What is pulmonary congestion?

Pulmonary congestion, also known as pulmonary edema (or pulmonary oedema), is a condition where too much fluid builds up in the lungs^[1]. This fluid collects in the many tiny air sacs of the lungs, called alveoli, which are normally meant to hold air, not fluid. When these air sacs fill with liquid instead of air, it becomes very hard to breathe^[2].

The lungs need to take oxygen from the air you breathe and put it into your bloodstream. When fluid fills the lungs, they cannot do this job properly. This means the rest of your body does not get enough oxygen^[1]. The feeling has been described as drowning or suffocating^[6].

Pulmonary congestion can develop suddenly, which doctors call acute pulmonary edema. This is a medical emergency that needs immediate care^[1]. The condition can also develop slowly over time, which is called chronic pulmonary edema^[2]. If not treated, pulmonary edema can be life-threatening^[8].

Fortunately, pulmonary congestion is a reversible condition. The faster it is treated, the better the outcome is likely to be^[6].

What causes pulmonary congestion?

The causes of pulmonary congestion can be divided into two main groups: heart-related causes and causes not related to the heart^[2].

Heart-related causes

The most common cause of pulmonary congestion is a heart problem called congestive heart failure^[1][8]. This happens when the heart cannot pump blood properly through the body. When the left side of the heart stops working correctly, blood backs up into the blood vessels in the lungs. As pressure in these blood vessels increases, fluid is pushed out into the air sacs^[2].

Heart problems that can lead to pulmonary congestion include^[2][4]:

• Heart attack
• Weakened heart muscles (a condition called cardiomyopathy)
• Heart valves that are leaky or narrowed
• Sudden, severe high blood pressure
• Abnormal heart rhythm (arrhythmia)
• Inflammation of the heart muscle (myocarditis)
• Fluid around the heart (pericardial effusion)

Causes not related to the heart

Pulmonary congestion can also happen because of other diseases and conditions that do not involve the heart^[2]. Some examples include:

• Pneumonia (lung infection)
• Kidney failure
• Liver failure
• Lung damage from severe infection or blood poisoning (sepsis)
• Exposure to high altitudes (called high altitude pulmonary edema or HAPE)
• Certain medications, including some drugs like heroin, cocaine, and aspirin
• Lung damage from inhaling smoke or poisonous gases
• Major injury or trauma
• Near-drowning
• Blood clots moving to the lungs (pulmonary embolism)
• Blockage in the upper airways

More than one million patients are admitted to hospitals each year with pulmonary edema related to heart failure^[4].

Signs and symptoms

The symptoms of pulmonary congestion depend on whether it develops suddenly or over time^[1].

Sudden (acute) symptoms

When pulmonary congestion develops suddenly, symptoms may include^[1][6]:

• Extreme shortness of breath or difficulty breathing that gets worse with activity or when lying down
• A feeling of suffocating or drowning that worsens when lying down
• A cough that produces frothy mucus (called sputum) that may have blood in it
• A rapid, irregular heartbeat (palpitations)
• Anxiety, restlessness, or a feeling that something bad is about to happen
• Cold, clammy skin
• Wheezing or gasping for breath
• Chest pain (if caused by heart disease)
• Pale or bluish skin
• Excessive sweating

Long-term (chronic) symptoms

When pulmonary congestion develops slowly over time, symptoms may include^[1][8]:

• Waking up at night with a cough or feeling breathless (which may be relieved by sitting up)
• Difficulty breathing with activity or when lying flat
• Fatigue
• More shortness of breath than usual during physical activity
• New or worsening cough
• Rapid weight gain
• Swelling in the legs and feet
• Wheezing

High altitude pulmonary edema

High altitude pulmonary edema (HAPE) can occur in adults and children who travel to high altitudes or rapidly climb mountains^[1]. HAPE is a severe form of altitude sickness that occurs because oxygen levels are lower at higher altitudes^[2]. It can make you tired, weak, achy, and short of breath, and can cause coughing and chest tightness. HAPE is a medical emergency and requires immediate descent and medical treatment^[2].

How is it diagnosed?

Breathing problems require immediate diagnosis and treatment. A healthcare provider will make a diagnosis based on your symptoms, medical history, physical examination, and certain tests^[9].

Physical examination

During the physical exam, the doctor will listen to your lungs and heart with a stethoscope^[8]. They will check for:

• Crackling sounds in the lungs
• Abnormal heart sounds
• Increased heart rate
• Rapid breathing
• Leg or abdominal swelling
• Abnormalities in the neck veins (which can show too much fluid in the body)
• Pale or blue skin color

Tests

Tests that can help diagnose pulmonary congestion include^[4][9]:

• Chest X-ray: This is usually the first test done and can confirm the diagnosis of pulmonary edema
• Blood tests: Including blood chemistry, complete blood count, and tests to measure oxygen and carbon dioxide levels in the blood
• B-type natriuretic peptide (BNP) blood test: Increased levels may signal a heart condition
• Pulse oximetry: A sensor attached to a finger or ear that uses light to measure how much oxygen is in the blood
• Electrocardiogram (ECG or EKG): This painless test records the electrical signals of the heart and can show signs of heart problems or previous heart attack
• Echocardiogram: An ultrasound test that uses sound waves to create images of the heart and can show if there are problems with the heart muscle
• Chest CT scan: Provides more detailed images of the lungs

Treatment options

Pulmonary edema is almost always treated in the emergency room or hospital. You may need to be in an intensive care unit^[8]. The goals of treatment are to improve your ability to breathe, treat the underlying cause, and prevent further damage to allow the lungs to fully recover^[3].

