PULMONARY OEDEMA/ARDS

Respiratory distress/tachypnoea
Desaturation
Increased inspiratory pressure
Pink frothing sputum up ETT / LMA (diagnostic)
Crepitations or bronchospasm
 

Fluid overload (2)
Non cardiogenic:
     Post airway obstruction (3)
     Anaphylaxis
     Neurogenic
     Sepsis
     Pulmonary aspiration
     Multiple organ failure
Cardiogenic (4)
 

Titrate inspired oxygen concentration against SpO2
Head up tilt/sit up if possible
If breathing spontaneously apply CPAP (5)
Intubate if necessary
IPPV and PEEP if intubated
Consider drug therapy: - morphine / GTN / frusemide (6)
 

Consider and investigate likely causes
Chest x-ray
Review perioperative fluid balance/renal function
Non-cardiogenic: consider following airway obstruction
     Allergy/anaphylaxis
     Aspiration
     Sepsis
     Multiple organ failure, eg major trauma, pancreatitis
     Renal - renal function tests
Cardiogenic:
     ECG
     Fractionated cardiac enzymes
     Echocardiogram
Consider admission to high dependency area / ICU

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The figures reported here are based on an analysis of 35 of the first 4000 AIMS anaesthesia incidents. It was considered the full algorithm plus the specific sub-algorithm would be required once the initial diagnosis was made.
(1) Hypoxia - 46%; pink frothy sputum - 23%; increased airway pressures - 14%; respiratory distress - 14%; crepitations or wheeze - 9%.
(2) Fluid overload was judged to be the cause in 46% of incidents. 81% of these had pre-existing conditions making them more susceptible to overhydration: age > 70, cardiovascular disease or hypertension, renal failure and chronic airflow limitation.
(3) 23% of incidents were judged to be following upper airway obstruction.
(4) 14% were judged to be cardiogenic in origin, eg. valvular heart disease, ischaemia/infarction, cardiac failure, arrhythmia.
(5) CPAP is important specific therapy for pulmonary oedema (in addition to treatment for hypoxia).
(6) Preload reduction:
     Morphine 0.02 mg/kg IV doses, titrating response
     Glyceryl trinitrate infusion 50 mg in 500 ml
           commence at 0.1 ml/kg/hr
Fluid reduction:
     Frusemide 25mg IV if fluid overload (place urinary catheter)
If hypotensive:
     Adrenaline infusion  6 mg/100ml (mls/hour = micrograms/minute).
            For adults, start at 3 ml/hour (be aware of Note (4) above)
            For children, start with no greater than 0.00015 mg(0.15 micrograms)/kg/minute
     Titrate against heart rate and blood pressure

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