Neurogenic Pulmonary Edema Treatment & Management
- Author: Tej K Naik, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
Neurologic disorder and neurogenic pulmonary edema (NPE)
Focus treatment on the underlying neurologic disorder and associated complications.
The initial focus should be on control of the underlying neurologic insult, which may include surgical options.
Control neurogenic pulmonary edema with supportive and conservative measures.
Neurogenic pulmonary edema resolves within 48-72 hours in the majority of affected patients.
General supportive care for neurogenic pulmonary edema
Supplemental oxygen is required in most patients to correct hypoxemia.
Mechanical ventilation may be necessary, either noninvasive with a face mask or via an endotracheal tube.  The goals of mechanical ventilation are to assure adequate oxygenation and ventilation and to prevent iatrogenic lung injury. To avoid excessively high inflation pressures, tidal volumes between 5 and 6 mL/kg or predicted body weight are used.
With the use of low inflation volumes, positive end-expiratory pressure (PEEP) is added to prevent compression atelectasis. The peak inspiratory (plateau) pressure should be kept below 30-35 cm water, and eucapnia should be maintained to avoid further increases in intracranial pressure.
High levels of PEEP may be required to treat severe hypoxemia. Caution is advised, however, because PEEP can inhibit cerebral venous return and increase intracranial hypertension.
Diuretic therapy may reduce lung water by decreasing capillary hydrostatic pressure and increasing colloid osmotic pressure, but the strategies to reduce lung water are not uniformly successful. The use of diuretics to minimize or reduce fluid overload seems a more reasonable approach, but adequate cardiac output and cerebral perfusion pressure must be maintained.
The goal of management in respiratory failure is to achieve an adequate level of oxygenation in the vital organs. Swan-Ganz catheterization may be helpful in guiding fluid and hemodynamic management, particularly if diuretics are used.
To maintain adequate tissue oxygenation, sufficient cardiac output (cardiac index >2.2 L/min/m 2) and hemoglobin (>10 g/L) are required to ensure optimal oxygen delivery. Because cardiac output depends on cardiac filling pressures (central venous pressure and wedge pressure), meticulous monitoring of intravascular volume is mandatory. See the Cardiac Output calculator.
Pharmacological therapy for neurogenic pulmonary edema: Pharmacological agents are not used routinely in the treatment of neurogenic pulmonary edema. Several agents, such as alpha-adrenergic antagonists, beta-adrenergic blockers, dobutamine, and chlorpromazine, are advocated by some authors, but assessment of their effectiveness is difficult because neurogenic pulmonary edema is usually a self-limited condition that resolves spontaneously.
Alpha-adrenergic antagonists (eg, phentolamine) can prevent neurogenic pulmonary edema or hasten its resolution in experimental models. However, no human trials have established the safety and efficacy of these agents. These agents may be used to treat concomitant systemic hypertension, if present, but care must be taken to avoid significant hypotension that can diminish cerebral perfusion. 
Beta-adrenergic agonists, in theory, are used to counteract the alpha-adrenergic–induced increase in systemic vascular resistance by increased inotropic effect with reflex-mediated decrease in afterload. Some studies have used dobutamine and shown a distinct improvement in myocardial function in patients with neurogenic pulmonary edema.  A more recent study looked at patients with neurogenic pulmonary edema who were taking lower doses of dopamine (< 6 mcg/min/kg) and showed this to be a reasonable alternative to dobutamine. Recommendations against using higher doses of dopamine have also been published, given the possible effects on increased afterload.
Surgical management is directed at the neurologic insult (eg, intracerebral hemorrhage, subdural hematoma) because neurogenic pulmonary edema has no direct surgical treatment.
Consultations may include the following:
Critical care medicine specialist or intensivist for ongoing intensive care
Neurosurgeon and/or neurologist for evaluation and management of any underlying precipitating event
Interventional radiologist for some specific neurologic vascular issues
No specific dietary recommendations are needed for patients with neurogenic pulmonary edema.
Patients with neurogenic pulmonary edema usually have limited mobility as a result of their neurologic condition. No specific restrictions on activity are needed, except those required for treatment of the neurologic condition, especially patients undergoing neurologic surgery. Early ambulation and rehabilitation are crucial for recovery.
Sedy J, Zicha J, Kunes J, Jendelova P, Sykova E. Mechanisms of neurogenic pulmonary edema development. Physiol Res. 2008. 57(4):499-506. [Medline].
Hoff JT, Nishimura M, Garcia-Uria J, Miranda S. Experimental neurogenic pulmonary edema. Part 1: The role of systemic hypertension. J Neurosurg. 1981 May. 54(5):627-31. [Medline].
Maron MB, Dawson CA. Pulmonary venoconstriction caused by elevated cerebrospinal fluid pressure in the dog. J Appl Physiol. 1980 Jul. 49(1):73-8. [Medline].
Baumann A, Audibert G, McDonnell J, Mertes PM. Neurogenic pulmonary edema. Acta Anaesthesiol Scand. 2007 Apr. 51(4):447-55. [Medline].
Mutoh T, Kazumata K, Ueyama-Mutoh T, Taki Y, Ishikawa T. Transpulmonary Thermodilution-Based Management of Neurogenic Pulmonary Edema After Subarachnoid Hemorrhage. Am J Med Sci. 2015 Nov. 350 (5):415-9. [Medline].
