Flash pulmonary edema

Revascularization in a Time After CORAL

Revascularization of renal artery stenosis became less common following randomized controlled trials that failed to demonstrate benefit in low-risk patients. An 88-year-old patient with recurrent acute pulmonary edema and progressive kidney disease in the setting of high-grade renal artery stenosis, a phenotype excluded from these trials, underwent revascularization.

Clinical Review of Hypertensive Acute Heart Failure

Although acute heart failure (AHF) is a common disease associated with significant symptoms, morbidity and mortality, the diagnosis, risk stratification and treatment of patients with hypertensive acute heart failure (H-AHF) still remain a challenge in modern medicine. Despite great progress in diagnostic and therapeutic modalities, this disease is still accompanied by a high rate of both in-hospital (from 3.8% to 11%) and one-year (from 20% to 36%) mortality. Considering the high rate of rehospitalization (22% to 30% in the first three months), the treatment of this disease represents a major financial blow to the health system of each country. This disease is characterized by heterogeneity in precipitating factors, clinical presentation, therapeutic modalities and prognosis. Since heart decompensation usually occurs quickly (within a few hours) in patients with H-AHF, establishing a rapid diagnosis is of vital importance. In addition to establishing the diagnosis of heart failure itself, it is necessary to see the underlying cause that led to it, especially if it is de novo heart failure. Given that hypertension is a precipitating factor of AHF and in up to 11% of AHF patients, strict control of arterial blood pressure is necessary until target values are reached in order to prevent the occurrence of H-AHF, which is still accompanied by a high rate of both early and long-term mortality.

Pickering Syndrome: An Overlooked Renovascular Cause of Recurrent Heart Failure

ABSTRACTRecurring and rapidly developing (flash) pulmonary edema is the hallmark of Pickering syndrome, affecting patients with hypertension and atherosclerotic renal artery stenosis (either bilateral or unilateral) in a solitary functioning kidney, and impaired renal function. We herein report on a series of consecutive patients with recurrent hospital admissions for pulmonary edema, impaired renal function (chronic kidney disease class 4-5), and atherosclerotic bilateral renal artery stenosis, in whom Pickering syndrome had been long neglected. We also describe a streamlined diagnostic strategy entailing little or no need for contrast medium, thus carrying no risks of further worsening of renal function. This allowed us to make the correct diagnosis and opened the way to revascularization by percutaneous transluminal renal angioplasty with stent, which provided swift recovery of kidney function with resolution of pulmonary congestion and long-term pulmonary edema- and dialysis-free survival in all cases. In summary, these findings support the following key messages: (1) considering the diagnosis of Pickering syndrome, followed by searching atherosclerotic renal artery stenosis, is an essential step toward a life-saving revascularization that avoids dialysis and an otherwise poor outcome; and (2) a simplified strategy entailing little or no need for contrast medium, carrying no associated risks of deteriorating renal function, permits the diagnosis of Pickering syndrome.

Pickering syndrome in a patient with a single kidney: role of renal artery stenting

Renal artery stenosis (RAS) is associated with hypertension and high mortality rates. With its prevalence and associated risk of death, it is important to screen for patients displaying symptoms of RAS. RAS has a wide spectrum of clinical manifestations and is usually resistant to medical therapy. Of these clinical manifestations is Pickering syndrome which is characterized by bilateral renal arterial occlusion inflow lesions, flash pulmonary edema, acute kidney injury, and hypertensive emergencies in the setting of a preserved left ventricle function. Stenting techniques have been used extensively to treat symptomatic renal artery stenosis with excellent primary patency rate, however have failed to demonstrate a long-term benefit over the optimal medical management alone in randomized trials. However, accumulating evidence suggests that stenting is justified in specific patient subgroups that have severe occlusive renal artery stenoses with significant clinical sequelae, including flash pulmonary edema, acute ischemic kidney injury, and uncontrolled hypertension. In this report we discuss the case of a 32-year-old male who presented to our center with recurrent flash pulmonary edema and hypertensive emergency and was found to have RAS, which responded well to renal artery stenting. In conclusion, correcting the renal arterial inflow stenosis is beneficial and warranted in selective clinical scenarios.

