What are the treatment options for lung congestion?

Treatment of Lung Congestion

For lung congestion related to heart failure, immediately administer intravenous loop diuretics (furosemide, torsemide, or bumetanide) as first-line therapy to reduce fluid overload and improve symptoms, while ensuring oxygen supplementation to maintain arterial saturation >90%. 1, 2

Immediate Pharmacological Management

First-Line Therapy: Diuretics

• Intravenous loop diuretics should be administered promptly to patients with pulmonary congestion and evidence of volume overload 1, 2
• Low- to intermediate-dose furosemide, torsemide, or bumetanide are recommended 1
• Caution: Avoid diuretics in patients who have not received volume expansion, as they may worsen hemodynamics 1
• Therapy should be titrated to resolve clinical evidence of congestion to reduce symptoms and rehospitalizations 1
• For optimal efficacy with bolus injections, maintain a 6-hour interval between doses to maximize tubular diuretic concentration 1

Oxygen Therapy

• Oxygen supplementation is mandatory for patients with pulmonary congestion to maintain arterial saturation >90% 1, 2
• In patients with pulmonary edema and oxygen saturation <90%, oxygen therapy should be administered to maintain saturation >95% 2

Vasodilator Therapy

• Nitrates should be administered to patients with pulmonary congestion unless systolic blood pressure is <100 mmHg or >30 mmHg below baseline 1, 2
• Nitrates are recommended for symptomatic heart failure patients with systolic blood pressure >90 mmHg to improve symptoms and reduce congestion 2

Morphine Sulfate

• Morphine should be given to patients with pulmonary congestion to relieve dyspnea and anxiety 1, 2
• Respiratory monitoring is required when administering morphine 2

Blood Pressure-Guided Algorithm

If Systolic BP ≥100 mmHg:

• Start IV loop diuretics + nitrates + morphine + oxygen 1, 2
• Initiate ACE inhibitor with low-dose titration (e.g., captopril 1-6.25 mg) 1

If Systolic BP <100 mmHg or >30 mmHg Below Baseline:

• Avoid nitrates and ACE inhibitors 1
• Administer IV loop diuretics cautiously 1
• These patients often require circulatory support with inotropic agents (dobutamine infusion) and/or vasopressor agents 1
• Consider intra-aortic balloon counterpulsation to relieve pulmonary congestion and maintain adequate perfusion 1

Non-Invasive Ventilatory Support

• Non-invasive positive pressure ventilation should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SaO2 <90%) without hypotension 2
• This intervention can reduce the work of breathing and improve oxygenation in acute pulmonary edema 2

Long-Term Management Post-Stabilization

Secondary Prevention Medications:

• Beta-blockade should be initiated before discharge for secondary prevention 1
• For patients remaining in heart failure throughout hospitalization, start with low doses and gradually titrate on an outpatient basis 1
• Long-term aldosterone blockade should be prescribed for post-event patients without significant renal dysfunction (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women) or hyperkalemia (potassium ≤5.0 mEq/L) who are already receiving therapeutic doses of an ACE inhibitor and have LVEF ≤0.4 1

Monitoring Parameters

Clinical Assessment:

• Careful measurement of fluid intake and output, vital signs, daily weight, and clinical signs of congestion 2
• Lung ultrasound to assess B-lines can detect pulmonary congestion with 94% sensitivity and 92% specificity 1, 2
• Natriuretic peptides (BNP or NT-proBNP): A decrease >30% at day 5 with discharge value <1500 pg/mL indicates good prognosis 1

Imaging Tools:

• Chest X-ray signs include peri-bronchial cuffing, cardiomegaly, pulmonary venous congestion, and pleural effusion 1
• Transthoracic echocardiography is the gold standard for evaluating volume status and left ventricular filling pressures (E/e' ratio) 1

Critical Pitfalls to Avoid

• Never administer beta-blockers or calcium channel blockers acutely to patients with frank cardiac failure evidenced by pulmonary congestion 2
• Do not delay diuretic administration in patients with clear volume overload, as this may increase mortality risk 1
• Avoid aggressive volume loading in patients with clinical evidence of volume overload 1
• Rhythm disturbances or conduction abnormalities causing hypotension must be corrected immediately 1

Underlying Etiology Identification

Identify and treat the precipitating cause immediately using the CHAMPIT acronym 1:

• Coronary syndrome (acute MI)
• Hypertensive emergency
• Arrhythmias (rapid or severe bradycardia)
• Mechanical causes (pulmonary embolism, valve rupture)
• Pericardial tamponade
• Infection (myocarditis, endocarditis)
• Toxins/medications

For patients with cardiogenic shock or mechanical complications (ventricular septal rupture, papillary muscle rupture), coronary artery revascularization with PCI or CABG is strongly recommended and has been shown to decrease mortality 1