Acute Pulmonary Edema (Summary)

Presented by Dr. Anand Swaminathan, NYU/Bellevue.

A 65 yo M pt with PMH of ESRD, HTN, CAD comes in c/o SOB x3 days after missing hemodialysis twice in the past week. A portable CXR is ordered, and it looks similar to this:
http://radiopaedia.org/cases/apo-arrowsjpg

Acute Pulmonary Edema.
Causes: MI, PE, dysrhythmia, infection, tox, therapy non-compliance

Managment:
– firstly, supportive – ABCs, IV, o2, monitor
– Airway? less and less patients need to be intubated

The pathophysiology helps us better understand/affects our management:
– LV can’t pump blood out as fast, resulting in blood backing up.
– fluids fills the alveoli, washes out surfactant
– results in sympathetic surge.
– RAAS is activated, leading to vasconstriction and water reabsorption
– ADH released, increasing the circulating volume

Treatment Options:
1.) Nitro
Effect of sublingual nitroglycerin in emergency treatment of severe pulmonary edema, Bussmann et al.
(http://www.ncbi.nlm.nih.gov/pubmed/417614)
– decreased in LV filling pressure, decrease in cardiac output
– nitrates are good for preload (and afterload) reduction

2.) Morphine
Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis, Peacock et al.
(http://www.ncbi.nlm.nih.gov/pubmed/18356349)
– increased risk of ICU admissions, mechanical ventilation, and mortality
– (study not randomized, and more correlational than causal)

3.) Loop Diuretics
Comparison of nitroglycerin, morphine and furosemide in treatment of presumed pre-hospital pulmonary edema, Hoffman et al.
(http://www.ncbi.nlm.nih.gov/pubmed/3115687)
– pts who got morphine and furosemide did worse
– a lot of pts DON’T have fluid overload
– lots DON’T have functioning kidneys
– splanchinic circulation is clamped, so lasix won’t reach the kidney

4.) ACE Inhibitors
Rapid improvement of acute pulmonary edema with sublingual captopril, Hamilton et al.
(http://www.ncbi.nlm.nih.gov/pubmed/8673775)
– sublingual administration of captopril vs NG
– decreases afterload

5.) BiPAP
Randomized Trial of Bilevel versus Continuous Positive Airway Pressure for Acute Pulmonary Edema, Liesching et al.
(http://www.ncbi.nlm.nih.gov/pubmed/24071031)
although mechanism has not been proven:
-surfactant thought to be washed out of alveoli
– PEEP keeps alveoli open
– reduces afterload (especially versus CPAP)

**Takeaway point**
Initial APE Tx = Nitro + BiPAP

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