Approach to patient with Pulmonary edema

Pulmonary edema is a life-threatening condition that occurs due to abnormal fluid build-up in the lungs, leading to impaired gaseous exchange, acute respiratory distress, and may cause respiratory failure. It can be classified as:

• Cardiogenic pulmonary edema – due to increased hydrostatic pulmonary pressure (HF).

• Non-cardiogenic pulmonary edema – due to increased permeability (acute lung injury and allergic alveolitis).

Note

Cardiogenic and non-cardiogenic pulmonary edema have no clear-cut differences in clinical presentation; however, identifying the specific underlying cause of pulmonary edema is significant for therapeutic and prognostic purposes.

Clinical presentation

• Shortness of breath

• Use of accessory muscles

• Diaphoresis

• Tachypnoea

• Crepitations

Investigations

• Chest X-ray

• Blood gases

• Serum creatinine and urea

• POC ECG

• POC troponin

• Serum electrolytes

• Bedside ultrasound

Non-pharmacological management

• Perform both primary and secondary assessment and provide necessary interventions.

• Give high-flow oxygen therapy.

• Put patient on cardiac monitor (if available) and obtain vital signs.

• Position patient at a 45° angle or sitting upright position.

• Perform ECG (rule out ischemia, dysrhythmia).

• Perform bedside ECHO (to rule out cardiac causes—contractility, pericardial effusion).

• Perform chest ultrasound (comet tails and B lines).

Pharmacological management

Control hypertension (for SBP >90 mmHg)

S: Nitroglycerin (IV): Adult loading 100 mcg/min, titrate rapidly to 400 mcg/min over 2 minutes.

CAUTION!

Beware of preload-sensitive conditions, for example inferior or right ventricular myocardial infarction, and phosphodiesterase inhibitor use.

Reduce intravascular volume if fluid overloaded

B: Furosemide (IV/IM): 0.5–1 mg/kg over 20 minutes (maximum 120 mg) or infusion IV 5–10 mg/kg (maximum 120 mg).

CAUTION!

Beware of renal insufficiency and volume-depleted patients; check size of IVC.

Ventilation

• Oxygen therapy (target saturation >95%).

• CPAP or BiPAP (for persistent respiratory distress, hypoxia, or acidosis despite high-flow oxygen therapy).

• Intubation and mechanical ventilation (for respiratory failure despite CPAP/BiPAP).

Disposition

Goal of treatment

• Relieve hypoxemia (improve oxygenation).

• Reduce pulmonary capillary pressure.

• Improve perfusion.

Admission

• Admit all patients with pulmonary edema to HDU/ICU.

• Transfer the patient to a health facility with ICU/HDU capacity if such services are not available.