What is pulmonary edema?

pulmonary edema

What is pulmonary edema?

Pulmonary edema is collection of fluid within the lungs. This is different from pleural effusion, which is collection of fluid between the inner and outer coverings of the lung. The most important cause of pulmonary edema is heart failure, specifically, failure of the left ventricle, lower muscular chamber which pumps oxygenated blood to the rest of the body. Pulmonary edema can also occur when there is fluid overload in the body as in kidney failure.

Other causes of pulmonary edema are obstruction to the mitral valve (valve between the left upper (left atrium) and left lower (left ventricle) chambers of the heart, obstruction to the blood vessels draining oxygenated blood from the lungs to the left atrium (pulmonary veins) and increased permeability of the small blood vessels of the lungs (noncardiogenic pulmonary edema – e.g. adult respiratory distress syndrome or ARDS).

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Narrowing of heart valves

Narrowed heart valve

What causes narrowing of heart valves?

Narrowing of heart valves can occur at birth. Then it is called congenital narrowing of heart valves. Narrowing of heart valves is given the technical name ‘stenosis‘. Narrowing of aortic valve (valve between the left ventricle – lower muscular chamber of the heart – and the aorta – large blood vessel carrying oxygenated blood to the body) is known as aortic stenosis. Narrowing the valve between the left upper and lower chambers of the heart is known as mitral stenosis. Corresponding names on the right side of the heart are tricuspid stenosis and pulmonary stenosis.

An important cause of narrowing of heart valves in developing countries is rheumatic fever. Degeneration of valve structures by age can lead to narrowing of the aortic valve causing aortic stenosis. As time goes by, these valves can get calcified, with deposit of compounds containing calcium. Then it is called calcific aortic stenosis. Birth defect of the aortic valve in which it has only two cusps instead of the normal three is known as bicuspid aortic valve. Bicuspid aortic valve can degenerate earlier than normal aortic valve causing aortic stenosis. Valves can also get narrowed due to deposition of other materials in certain diseases (infiltrative disorders).

What is the difference between invasive and non invasive ventilation?

Invasive ventilation

What is the difference between invasive and non invasive ventilation?

Ventilator is device used to support breathing. It is used when there is difficulty in breathing or when spontaneous breathing has stopped. Ventilator is an important life supporting device useful in many life threatening conditions.

Invasive ventilator is usually used in the intensive care setting or the operating room. A tube is placed in the windpipe (trachea) under local anaesthesia with sedation or general anaesthesia. This tube is connected to a mechanical ventilator using appropriate connection tubings. Ventilator senses the breathing needs of the individual and gives appropriate pressures to inflate the lungs to either replace the breathing efforts of the individual or supplement spontaneous breathing in various disease conditions.

Non invasive ventilator is usually a smaller device with less sophistication. It is connected using an external mask which is tight fitting over the nostrils and mouth. A good air seal at the mask – face interface is needed for proper functioning of non-invasive ventilator. But the advantage is that the individual can remain fully alert, without any need for sedation or anaesthesia. There is no need to place a tube (endo tracheal tube) in the wind pipe. The non invasive ventilator usually supplies two levels of pressure – on during breathing in (inspiration) and another during breathing out (expiration). Pressure applied during inspiration is higher than that in in expiration. This type of non invasive ventilation is known as bi-level positive airway pressure (BiPAP) ventilation.

Broken heart syndrome

Broken heart

What is broken heart syndrome?

Sudden emotional stress can precipitate a heart disease called ‘Broken Heart Syndrome’ or stress cardiomyopathy. It is a disease of the heart muscle, usually following a major stressful life event like loss of spouse or a dear one. Sometimes it can be associated with another acute illness as well. It may manifest with chest pain or breathlessness and ECG findings may mimick a heart attack. Ultrasound imaging of the heart (echocardiogram) shows a peculiar finding: ballooning of tip of the left ventricle (lower muscular chamber of the heart). Hence this condition is also called apical ballooning syndrome. Though symptoms often resemble that of a heart attack, there is no significant block in any of the coronary arteries (blood vessel carrying oxygenated blood to the heart muscle). Most cases of broken heart syndrome recover over a period of time and heart muscle function is fully regained. For some reason, heart rhythm abnormalities are less common in broken heart syndrome than in a heart attack of corresponding severity. Broken heart syndrome can occasionally be fatal. It may noted that an actual heart attack (myocardial infarction) can also be precipitated by a major emotional stress. But it is different from broken heart syndrome in that there is a blockage in one or more coronary arteries in case of heart attack.

Left sided chest pain

Left sided chest pain

Is left sided chest pain always due to heart disease?

Heart disease is only one cause of chest pain. Diseases of other organs of the chest can also cause chest pain. Pain can originate from the skin, muscles, bone, lung, covering of the lung (pleura) and food pipe (esophagus). Inflammation of the pleura is known as pleurisy. Nature of the pain and associations often help in differentiating the origin. For example, pain arising from the skin will often be associated with redness and local tenderness. Pain arising from the lung or pleura can increase on deep breathing and coughing. Muscle pain is aggravated by movement of the involved muscle. Bone pain also can be increased by local movement and associated with local tenderness (pain on local pressure with the hand).

