or in the right side of the heart. This obstruction compromises gas exchange in the affected part of the lung.

Pulmonary Embolism clinical manifestations include:

  • dyspnoea
  • tachypnoea
  • chest pain
  • anxiety
  • fever
  • tachycardia
  • apprehension (feeling something wrong is about to happen)
  • cough
  • diaphoresis (excessive sweating)
  • haemoptysis (coughing up blood)
  • shock

Pulmonary Embolism assessment may include:

  • chest x-ray
  • ECG
  • ABGs
  • pulmonary angiogram (CT PA)

Pulmonary Embolism prevention:

  • ambulate
  • encourage leg exercises if patient is on bed rest
  • advise against prolonged sitting, immobility and constrictive clothing
  • advise against leg dangling and/or leg crossing
  • do not leave IV catheters in situ for long periods
  • use compression stockings
  • administer anti-coagulation therapy

Pulmonary Embolism Management:

  • oxygen therapy – relieves hypoxaemia, respiratory distress & central cyanosis; assess for signs of hypoxaemia and monitor pulse oximetry; teach deep breathing exercises; if necessary administer nebuliser therapy or percussion and postural drainage to help with secretions
  • anti-coagulation therapy
  • place patient in semi fowler’s position and administer analgesics if patient experiences severe chest pain

Pulmonary Embolism complications:

  • cardiogenic shock (heart becomes unable to pump enough blood to meet the body’s needs)
  • right sided heart failure (right side of the heart is not pumping enough blood to the lungs a.k.a. cor pulmonale or pulmonary heart disease)

Pneumothorax

Pneumothorax happens when the parietal or visceral pleura is breached, causing air to enter the pleural cavity, leading to partial or full lung collapse. Similarly, haemothorax results from a collection of blood within the pleural cavity due to torn intercostal vessels or laceration of the lungs through trauma.

  • Simple Pneumothorax (does not shift the mediastinal structures)
  • Traumatic Pneumothorax (caused by an injury that tears the lung and allows air to enter the pleural space)
  • Tension Pneumothorax (life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function)

Pneumothorax clinical manifestations include:

  • sudden onset of pleuritic pain
  • minimal respiratory distress (in small pneumothorax) or acute respiratory distress (in large pneumothorax)
  • anxiety
  • hypotension
  • tachycardia
  • profuse diaphoresis (excessive sweating)
  • dyspnoea & air hunger
  • use of accessory muscles during breathing
  • central cyanosis (in severe hypoxaemia)
  • diminished or absent breathing sounds
  • normal or hyperresonant percussion on pneumothorax side (depending on its size)
  • decreased chest expansion
  • shifting of the trachea to one side (depending on pneumothorax size)

Pneumothorax assessment is done through a chest x-ray.

Pneumothorax medical management:

  • thoracentesis with suction
  • antibiotics (due to contamination infection)
  • oxygen therapy
  • thoracotomy (a surgical procedure in which a cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax)

Pneumothorax nursing management includes:

  • assist chest tube insertion
  • assess chest drainage process and water seal
  • monitor respiratory status and lung re-expansion with the use of pulmonary support interventions
  • provide information and reassurance to the patient and family members

Empyema

Empyema refers to a collection of thick purulent (infected) fluid in the pleural space.

Empyema clinical manifestations:

  • fever
  • night sweats
  • pleural pain
  • cough
  • dyspnoea
  • anorexia
  • weight loss

Empyema assessment:

  • auscultation of the chest for decreased or absent breathing sounds in the affected area
  • dullness on chest percussion
  • CT scan
  • thoracentesis

Empyema medical management:

  • drain pleural cavity to promote complete lung re-expansion
  • administer antibiotics
  • needle thoracentesis (if fluid amount is small and not too thick)
  • tube thoracostomy
  • open chest drainage via thoracotomy to remove thickened pleura, pus and debris as well as diseased pulmonary tissue

Empyema nursing management should be done in the same way as in pneumonia.

Pleurisy

Pleurisy happens when there is inflammation of the visceral and parietal pleurae. When these two rub together, the individual experiences severe sharp knife-like pain during breathing, which increases on inspiration. Pleurisy may develop when the individual has pneumonia, plumonary embolism and other respiratory conditions.

Pleurisy clinical manifestations:

  • pain that worsens with deep breathing, coughing or sneezing, and which is usually focused on one side only
  • pain may be localised as well as radiating towards the shoulder or the abdomen
  • pain decreases when the individual holds breath
  • on auscultation, friction rub can be heard
  • pain diminishes once pleural fluid develops again

Pulmonary Oedema

Pulmonary Oedema refers to an accumulation of fluid in the interstitial spaces of the lungs that diffuses into the alveoli.

Pulmonary Oedema clinical manifestations:

  • restlessness
  • anxiety
  • breathlessness
  • sense of suffocation
  • cyanotic nail beds
  • greyish skin tone
  • cold and moist hands
  • weak and rapid pulse
  • jugular vein distension
  • coughing
  • increasing foamy sputum
  • confusion and stuporous (as pulmonary oedema progresses)
  • rapid noisy moist-sounding breathing
  • significant decrease in oxygen saturation level

Pulmonary Oedema assessment includes crackles on auscultation.

Pulmonary Oedema medical and nursing management:

  • oxygen therapy (patient may need to be intubated and provided with mechanical ventilation)
  • position patient in an upright position or with legs and feet down or ideally dangling over the side of bed to promote better circulation
  • reassure patient to reduce anxiety
  • administer diuretics (monitor for medication effects)

Pleural Effusion

Pleural Effusion is a collection of fluid within the pleural space, commonly seen in pneumonia, congestive heart failure and respiratory infections.

Pleural Effusion clinical manifestations:

  • dullness/flatness to percussion over affected area
  • minimal or absent breathing sounds
  • decreased fremitus (vibratory sensation felt on chest during speech)
  • tracheal deviation to the unaffected side
  • dyspnoea may not be present in small to moderate effusions
  • shortness of breath leading to acute respiratory distress (in large effusions)

Pleural Effusion assessment:

  • physical examination
  • chest x-ray
  • CT scan
  • thoracentesis with pleural fluid analysis (culture, chemistry and cytology)

Pleural Effusion medical and nursing management:

  • thoracentesis
  • chemical pleurodesis (a procedure to achieve symphysis between the two layers of pleura by sclerosing agents)
  • the nurse should monitor chest tube drainage and water seal system, as well as document the amount of drainage

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels RadiometerMedical, MotionLit, RegisteredNurseRN, SurgEdVidz, Dr Aishwarya Kelkar, Respiratory Therapy Zone, Larry Mellick and FSUMedMedia.

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