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Noncardiogenic pulmonary edema

Michael M Givertz, MD
Section Editor
Stephen S Gottlieb, MD
Deputy Editor
Geraldine Finlay, MD


Pulmonary edema is due to the movement of excess fluid into the alveoli as a result of an alteration in one or more of Starling's forces. In cardiogenic pulmonary edema, a high pulmonary capillary pressure (as estimated clinically from the pulmonary artery wedge pressure) is responsible for the abnormal fluid movement [1]. (See "Pathophysiology of cardiogenic pulmonary edema" and "Evaluation of acute decompensated heart failure".)

In contrast, noncardiogenic pulmonary edema is caused by various disorders in which factors other than elevated pulmonary capillary pressure are responsible for protein and fluid accumulation in the alveoli [1]. The distinction between cardiogenic and noncardiogenic causes is not always possible, since the clinical syndrome may represent a combination of several different disorders. The diagnosis is important, however, because treatment varies considerably depending upon the underlying pathophysiologic mechanisms.


Fluid balance between the interstitium and vascular bed in the lung, as in other microcirculations, is determined by the Starling relationship, which predicts the net flow of liquid across a membrane. This can be expressed in the following equation:

Net filtration  =  (Lp x S)   x   (delta hydraulic pressure  -  delta oncotic pressure)

=   (Lp x S)   x   [(Pcap   -   Pif)   -  s(πcap   -   πif)]