Oxygen and breathing support

Oxygen is the first treatment given and is provided through a face mask or tiny plastic tubes placed in the nose^[8]. In severe cases, a breathing tube may be placed into the windpipe so you can be connected to a breathing machine (ventilator)^[8]. Some patients may need noninvasive pressure support ventilation, such as BiPAP or CPAP, which helps keep the airways open without needing a breathing tube^[14].

Medications

Several types of medicines may be used to treat pulmonary congestion^[8][14]:

• Diuretics: These medicines (often called “water pills”) help remove excess fluid from the body. Furosemide is commonly used and should be given by slow injection into a vein
• Medicines that strengthen the heart muscle: Used when the heart is not pumping properly
• Medicines that control the heartbeat: Help regulate abnormal heart rhythms
• Medicines that relieve pressure on the heart: Including nitrates, which help relax blood vessels and reduce the workload on the heart
• Other medicines: Used when heart failure is not the cause of the pulmonary edema

For patients with very low blood pressure and signs of poor organ function, medicines called inotropes may be needed to help the heart pump more effectively. Dobutamine is usually the first choice in these cases^[14].

Treating the underlying cause

The underlying cause of pulmonary congestion must be identified and treated quickly^[8]. For example, if a heart attack caused the condition, it must be treated right away. If an infection is the cause, antibiotics or antiviral medicines may be needed^[4].

Other treatments

In some cases, additional treatments may be needed^[14]:

• Mechanical ventilation for severe breathing problems
• Intra-aortic balloon pumping (a device that helps the heart pump blood)
• Ultrafiltration (a procedure to remove excess fluid)
• Renal replacement therapy (for kidney-related causes)

Prevention and self-care

If you have been diagnosed with pulmonary congestion or are at risk for developing it, there are important steps you can take at home^[15][21]:

Take your medicines as directed

Take all medicines exactly as prescribed by your doctor. Review all your regular medicines with your healthcare provider. Do not take any natural health products without talking to your doctor first^[15].

Follow a healthy diet

Eating a balanced diet is important. Specific dietary recommendations include^[15]:

• Do not eat more than 2,000 milligrams of sodium (salt) each day. This is less than 1 teaspoon of salt per day, including all the salt in prepared or packaged foods
• Do not add salt while cooking or at the table
• Use garlic, lemon juice, onion, vinegar, herbs, and spices instead of salt
• Eat fewer processed foods and restaurant meals, including fast food
• Use fresh or frozen foods instead of canned
• Check food labels for sodium content

Stay hydrated

Drinking plenty of water helps keep the mucus in your respiratory passages thin and flowing properly^[4]. However, follow your doctor’s instructions about fluid intake if you have been diagnosed with heart failure.

Lifestyle changes

Important lifestyle measures include^[15]:

• Stay away from air pollution, smog, cold dry air, hot humid air, and high altitudes
• Take rest breaks often when doing housework and other activities
• Start light exercise if your doctor approves. Walking is a good way to start if you have not exercised before
• Get enough rest at night. Sleeping with 1 or 2 pillows under your upper body and head may help you breathe easier
• Do not smoke or use other tobacco products. If you need help quitting, talk to your doctor
• Do not use alcohol or illegal drugs

Monitor your condition

Watch for changes in your health and contact your doctor if^[15]:

• Your breathing or wheezing is getting worse
• You are coughing more deeply or more often
• You cough up blood
• You develop a fever
• You have more swelling in your legs or belly
• You experience rapid weight gain

When to seek emergency care

Call emergency services (911 in the United States) immediately if you experience^[15]:

• Severe trouble breathing
• Loss of consciousness
• Symptoms of a heart attack, which may include chest pain or pressure, sweating, shortness of breath, nausea or vomiting, pain spreading to the back, neck, jaw, or arms, lightheadedness or sudden weakness, or a fast or irregular heartbeat

Seek immediate medical care if you have^[15]:

• Trouble breathing or wheezing that is getting worse
• Increased coughing
• Coughing up blood
• Fever
• Increased swelling in your legs or abdomen

The one-year mortality rate for patients admitted to hospital with acute pulmonary edema is up to 40 percent^[12]. However, with prompt treatment, many people recover well. Follow-up care is a key part of your treatment and safety^[15].