Non-Cardiogenic Pulmonary Edema Complicating Electroconvulsive Therapy: Short Review of the Pathophysiology and Diagnostic Approach

Abstract

Two types of pulmonary edema occur in clinical medicine: cardiogenic pulmonary edema (or hydrostatic pulmonary edema) and noncardiogenic pulmonary edema, better known as acute lung injury or acute respiratory distress syndrome (ARDS). Their clinical manifestations are very similar, so the differentiation between them, based only on clinical grounds, may be very difficult, and knowing the precise etiology of the episode of acute pulmonary edema has major implications in the treatment plan. Cardiogenic pulmonary edema is usually due to systolic and/or diastolic left ventricular dysfunction and is typically treated with diuretics, nitrates, and afterload reduction medications such as angiotensin converting enzyme inhibitors, although some cases also require coronary revascularization. Noncardiogenic pulmonary edema is usually secondary to a more systemic severe medical or surgical pathology that triggers the event, and the treatment should be directed to treat that pathology. Oxygen supplementation in the form of mechanical ventilation (invasive or non-invasive) is always required. A rapid diagnosis of the cause of the episode of acute pulmonary edema facilitates a timely and appropriate therapeutic intervention.Electroconvulsive therapy (ECT) is recognized as a well-established, highlyeffective, safe psychiatric treatment. It is estimated that 100,000 patients per year receive a course of ECT across the United States, with an average of 8 to 10 treatments per course of therapy. Severe complications are very infrequent and generally reported as transitory cardiac arrhythmias and severe transitory Acute pulmonary edema complicating electroconvulsive therapy is an extremely uncommon event that has rarely been described in the literature. Different theories, including one suggesting a cardiogenic component, have been proposed to explain its genesis. The present report describes a classic presentation of this condition with review of its potential mechanisms and diagnostic approach. After successful completion of a session of electroconvulsive therapy, a 42-year-old woman with major depressive disorder developed acute systemic high blood pressure, shortness of breath, and hemoptysis. A chest radiograph demonstrated diffuse bilateral pulmonary infiltrates. Initially cardiogenic pulmonary edema was presumed, but an extensive diagnostic work-up demonstrated normal systolic and diastolic left ventricular function, and with only supportive measures, a complete clinical and radiographic recovery was achieved within 48 hours. The present case does not support any cardiogenic mechanism in the genesis of this condition.

Neurogenic Pulmonary Edema After Electroconvulsive Therapy in 2 Young Patients

“…In 2 other case reports of NPE associated with ECT, patients also did not have severe cardiovascular comorbidities and had previously received ECTwithout complications. 2,3 However, there are reports of unfavorable outcomes. In the first reported case of post-ECT NPE, published in 1982 by Buisseret,4 the patient died hours after the procedure.…”

“…2 However, there are limited data regarding the management of these symptoms, especially in patients with acute suicidality during an MDE. 2,3 Notably, trials examining management of depressive symptoms in patients with DLB demonstrate lack of efficacy and high adverse effect burden associated with pharmacologic interventions, a concerning finding given the already increased propensity for neuroleptic sensitivity in patients with DLB. 2,3 As such, investigative efforts into nonpharmacologic management strategies like electroconvulsive therapy (ECT) are especially attractive in this population.…”

“…2,3 Notably, trials examining management of depressive symptoms in patients with DLB demonstrate lack of efficacy and high adverse effect burden associated with pharmacologic interventions, a concerning finding given the already increased propensity for neuroleptic sensitivity in patients with DLB. 2,3 As such, investigative efforts into nonpharmacologic management strategies like electroconvulsive therapy (ECT) are especially attractive in this population. Although there is strong evidence substantiating the efficacy of ECT in the treatment of major depressive disorder (MDD), including MDD with psychotic features (MDD-Psy), and other subtypes of dementia, there is a relative paucity of literature exploring the efficacy of ECT in DLB.…”

Prevention and Treatment of Life-Threatening COVID-19 May Be Possible with Oxygen Treatment

“…It is merely a general sign of interstitial pulmonary edema occurring from diverse causes, of which the best characterized is the aforementioned HAPE from HH. Acute GGO has also been described as a serious complication in conditions such as during forceful swimming in triathlons and scuba diving and following electroconvulsive therapy (ECT), epileptic seizures, and CNS insults in general [ 126 , 127 , 128 , 129 , 130 , 131 ]. A characteristic feature of GGOs occurring in these connections is that they rapidly resolved with appropriate therapy, usually consisting of oxygen and diuretics.…”

Electroconvulsive Therapy Use among Depressive Inpatients : Position Statement

“…Case report study of monozygotic twins who were treated with ECT reported prolonged apnea due to anesthesia procedure of ECT that increased suspicion about using ECT as effective therapy (Zavorotnyy & Zwanzger, 2011). Moreover, Electrocardiogram changes during ECT session indicated increasing pulmonary odema (Manne, Kasirye, Epperla & Garcia-Montilla, 2012). On the other hand, pre ECT procedure required full physical and mental assessment due to its precautions on multiple cases as increasing intracranial pressure or tumor, myocardial infarction, heart valve abnormalities, severe liver diseases, severe pulmonary diseases, intra cerebral vascular malformations, osteoporosis, esophageal hernia and others (Baghai& Möller, 2008).…”