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Literature review current through: Sep 2016. | This topic last updated: Sep 22, 2015.
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  1. Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med 2005; 353:2788.
  2. Givertz MM, Colucci WS, Braunwald E. Clinical aspects of heart failure; pulmonary edema, high-output failure. In: Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed, Zipes DP, Libby P, Bonow RO, Braunwald E (Eds), Elsevier Saunders, Philadelphia 2005. p.539.
  3. Fein A, Grossman RF, Jones JG, et al. The value of edema fluid protein measurement in patients with pulmonary edema. Am J Med 1979; 67:32.
  4. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 2000; 342:1334.
  5. Montgomery AB, Stager MA, Carrico CJ, Hudson LD. Causes of mortality in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1985; 132:485.
  6. Kanner C, Hardy SM. An unusual cause of unilateral pulmonary edema. Ann Intern Med 2013; 158:639.
  7. Neerukonda SK, Petty TL. Unilateral pulmonary edema. Hosp Pract (Off Ed) 1992; 27:85, 88.
  8. Calenoff L, Kruglik GD, Woodruff A. Unilateral pulmonary edema. Radiology 1978; 126:19.
  9. Attias D, Mansencal N, Auvert B, et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010; 122:1109.
  10. Jardin F, Fourme T, Page B, et al. Persistent preload defect in severe sepsis despite fluid loading: A longitudinal echocardiographic study in patients with septic shock. Chest 1999; 116:1354.
  11. Monchi M, Bellenfant F, Cariou A, et al. Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. Am J Respir Crit Care Med 1998; 158:1076.
  12. Morrison LK, Harrison A, Krishnaswamy P, et al. Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. J Am Coll Cardiol 2002; 39:202.
  13. Levitt JE, Vinayak AG, Gehlbach BK, et al. Diagnostic utility of B-type natriuretic peptide in critically ill patients with pulmonary edema: a prospective cohort study. Crit Care 2008; 12:R3.
  14. Determann RM, Royakkers AA, Schaefers J, et al. Serum levels of N-terminal proB-type natriuretic peptide in mechanically ventilated critically ill patients--relation to tidal volume size and development of acute respiratory distress syndrome. BMC Pulm Med 2013; 13:42.
  15. Schmickl CN, Pannu S, Al-Qadi MO, et al. Decision support tool for differential diagnosis of Acute Respiratory Distress Syndrome (ARDS) vs Cardiogenic Pulmonary Edema (CPE): a prospective validation and meta-analysis. Crit Care 2014; 18:659.
  16. Federici AB, Intini D, Lattuada A, et al. Supportive transfusion therapy in cancer patients with acquired defects of hemostasis. Thromb Res 2014; 133 Suppl 2:S56.
  17. Cheng IW, Matthay MA. Acute lung injury and the acute respiratory distress syndrome. Crit Care Clin 2003; 19:693.
  18. Humphrey H, Hall J, Sznajder I, et al. Improved survival in ARDS patients associated with a reduction in pulmonary capillary wedge pressure. Chest 1990; 97:1176.
  19. Mitchell JP, Schuller D, Calandrino FS, Schuster DP. Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization. Am Rev Respir Dis 1992; 145:990.
  20. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354:2564.
  21. Malhotra A, Drazen JM. High-frequency oscillatory ventilation on shaky ground. N Engl J Med 2013; 368:863.
  22. Milberg JA, Davis DR, Steinberg KP, Hudson LD. Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983-1993. JAMA 1995; 273:306.
  23. Zambon M, Vincent JL. Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest 2008; 133:1120.
  24. Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293.
  25. Hackett P, Rennie D. High-altitude pulmonary edema. JAMA 2002; 287:2275.
  26. Bärtsch P, Swenson ER. Clinical practice: Acute high-altitude illnesses. N Engl J Med 2013; 368:2294.
  27. Sedý J, Zicha J, Kunes J, et al. Mechanisms of neurogenic pulmonary edema development. Physiol Res 2008; 57:499.
  28. Mayer E, Jenkins D, Lindner J, et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg 2011; 141:702.
  29. Piazza G, Goldhaber SZ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2011; 364:351.
  30. Thistlethwaite PA, Madani MM, Kemp AD, et al. Venovenous extracorporeal life support after pulmonary endarterectomy: indications, techniques, and outcomes. Ann Thorac Surg 2006; 82:2139.
  31. Berman M, Tsui S, Vuylsteke A, et al. Successful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy. Ann Thorac Surg 2008; 86:1261.
  32. Sohara Y. Reexpansion pulmonary edema. Ann Thorac Cardiovasc Surg 2008; 14:205.
  33. Yoon JS, Suh JH, Choi SY, et al. Risk factors for the development of reexpansion pulmonary edema in patients with spontaneous pneumothorax. J Cardiothorac Surg 2013; 8:164.
  34. Taira N, Kawabata T, Ichi T, et al. An analysis of and new risk factors for reexpansion pulmonary edema following spontaneous pneumothorax. J Thorac Dis 2014; 6:1187.
  35. Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007; 84:1656.
  36. Gleeson T, Thiessen R, Müller N. Reexpansion pulmonary edema: computed tomography findings in 22 patients. J Thorac Imaging 2011; 26:36.
  37. Sherman SC. Reexpansion pulmonary edema: a case report and review of the current literature. J Emerg Med 2003; 24:23.
  38. Osler W. Oedema of the left lung—morphia poisoning. Montreal General Hospital Reports Clinical and Pathological, vol 1, Dawson Bros Publishers, Montreal 1880. p.291.
  39. Sporer KA. Acute heroin overdose. Ann Intern Med 1999; 130:584.
  40. Radke JB, Owen KP, Sutter ME, et al. The effects of opioids on the lung. Clin Rev Allergy Immunol 2014; 46:54.
  41. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest 2001; 120:1628.
  42. Cobaugh DJ, Gainor C, Gaston CL, et al. The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. Am J Health Syst Pharm 2014; 71:1539.
  43. Winklhofer S, Surer E, Ampanozi G, et al. Post-mortem whole body computed tomography of opioid (heroin and methadone) fatalities: frequent findings and comparison to autopsy. Eur Radiol 2014; 24:1276.
  44. Heffner JE, Sahn SA. Salicylate-induced pulmonary edema. Clinical features and prognosis. Ann Intern Med 1981; 95:405.
  45. Glisson JK, Vesa TS, Bowling MR. Current management of salicylate-induced pulmonary edema. South Med J 2011; 104:225.
  46. Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part II: risk stratification, treatment, and prevention. Circulation 2003; 108:2834.
  47. Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med 2010; 363:266.
  48. Porcel JM, Light RW. Pleural effusions due to pulmonary embolism. Curr Opin Pulm Med 2008; 14:337.
  49. Brown SE, Light RW. Pleural effusion associated with pulmonary embolization. Clin Chest Med 1985; 6:77.
  50. Porcel JM, Madroñero AB, Pardina M, et al. Analysis of pleural effusions in acute pulmonary embolism: radiological and pleural fluid data from 230 patients. Respirology 2007; 12:234.
  51. Peters CJ, Khan AS. Hantavirus pulmonary syndrome: the new American hemorrhagic fever. Clin Infect Dis 2002; 34:1224.
  52. Ho M, Chen ER, Hsu KH, et al. An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group. N Engl J Med 1999; 341:929.
  53. Ksiazek TG, Erdman D, Goldsmith CS, et al. A novel coronavirus associated with severe acute respiratory syndrome. N Engl J Med 2003; 348:1953.
  54. Taylor AE. Capillary fluid filtration. Starling forces and lymph flow. Circ Res 1981; 49:557.
  55. Arquès S, Ambrosi P, Gélisse R, et al. Hypoalbuminemia in elderly patients with acute diastolic heart failure. J Am Coll Cardiol 2003; 42:712.
  56. Uthamalingam S, Kandala J, Daley M, et al. Serum albumin and mortality in acutely decompensated heart failure. Am Heart J 2010; 160:1149.
  57. Bonilla-Palomas JL, Gámez-López AL, Moreno-Conde M, et al. Hypoalbuminemia in acute heart failure patients: causes and its impact on hospital and long-term mortality. J Card Fail 2014; 20:350.