Pain may arise in the nerves (nerve root pain) of the chest wall. For example, in a condition called Herpes Zoster, chicken pox virus involves the sensory nerve roots, producing severe pain localised to the region of the skin supplied by the concerned nerve. Pain starts a few days prior to the eruptions in skin so that it may be mistaken for other causes of chest pain in the initial days. Diagnosis is clear when the vesicles appear on the skin in the distribution of the nerve supply, strictly to one side of the mid line of the body. In this condition the pain may sometimes persist long after the healing of the vesicles (post herpetic neuralgia). Pain can also be due to damage or compression of the nerve root by bony structures or masses within the spine from where the nerves arise.

Thus a lot more illnesses than heart disease can cause chest pain, either on the left or right side and it needs careful evaluation and work up to identify the exact cause.

Transient blackouts (Syncope)

Blackout

Can transient blackouts be a manifestation of heart disease?

Transient loss of consciousness (TLOC) with a fall is called ‘syncope’. It could be due to a variety of causes including heart disease. Causes other than cardiac ailment could be some forms of epilepsy (seizure), anemia (lowering of hemoglobin content of blood) or even a simple faint. Of the lot, the simple faint (vasovagal syncope or neurocardiogenic syncope) if probably the most common. It is quite common in children, especially while standing in school assembly in hot season. Dehydration can predispose to this form of syncope.

Syncope due to ailments of the heart can be due to several causes. Serious obstruction to any heart valve can cause syncope, especially during exertion as the heart is not able to meet the extra demand for blood supply with exercise. High blood pressure in the blood vessels of the lung (pulmonary hypertension) is a rare by serious cause of syncope. Obstruction to blood flow to the lungs due to sudden migration of blood clots from another part of the body like the legs can sometimes cause syncope. Another important group of cardiac illness which can cause syncope are the disorders of heart rhythm. A very fast heart rhythm or a very slow heart rhythm, both can cause syncope. In both cases, heart is not able to pump sufficient amount of blood to maintain the circulation to the brain well. Diseases of the heart muscle which leads to poor function of the heart as a pump can cause syncope, mostly during exertion. Gross thickening of the heart muscle in certain heart diseases (hypertrophic cardiomyopathy) can cause obstruction to blood flow from the left ventricle (lower muscular chamber) to the aorta (largest blood vessel supplying oxygenated blood to the body) can lead to syncope, typically occurring while taking rest after exertion.

What tests are likely to be done in a person with syncope?

The most important aspect of evaluation of person with history of syncope is the detailed history of the event and the narration from an eye witness in case one is available. Usually evaluation needs a multidisciplinary approach. Most cases would need both cardiac and neurological work up as the cause often not very evident. If the history points to one form of disease, priority is given for that workup. Important general test is a routine blood count to rule out anemia. Basic blood investigations are also often done to rule out associated important illnesses. Specific cardiac (related to the heart) tests may include an electrocardiogram (ECG), echocardiogram (ultrasound imaging of the heart) and ambulatory electrocardiographic monitoring (24 or 48 hour Holter monitoring). Neurological (related to the brain and nerves) tests may include electroencephalogram (EEG) and brain imaging studies (computerised tomographic or CT scan and/or magnetic resonance imaging (MRI) of the brain. Further workup will depend on the results of these initial tests.

Precautions while taking Warfarin (blood thinner)

Blood thinner

What are the precautions while taking Warfarin (blood thinner) ?

Warfarin is a blood thinner medication used to prevent the formation of blood clots within the heart and blood vessels. It is used in a variety of conditions involving the heart and blood vessels. Though it is a very effective medication, it has a narrow window of safety. This means that the dose has to be carefully adjusted with appropriate blood testing. A test known as prothrombin time with international normalized ratio (PT-INR) is used to adjust the dosage according to the condition for which it is given. Frequent monitoring is needed, because the effect of Warfarin in the body can be influenced by food and other medications which are taken along with it. For example, leafy vegetables and other foods which contain a lot of vitamin K will reduce the effectiveness of the drug. On the other hand certain medications increase the effectiveness of the drug by displacing it from the proteins in the blood, thereby increasing its effective blood level. So it is essential to check PT-INR whenever there is any change in the diet or medication pattern. Concomitant liver disease will also increase the bleeding risk with Warfarin as the factors needed for blood clotting are synthesized in the liver.

While taking Warfarin, a constant vigil has to be there for all potential types of bleeding which may otherwise go unnoticed. If any abnormal bleeding is noted, PT-INR has to be checked. Bleeding may be blood in stools, urine or vomitus. Bleeding into the skin can appear like bruises. Bleeding in the upper intestine (small intestine) manifest as black tarry stools instead of red stools in case of bleeding from the lower intestine (large intestine). Bleeding into brain can manifest a stroke with weakness of one side of the body with or without loss of consciousness.