What is the dose of sublingual nitroglycerin (glyceryl trinitrate) for acute pulmonary edema?

From the Guidelines

The recommended dose of sublingual nitroglycerin for acute pulmonary edema is 0.4 mg, repeated every 5 minutes as needed, up to a maximum of 3 doses. To administer:

1. Place one 0.4 mg tablet or spray under the tongue
2. Allow it to dissolve completely
3. Do not swallow
4. Wait 5 minutes and reassess symptoms
5. Repeat up to 2 more times if needed Monitor blood pressure closely, as nitroglycerin can cause hypotension. Do not use if systolic blood pressure is below 90 mmHg. Have the patient sit or lie down during administration to prevent falls. Nitroglycerin works by dilating veins, reducing preload to the heart, and subsequently decreasing pulmonary congestion. It also dilates coronary arteries, improving myocardial oxygen supply. This rapid action helps relieve the symptoms of acute pulmonary edema within minutes. The evidence from the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1 and the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1 supports the use of sublingual nitroglycerin for acute pulmonary edema, with a recommended dose of 0.4 mg repeated every 5 minutes as needed, up to a maximum of 3 doses. Key considerations when administering nitroglycerin include:

• Monitoring blood pressure closely to avoid hypotension
• Avoiding use in patients with systolic blood pressure below 90 mmHg
• Having the patient sit or lie down during administration to prevent falls
• Reassessing symptoms after each dose and repeating up to 2 more times if needed. The most recent and highest quality study, the 2013 ACCF/AHA guideline 1, provides the recommended dose and administration guidelines for sublingual nitroglycerin in the context of acute pulmonary edema.

From the Research

Dose of Sublingual Nitroglycerin for Acute Pulmonary Edema

• The provided studies do not specify the dose of sublingual nitroglycerin for acute pulmonary edema.
• However, the studies discuss the use of intravenous nitroglycerin and its effectiveness in managing acute pulmonary edema 2, 3, 4, 5.
• One study mentions the use of sublingual nitroglycerin but does not provide a specific dose, instead focusing on the use of intravenous nitroglycerin in the prehospital setting 5.
• Another study discusses the use of high-dose nitroglycerin bolus for sympathetic crashing acute pulmonary edema, but it does not provide information on sublingual dosing 4.
• The studies suggest that intravenous nitroglycerin can be effective in managing acute pulmonary edema, but the dose of sublingual nitroglycerin is not specified 6, 2, 3, 4, 5.

Alternative Administration Routes

• The studies primarily focus on intravenous administration of nitroglycerin for acute pulmonary edema, with doses ranging from 1 mg bolus 5 to a mean bolus dose of 872 μg and a mean cumulative dose of 35 mg 4.
• The use of noninvasive ventilation and bilevel positive airway pressure support is also discussed in conjunction with nitroglycerin administration 2, 3, 4.

Safety and Efficacy

• The studies suggest that high-dose nitroglycerin can be safe and effective in managing acute pulmonary edema, with rapid resolution of symptoms and low incidence of adverse events 2, 3, 4, 5.
• However, the dose of sublingual nitroglycerin for acute pulmonary edema remains unclear based on the provided studies.