Cardiogenic Pulmonary Edema Differential Diagnoses

Updated: Jul 23, 2020
  • Author: Ali A Sovari, MD, FACP, FACC; Chief Editor: Gyanendra K Sharma, MD, FACC, FASE  more...
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Diagnostic Considerations

Cardiogenic pulmonary edema (CPE) should be differentiated from pulmonary edema associated with injury to the alveolar-capillary membrane, caused by diverse etiologies. Damage to the alveolar-capillary barrier can be seen in various direct lung injuries (from pneumonia, aspiration pneumonitis, toxin inhalation, pulmonary contusion, radiation, drowning, or fat emboli) and indirect lung injuries (from sepsis, shock and multiple transfusions, acute pancreatitis, or anaphylactic shock).

Several conditions related to noncardiogenic pulmonary edema (NCPE) primarily affect Starling forces rather than the alveolar-capillary barrier. These conditions include decreased oncotic pressure of the plasma due to various etiologies and increased negativity of interstitial pressure due to rapid removal of pneumothorax. Lymphatic insufficiency (eg, from lymphangitic carcinomatosis, fibrosing lymphangitis, or lung transplantation) is another important etiologic mechanism of NCPE.

Several features may differentiate CPE from NCPE. In CPE, a history of an acute cardiac event is usually present. Physical examination shows a low-flow state, an S3 gallop, jugular venous distention, and crackles on auscultation. Patients with NCPE have a warm periphery, a bounding pulse, and no S3 gallop or jugular venous distention. Definite differentiation is based on pulmonary capillary wedge pressure (PCWP) measurements. The PCWP is generally >18 mm Hg in CPE and < 18 mm Hg in NCPE, but superimposition of chronic pulmonary vascular disease can make this distinction difficult to assess.

Conditions to consider in the differential diagnosis of CPE include the following:

  • Pneumothorax

  • High-altitude pulmonary edema

  • Neurogenic pulmonary edema

  • Pulmonary embolism

  • Respiratory failure

Differential Diagnoses