For Nagabhushan, a 70-year-old agriculturist from Tumkur, Karnataka, it all started with a viral fever that persisted followed by a feeling of uneasiness, breathlessness and fatigue in April 2021.
His family struggled to get him admitted for oxygen support during the pandemic when beds were scarce and a negative report of Covid test was the prerequisite for further diagnosis.
Post-admission, an X-ray along with an examination of his medical history helped the doctor diagnose his condition as pulmonary edema.
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Understanding acute and chronic pulmonary edema
The lungs contain multiple small, elastic air sacs called alveoli. When we breathe, these air sacs take in oxygen and release carbon dioxide. This exchange usually happens seamlessly. When the alveoli get filled with fluid instead of air, it disrupts the exchange by restricting the bloodstream from taking in oxygen. This means oxygen from the air can’t travel through the lungs into the blood where it’s needed. The condition is called pulmonary edema and can develop gradually or can be sudden leaving a slim window for medical intervention.
Although Bhushan’s sudden onset of breathlessness indicated acute pulmonary edema, it eventually developed into a chronic condition requiring a readmission a couple of months later. When he was readmitted, he grappled additionally with multiple organ infections, high sugar and creatinine levels that strained his kidneys tremendously.
Explaining the difference between sudden and gradual pulmonary edema, Dr Nikhil Modi, senior consultant, department of respiratory critical care and sleep medicine, Apollo Hospital, Delhi, says acute pulmonary edema is sudden due to acute kidney failure or high-altitude pulmonary edema.
Chronic edema persists over a few weeks to months or even longer and is most common in people with heart issues due to which fluid keeps on accumulating in the lungs on a regular basis, he says.
Dr Prashant Chhajed, director, pulmonology and sleep centre, Fortis Hiranandani Hospital, Vashi, Mumbai, further points out that in acute pulmonary edema there is a sudden onset of breathlessness. It is seen in acute myocardial infarction (when a blood clot stops the flow of blood in the heart) or acute pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot).
He adds that Individuals with chronic pulmonary edema have a history of co-morbidities such as cardiac or respiratory disease and have breathlessness that is long-standing.
Congestive heart failure — the common cause?
“Congestive heart failure is one of the most common causes of pulmonary edema,” says Dr Modi. The heart gets the blood from the lungs after the blood picks up oxygen from the lungs and pumps it to various organs. A weak heart is unable to pump blood, leading to congestion of blood in the lungs, which in turn leads to pulmonary edema, he says.
Bhushan the septuagenarian had a history of stroke, hypertension and diabetes before he was admitted for breathlessness in 2021. The doctor diagnosed his weakened heart operating at a capacity of 20 per cent due to a triple vessel blockage as the reason for his chronic pulmonary edema.
“But pulmonary edema is not always cardiogenic (related to the heart),” says Dr Chhajed. The fluid accumulation in the lungs can also be due to the fluid overload in the body leading to a build-up of back pressure, which eventually causes fluid accumulation in the lungs, he says.
“Pulmonary embolism (blockage of arteries in the lungs by blood clots) due to high altitude, acute respiratory distress syndrome (ARDS), near drowning and drug reactions all lead to non-cardiogenic (not related to the heart) pulmonary edema,” says Dr Chhajed.
Dr Modi says that low protein and hemoglobin levels and kidney failure leading to excess accumulation of fluid in the body can also cause pulmonary edema.
Pulmonary edema due to high altitude
At high altitudes, there is less oxygen in the air one breathes. This means blood from all areas of the lungs is short on oxygen. The lungs respond to this shortage of oxygen by tightening the blood vessels. Result: the blood vessels in the lungs squeeze together, increasing pressure within and causing fluid to leak into the lung tissues and eventually into the air sacs. This condition is called high-altitude pulmonary edema.
Diagnosis and treatment
Dr Modi says that treating the underlying cause of pulmonary edema is more important than treating only edema hence diagnosis should focus on the history of existing diseases that cause fluid build-up. Parallelly medicines that increase urine output (diuretics) help flush out excess fluid from the body, he says.
Dr Chhajed says the diagnosis is confirmed through clinical examination and aided by a CT scan chest, 2D Echo, chest ultrasonography and biomarkers such as NT-proBNP (biological markers in the blood indicating normal and abnormal processes within the body).
The supportive treatment, according to the Mumbai-based Dr Chhajed, includes diuretics, oxygen, continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) and mechanical ventilation for symptomatic relief until the primary condition that caused the pulmonary edema is treated.
Unfortunately for Bhushan, a bypass surgery that could have cured his pulmonary edema wasn’t advised by the doctor due to the risk associated with his age, his low body weight and high creatinine levels. To manage the edema, he was prescribed lifelong anti-diuretics and nebulisation.
As a preventive measure, Dr Chhajed suggests lifestyle changes like controlling blood pressure and cholesterol by exercising, eating healthy and avoiding alcohol and tobacco intake for maintaining heart health.
Dr Modi stresses on regular health checks to identify any illness at an early stage for it to be treated more effectively.
This advice also holds true in Bhushan’s case where a lack of regular monitoring of health post-stroke led to the worsening of his condition and sudden pulmonary edema.
Pulmonary edema vs pleural effusion vs pneumonia
Pulmonary edema can be easily mixed up with other lung conditions such as pleural effusion and pneumonia.
In pulmonary edema, the fluid collects inside the lungs, whereas in pleural effusion it accumulates in the layers of the pleura that are present on the outside of lungs and on the inner side of the chest. Symptoms are chest pain, shortness of breath and a dry cough.
Pneumonia also means the build-up of fluid in the tiny air sacs of the lungs, but the condition is caused by a bacterial, fungal or viral infection. The symptoms include chest pain, coughing, fatigue, a fever, shortness of breath and stomach problems.
Wiser and healthier
Although the quality of his life is significantly affected in terms of independence and stamina levels, Bhushan is now wiser. He ensures that his liquid intake does not exceed more than 1.5 litres per day and avoids overexerting himself. He also follows a strict low-sugar, low-salt diet to manage his hypertension and high sugar conditions.