Flash pulmonary oedema following arteriovenous fistula surgery: rapid assessment and treatment is key to break the vicious cycle

An early adolescent boy with chronic kidney disease on haemodialysis was referred to the surgical clinic for the creation of an arteriovenous fistula. He was undergoing treatment for dilated cardiomyopathy and extrapulmonary tuberculosis. The patient was haemodynamically stable during the procedure, but he developed rapidly progressing dyspnoea, tachycardia and tachypnoea about 10 min after the vessels were declamped. His blood pressure rapidly rose above 220/120 mm Hg and saturation dropped below 90%. A multidisciplinary team (MDT) constituted of surgeons, nephrologists and intensivists was quickly activated. The patient was put on a mechanical ventilator and resuscitated with parenteral antihypertensives, diuretics, amiodarone and haemodialysis. The patient improved clinically and was discharged on the third postoperative day. Thus, a rapidly activated MDT approach was key in breaking the vicious cycle caused by hypertensive crisis, myocardial dysfunction and impending ventilatory failurethat occurred following access surgery.

Flash pulmonary oedema associated with paroxysmal supraventricular tachycardia: report of two cases

Case summary

We describe two cats that had episodic tachypnoea and increased respiratory effort during periods of paroxysmal supraventricular tachycardia (SVT). Thoracic radiographs at the time of clinical signs were consistent with cardiogenic pulmonary oedema. Echocardiography following stabilisation revealed a hypertrophic cardiomyopathy phenotype with normal left atrial size in both cats. The first cat was initially treated with diltiazem, but this did not reduce the frequency of the clinical episodes. Diltiazem was switched to atenolol and the cat remained well without further recurrence. At the time of writing, the cat was reported to be well, 3 years after the initial diagnosis of SVT. The second cat was first managed with diltiazem and was then transitioned to atenolol due to recurrent clinical episodes. The episodes were less frequent with atenolol but still present. Therefore, atenolol was changed to sotalol. The cat remained well on sotalol for 2 years with only one recurrent episode during a painful event. The patient then suffered a sudden cardiac death, 5 years after the initial diagnosis of SVT.

Relevance and novel information

To our knowledge, this is the first report that describes flash pulmonary oedema developing secondary to episodic paroxysmal SVT in cats. Despite the severity and speed of respiratory compromise, prognosis may be good with an adequate arrhythmia control.

Acute Pulmonary Edema During a Cesarean Delivery After an Adverse Drug Event

Acute pulmonary edema (APEd) is rare in pregnancy and in the postpartum period. An intermediate type of APEd characterized as a transudate with a protein concentration between that of cardiogenic and noncardiogenic APEd has been described in the literature. This transudate might actually be the result of capillary pressure having increased to a point of high-permeability edema and/or alveolar hemorrhage. Clinically, the presentation would be a dramatic form of APEd - flash pulmonary edema - characterized by a rapid accumulation of fluid within the lung's interstitial and alveolar spaces as a result of suddenly elevated cardiac filling pressures. Here, we present a case of a healthy pregnant woman who underwent cesarean delivery and developed a constellation of signs and symptoms, suggestive of an APEd, after a supratherapeutic bolus of phenylephrine. During the diagnostic excursion, bilateral parenchymal infiltrations suggestive of hemorrhage were observed on a computed tomography scan. This case highlights the high morbidity associated with adverse drug events and the imperative to prevent them. It also underscores the critical need for careful management of volume shifts and hemodynamics in full-term pregnancies.

Flash Pulmonary Edema: A Rare Presentation of Graves’ Disease

Graves’ disease is the most common cause of hyperthyroidism. It has an autoimmune basis with the activating thyrotropin-receptor antibodies inducing thyroid hormone overproduction. The most common manifestations of hyperthyroidism are weight loss, fatigue, heat intolerance, tremor, and palpitations, but there are several other symptoms and signs associated with this condition. We report a case of a young woman who presented in the emergency room with acute onset of cough with mild hemoptysis and dyspnea at rest. She reported one month of insomnia, palpitations, and anxiety. The diagnostic investigation leads to the diagnosis of Graves’ disease in thyrotoxic crisis presenting with flash pulmonary edema. Therapy with propranolol and methimazole was instituted with remarkable clinical improvement.

