What is the dilution for Nitrolingual (nitroglycerin) in the treatment of pulmonary edema?

From the Guidelines

Nitrolingual (nitroglycerin) should be administered intravenously at 10-20 mcg/min, titrated upward to 200 mcg/min, in patients with pulmonary edema and a systolic blood pressure (SBP) ≥ 90 mmHg, as recommended by the most recent and highest quality study 1. The recommended dosing is based on the study published in the European Journal of Heart Failure in 2010, which provides guidance on the management of acute heart failure due to peripartum cardiomyopathy.

• Key considerations for the use of nitroglycerin in pulmonary edema include:
  • Monitoring blood pressure closely during administration to avoid hypotension
  • Avoiding use in patients with severe hypotension (systolic BP < 90 mmHg)
  • Avoiding use in patients with right ventricular infarction or those who have recently taken phosphodiesterase-5 inhibitors like sildenafil
• The dual action of nitroglycerin, causing venodilation and reducing preload and pulmonary congestion, and at higher doses causing arterial dilation, reducing afterload and improving cardiac output, makes it particularly effective for pulmonary edema, especially when caused by acute heart failure or myocardial infarction.
• Other studies, such as the 2012 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1 and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1, also provide guidance on the use of nitroglycerin in pulmonary edema, but the 2010 study 1 is the most relevant and highest quality study for this specific question.

From the Research

Treatment of Pulmonary Edema

• The provided studies do not directly address the dilution for Nitrolingual (nitroglycerin) in the treatment of pulmonary edema.
• However, the studies discuss the use of non-invasive ventilation and nitrate therapy in the management of acute cardiogenic pulmonary edema 2, 3, 4, 5, 6.
• One study found that nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema, with similar effectiveness in improving oxygenation 4.
• Another study found that non-invasive positive pressure ventilation (NPPV) is an effective and safe intervention for the treatment of adult patients with acute cardiogenic pulmonary oedema, reducing hospital mortality and endotracheal intubation 6.

Nitroglycerin Therapy

• A study from 1998 found that nitroglycerin/N-acetylcysteine (NTG/NAC) therapy is as effective as furosemide/morphine in the initial management of acute pulmonary edema, regardless of the presence or absence of respiratory failure 4.
• However, the study does not provide information on the dilution for Nitrolingual (nitroglycerin) in the treatment of pulmonary edema.

Non-Invasive Ventilation

• Several studies discuss the use of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema, including continuous positive airway pressure (CPAP) and non-invasive positive-pressure ventilation (NPPV) 2, 3, 5, 6.
• The studies found that non-invasive ventilation is effective in reducing the need for endotracheal intubation and improving oxygenation, but does not provide information on the dilution for Nitrolingual (nitroglycerin) in the treatment of pulmonary edema.