Flash pulmonary edema: Difference between revisions
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==Background== | ==Background== | ||
* | *Different from acute [[CHF]] exacerbation or hypotensive [[cardiogenic shock]], which do not have sympathetic overdrive | ||
* | *Patients can decompensate rapidly, so rapid intervention required | ||
* | *Patients are generally more fluid depleted despite "wet" lungs, so do ''not'' give diuretics | ||
*Usually | *Usually history of poorly controlled [[hypertension]] | ||
**Acute afterload increase causes pulmonary edema and poor peripheral perfusion | **Acute afterload increase causes [[pulmonary edema]] and poor peripheral perfusion | ||
**Sympathetic surge occurs as a result of decreased systemic perfusion | **Sympathetic surge occurs as a result of decreased systemic perfusion | ||
**Afterload further increases and | **Afterload further increases and patient rapidly decompensates | ||
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]] | [[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]] | ||
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==Clinical Features== | ==Clinical Features== | ||
*Rales, crackles | *Rales, crackles | ||
*SBP > 180 mmHg | *[[Hypertensive emergency|SBP >180 mmHg]] | ||
* | *[[Tachycardia]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Pulmonary edema types}} | {{Pulmonary edema types}} | ||
== | ==Evaluation== | ||
*CBC ( | *CBC (rule out anemia) | ||
*Chem | *Chem | ||
*ECG | *[[ECG]] | ||
*CXR - '''signs of pulmonary congestion may not show for hours after acute flash pulmonary edema, so normal CXR is frequently seen''' | *[[CXR]] - '''signs of pulmonary congestion may not show for hours after acute flash pulmonary edema, so normal CXR is frequently seen''' | ||
**Cephalization | **Cephalization | ||
**Interstitial edema | **Interstitial edema | ||
**Pulmonary venous congestion | **Pulmonary venous congestion | ||
**Pleural effusion | **[[Pleural effusion]] | ||
**Alveolar edema | **Alveolar edema | ||
**Cardiomegaly | **Cardiomegaly | ||
*Troponin | *[[Troponin]] | ||
*[[ | *[[Echocardiography]] | ||
**Bedside to assess [[ | **Bedside to assess [[Cardiac ultrasound|global function]], [[Ultrasound: lungs|B lines]], [[IVC ultrasound|assessment of IVC]] | ||
**Formal TTE/TEE | **Formal TTE/TEE | ||
*Consider arterial line monitoring for titration of NTG | *Consider [[arterial line]] monitoring for titration of NTG | ||
{{BNP value}} | {{BNP value}} | ||
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==Management== | ==Management== | ||
''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, | *High dose [[nitroglycerin]] over 2 min (at these doses, [[nitroglycerin]] 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 | **Goal BP at the patient's norm | ||
**Load 800 mcg over 2 min (may start at 100 mcg/min, then titrate rapidly to 400 mcg/min for 2 min) | **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 | **Then start maintenance at 100 mcg/min, titrate up as needed | ||
** | **NOTE: it takes time to set up [[nitroglycerin]] drip, so consider SL [[nitroglycerin]] in interim | ||
***0. | ***0.4mg tab during 5 min = ~80 mcg/min (2 tabs = ~160 mcg/min, etc.) | ||
***Difficult to titrate if giving more than 1-2 tabs | ***Difficult to titrate if giving more than 1-2 tabs | ||
*Patients are likely more dehydrated that overloaded but should be recurrently volume assessed | *Patients are likely more dehydrated that overloaded but should be recurrently volume assessed | ||
*Consider captopril 12.5 - | *Consider [[captopril]] 12.5 - 25mg 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 | *Wean CPAP after sustained BP at patient's baseline | ||
**Decrease FiO2 to 40% | **Decrease FiO2 to 40% | ||
**Wean PEEP down 2 cm H2O q10 min | **Wean PEEP down 2 cm H2O q10 min | ||
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===Other Interventions=== | ===Other Interventions=== | ||
*Furosemide | *[[Furosemide]] | ||
**Targets kidneys which are poorly perfused in BOTH hypotension and catecholamine surge | **Targets kidneys which are poorly perfused in BOTH hypotension and catecholamine surge | ||
**Consider waiting until BiPAP and | **Consider waiting until BiPAP and [[nitroglycerin]] control hypertension first | ||
*Nitroprusside, alternative when insufficient response to NTG | *[[Nitroprusside]], alternative when insufficient response to NTG | ||
