Severe pulmonary oedema

Begin treatment before investigations

Investigations

• CXR: cardiomegaly, signs of pulmonary oedema: look for shadowing (usually bilateral), small effusions at costophrenic angles, fluid in the lung fissures, and Kerley B lines (septal linear opacities).
• ECG: signs of MI, dysrhythmias.
• Urea& Creatinine
• Electrolytes
• Troponin
• ABG
• Echo.
• BNP may be helpful if diagnosis in question (high negative predictive value).

Monitor

• BP
• Pulse
• Cyanosis
• Respiratory rate
• JVP
• Urine output
• ABG
• Observe on cardiac monitor.

Management

• Sit the patient upright
• Oxygen: High-flow if reduced SpO2
• IV access
• Monitor ECG: Treat any arrhythmias
• Investigations whilst continuing treatment
• Diamorphine 1.25–5mg IV slowly Caution in liver failure and COPD
• Furosemide 40–80mg IV slowly Larger doses required in renal failure
• GTN: 2 x 0.3mg tablets SL or spray 2 puffs SL (Don’t give if systolic BP <90mmHg)
• Necessary investigations, examination, and history
• Nitrate infusion: If systolic BP ≥100mmHg, (e.g. isosorbide dinitrate 2–10mg/h IVI), keep systolic BP ≥90mmHg
• If the patient is worsening
• Further dose of furosemide 40–80mg
• Consider CPAP: improves ventilation, driving fluid out of alveolar spaces
• Increase nitrate infusion (if able to do so without dropping systolic BP <100mmHg)
• Consider alternative diagnoses (e.g. hypertensive heart failure, aortic dissection, pulmonary embolism, pneumonia)

If systolic BP less than 100mmHg, treat as cardiogenic shock and refer to ICU