Chen WL, Huang CH, Chen JH, Tai HC, Chang SH, Wang YC. Electrocardiographic abnormalities predict neurogenic pulmonary edema in patients with subarachnoid hemorrhage. Am J Emerg Med. 2015 Sep 25. [Medline].
Khademi S, Frye MA, Jeckel KM, Schroeder T, Monnet E, Irwin DC, et al. Hypoxia mediated pulmonary edema: potential influence of oxidative stress, sympathetic activation and cerebral blood flow. BMC Physiol. 2015 Oct 9. 15 (1):4. [Medline].
Reuter-Rice K, Duthie S, Hamrick J. Neurogenic pulmonary edema associated with pediatric status epilepticus. Pediatr Emerg Care. 2011 Oct. 27(10):957-8. [Medline].
Muroi C, Keller M, Pangalu A, Fortunati M, Yonekawa Y, Keller E. Neurogenic pulmonary edema in patients with subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2008 Jul. 20(3):188-92. [Medline].
Piazza O, Venditto A, Tufano R. Neurogenic pulmonary edema in subarachnoid hemorrage. Panminerva Med. 2011 Sep. 53(3):203-10. [Medline].
Solenski NJ, Haley EC Jr, Kassell NF, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med. 1995 Jun. 23(6):1007-17. [Medline].
Fontes RB, Aguiar PH, Zanetti MV, Andrade F, Mandel M, Teixeira MJ. Acute neurogenic pulmonary edema: case reports and literature review. J Neurosurg Anesthesiol. 2003 Apr. 15(2):144-50. [Medline].
Lee VH, Oh JK, Mulvagh SL, Wijdicks EF. Mechanisms in neurogenic stress cardiomyopathy after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2006. 5(3):243-9. [Medline].
Wartenberg KE, Mayer SA. Medical complications after subarachnoid hemorrhage: new strategies for prevention and management. Curr Opin Crit Care. 2006 Apr. 12(2):78-84. [Medline].
Goncalves V, Silva-Carvalho L, Rocha I. Cerebellar haemorrhage as a cause of neurogenic pulmonary edema - case report. Cerebellum. 2005. 4(4):246-9.
Qin SQ, Sun W, Wang HB, Zhang QL. Neurogenic pulmonary edema in head injuries: analysis of 5 cases. Chin J Traumatol. 2005 Jun. 8(3):172-4, 178. [Medline].
Rochester CL, Mohsenin V. Respiratory complications of stroke. Semin Respir Crit Care Med. 2002 Jun. 23(3):248-60. [Medline].
Brewer RP, Borel CO. Neurogenic pulmonary edema during intracranial endovascular therapy. Neurocrit Care. 2004. 1(4):423-7. [Medline].
Naidech AM, Bassin SL, Garg RK, et al. Cardiac troponin I and acute lung injury after subarachnoid hemorrhage. Neurocrit Care. 2009. 11(2):177-82. [Medline].
Nakamura T, Okuchi K, Matsuyama T, et al. Clinical significance of elevated natriuretic peptide levels and cardiopulmonary parameters after subarachnoid hemorrhage. Neurol Med Chir (Tokyo). 2009 May. 49(5):185-91; discussion 191-2. [Medline].
Fletcher SJ, Atkinson JD. Use of prone ventilation in neurogenic pulmonary oedema. Br J Anaesth. 2003 Feb. 90(2):238-40. [Medline].
Schraufnagel DE, Thakkar MB. Pulmonary venous sphincter constriction is attenuated by alpha-adrenergic antagonism. Am Rev Respir Dis. 1993 Aug. 148(2):477-82. [Medline].
Knudsen F, Jensen HP, Petersen PL. Neurogenic pulmonary edema: treatment with dobutamine. Neurosurgery. 1991 Aug. 29(2):269-70. [Medline].
[Guideline] Institute for Clinical Systems Improvement (ICSI). Palliative care. National Guidelines Clearinghouse. 2008 May.
Jain R, Deveikis J, Thompson BG. Management of patients with stunned myocardium associated with subarachnoid hemorrhage. AJNR Am J Neuroradiol. 2004 Jan. 25(1):126-9. [Medline].
Ohlmacher AP. Acute pulmonary edema as a terminal event in certain forms of epilepsy. Am J Med Sci. 1910. 139:417.
Simmons RL, Heisterkamp CA 3rd, Collins JA, Bredenberg CE, Mills DE, Martin AM Jr. Respiratory insufficiency in combat casualties. IV. Hypoxemia during convalescence. Ann Surg. 1969 Jul. 170(1):53-62. [Medline].
Simon RP, Gean-Marton AD, Sander JE. Medullary lesion inducing pulmonary edema: a magnetic resonance imaging study. Ann Neurol. 1991 Nov. 30(5):727-30. [Medline].
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000 May 4. 342(18):1301-8. [Medline].
Tung P, Kopelnik A, Banki N, et al. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004 Feb. 35(2):548-51. [Medline].
Wray NP, Nicotra MB. Pathogenesis of neurogenic pulmonary edema. Am Rev Respir Dis. 1978 Oct. 118(4):783-6. [Medline].