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Acute pulmonary oedema management

Include in assessment

  • ECG – the acute LVF may be caused by ACS or an arrhythmia
  • CXR
  • Echocardiogram
  • Catheterise and implement strict fluid balance charting 
  • Serial weights
  • B-type natriuretic peptide
  • Troponin if ACS suspected
  • ABG

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
  • Tamponadepericardiocentesis
  • 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)

Long-term heart failure management

  • Treat cause where possible 
  • Diuretic (e.g. furosemide, bumetanide) if fluid overloaded
  • Treatments with prognostic benefit for heart failure with reduced ejection function (use all)
    • ACE inhibitor or angiotensin receptor blocker or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)
    • β-blocker (e.g. bisoprolol)
    • Aldosterone antagonist (e.g. spironolactone, eplerenone) 
    • SGLT2-inhibitor (e.g. dapagliflozin, empagliflozin)
  • Control specific causes/associated conditions (e.g. hypertension, AF, obesity, diabetes, myocardial ischaemia) for heart failure with preserved ejection function
  • Non-pharmacological treatments
    • Cardiac resynchronisation therapy device: considered if QRS significantly prolonged
    • Implantable cardioverter defibrillator: considered if risk of ventricular arrhythmias

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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