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Acute pulmonary oedema management

Initial ABCDE approach

Follow usual ABCDE approach if critically ill.

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

Treatment – PODMAN

  • Position (sit up)
  • Oxygen (high-flow initially; titrate to keep oxygen saturations 92-96%, consider CPAP on CCU or HDU)
  • Diuretic if fluid overloaded or usually on it (e.g. furosemide 40mg IV initially) 
  • Morphine if patient anxious/distressed (e.g. morphine 2-4mg IV)
  • Antiemetic if nauseous or giving morphine (e.g. metoclopramide 10mg IV)
  • Nitrates in severe pulmonary oedema (GTN infusion if SBP >110, or 2 puffs GTN spray if SBP 90-110) 

Identify and treat cause

  • ACS → PCI
  • Arrhythmiasee 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)

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
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