Unilateral renal artery stenosis causing hypertensive flash pulmonary oedema

Flash pulmonary oedema can occur as a result of multiple triggers that may act independently or in concert. One such precipitating factor is bilateral renal artery stenosis which can be treated either with revascularisation or with medical therapy. Unilateral renal artery stenosis, however, is a rare cause of flash pulmonary oedema, especially when the contralateral kidney is still functional. We describe a case of an elderly woman with a history of heart failure with preserved ejection fraction and multiple hospitalisations for hypertensive crisis and flash pulmonary oedema who was found to have right, ostial renal artery stenosis that was treated with stent placement.

Pickering syndrome: a rare presentation in emergency department

Sympathetic crash acute pulmonary edema (SCAPE) is a life-threatening injury, which requires early recognition and intervention to prevent mortality. We present a case of 18-year-old woman with no previous comorbidity, presenting with SCAPE who was successfully resuscitated and eventually diagnosed with renal artery stenosis. Pickering syndrome is a rare cause of hypertensive emergency and should be considered in a young patient presenting with SCAPE in emergency department.

Cardiogenic pulmonary edema: mechanisms and treatment - an intensivist's view

PURPOSE OF REVIEW

This review summarizes current understanding of the pathophysiology of cardiogenic pulmonary edema, its causes and treatment.

RECENT FINDINGS

The pathobiology and classification of pulmonary edema is more complex than the hydrostatic vs. permeability dichotomy of the past. Mechanisms of alveolar fluid clearance and factors that affect the clearance rate are under intensive study to find therapeutic strategies. Patients need early stabilization of oxygenation and ventilation, preferably with high-flow nasal cannula oxygen or noninvasive ventilation whereas the diagnostic cause is quickly sought with echocardiography and other testing.

SUMMARY

Treatments must be initiated early, whereas evaluation still is occurring and requires multimodality intervention. The general treatment of cardiogenic pulmonary edema includes diuretics, possibly morphine and often nitrates. The appropriate use of newer approaches - such as, nesiritide, high-dose vasodilators, milrinone, and vasopressin receptor antagonists - needs larger clinical trials.

Imaging findings of pulmonary edema: Part 1. Cardiogenic pulmonary edema and acute respiratory distress syndrome

Pulmonary edema has many causes; differentiating between these conditions is important. The purpose of this review article is to describe the pathophysiology of pulmonary edema, thereby explaining the imaging findings that differentiate between etiologies. Chest computed tomography provides details on the physiological response and the changes in the anatomical structures of pulmonary edema. An understanding of the pathophysiology underlying the imaging findings facilitates the correct identification of the cause of pulmonary edema.

Saddle coronary embolism precipitates flash pulmonary edema

Coronary artery embolism is as an infrequent but important cause of acute myocardial infarction. We present a rare case of a large saddle embolism in the coronary vasculature which led to an acute myocardial infarction and consequently flash pulmonary edema. Despite intensive medical management, our patient did not survive.

Modeling of Transport Mechanisms in the Respiratory System: Validation via Congestive Heart Failure Patients

The heart and lungs are intricately related. For congestive heart failure patients, fluid (plasma) backs up into the pulmonary system. As a result, pulmonary capillary pressure increases, causing fluid to seep into the lungs (pulmonary edema) within minutes. This excess fluid induces extra stress during breathing that affects respiratory health. In this paper, we focus on the effect that high pulmonary capillary pressure has on the development of this extravascular lung water (EVLW). A mathematical model of pulmonary fluid and mass transport mechanisms is developed in order to quantitatively analyze the transport phenomena in the pulmonary system. The model is then validated on 15 male heart failure patients from published literature [1]. The model shows reasonable estimation of EVLW in heart failure patients, which is useful in assessing the severity of pulmonary edema.

Flash pulmonary edema: A rare cause and possible mechanisms

Flash pulmonary edema frequently develop in case of bilateral renal artery stenosis and unilateral renal artery stenosis with functional solitary kidney. In some rare cases, unilateral renal artery stenosis with bilaterally functional kidneys may also lead to flash pulmonary edema. Here, we present a case of flash pulmonary edema caused by accessory renal artery stenosis. To our knowledge, it is the first case reported in the literature.

