Flash pulmonary edema: Difference between revisions
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==Management==
==Management==
*Key is to vasodilate arterial side, while maintaining oxygenation
''Vasodilate arterial side, while maintaining oxygenation''
*BiPAP with PEEP of 8 mmHg
*BiPAP with PEEP of 8 mmHg
*Titrate PEEP quickly to 12
**Titrate PEEP quickly to 12
*High dose nitroglycerin over 2 min (at these doses, NTG has vasodilation > venodilation<ref>Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.</ref>)
*High dose nitroglycerin over 2 min (at these doses, NTG has vasodilation > venodilation<ref>Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.</ref>)
**Goal BP at the pt's norm
**Goal BP at the pt's norm
Line 45: Line 45:
**Then start maintenance at 100 mcg/min, titrate up as needed
**Then start maintenance at 100 mcg/min, titrate up as needed
*Give fluids to avoid decreasing BP too much (pts are likely more dehydrated that overloaded)
*Give fluids to avoid decreasing BP too much (pts are likely more dehydrated that overloaded)
*However, after critical parts under control, assess for volume overload
**However, after critical parts under control, assess for volume overload
*Consider captopril 12.5 - 25 mg SL for continuation of afterload reduction<ref>Hamilton RJ, Carter WA, Gallagher JE.  Rapid Improvement of acute pulmonary edema with sublingual captopril.  Acad Emerg Med 1996; 3: 205-12.</ref>
*Consider captopril 12.5 - 25 mg SL for continuation of afterload reduction<ref>Hamilton RJ, Carter WA, Gallagher JE.  Rapid Improvement of acute pulmonary edema with sublingual captopril.  Acad Emerg Med 1996; 3: 205-12.</ref>
*Wean CPAP after sustained BP at pt's norm<ref>Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/</ref>
*Wean CPAP after sustained BP at pt's norm<ref>Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/</ref>

Revision as of 04:52, 9 September 2015

Background

  • Differentiate this from acute CHF exacerbation or hypotensive cardiogenic shock, which does not display sympathetic overdrive
  • Pts can decompensate rapidly, so rapid intervention required.
  • Pts are generally more fluid depleted despite "wet" lungs, so don't give diuretics
  • Usually hx of poorly controlled HTN
    • Acute afterload increase causes pulmonary edema and poor peripheral perfusion
    • Sympathetic surge occurs as a result of decreased systemic perfusion
    • Afterload further increases and pt rapidly decompensates
Pulmonary edema with small pleural effusions on both sides.

Clinical Features

  • Rales, crackles
  • SBP > 180 mmHg
  • Tachycardic

Differential Diagnosis

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[1]

Diagnosis

Brain natriuretic peptide (BNP)[2]

  • Measurement
    • <100 pg/mL: Negative for acute CHF (Sn 90%, NPV 89%)
    • 100-500 pg/mL: Indeterminate (Consider differential diagnosis and pre-test probability)
    • >500 pg/mL: Positive for acute CHF (Sp 87%, PPV 90%)
    • Combination of BNP with clinician judgment 94% sensitive 70% specific (compared to 49% sn and 96% spec clinical judgement alone) [3]

NT-proBNP[4][5][6]

  • <300 pg/mL → CHF unlikely
  • CHF likely in:
    • >450 pg/mL in age < 50 years old
    • >900 pg/mL in 50-75 years old
    • >1800 pg/mL in > 75 years old

Management

Vasodilate arterial side, while maintaining oxygenation

  • BiPAP with PEEP of 8 mmHg
    • Titrate PEEP quickly to 12
  • High dose nitroglycerin over 2 min (at these doses, NTG has vasodilation > venodilation[7])
    • Goal BP at the pt's norm
    • Load 800 mcg over 2 min (may start at 100 mcg/min, then titrate rapidly to 400 mcg/min for 2 min)
    • Then start maintenance at 100 mcg/min, titrate up as needed
  • Give fluids to avoid decreasing BP too much (pts are likely more dehydrated that overloaded)
    • However, after critical parts under control, assess for volume overload
  • Consider captopril 12.5 - 25 mg SL for continuation of afterload reduction[8]
  • Wean CPAP after sustained BP at pt's norm[9]
    • Decrease FiO2 to 40%
    • Wean PEEP down 2 cmH2O q10 min
    • At 5 cmH2O, trial of NC

Disposition

  • Admit

See Also

External Links

References

  1. ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
  2. ↑ Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161-167. doi:10.1056/NEJMoa020233.
  3. ↑ McCullough et al. B-Type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from breathing not properly (BNP) multinational study. Circulation. 2002:DOI: 10.1161/01.CIR.0000025242.79963.4
  4. ↑ Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006 Feb. 27(3):330-7.
  5. ↑ Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med. 2005 Feb 17. 352(7):666-75.
  6. ↑ Moe GW, Howlett J, Januzzi JL, Zowall H,. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. Circulation. 2007 Jun 19. 115(24):3103-10.
  7. ↑ Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.
  8. ↑ Hamilton RJ, Carter WA, Gallagher JE. Rapid Improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996; 3: 205-12.
  9. ↑ Weingart, S. When to wean the CPAP in SCAPE. Oct 2011. http://emcrit.org/blogpost/when-to-wean-cpap-scape/
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