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Edema polmonare



Pulmonary edema - respiratory lung disease infographic with flat cartoon man drawing showing his internal organs

Definizione

 

L’edema polmonare è caratterizzato da un aumento del contenuto liquido del polmone con conseguente trasudazione dai capillari nell’interstizio polmonare e successivamente negli alveoli. In base alla differente patogenesi gli edemi polmonari vengono suddivisi in due gruppi: edema polmonare cardiogeno (secondario ad un incremento della pressione idrostatica dei capillari polmonari) ed edema polmonare non cardiogeno o ARDS (secondario ad un aumento della permeabilità dei capillari alveolari).

Aspetti clinico diagnostici

L’edema polmonare cardiogeno trae origine da un un’anomalia del cuore:

L’edema polmonare non cardiogeno è caratterizzato da un’anamnesi positiva per una delle eterogenee cause:

  • Infettive
  • Traumatiche
  • Tossiche
  • Metaboliche
  • Immunologiche
  • Da un esordio recente dei sintomi, con incidenza frequente in pazienti relativamente giovani.

 

 



Eziologia

Tutte le cardiopatie che provocano un sovraccarico di volume o di pressione del ventricolo sinistro o una diminuzione della sua contrattilità, possono essere causa di edema polmonare.

Le cause più frequenti sono:

  • Ipertensione arteriosa, i vizi valvolari mitralici o aortici, le cardiopatie ischemiche, le tachicardie parossistiche prolungate.

Cause extracardiache

  • Infiltrazione delle vie aeree per inalazione di gas di polveri tossiche.
  • Aspirazione del contenuto gastrico durante il vomito.
  • Eccessi di liquidi per via endovenosa.
  • Sequele di annegamento.
  • Interessamento del sistema nervoso centrale, trauma cranio-cerebrale.
  • Passaggio rapido ad altezze elevate.
  • Farmaci: overdose di eroina o di morfina.
  • Blocco dei linfatici per un’infiammazione o un processo neoplastico massivo e acuto.
  • Edema polmonare dopo evacuazione troppo rapide e troppo voluminose di un versamento pleurico o di un ascite.
  • Edema polmonare dopo un intervento di cardiochirurgia in circolazione extracorporea.
  • Lo stato di shock ipovolemico o tossico può complicarsi con una forma particolare di edema polmonare, a predominanza interstiziale (polmone da shock).

 

Fisiopatologia

 

Segni fisici

L’edema cardiogeno è caratterizzato da:

  • Cardiomegalia
  • Galoppo atriale o ventricolare sinistro
  • Versamento pleurico (spesso bilaterale)
  • Polso alterno

L’edema non cardiogeno è caratterizzato da:

  • Assenza di cardiomegalia o di segni clinici di insufficienza cardiaca sinistra.

 

 



Sintomi

Segni funzionali: nell’insufficienza cardiaca sinistra, l’edema polmonare appare durante le prime ore della notte e dopo uno sforzo fisico inabituale. Si manifesta con una dispnea intensa, accessi di tosse soffocanti, con espettorazioni abbondanti, schiumose, rosa salmone. Il malato è obbligato a sedersi, la cianosi è costante e le estremità sono umide e fredde.

Segni fisici: rantoli bollosi, gementi e sibilanti, che che salgono dalla base verso gli apici. Si ascolta talvolta un sibilo respiratorio che può simulare l’asma bronchiale. Il polso rapido, talvolta irregolare (fibrillazione atriale). La pressione arteriosa è variabile e deve essere interpretata in funzione dei valori precedenti all’edema polmonare, che può essere provocata da un’ ipertensione parossistica. Un ritmo di galoppo è frequente.

Diagnosi

L’espettorato e l’auscultazione sono caratteristici. In caso di spasmo bronchiale, l’edema polmonare acuto può simulare l’asma bronchiale. La radiografia del torace consente rapidamente la diagnosi esatta.

 

Prognosi

Dipende dalla patologia causale. La prognosi immediata dell’edema polmonare trattato precocemente non è sfavorevole. Ma, nelle forme di origine cardiaca, la recidiva è frequente e la prognosi a lungo termine resta riservata.



Terapia

La terapia deve essere adattata alla gravità dell’edema polmonare. Le forme minori reagiscono spesso rapidamente alla somministrazione di morfina e di furosemide. Le forme subacute, secondarie a un infarto, una ipertensione parossistica o complicata da stato di shock richiedono una terapia complessa, se possibile in un servizio di cure intensive.

Edema polmonare ad eziologia non cardiaca: la terapia suddetta può anche essere impiegata in quello ad eziologia non cardiaca. L’accento è tuttavia da porre sul trattamento dell’ ipossiemia:

  • Mantenimento della permeabilità delle vie aeree, drenaggio posturale bronco-aspirazione.
  • Intubazione e ventilazione assistita a pressione positiva costante.
  • Antibiotici: sono indicati nell’ edema polmonare acuto secondario di un’infezione polmonare. L’antibiotico viene scelto secondo la clinica e l’aspetto radiologico della sindrome infettiva; dosi elevate per via endovenosa.
  • Corticosteroidi a forti dosi: potrebbe essere efficaci nell”edema acuto con alterazione della permeabilità della membrana alveolo-capillare.
  • Correzione dei disturbi dell’equilibrio idrico e acido-base.

 

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