Modern Management of Cardiogenic Pulmonary Edema
Section snippets
Pathophysiology
CPE results from leakage of fluid from the pulmonary capillaries and venules into the alveolar space as a result of increased hydrostatic pressure. When the pulmonary capillary hydrostatic pressure exceeds pulmonary interstitial pressure, fluid transudates into the pulmonary alveoli and interstitium [2]. Hydrostatic pressure rises when the left ventricle (LV) is unable to effectively handle its pulmonary venous return [4]. Once fluid begins to build up in the pulmonary interstitium, a vicious
Etiologies
There are five major causes of CPE in clinical practice (Box 1). The most common cause is an acute exacerbation of chronic LV failure. Chronic LV failure usually is the result of congestive heart failure (CHF) or a cardiomyopathy. An acute exacerbation of chronic LV failure can occur because of medication or dietary noncompliance (eg, discontinuation of diuretic medications, excessive salt intake, and so forth) or from acute cardiac ischemia.
Patients without a prior history of chronic LV
Emergency department evaluation
Traditionally, the diagnosis of CPE in the ED has been based on history, physical examination, and chest radiography. Most patients presenting with CPE have a prior history of CHF. Most report the onset of dyspnea on exertion progressing to dyspnea at rest, orthopnea, peripheral edema, and paroxysmal nocturnal dyspnea. The progression of symptoms before ED presentation may take hours to days; however, an episode of acute ischemia or acute valvular dysfunction may cause symptoms to progress much
Emergency department management
Initial management of patients who experience CPE should focus on the “ABCs” of resuscitation. Large bore intravenous (IV) lines should be in place to administer needed medications. Patients should be placed in an upright sitting position attached to a cardiac monitor and pulse oximetry. Supplemental oxygen should be provided by way of a facemask with fraction of inspired oxygen of 1.0. If the patient remains persistently hypoxic despite the supplemental oxygen, or if the patient develops
Preload reduction
The first goal in pharmacologic treatment of CPE is preload reduction. Preload reduction reduces right heart and pulmonary venous return and, therefore, right-heart filling pressures and pulmonary capillary hydrostatic pressures, resulting in early symptomatic improvements in dyspnea. The typical medications used for preload reduction are nitroglycerin, morphine sulfate, and loop diuretics. More recently, a recombinant form of beta-natriuretic peptide known as nesiritide has been used for
Noninvasive positive pressure ventilation
NPPV has been used successfully in patients who present with CPE and has gained popularity amongst acute care physicians. There are two types of NPPV, continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). In CPAP, the patient breaths against a continuous flow of positive airway pressure. In BiPAP, the patient receives additional positive pressure during inspiration. As a result, higher pressures can be applied during inspiration and lower pressures during
Assisted circulation
Placement of an intra-aortic balloon pump (IABP) can be a life-saving intervention in patients who experience CS. Shock in these patients is usually the result of a large AMI or acute valvular disorder. The IABP serves as a temporizing measure while preparations for more definitive therapies are made. IABP counterpulsation provides blood pressure support while also providing improvements in coronary diastolic perfusion, afterload, and cardiac output. Definitive therapy for the patient who
Disposition
Although patients who experience mild CHF decompensations that are attributable to dietary indiscretions (excessive salt intake) or medication noncompliance can receive diuretics in the ED for symptomatic improvement and be discharged, patients who present with pulmonary edema should be admitted to a cardiac-monitored bed. Patients who require mechanical ventilation, experience acute valvular dysfunction, require inotropic support, and present with evidence of acute cardiac ischemia/infarction
Summary
CPE is a life-threatening condition associated with an in-hospital mortality rate of 15% to 20%. To minimize morbidity and mortality, physicians must be able to promptly diagnose and treat these patients. The use of BNP testing is associated with improvements in diagnostic ability beyond physical assessment and chest radiography. Treatment should focus on fluid redistribution through preload and afterload reduction rather than simply diuresis. The most effective and safest preload-reducing
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2017, Journal of Emergency MedicineCitation Excerpt :The patient may provide a history of orthopnea or paroxysmal nocturnal dyspnea. Treatment of “flash” pulmonary edema usually involves venodilators and positive pressure ventilation, and therapy must be tailored to the individual patient (for example, the degree of volume overload or lack thereof, evidence of an ischemic cardiac cause, etc.) (7,8). Diuretics can be added after appropriate venodilation in patients with flash pulmonary edema.
Morphine in the treatment of acute pulmonary oedema - Why?
2016, International Journal of CardiologyCitation Excerpt :The third drug, morphine, has been used due to its anticipated anxiolytic and vasodilatory properties. During the last decade, a discussion about the benefits and especially the risks accompanying the use of morphine in cases of pulmonary oedema has been raised [1,4,8–11]. In a retrospective study from 2008 based on the ADHERE registry, morphine given in acute decompensated heart failure was an independent predictor of increased hospital mortality, with an odds ratio of 4.8 (95% CI: 4.52–5.18, p < 0.001) [2].
Congestive Heart Failure
2015, Emergency Medicine Clinics of North AmericaPostoperative Intensive Care Management in Adults
2015, Transplantation of the Liver: Third EditionPrehospital Use of Continuous Positive Airway Pressure: Implications for the Emergency Department
2009, Journal of Emergency Nursing