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Cardiogenic Pulmonary Oedema

Even a simple bedside echo can help in the diagnosis and treatment. Get one as soon as possible. Causes of flash pulmonary oedema includes severe left ventricular (LV) dysfunction, paroxysmal arrhythmias, three-vessel or left main stem coronary disease, in the context of hypertension, renal artery stenosis and phaeochromocytoma.

Clinical

SOB, orthopnoea (needing to sleep on more pillows), frothy sputum,
Tachypnoea, fine inspiratory crackles

Investigations

Bloods: FBC (anaemia/infection?)
U&Es (renal function), CRP
BNP <100 = normal, BNP 100-400 = some degree of HF likely, >400 = 95% chance of heart failure)
Troponin: exclude MI
Chest X-ray :cardiomegaly, upper lobe diversion, bat wing alveolar oedema, Kerley B lines
ABG: hypoxia (DDx COPD, Pneumonia)
Echo: Poor LV function, ?ejection fraction. Check patient centre, old EDNs and EPR for old ECHO reports.
ECG: may show arrhythmia, acute STEMI, old infarcts, LV hypertrophy or strain. Normal ECG makes heart failure unlikely.

Management

Sit up and give O2 to maintain SpO2 >94%. If severe call ITU ASAP as input may be needed. Monitor obs including HR, RR, BP and SpO2 whilst giving 40-120mg IV furosemide (start at 40mg and work up) +/- diamorphine 1mg boluses IV (up to 5mg). Watch RR and SpO2 as can cause resp depression. Further management should be guided by BP
IV Furosemide 40-80 mg IV. Higher or repeated doses may be needed
Morphine 2.5-5 mg slow IV or Diamorphine 2.5 mg + Metoclopramide 10 mg IV
Consider GTN spray. Consider IV Nitrate if BP > 110 mmHg
Consider Continuous positive airways pressure (CPAP) 5-10 mmHg can be every effective
Control rate with Digoxin if AF. Amiodarone or DC countershock
Look for treatable Causes - STEMI, Arrhythmias, Aortic stenosis - Bedside Echo can be invaluable
Treat hypertension with IV Nitrates.
Dialysis/Ultrafiltration if oliguric and renal failure

Using IV nitrates

Systolic BP >100 : give 2 sprays of sub-lingual GTN (400mcg per dose) followed by IV GTN infusion, starting at 4mg/hour and increasing by 2mg/hour every 10 minutes usual range 4- 10mg/hour. Aim to keep systolic BP >100.
Systolic BP <100 (unless BP normal for them. Ask pt, heart failure book, old EDNs, GP records etc.) the patient may be in cardiogenic shock. Call ITU as inotropes usually required if in cardiogenic shock. Do NOT give nitrates.
If no improvement gives furosemide up to 120mg total and consider CPAP. Insert catheter for fluid balance +/- CVP monitoring. Call outreach/ITU.
Don't stop B blockers in patients already taking them unless heart rate <50bpm.
If usually on diuretics, give usual dose but IV e.g 1mg bumetanide = 40mg furosemide IV.
Once condition stabilised start or restart B blockers in hospital.
Offer ACEi or ARB if intolerable side effects in those with acute heart failure and?LVEF. Offer aldosterone antagonist if ACEi or ARB not tolerated.

Ongoing care

Daily weights and Fluid balance chart and fluid restriction if heart failure (1.5L/day)
Document LV function with ECHO and optimise Rx of heart failure if present (If no ECHO in last 12 months needs inpatient ECHO)
Opmise heart failure medication and Monitor renal function

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. The official launch will be at the end of 2018. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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