Approach to atherosclerotic renovascular disease: 2016

The management of atherosclerotic renal artery stenosis in patients with hypertension or impaired renal function remains a clinical dilemma. The current general consensus, supported by the results of the Angioplasty and Stenting for Renal Atherosclerotic Lesions and Cardiovascular Outcomes for Renal Artery Lesions trials, argues strongly against endovascular intervention in favor of optimal medical management. We discuss the limitations and implications of the contemporary clinical trials and present our approach and formulate clear recommendations to help with the management of patients with atherosclerotic narrowing of the renal artery.

Renovascular heart failure: heart failure in patients with atherosclerotic renal artery disease

Atherosclerotic renal artery disease presents with a broad spectrum of clinical features, including heart failure as well as hypertension, and renal failure. Although recent randomized controlled trials failed to demonstrate renal artery stenting can reduce blood pressure or the number of cardiovascular or renal events more so than medical therapy, increasing attention has been paid to flash pulmonary edema and congestive heart failure associated with atherosclerotic renal artery disease. This clinical entity "renovascular heart failure" is diagnosed retrospectively. Given the increasing global burden of heart failure, this review highlights the background and catheter-based therapeutic aspects for renovascular heart failure.

Sympathetic crashing acute pulmonary edema

Sympathetic crashing acute pulmonary edema (SCAPE) is the extreme end of the spectrum of acute pulmonary edema. It is important to understand this disease as it is relatively common in the emergency department (ED) and has better outcomes when managed appropriately. The patients have an abrupt redistribution of fluid in the lungs, and when treated promptly and effectively, these patients will rapidly recover. Noninvasive ventilation and intravenous nitrates are the mainstay of treatment which should be started within minutes of the patient's arrival to the ED. Use of morphine and intravenous loop diuretics, although popular, has poor scientific evidence.

Diagnosing and managing acute heart failure in the emergency department

Heart failure is a clinical syndrome that results from the impairment of ventricular filling or ejection of blood and affects millions of people worldwide. Diagnosis may not be straightforward and at times may be difficult in an undifferentiated patient. However, rapid evaluation and diagnosis is important for the optimal management of acute heart failure. We review the many aspects of diagnosing and treating acute heart failure in the emergency department.

Resistant hypertension: what the cardiologist needs to know

Treatment-resistant hypertension (TRH) affects between 3 and 30% of hypertensive patients, and its presence is associated with increased cardiovascular morbidity and mortality. Until recently, the interest on these patients has been limited, because providing care for them is difficult and often frustrating. However, the arrival of new treatment options [i.e. catheter-based renal denervation (RDN) and baroreceptor stimulation] has revitalized the interest in this topic. The very promising results of the initial uncontrolled studies on the blood pressure (BP)-lowering effect of RDN in TRH seemed to suggest that this intervention might represent an easy solution for a complex problem. However, subsequently, data from controlled studies have tempered the enthusiasm of the medical community (and the industry). Conversely, these new studies emphasized some seminal aspects on this topic: (i) the key role of 24 h ambulatory BP and arterial stiffness measurement to identify 'true' resistant patients; (ii) the high prevalence of secondary hypertension among this population; and (iii) the difficulty to identify those patients who may profit from device-based interventions. Accordingly, for those patients with documented TRH, the guidelines suggest to refer them to a hypertension specialist/centre in order to perform adequate work-up and treatment strategies. The aim of this review is to provide guidance for the cardiologist on how to identify patients with TRH and elucidate the prevailing underlying pathophysiological mechanism(s), to define a strategy for the identification of patients with TRH who may benefit from device-based interventions and discuss results and limitations of these interventions, and finally to briefly summarize the different drug-based treatment strategies.

Therapeutic Effects of PPAR α on Neuronal Death and Microvascular Impairment

Peroxisome-proliferator activated receptor-alpha (PPARα) is a broadly expressed nuclear hormone receptor and is a transcription factor for diverse target genes possessing a PPAR response element (PPRE) in the promoter region. The PPRE is highly conserved, and PPARs thus regulate transcription of an extensive array of target genes involved in energy metabolism, vascular function, oxidative stress, inflammation, and many other biological processes. PPARα has potent protective effects against neuronal cell death and microvascular impairment, which have been attributed in part to its antioxidant and anti-inflammatory properties. Here we discuss PPARα's effects in neurodegenerative and microvascular diseases and also recent clinical findings that identified therapeutic effects of a PPARα agonist in diabetic microvascular complications.

Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy

Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplant. It occurs most frequently in the first 6 months after kidney transplant, and is one of the major causes of graft loss and premature death in transplant recipients. Renal hypoperfusion occurring in TRAS results in activation of the renin–angiotensin–aldosterone system; patients usually present with worsening or refractory hypertension, fluid retention and often allograft dysfunction. Flash pulmonary edema can develop in patients with critical bilateral renal artery stenosis or renal artery stenosis in a solitary kidney, and this unique clinical entity has been named Pickering Syndrome. Prompt diagnosis and treatment of TRAS can prevent allograft damage and systemic sequelae. Duplex sonography is the most commonly used screening tool, whereas angiography provides the definitive diagnosis. Percutaneous transluminal angioplasty with stent placement can be performed during angiography if a lesion is identified, and it is generally the first-line therapy for TRAS. However, there is no randomized controlled trial examining the efficacy and safety of percutaneous transluminal angioplasty compared with medical therapy alone or surgical intervention.

Pulmonary oedema in the emergency room: what is hidden beyond an apparently common presentation

Cardiogenic flash pulmonary oedema is a common and potentially fatal cause of acute respiratory distress. Although it often results from acute decompensated heart failure, abrupt-onset aortic regurgitation can sharply rise cardiac filling pressure and, consequently, pulmonary venous pressure, leading to rapid fluid accumulation in the interstitial and alveolar spaces. We report a case of a 64-year-old woman admitted to the emergency department with a flash pulmonary oedema; a careful clinical investigation subsequently revealed a rare aetiology for this 'common' presentation. After a detailed auscultation that unmasked a diastolic cardiac murmur, an acute severe aortic insufficiency was further confirmed by echocardiography, showing inflammation and thickening of the entire aorta wall. The patient was submitted to valve replacement surgery, and histological examination, to our surprise, showed features of aortitis, remarkable for the presence of giant cells. A diagnosis of idiopathic aortitis versus inaugural giant cell arteritis was proposed and treatment started with corticosteroids.

Ventricular diastolic abnormalities in the critically ill

PURPOSE OF REVIEW

Left-ventricular diastolic dysfunction is associated with various conditions frequently encountered in ICU patients. Due to prolonged relaxation and increased left-ventricular stiffness, patients with diastolic dysfunction are at high risk of developing abrupt pulmonary venous congestion. The present review describes the clinical spectrum of left-ventricular diastolic abnormalities in ICU patients.

RECENT FINDINGS

Left-ventricular diastolic dysfunction is associated with a preserved ejection fraction in half of the patients presenting with acute pulmonary edema. These patients may have dramatic presentation, such as flash pulmonary edema during a hypertensive crisis. Left-ventricular diastolic dysfunction is frequently involved in patients who fail extubation and may trigger weaning pulmonary edema. Sepsis and myocardial ischemia may also be associated with left-ventricular diastolic dysfunction. The diagnosis of left-ventricular diastolic dysfunction practically relies on two-dimensional and Doppler echocardiography. Further large-scale clinical studies are needed to better characterize the prevalence, the clinical relevance and time-course of left-ventricular diastolic dysfunction in ICU patients.

SUMMARY

Left-ventricular diastolic dysfunction accounts for a growing proportion of cardiogenic pulmonary edema and weaning failure in ICU patients. It may be reversible when induced by sepsis or myocardial ischemia. Its prognostic value in the ICU settings remains to be further investigated.

Secondary arterial hypertension: when, who, and how to screen?

Secondary hypertension refers to arterial hypertension due to an identifiable cause and affects ∼5-10% of the general hypertensive population. Because secondary forms are rare and work up is time-consuming and expensive, only patients with clinical suspicion should be screened. In recent years, some new aspects gained importance regarding this screening. In particular, increasing evidence suggests that 24 h ambulatory blood pressure (BP) monitoring plays a central role in the work up of patients with suspected secondary hypertension. Moreover, obstructive sleep apnoea has been identified as one of the most frequent causes. Finally, the introduction of catheter-based renal denervation for the treatment of patients with resistant hypertension has dramatically increased the interest and the number of patients evaluated for renal artery stenosis. We review the clinical clues of the most common causes of secondary hypertension. Specific recommendations are given as to evaluation and treatment of various forms of secondary hypertension. Despite appropriate therapy or even removal of the secondary cause, BP rarely ever returns to normal with long-term follow-up. Such residue hypertension indicates either that some patients with secondary hypertension also have concomitant essential hypertension or that irreversible vascular remodelling has taken place. Thus, in patients with potentially reversible causes of hypertension, early detection and treatment are important to minimize/prevent irreversible changes in the vasculature and target organs.

