Abstract
By definition, pulmonary edema is simply excess fluid in the lung. The distribution of the fluid dictates the clinical significance of the edema. As far as a mechanism of edema formation, microvascular hydrostatic pressure remains the predominant Starling force. The lung interstitium is a major factor in determining both the amount of edema formed as well as the distribution. Increased permeability edema, with a more peripheral distribution of fluid as seen in the adult respiratory distress syndrome, may well be the result of interstitial matrix and basement membrane changes rather than simply more holes in the endothelial membrane. The significance of the edema, again, depends on its distribution, with perihilar interstitial fluid being much less significant than alveolar flooding. The relevance of the measurement of lung water, therefore, is dependent as much on where the water resides as on the absolute amount. The clinical applicability of methods that do not give information on distribution, therefore, is dependent on the clinician's understanding of the differences in distribution with various disease states and, therefore, the importance of the water in producing the pulmonary abnormalities.
Résumé
Par définition, l'oedème pulmonaire consiste simplement en un excès de liquide au niveau du poumon. La répartition de ce liquide donne sa significación clinique à l'oedème. En ce qui concerne le mécanisme de la formation de l'oedème, la pression hydrostatique microvasculaire reste la force prédominante de Starling. Le tissu interstitiel du parenchyme pulmonaire joue un rôle majeur en déterminant à la fois la quantité d'oedème formé et sa distribution. L'oedème par augmentation de la perméabilité avec une distribution plus périphérique du liquide comme elle est constatée dans le syndrome de détresse respiratoire de l'adulte peut être le résultat de modification de la membrane basale et de la matrice interstitielle plutôt que le résultat de la constitution de nombreux orifices dans la membrane endothéliale. Une fois encore la signification de l'oedème dépend de sa distribution, le liquide interstitiel péri-hilaire étant moins significatif que l'inondation alvéolaire. La valeur de la mesure de l'eau dans le poumon dépend plus de sa localisation que de sa quantité. L'applicabilité clinique des méthodes qui ne permettent pas de préciser la répartition de l'oedème dépend, de ce fait, de la connaissance par le clinicien des différences de distribution de l'oedème en fonction des différents états pathologiques.
Resumen
Por definición el edema pulmonar es simplemente un exceso de líquido en el pulmón. La distribution del líquido determina la significación clínica del edema. En cuanto al mecanismo de formación del edema, la presión hidrostática microvascular sigue siendo la fuerza primaria dentro de la ecuación de Starling. El intersticio pulmonar es el factor determinante principal, tanto del volumen de edema acumulado como de su distribución. El edema por permeabilidad aumentada, con una distribución más periférica del líquido, tal como se presenta en el síndrome de dificultad respiratoria del adulto, parece ser el resultado de cambios en la matrix intersticial y en la membrana basai, más que el simple aumento del número de orificios presentes en membrana endotelial. La significación clínica del edema depende de su distribución, y así el líquido intersticial perihiliar es bastante menos significativo que la inundación alveolar. Por consiguiente la pertinencia de la medición del agua pulmonar se refiere tanto a la ubicación del agua acumulada como a la cantidad absoluta. La aplicación clínica de métodos que no proveen información sobre distribución depende, por lo tanto, de la comprensión por parte del médico de las diferencias de distribución en las diversas condiciones clínicas y, por consiguiente, la importancia del agua en la producción de alteraciones pulmonares.
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Supported in part by NIH grants GM 31622 and HL 30068.
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Demling, R.H. Pulmonary edema: Current concepts of pathophysiology, clinical significance, and methods of measurement. World J. Surg. 11, 147–153 (1987). https://doi.org/10.1007/BF01656396
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DOI: https://doi.org/10.1007/BF01656396