From the Guidelines
The physical exam for patients with pulmonary edema is expected to include a focused history and physical examination, as outlined in the guidelines for the evaluation and management of heart failure 1. The physical exam typically reveals several characteristic findings, including:
- Respiratory distress with tachypnea, tachycardia, and use of accessory muscles of respiration
- Bilateral crackles (rales) on auscultation of the lungs, more prominent at the lung bases but can extend upward in severe cases
- Wheezing, sometimes referred to as "cardiac asthma"
- Dullness at the lung bases on percussion if pleural effusions are present
- Cardiac examination revealing an S3 gallop, indicating ventricular dysfunction, and possibly an S4 gallop in patients with diastolic dysfunction
- Jugular venous distention, reflecting elevated right-sided pressures
- Lower extremity edema, especially in chronic heart failure
- Elevated or low blood pressure due to sympathetic activation or cardiogenic shock
- Cyanosis in severe cases with significant hypoxemia These findings are consistent with the guidelines for the evaluation and management of heart failure, which recommend a brief medical history and directed physical examination to initiate therapy 1. The physical examination is a crucial component of the initial diagnostic evaluation of acute pulmonary edema, and it should be performed in conjunction with other diagnostic tests, such as continuous ECG monitoring, 12-lead ECG, blood-serum studies, and chest radiograph 1.
From the Research
Physical Exam for Patients with Pulmonary Edema
The physical exam for patients with pulmonary edema typically includes:
- Assessment of respiratory status, including oxygen saturation and presence of crackles or rales over the lung fields 2, 3, 4, 5
- Evaluation of cardiac function, including heart rate and rhythm, and presence of S3 gallop or jugular venous distention 2, 6, 5
- Assessment of peripheral circulation, including presence of edema or cool extremities 2, 5
- Measurement of blood pressure and assessment of overall hemodynamic status 2, 3, 4, 5
Key Findings
Key findings on physical exam may include:
- Fine crepitant rales or crackles over the lung fields, indicating pulmonary edema 3, 4, 5
- S3 gallop, indicating ventricular volume overload 2, 6, 5
- Jugular venous distention, indicating elevated pulmonary venous pressure 2, 6, 5
- Low-flow state, indicated by cool extremities or decreased peripheral pulses 2, 5
Diagnostic Evaluation
The diagnostic evaluation for pulmonary edema may include:
- Chest X-ray to evaluate for pulmonary edema and cardiomegaly 2, 5
- Echocardiography to evaluate cardiac function and estimate pulmonary venous pressure 2, 6, 5
- Blood gas analysis to evaluate oxygenation and ventilation 4, 5
- Laboratory tests, including biomarkers such as BNP or troponin, to evaluate for cardiac injury or dysfunction 5