An unusual cause of flash pulmonary oedema

We report a case of young woman who presented with acute cardiogenic pulmonary oedema and respiratory failure. She underwent emergent endotracheal intubation and was transferred to the intensive care unit. She responded to intravenous diuretics and positive pressure ventilation. Subsequent workup revealed that she had Graves' disease and was in thyrotoxic crisis. Therapy with propranolol and propylthiouracil was instituted to which she showed remarkable improvement.

Histochemical analyses and quantum dot imaging of microvascular blood flow with pulmonary edema in living mouse lungs by "in vivo cryotechnique"

Light microscopic imaging of blood vessels and distribution of serum proteins is essential to analyze hemodynamics in living animal lungs under normal respiration or respiratory diseases. In this study, to demonstrate dynamically changing morphology and immunohistochemical images of their living states, "in vivo cryotechnique" (IVCT) combined with freeze-substitution fixation was applied to anesthetized mouse lungs. By hematoxylin-eosin staining, morphological features, such as shapes of alveolar septum and sizes of alveolar lumen, reflected their respiratory conditions in vivo, and alveolar capillaries were filled with variously shaped erythrocytes. Albumin was usually immunolocalized in the capillaries, which was confirmed by double-immunostaining for aquaporin-1 of endothelium. To capture accurate time-courses of blood flow in peripheral pulmonary alveoli, glutathione-coated quantum dots (QDs) were injected into right ventricles, and then IVCT was performed at different time-points after the QD injection. QDs were localized in most arterioles and some alveolar capillaries at 1 s, and later in venules at 2 s, reflecting a typical blood flow direction in vivo. Three-dimensional QD images of microvascular networks were reconstructed by confocal laser scanning microscopy. It was also applied to lungs of acute pulmonary hypertension mouse model. Erythrocytes were crammed in blood vessels, and some serum components leaked into alveolar lumens, as confirmed by mouse albumin immunostaining. Some separated collagen fibers and connecting elastic fibers were still detected in edematous tunica adventitia near terminal bronchioles. Thus, IVCT combined with histochemical approaches enabled us to capture native images of dynamically changing structures and microvascular hemodynamics of living mouse lungs.

Integration of baroreflex and autoregulation control of bronchial blood flow in awake dogs

AIM

Baroreflex control of the bronchial circulation is unresolved. Early studies suggested that baroreflexes dilate or have no effect, but recent studies in awake dogs suggested baroreflexes did not normally engage tonic vasoconstrictor efferents but during excitement systemic pressure rises may also trigger local sensory-motor dilator reflexes. We examined the postulate that bronchial flow is normally regulated at rest during controlled changes in pressure gradient (Pg) by integration of tonic autonomic activity with autoregulation.

METHODS

Twelve greyhounds were instrumented under general anaesthesia by surgical implantation of pulsed Doppler flow transducers on the right bronchial artery (BA). After recovery baroreflex effects were evoked by raising and lowering aortic pressure using a lower thoracic aortic balloon in 11 animals, and in six of these after cholinoceptor plus adrenoceptor blockade.

RESULTS

The right BA bed showed pressure-passive responses and the time-dependent bronchial bed effects in the autonomically intact state (INT) were largely similar to those in the blocked state (TAB). When results were replotted as pressure-flow relationships and analysed using covariance, the regression line over the pressure range 70-135 mmHg for TAB demonstrated a significant slope (P < 0.05), a linear regression elevated 120% (P = 0.006) above and parallel to INT (Y(Q) = 0.034 + 0.00033(X(Pg) - 104.6). The regression fell on the line of equal proportional change.

CONCLUSION

Baroreflexes do not functionally engage the autonomic outflow to the bronchial circulation. Under controlled conditions of systemic Pg change, the bronchial circulation is normally controlled by the integration of resting autonomic tone, myogenic autoregulation and pressure-passive effects.