Pulmonary edema

Background

• Cardiogenic vs Non-Cardiogenic (ARDS/Altitude/Neurogenic)
• Mechanism of Cardiogenic
  • Failing heart > pulm edema > stress response > incr afterload
    • Incr afterload > incr pulm edema
• Pts often intravascularly depleted; avoid diuretics!

Diagnosis

• Crackles
• Respiratory distres

Treatment

1. CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
2. Nitroglycerin
   1. Dosing Options
      1. Loading dose: 400mcg/min x 2min
         1. With 100mg/250mL NTG in D5W, draw up 2mL (400mcg/mL), push over 2 min, equiv to above
            1. Helpful is RN unwilling to run at 400 mcg/min or delay in setting up drip
         2. Then drop to 100mcg/min and titrate up as needed
      2. Repeated sublingual 0.4 mg q1min until IV NTG (0.5-0.7 mcg/kg/min) is started
         1. Titrate IV NTG rapidly upward (200mcg/min or higher) until BP is controlled
   2. If NTG fails to reduce BP consider nitroprusside
3. ACEI
   1. After pt improves titrate off NTG as enaliprilat or captopril are started

See Also

• Congestive Heart Failure (CHF)
• Acute Respiratory Distress Syndrome

Source

Tintinalli

EMCrit Podcast 1