**Start 0.5 mcg/kg/min, titrate to blood pressure | **Start 0.5 mcg/kg/min, titrate to blood pressure | ||
**Max 10 mcg/kg/min for x10 min | **Max 10 mcg/kg/min for x10 min | ||
Line 72: | Line 72: | ||
==External Links== | ==External Links== | ||
*[http://emcrit.org/podcasts/scape/ EMCrit Podcast | *[http://emcrit.org/podcasts/scape/ EMCrit Podcast - Sympathetic Crashing Acute Pulmonary Edema] | ||
*[http://emcrit.org/blogpost/when-to-wean-cpap-scape/ EMCrit Podcast - When to wean the CPAP in SCAPE] | |||
*[http://emergencymedicinecases.com/episode-4-acute-congestive-heart-failure/ Emergency Medicine Cases Podcast - Acute Congestive Heart Failure] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Pulmonary]] | ||
[[Category:Critical_Care]] | [[Category:Critical_Care]] |
Revision as of 16:18, 17 September 2019
Background
- Different from acute CHF exacerbation or hypotensive cardiogenic shock, which do not have sympathetic overdrive
- Patients can decompensate rapidly, so rapid intervention required
- Patients are generally more fluid depleted despite "wet" lungs, so do not give diuretics
- Usually history of poorly controlled hypertension
- Acute afterload increase causes pulmonary edema and poor peripheral perfusion
- Sympathetic surge occurs as a result of decreased systemic perfusion
- Afterload further increases and patient rapidly decompensates
Clinical Features
- Rales, crackles
- SBP >180 mmHg
- Tachycardia
Differential Diagnosis
Pulmonary Edema Types
Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[1]
- Cardiogenic pulmonary edema
- Noncardiogenic pulmonary edema
- Negative pressure pulmonary edema
- Upper airway obstruction
- Reexpansion pulmonary edema
- Strangulation
- Neurogenic causes
- Iatrogenic fluid overload
- Multiple blood transfusions
- IV fluid
- Inhalation injury
- Pulmonary contusion
- Aspiration pneumonia and pneumonitis
- Other
- High altitude pulmonary edema
- Hypertensive emergency
- ARDS
- Flash pulmonary edema
- Immersion pulmonary edema
- Hantavirus pulmonary syndrome
- Missed dialysis in kidney failure
- Naloxone reversal
- Negative pressure pulmonary edema
Evaluation
- CBC (rule out anemia)
- Chem
- ECG
- CXR - signs of pulmonary congestion may not show for hours after acute flash pulmonary edema, so normal CXR is frequently seen
- Cephalization
- Interstitial edema
- Pulmonary venous congestion
- Pleural effusion
- Alveolar edema
- Cardiomegaly
- Troponin
- Echocardiography
- Bedside to assess global function, B lines, assessment of IVC
- Formal TTE/TEE
- Consider arterial line monitoring for titration of NTG
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, nitroglycerin has vasodilation > venodilation[7])
- Goal BP at the patient'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
- NOTE: it takes time to set up nitroglycerin drip, so consider SL nitroglycerin in interim
- 0.4mg tab during 5 min = ~80 mcg/min (2 tabs = ~160 mcg/min, etc.)
- Difficult to titrate if giving more than 1-2 tabs
- Patients are likely more dehydrated that overloaded but should be recurrently volume assessed
- Consider captopril 12.5 - 25mg SL for continuation of afterload reduction[8]
- Wean CPAP after sustained BP at patient's baseline
- Decrease FiO2 to 40%
- Wean PEEP down 2 cm H2O q10 min
- At 5 cmH2O, trial of NC
Other Interventions
- Furosemide
- Targets kidneys which are poorly perfused in BOTH hypotension and catecholamine surge
- Consider waiting until BiPAP and nitroglycerin control hypertension first
- Nitroprusside, alternative when insufficient response to NTG
- Start 0.5 mcg/kg/min, titrate to blood pressure
- Max 10 mcg/kg/min for x10 min
- Cyanide toxicity risk increases proportionately with infusion rate as well as length of time[9]
- If intubation required, consider delayed sequence intubation
Disposition
- Admit
See Also
External Links
- EMCrit Podcast - Sympathetic Crashing Acute Pulmonary Edema
- EMCrit Podcast - When to wean the CPAP in SCAPE
- Emergency Medicine Cases Podcast - Acute Congestive Heart Failure
References
- ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Haber et al. Bolus intravenous nitroglycerin predominantly reduces afterload in patients with excessive arterial elastance. J Am Coll Cardiol. 1993;22(1):251-257.
- ↑ Hamilton RJ, Carter WA, Gallagher JE. Rapid Improvement of acute pulmonary edema with sublingual captopril. Acad Emerg Med 1996; 3: 205-12.
- ↑ GlobalRPH. Nitroprusside (Nipride®). http://www.globalrph.com/nitroprusside_dilution.htm