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Pulmonary Edema in Severe

Falciparum Malaria
Udomsak Silachamroon M.D.

Pulmonary Edema
Leakage of fluid into alveoli
Incidence in malaria
Pf ~ 0.1%
21% in cerebral malaria

Associated factors:

Hyperparasitemia
Cerebral malaria
Pregnancy
Renal failure

Mechanisms
Increase pulmonary capillary pressure
Heart failure (cardiogenic PE), volume
overload

Increase alveolar-capillary membrane


permeability (non- cardiogenic PE)
Lung injury: sepsis, shock
Decrease threshold of increase pressure PE

Combination of both mechanisms

Clinical Characteristics
Onset
acute
at presentation or delayed (1-2 days after
treatment)
at the time of recovery of cerebral malaria,
clearing of parasitemia

Progression: rapid

Clinical Characteristics
Symptoms & signs:

tachypnea (most early)


cough, dyspnea, respiratory distress
bilateral basal rales
cyanosis (severe case)

DDx of tachypnea in severe falciparum


malaria: metabolic acidosis, basal atelectasis,
pneumonia (aspiration, infection)

Laboratory Findings
Radiographic findings:
bilateral alveolar edema
no cardiac enlargement in non-cardiogenic PE

Arterial blood gas analysis:


Hypoxemia: various degree depending on
severity
Respiratory alkalosis (hyperventilation,
metabolic acidosis)

Day1

Day 3

Day 4

Day 6

Day 13

CVP & PCWP


Central venous pressure (CVP)
elevated in volume overload
normal in non-cardiogenic PE

Pulmonary capillary wedge pressure


(PCWP): Swan-Ganz catheter
elevated in volume overload
normal in non-cardiogenic PE
cut point - 18 mmHg

Severity
Respiratory failure may occur
Cardiogenic PE: no severity classification
Non-cardiogenic PE
P/F ratio = PaO2/FiO2
Acute lung injury (ALI): P/F <300
Acute respiratory distress syndrome (ARDS):
P/F <200
a part of Multiple Organ Dysfunction
Syndrome (MODS)

Treatment
Specific treatment: antimalarial drugs
Fluid balance:
Keep the lungs dry, diuretic in volume
overload
Not compromising cardiac & renal function

Treatment for hypoxemia:


Supplemental oxygen: volume overload, ALI
Mechanical ventilation with positive end
expiratory pressure (PEEP): ARDS

Prognosis
Mortality: varies (as high as 70% in the
past)
Depending on:

Severity: ARDS
Reversibility of mechanisms; volume
Level of intensive care
Associated complication; intractable shock,
acidosis

Survivors: good recovery