Acute management of cardiogenic pulmonary oedema

Consideration of the underlying cause


  • Sit the patient up, Check BP, IV access, cardiac monitor
  • Oxygen (start with non-rebreathing reservoir mask in all)
  • Request an ECG (If AMI call for help re thrombolysis / Primary angioplasty)
  • Treat arrhythmias aggressively
  • Nitrates are the first line drugs[BestBets]
  • GTN spray or buccal suscard (2mg) whilst setting up infusion [BestBets]
  • All patients presenting with acute pulmonary oedema should be considered for CPAP [BestBets], (in preference to BiPAP [BestBets])
  • Frusemide: Controversy re:
    • Low dose : 20 mg iv / PO or
    • High dose - > 100mg IV (appropriate in those already on diuretics)
  • Consider Captopril:
    • 25mg sublingual if systolic BP > 110 mmHg
    • 12.5 mg if systolic BP 90 - 110 mmHg
    • Withhold if systolic BP < 90 mmHg
    • Consider repeat after 30 - 60 mins
  • Inotropes may be required
  • Morphine should only be used for severe distress, or for pain. It has been associated with an increased risk of ICU admission and intubation

Patients who present with acute cardiogenic pulmonary oedema are not suitable for the CDU.

Class NYHA Functional Classification
i Patients with cardiac disease but physical activity not limited
ii Patients with cardiac disease resulting in slight limitation of physical activity
iii Patients with cardiac disease resulting in marked limitation of physical activity
iv Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort

Content by Dr Íomhar O' Sullivan.Last review Dr ÍOS 10/06/21.