Acute pulmonary oedema management

Initial ABCDE approach

Follow usual ABCDE approach if critically ill.

Treatment – POND

• Position (sit up)
• Oxygen (high-flow initially; titrate to keep oxygen saturations 92-96%, consider CPAP on CCU or HDU if required)
• Nitrates in severe pulmonary oedema (GTN infusion if SBP >110, or 2 puffs GTN spray if SBP 90-110) 
• Diuretic if fluid overloaded or usually on it (e.g. furosemide 40mg IV initially) 
• +treat cause

Identify and treat cause

• ACS → see notes on ACS
• Arrhythmia → see notes on arrhythmias
• Tamponade → pericardiocentesis
• Acute aortic/mitral regurgitation → valve replacement
• Hypertensive crisis → BP management
• Fluid overload → regular furosemide

Further interventions if required

• CPAP if hypoxaemic despite above interventions
• Inotropes ± intra-aortic balloon pump in ICU if in cardiogenic shock (hypotension + overload)

Test your knowledge

What is the formula to determine cardiac output?

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What is preload, contractility and afterload? How are they related to stroke volume? What happens to these in heart failure?

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How do nitrates work in severe pulmonary oedema?

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In a patient admitted with fluid overload receiving intravenous diuresis, what is your daily fluid balance and weight loss target?

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