What is the management of haemodynamically unstable acute pulmonary edema?

From the Guidelines

Management of hemodynamically unstable acute pulmonary edema requires immediate intervention with a focus on improving oxygenation, reducing preload and afterload, and addressing the underlying cause, as outlined in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The initial approach should involve positioning the patient upright to decrease venous return and improve respiratory mechanics.

• Administer high-flow oxygen via non-rebreather mask or consider non-invasive positive pressure ventilation (NIPPV) such as CPAP at 5-10 cmH2O or BiPAP with inspiratory pressure 10-15 cmH2O and expiratory pressure 5 cmH2O to reduce work of breathing and improve oxygenation, as suggested by the recommendations on pre-hospital & early hospital management of acute heart failure 1.
• If respiratory failure persists, proceed to endotracheal intubation and mechanical ventilation.
• Give intravenous loop diuretics such as furosemide 40-80mg IV (higher doses if the patient has been on chronic diuretics) to reduce pulmonary congestion.
• For patients with systolic blood pressure >100 mmHg, administer nitroglycerin starting at 10-20 mcg/min IV and titrate upward to reduce preload, as recommended in the guidelines for the evaluation and management of heart failure 1.
• For severely hypotensive patients (systolic BP <90 mmHg), initiate inotropic support with dobutamine 2-20 mcg/kg/min or norepinephrine 0.01-3 mcg/kg/min if there's evidence of cardiogenic shock.
• Morphine 2-4mg IV can be considered for its anxiolytic and venodilatory effects but use cautiously due to respiratory depression risk.
• Continuous cardiac monitoring, frequent vital sign checks, and serial arterial blood gases are essential, as emphasized in the 2016 ESC guidelines 1.
• Treat the underlying cause, which may include acute coronary syndrome (consider urgent coronary angiography), arrhythmias (rate/rhythm control), or valvular dysfunction. These interventions work by reducing venous return to the heart, decreasing pulmonary capillary hydrostatic pressure, improving cardiac contractility, and enhancing oxygenation, ultimately resolving the pulmonary edema and stabilizing the patient's hemodynamic status, in line with the recommendations from the European Society of Cardiology 1 and the Heart Failure Association of the European Society of Cardiology 1.

From the Research

Management of Haemodynamically Unstable Acute Pulmonary Oedema

• The management of acute pulmonary oedema requires immediate intervention with a management plan and an evidence-based treatment protocol 2.
• Noninvasive ventilation may reduce intubation rate and mortality in patients with acute cardiogenic pulmonary edema 3.
• Clinical characteristics, such as higher systolic blood pressures and left ventricular ejection fraction, can help identify patients with acute pulmonary oedema 4.
• Patients with haemodynamically unstable acute pulmonary embolism, especially those with COVID-19, require early detection and prompt treatment with systemic thrombolysis 5.
• Advanced treatment options, such as interventional and surgical therapies, may be considered for patients with high-risk acute pulmonary embolism who are unresponsive to thrombolytic therapy and anticoagulation 6.

Treatment Options

• Noninvasive ventilation, including continuous positive airway pressure (CPAP) and bilevel noninvasive pressure support ventilation (NIPSV), can reduce the need for intubation and mortality in patients with acute cardiogenic pulmonary edema 3.
• Systemic thrombolysis is a first-line treatment for haemodynamically unstable acute pulmonary embolism, especially in patients with COVID-19 5.
• Anticoagulant therapy, in addition to systemic thrombolysis, is a mainstay of medical therapy for patients with high-risk acute pulmonary embolism 6.

Risk Stratification and Multidisciplinary Approach

• Early and accurate risk stratification is crucial in the management of haemodynamically unstable acute pulmonary oedema 4, 6.
• A multidisciplinary team approach, in the form of a pulmonary embolism response team, is essential for improving outcomes in patients with high-risk acute pulmonary embolism 6.