How to administer Nitrolingual (nitroglycerin) for pulmonary edema?

From the Guidelines

To administer Nitrolingual (nitroglycerin) for pulmonary edema, the recommended dose is 0.4 mg sublingual every 5 min up to 3 doses as blood pressure allows, as stated in the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. When administering Nitrolingual, it is essential to monitor the patient's blood pressure closely, ensuring that their systolic blood pressure remains above 90 mmHg before each dose.

• The patient should be in a seated or supine position during administration to prevent falls if hypotension occurs.
• Contraindications for nitroglycerin administration include suspected right ventricular infarction, systolic blood pressure less than 90 mmHg, or a decrease in systolic blood pressure of more than 30 mmHg below baseline, as well as recent use of phosphodiesterase-5 inhibitors like sildenafil 1.
• Nitroglycerin works by dilating veins, reducing preload, and subsequently decreasing pulmonary congestion, which helps alleviate symptoms of pulmonary edema.
• Common side effects of nitroglycerin include headache, dizziness, and hypotension, and the patient should be closely monitored for these adverse effects. The European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure also emphasize the importance of careful patient monitoring and adjustment of therapy based on clinical response 1.
• In patients with pulmonary edema, it is crucial to assess their clinical status regularly, including symptoms, heart rate, blood pressure, and oxygen saturation.
• The guidelines recommend oxygen therapy, non-invasive ventilation, and diuretic therapy as initial treatments for pulmonary edema, with nitroglycerin administration considered for patients with ongoing chest pain or hypertension 1.

From the Research

Administration of Nitrolingual (Nitroglycerin) for Pulmonary Edema

• Nitroglycerin can be administered in various forms, including sublingual, intravenous, and topical, for the management of pulmonary edema 2, 3, 4, 5, 6
• High-dose nitroglycerin infusion has been shown to be effective in managing sympathetic crashing acute pulmonary edema (SCAPE) by reducing afterload and improving symptoms 2, 4, 6
• The dosage of nitroglycerin can vary, with studies using doses ranging from 10-20 μg/min to ultra-high doses of 9 mg intravenous bolus with 76 mg infusion 3, 5, 6
• Non-invasive ventilation can be used in conjunction with nitroglycerin to manage pulmonary edema and prevent mechanical ventilation 2, 6
• The administration of nitroglycerin should be done with caution, as it can cause hypotension and other adverse effects, although these are rare 3, 5

Key Considerations

• The primary objective of nitroglycerin administration in pulmonary edema is to reduce afterload and improve symptoms 2, 4, 6
• High-dose nitroglycerin infusion may be more effective in achieving blood pressure targets and improving outcomes compared to low-dose infusion 5
• The use of ultra-high dose nitroglycerin bolus and infusion may be safe and effective in managing SCAPE patients, but more studies are needed to confirm this 6
• Non-invasive ventilation and nitroglycerin can be used together to manage pulmonary edema and prevent mechanical ventilation 2, 6