What is the acute management of pulmonary edema in the Emergency Room (ER)?

From the Guidelines

The acute management of pulmonary edema in the ER should prioritize non-invasive positive pressure ventilation (NIPPV) such as CPAP, supplemental oxygen, and intravenous loop diuretics like furosemide, as these interventions have been shown to improve oxygenation, reduce preload and afterload, and enhance diuresis, ultimately reducing pulmonary congestion and improving cardiac function 1.

Key Interventions

• Position the patient upright and administer supplemental oxygen to maintain oxygen saturation above 92%
• Consider NIPPV such as CPAP (starting at 5-10 cmH2O) or BiPAP (inspiratory pressure 10-15 cmH2O, expiratory pressure 5 cmH2O) for severe respiratory distress
• Administer intravenous loop diuretics like furosemide 40-80 mg IV to reduce fluid overload
• Use nitroglycerin 0.4 mg sublingual every 5 minutes or IV infusion starting at 5-10 mcg/min and titrating up to 200 mcg/min to reduce preload by venodilation
• Consider IV nitroglycerin or nitroprusside to reduce afterload in patients with hypertension
• Obtain an ECG, cardiac enzymes, and chest X-ray to identify potential cardiac ischemia or other underlying causes

Rationale

The most recent and highest quality study, published in 2017, supports the use of NIPPV in acute cardiogenic pulmonary edema, demonstrating a reduction in the need for intubation and short-term mortality 1. Additionally, the 2016 ESC guidelines recommend the use of CPAP or BiPAP in patients with acute heart failure and respiratory distress, as it reduces respiratory distress and may decrease intubation and mortality rates 1.

Important Considerations

• Monitor patients closely for signs of respiratory failure, such as hypoxia, hypercapnia, and acidosis, and be prepared to intubate if necessary
• Use caution when administering oxygen therapy, as hyperoxia should be avoided unless contraindicated
• Consider the potential side effects of treatment, such as electrolyte imbalance, and communicate significant changes to the physician promptly.

From the FDA Drug Label

The usual initial dose of furosemide is 40 mg injected slowly intravenously (over 1 to 2 minutes). If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes). If necessary, additional therapy (e.g., digitalis, oxygen) may be administered concomitantly.

The acute management of pulmonary edema in the ER with furosemide (IV) involves:

• Initial dose: 40 mg injected slowly intravenously over 1 to 2 minutes 2
• Dose escalation: If no satisfactory response occurs within 1 hour, the dose may be increased to 80 mg injected slowly intravenously over 1 to 2 minutes
• Additional therapy: Digitalis, oxygen, or other treatments may be administered concomitantly if necessary

From the Research

Acute Management of Pulmonary Edema in the ER

• The goal of therapy is to decrease the pulmonary capillary wedge pressure by decreasing intravascular volume and shifting the blood volume into peripheral vascular beds 3
• Mainstays of therapy include:
  • Morphine sulfate (a venodilator and an anxiolytic)
  • Furosemide (a venodilator and diuretic)
  • Nitroglycerin preparations (venodilators)
  • Aminophylline, nitroprusside, and beta-adrenergic agents or milrinone in some cases 3
• Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema 4
• Nebulized furosemide can be used as an addition to standard treatment and has beneficial effects in the treatment of pulmonary edema, significantly improving respiratory rate and arterial blood oxygen with less hemodynamic changes than intravenous furosemide 5
• Patients who do not respond to more conservative measures may require interventional procedures, including:
  • Swan-Ganz catheterization or arterial pressure monitoring
  • Continuous positive airway pressure or mechanical ventilation
  • Intra-aortic balloon counterpulsation
  • Mechanical removal of fluid 3

Assessment and Monitoring

• Initial assessment, management, and monitoring should occur concurrently and must be modified in response to clinical changes 6
• Evaluation should include Doppler echocardiography, cardiac catheterization, and coronary angiography to define the cause of the edema during and after stabilization of the patient 3