Evidence for a Hydrostatic Mechanism in Human Neurogenic Pulmonary Edema

doi:10.1378/chest.111.5.1326

Chest

Volume 111, Issue 5, May 1997, Pages 1326-1333

https://doi.org/10.1378/chest.111.5.1326 Get rights and content

Study objectives

To identify the relative contribution of hydrostatic and permeability mechanisms to the development of human neurogenic pulmonary edema.

Design

Retrospective review of patients with neurogenic pulmonary edema who had pulmonary edema fluid analysis.

Setting

University hospital ICU.

Patients

Twelve patients with neurogenic pulmonary edema in whom the associated neurologic condition was subarachnoid hemorrhage (n=8, 67%), postcraniotomy (n=2), and stroke (n=2).

Measurements

Protein concentration was measured from pulmonary edema fluid and plasma samples obtained shortly after the onset of clinical pulmonary edema.

Results

The mechanism of pulmonary edema was classified according to the initial alveolar edema fluid to plasma protein concentration ratio. A hydrostatic mechanism (ratio ≤0.65) was observed in seven patients, none of whom had cardiac failure or intravascular volume overload. Five patients had evidence for increased permeability (ratio >0.70). Patients with a hydrostatic mechanism had better initial oxygenation (mean±SD PaO₂/FIo₂ [fraction of inspired oxygen]=233±132) compared with patients with increased permeability (PaO₂/FIo₂=80±42), and oxygenation improved more rapidly in the hydrostatic patients. Overall mortality (58%) was high, but it was related to unresolved neurologic deficits, not to respiratory failure.

Conclusion

Many of our patients had a hydrostatic mechanism for neurogenic pulmonary edema. This is a novel observation in humans since prior clinical case reports have emphasized increased permeability as the usual mechanism for neurogenic pulmonary edema. These findings are consistent with pulmonary venoconstriction or transient elevation in left-sided cardiovascular pressures as contributing causes to the development of human neurogenic pulmonary edema.

Section snippets

MATERIALS AND METHODS

The hospital charts of all patients who developed potential neurogenic pulmonary edema (see below) and had pulmonary edema fluid analysis between October 1982 and May 1994 at Moffitt-Long Hospital at the University of California, San Francisco were reviewed retrospectively.

Patients were classified as having potential neurogenic pulmonary edema if marked pulmonary edema occurred in the setting of a sudden change in their neurologic condition. Sixteen patients were identified who satisfied these

Patient Diagnoses and Demographics

Sixteen patients over a 12-year period developed sudden onset of pulmonary edema following a change in neurologic condition; all had pulmonary edema fluid obtained for analysis. Patients with concomitant cardiac disease, gastric aspiration, or another potential cause (reexpansion pulmonary edema) were excluded (four patients, see “Materials and Methods” section) to focus on patients with no cause for pulmonary edema other than a sudden change in neurologic status. These 12 patients constitute

DISCUSSION

Neurogenic pulmonary edema is characterized by an increase in extravascular lung water in patients who have sustained a sudden change in neurologic condition.²⁸,³⁷ The mechanism by which neurogenic pulmonary edema occurs is not clear, and two divergent theories have been proposed to explain its development: increased lung capillary permeability or increased pulmonary vascular hydrostatic pressures.

Increased permeability as a mechanism for neurogenic pulmonary edema is supported by some animal

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: Supported in part by NIH grant HL 51856.

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Chest

Clinical Investigations in Critical CareEvidence for a Hydrostatic Mechanism in Human Neurogenic Pulmonary Edema

Study objectives

Design

Setting

Patients

Measurements

Results

Conclusion

Section snippets

MATERIALS AND METHODS

Patient Diagnoses and Demographics

DISCUSSION

J Emerg Med

Chest

J Pediatr

Lancet

Br J Anaesth

Neurol Clin

Am J Med

Lancet

Clin Chest Med

Neurol Clin

Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage

Neurology

Increased intracranial pressure and pulmonary edema: I. Clinical study of 11 patients

J Neurosurg

Pulmonary edema secondary to subarachnoid hemorrhage

Neurology

Neurogenic pulmonary edema associated with ruptured intracranial aneurysm: case report

Neurosurgery

Edema and congestion of the lungs resulting from intracranial hemorrhage

Surgery

Respiratory insufficiency in combat casualties: II. Pulmonary edema following head injury

Ann Surg

Chlorpromazine treatment for neurogenic pulmonary edema

Crit Care Med

Neurogenic pulmonary edema: a sequela of non-hemorrhagic cerebrovascular accidents

Angiology

Neurogenic pulmonary edema associated with a colloid cyst in the third ventricle: case report

J Neurosurg

Acute pulmonary edema as a complication of epileptic seizures

NY Med J

Acute pulmonary edema as a terminal event in certain forms of epilepsy

Am J Med Sci

Pulmonary edema following an epileptic seizure

Am Rev Respir Dis

Postictal pulmonary edema

Arch Intern Med

Postictal pulmonary edema

Radiology

Pulmonary edema following a grand mal epileptic seizure

Am Rev Respir Dis

Clinical Investigations in Critical Care
Evidence for a Hydrostatic Mechanism in Human Neurogenic Pulmonary Edema