What is the treatment for pulmonary edema?

Treatment of Pulmonary Edema

The treatment of acute pulmonary edema should begin immediately with non-invasive positive pressure ventilation (CPAP or BiPAP) combined with high-dose intravenous nitroglycerin and low-dose furosemide, while positioning the patient upright. 1, 2

Immediate Respiratory Support (First Priority)

Non-invasive ventilation is the cornerstone intervention and must be applied before considering intubation. 3

• Apply CPAP (5-15 cmH₂O) or BiPAP immediately, as this significantly reduces both mortality (RR 0.80) and need for intubation (RR 0.60) 1, 2
• When available, initiate CPAP/NIV in the pre-hospital setting, which further decreases intubation need (RR 0.31) 1, 3
• Position patient upright or semi-seated to decrease venous return and pulmonary congestion 1, 2
• Administer supplemental oxygen only if SpO₂ <90%; avoid routine oxygen in non-hypoxemic patients as it causes vasoconstriction and reduces cardiac output 3
• Target oxygen saturation of 94-98% (or 88-92% if at risk of hypercapnia) 2

Pharmacological Management (Blood Pressure-Guided Algorithm)

For Systolic BP >100 mmHg (Most Common Presentation)

The European Society of Cardiology recommends high-dose intravenous nitrates combined with low-dose furosemide as superior to high-dose diuretic monotherapy alone. 2

Nitroglycerin Protocol:

• Start with sublingual nitroglycerin 0.4-0.6 mg, repeated every 5-10 minutes up to four times 1, 2, 3
• Transition to IV nitroglycerin at 0.3-0.5 μg/kg/min (or 5 mcg/min), increasing by 5 mcg/min every 3-5 minutes 1, 2
• Titrate to the highest hemodynamically tolerable dose to achieve optimal vasodilation 1, 2
• Monitor for tolerance to nitrates, which develops rapidly when given intravenously in high doses 1

Furosemide Protocol:

• Initial dose: 40 mg IV as a slow bolus over 1-2 minutes 2, 3
• Patients on chronic loop diuretics require higher initial doses 3
• Keep furosemide doses judicious, as aggressive diuresis is associated with worsening renal function and increased long-term mortality 2
• If urine output is <100 mL/h over 1-2 hours, double the dose up to equivalent of furosemide 500 mg 3

For Hypertensive Pulmonary Edema (SBP >160 mmHg)

Aim for rapid initial reduction of systolic or diastolic BP of 30 mmHg within minutes, followed by more progressive decrease over several hours. 3

• Sodium nitroprusside is the drug of choice when nitroglycerin is insufficient 2
• Starting dose: 0.1-0.3 μg/kg/min, titrated to effect 1, 2
• Maximum dose: 10 mcg/kg/min due to cyanide toxicity risk 2
• Target systolic BP reduction from 150-160 mmHg to 100-120 mmHg 2

For Systolic BP <70 mmHg (Cardiogenic Shock)

• Norepinephrine 30 μg/min IV 2
• Consider intraaortic balloon pump (IABP) 2

Adjunctive Pharmacological Therapy

Morphine may be considered in the early stage for patients with severe acute heart failure, particularly when associated with restlessness and dyspnea. 2, 3

• Morphine reduces anxiety, decreases preload, and improves dyspnea 2
• Avoid morphine in respiratory depression or severe acidosis 3

Management of Specific Underlying Causes

Acute Coronary Syndrome

• Urgent myocardial reperfusion therapy (cardiac catheterization or thrombolytic therapy) is required 1, 3
• Perform 12-lead ECG immediately to identify acute myocardial infarction/injury 3

Acute Valve Incompetence

• Obtain surgical consultation early for patients with acute valve incompetence from endocarditis 3
• Perform surgical intervention promptly in severe acute aortic or mitral regurgitation 3

Aortic Dissection

• Immediate diagnosis and surgical consultation are warranted 3
• Use transoesophageal echocardiography to assess valve morphology and function 3

Advanced Interventions for Refractory Cases

Pulmonary artery catheter monitoring should be considered in patients with deteriorating clinical course, uncertainty about diagnosis, or requirement for high-dose vasodilators or inotropes. 1, 3

• Reserve pulmonary artery catheterization for patients refractory to pharmacological treatment, persistently hypotensive, or with uncertain LV filling pressure 3

Intraaortic balloon counterpulsation (IABP) may benefit patients with severe refractory pulmonary edema or those requiring urgent cardiac catheterization and intervention. 1, 3

Critical Medications to AVOID

Never administer beta-blockers in patients with frank cardiac failure evidenced by pulmonary congestion (Class I recommendation). 1, 2, 3

• Beta-blockers carry risk of precipitating acute heart failure in patients with compensated CHF 2
• Verapamil and diltiazem should also be avoided due to their myocardial depressant activity 2
• Avoid aggressive simultaneous use of multiple hypotensive agents, which initiates a cycle of hypoperfusion-ischemia 1, 3
• Oral medications are explicitly discouraged due to unpredictable absorption from splanchnic hypoperfusion and too-slow onset of action (30-60 minutes) 2

Monitoring Parameters

Monitor continuously for at least the first 24 hours: 3

• Systolic blood pressure, heart rate and rhythm 1, 2, 3
• Oxygen saturation and respiratory rate/work of breathing 2, 3
• Urine output 1
• Renal function 2
• Symptoms of dyspnea, orthopnea, and treatment-related adverse effects (symptomatic hypotension) 3

Concurrent Diagnostic Evaluation

• Chest radiograph to confirm bilateral pulmonary congestion 3
• Cardiac enzymes, electrolytes, BUN, creatinine, CBC 3
• BNP/NT-proBNP 3
• Arterial blood gases/pulse oximetry 3
• Transthoracic echocardiography 3