What are the tips to optimize success in intubation with severe pulmonary edema from cardiogenic shock?

From the Guidelines

To optimize success in intubating patients with florid pulmonary edema from cardiogenic shock, prioritize preoxygenation with non-invasive positive pressure ventilation (NIPPV) or high-flow nasal cannula, as recommended by the European Respiratory Journal study 1, which demonstrated decreased mortality and need for intubation with NIV in patients with acute respiratory failure. However, it's crucial to note that this recommendation may not directly apply to patients with cardiogenic shock, as highlighted in the study 1. Given the high-risk nature of intubation in these patients, a rapid sequence intubation approach with careful selection of induction agents and paralysis is essential. The use of etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) for induction is preferred due to their ability to maintain hemodynamic stability, as opposed to propofol, which can cause hypotension. For paralysis, rocuronium (1.2 mg/kg) or succinylcholine (1.5 mg/kg) can be used. Having vasopressors ready before intubation, such as norepinephrine (0.05-0.5 mcg/kg/min) or push-dose phenylephrine (50-200 mcg) or epinephrine (5-20 mcg), is crucial to counteract potential post-intubation hypotension. Video laryngoscopy, if available, can improve first-pass success. Post-intubation, lung-protective ventilation strategies with low tidal volumes (6-8 mL/kg ideal body weight) and moderate PEEP (8-12 cmH2O) should be implemented to improve oxygenation while avoiding barotrauma, as suggested by the principles of managing cardiogenic shock 1. Additionally, considering diuretics like furosemide (40-80 mg IV) post-intubation may help reduce pulmonary edema. Key considerations in managing these patients include:

• Preoxygenation to increase oxygen reserves
• Careful selection of induction and paralysis agents to maintain hemodynamic stability
• Readiness to manage post-intubation hypotension with vasopressors
• Implementation of lung-protective ventilation strategies
• Consideration of diuretics to reduce pulmonary edema, all of which are guided by the principles outlined in 1 and the comprehensive approach to cardiogenic shock management 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Optimizing Success in Intubation with Florid Pulmonary Edema from Cardiogenic Shock

To optimize success in intubation with florid pulmonary edema from cardiogenic shock, several key points should be considered:

• Ensuring hemodynamic stability and correcting hypoxemia are crucial initial steps in managing acute pulmonary edema 2.
• The use of vasodilators such as nitroglycerin, loop diuretics, and in specific instances, opioids, can be beneficial in the management of acute pulmonary edema 2.
• In cases of cardiogenic shock, treatment consists of general measures to reverse acidosis and hypoxemia, as well as the use of vasopressors and inotropic drugs 2.
• Positive pressure ventilation (PPV) can improve gas exchange and cardiovascular hemodynamics in patients with cardiogenic shock, but requires careful consideration of cardiopulmonary interactions 3.
• Noninvasive ventilation, such as high-flow nasal cannula oxygen, can be used to stabilize oxygenation and ventilation in patients with cardiogenic pulmonary edema 4.
• The use of nitrates, such as nitroglycerin, can help reduce pre- and afterload, and prevent intubation in patients with acute pulmonary edema without cardiogenic shock 5.
• A treatment protocol and algorithm can be developed for the prevention of intubation in patients with acute pulmonary edema or sympathetic crashing acute pulmonary edema (SCAPE) and hypoxia without cardiogenic shock 5.

Key Considerations for Intubation

When considering intubation in patients with florid pulmonary edema from cardiogenic shock:

• Early stabilization of oxygenation and ventilation is crucial 4.
• The use of positive pressure ventilation (PPV) requires careful consideration of cardiopulmonary interactions to avoid hemodynamic deterioration 3.
• Noninvasive ventilation can be used to reduce the work of breathing and improve oxygenation in patients with cardiogenic pulmonary edema 4, 6.
• The selection of ventilator settings, induction, and sedation methods should be tailored to the individual patient's needs 3.
• An algorithm for liberation from PPV should be developed to ensure safe and effective weaning from mechanical ventilation 3.