Neurogenic Pulmonary Edema Workup

  • Author: Tej K Naik, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jan 18, 2012
 

Laboratory Studies

No specific laboratory study confirms the diagnosis of neurogenic pulmonary edema (NPE). Cardiac injury enzyme levels are elevated in patients with neurologic injury, especially subarachnoid hemorrhage. The magnitude of elevation often correlates with the severity of the neurologic event and its effect on cardiac function.

  • In one series, 20% of patients with subarachnoid hemorrhage were found to have serum troponin I levels greater than 1 mcg/L (range, 0.3-50 mcg/L).[16]
  • Elevated natriuretic peptides, A-type and B-type, have also been reported in patients with subarachnoid hemorrhage, with B-type natriuretic peptide peak levels reported as 355 ± 80 pg/mL.[17]
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Imaging Studies

Chest radiographs demonstrate a bilateral alveolar filling process and a normal-sized heart. This may mimic congestive heart failure with cephalization of blood flow, although other features of heart failure, such as septal Kerley B lines, are usually not evident. See the images below.

Neurogenic pulmonary edema in a patient with a subNeurogenic pulmonary edema in a patient with a subdural hematoma. Progression of neurogenic pulmonary edema in the sProgression of neurogenic pulmonary edema in the same patient in the image above, with subdural hematoma (day 2).
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Other Tests

No specific test confirms the diagnosis of neurogenic pulmonary edema.

  • Initial studies of cardiac function are usually unremarkable. These include normal ECG findings, echocardiography findings, central venous pressure, and pulmonary artery occlusion (pulmonary artery capillary wedge) pressure.
  • Serial monitoring of cardiac function may demonstrate reduced left ventricular function attributed to a neurogenic stress cardiomyopathy. Findings include regional wall motion abnormalities that extend beyond a single vascular bed. Echocardiographic findings may demonstrate a reduced ejection fraction and large areas of akinesis in the setting of modestly elevated serum troponin levels. Normal pulmonary artery capillary wedge pressures may increase and approach high levels.
  • Coronary angiography, if performed, shows no obstructing lesions.
  • Separating the cardiac effects of the neurologic event from the effect of therapy used in these critically ill patients may be difficult.
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Procedures

Hemodynamic measurements with right-sided heart catheterization (ie, Swan-Ganz catheter) may be necessary to differentiate neurogenic pulmonary edema from hydrostatic or cardiogenic pulmonary edema. Systemic blood pressure, cardiac output, and pulmonary capillary wedge pressure are usually normal by the time neurogenic pulmonary edema is diagnosed clinically.

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Histologic Findings

No specific histologic findings confirm the diagnosis of neurogenic pulmonary edema.

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Staging

No staging system is applicable to neurogenic pulmonary edema.

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Contributor Information and Disclosures
Author

Tej K Naik, MD  Associate, Southern California Permanente Medical Group, Pulmonary and Critical Care Medicine, Kaiser Foundation Hospital, Fontana, California

Tej K Naik, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Guy W Soo Hoo, MD, MPH  Clinical Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System

Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC  Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Cory Franklin, MD  Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital

Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold L Manning, MD  Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

References

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Neurogenic pulmonary edema in a patient with a subdural hematoma.
Progression of neurogenic pulmonary edema in the same patient in the image above, with subdural hematoma (day 2).
Factors leading to the development of neurogenic pulmonary edema in patients with subarachnoid hemorrhage.
 
 
 
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