Clinical Review Lesson of the week

Central venous air embolism causing pulmonary oedema mimicking left ventricular failure

BMJ 1998; 316 doi: (Published 14 February 1998) Cite this as: BMJ 1998;316:604
  1. Alan Fitchet, specialist registrar in cardiology (,
  2. Adam P Fitzpatrick, consultant cardiologist
  1. University Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester M13 9WL
  1. Correspondence to: Dr Fitchet
  • Accepted 8 September 1997

Venous air embolism should be considered in the differential diagnosis of acute pulmonary oedema

Central venous air embolism is recognised as a cause of acute cardiorespiratory collapse, and up to 50% mortality has been reported.1 A rare and more insidious presentation is that of non-cardiogenic pulmonary oedema.

Case report

A 71 year old woman presented with irregular palpitations. Resting 12 lead electrocardiogram showed sinus rhythm at 95 beats per minute, first degree heart block (PR interval 360 ms), left axis deviation, and anteroseptal Q waves suggestive of a previous myocardial infarction. These results were similar to those seen in an electrocardiogram performed in 1991.

Asymptomatic episodes of complete atrioventricular block, frequent ventricular extrasystoles, and infrequent episodes of non-sustained ventricular tachycardia were found on Holter monitoring. She was admitted to hospital to await transfer for insertion of a pacemaker. An Arrowset 8.5 French gauge Swan-Ganz introducer (Arrow International, Reading, PA) was inserted into the right subclavian vein, and a 6 French gauge temporary pacing wire was passed through it. A chest radiograph taken after insertion was normal.

During the first 24 hours after insertion amiodarone hydrochloride 1325 mg was given through the side arm of the subclavian catheter followed by 200 mg orally daily thereafter for 5 days. Displacement of the pacing wire twice in one night occurred 6 days after insertion and necessitated repositioning. A stable paced rhythm of 80 beats per minute was achieved, but she developed clinical and radiographic evidence of pulmonary oedema within 4 hours of the pacing wire being repositioned. Repeated doses of diuretics were given intravenously over 6 hours but did not relieve the patient's symptoms. Because her condition continued to deteriorate, she was …

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