Cardiogenic Pulmonary Oedema

Treatment

• Sit the patient up, Check BP, IV access, cardiac monitor
• Oxygen (start with non-rebreathing reservoir mask in all)
• Request an ECG (If AMI, discuss with cardiology re thrombolysis / Primary angioplasty)
• Treat arrhythmias aggressively
  • If Sinus Tachycardia, treat the underlying cause
  • If Atrial Fibrillation, see algorithm.

In normotensive/hypertensive patients, Nitrates are the first line drugs[BestBets]

• Rapid reduction of preload and afterload by venodilation (and arterial dilation at higher doses) offers faster symptomatic relief than diuretics alone
• Contraindicated in severe AS, RV infarction, and very cautious use in hypotension (SBP<100)
• GTN spray or buccal suscard (2mg) can be used whilst setting up infusion [BestBets]

In hypotensive patients, or those with clear volume overload, Furosemide (loop diuretic) is the preferred option

• Furosemide has an early venodilatory effect, with late effect by diuresis
• It is useful in situations where overload is the dominant problem, rather than redistribution
• If diuretic naive, starting dose of Furosemide 40mg IV
• If on oral diuresis at baseline, prescribe twice the oral dose, divided into BD dosing.

All patients presenting with acute pulmonary oedema should be considered for CPAP [BestBets], (in preference to BiPAP [BestBets])

In practice, most patients will get a combination of IV nitrate PLUS IV furosemide AND CPAP. Inotropes may also 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.