Notes – Pulmonary Edema

Pulmonary Edema

Patient Safety Considerations

No recommendations

Notes/Educational Pearls

Key Considerations

  1. Differential:
    1. MI
    2. CHF
    3. Asthma
    4. Anaphylaxis
    5. Aspiration
    6. COPD
    7. Pleural effusion
    8. Pneumonia
    9. PE
    10. Pericardial tamponade
    11. Toxin exposure
  2. Non-invasive positive pressure ventilation:
    1. Contraindications:
      1. Hypoventilation
      2. Altered level of consciousness
      3. Airway compromise
      4. Aspiration risk
      5. Pneumothorax
      6. Facial trauma/burns
      7. Systolic BP less than 90 mmHg
      8. Recent oropharyngeal/tracheal/bronchial surgery
    2. Benefits:
      1. Increased oxygenation and perfusion by reducing work of breathing
      2. Maintaining inflation of atelectatic alveoli
      3. Improving pulmonary compliance
      4. Decreases respiratory rate and the work of breathing, HR, and SBP
      5. Improves delivery of bronchodilators
      6. Reduces preload and afterload, improving cardiac output
    3. Complications:
      1. Most common is anxiety
      2. Theoretical risk of hypotension and pneumothorax as non-invasive positive pressure ventilation increases intrathoracic pressure which decreases venous return and cardiac output
      3. Sinusitis
      4. Skin abrasions
      5. Conjunctivitis – minimized with proper size mask
      6. Potential for barotrauma – pneumothorax or pneumomediastinum (rare)
  3. Allow patient to remain in position of comfort – patients may decompensate if forced to lie down
  4. CHF is a common cause of pulmonary edema – Other causes include:
    1. Medications
    2. High altitude exposure
    3. Kidney failure
    4. Lung damage caused by gases or severe infection
    5. Major injury
  5. The use of nitrates should be avoided in any patient who has used a phosphodiesterase inhibitor within the past 48 hours. Examples are: sildenafil (Viagra®, Revatio®), vardenafil (Levitra®, Staxyn®), tadalafil (Cialis®, Adcirca®) which are used for erectile dysfunction and pulmonary hypertension. Also avoid use in patients receiving intravenous epoprostenol (Flolan®) or treporstenil (Remodulin®) which is used for pulmonary hypertension. Administer nitrates with extreme caution, if at all, to patients with an inferior STEMI or suspected STEMI with right ventricular involvement because these patients require adequate RV preload.
  6. Nitroglycerin reduces left ventricular filling pressure primarily via venous dilation. At higher doses the drug variably lowers systemic afterload and increases stroke volume and cardiac output. Although some have advocated early use of ACE inhibitors in patients with acute decompensated heart failure, we do not recommend this approach. There are limited data on the safety and efficacy of initiating new ACE inhibitors or angiotensin receptor blockers therapy in the early phase of therapy of acute decompensated heart failure (i.e. the first 12 to 24 hours).
  7. Use of furosemide (Lasix®) is not recommended in the prehospital setting. Pulmonary edema is more commonly a problem of volume distribution than overload, so administration of furosemide provides no immediate benefit for most patients. Misdiagnosis of CHF and subsequent inducement of inappropriate diuresis can lead to increased morbidity and mortality in patients.
  8. Nitrates provide both subjective and objective improvement, and might decrease intubation rates, incidence of MIs, and mortality. High-dose nitrates can reduce both preload and afterload and potentially increase cardiac output. Because many CHF patients present with very elevated arterial and venous pressure, frequent doses of nitrates may be required to control blood pressure and afterload. High dose nitrate therapy, nitroglycerin SL, 0.8–2 mg q 3–5 minutes has been used in patients in severe distress such as hypoxia, altered mentation, diaphoresis, or speaking in one-word sentences. An approach is to give two SL NTG (0.8 mg) for SBP greater than 160 mmHg or three SL NTG (1.2 mg) when SBP is greater than 200 mmHg every 5 minutes. A concern with high doses of nitrates is that some patients are very sensitive to even normal doses and may experience marked hypotension. It is therefore critical to monitor blood pressure during high-dose nitrate therapy.

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914137 – Pulmonary Edema/CHF

Key Documentation Elements

  • Vital signs
  • Oxygen saturation
  • Time of intervention
  • Response to interventions

Performance Measures

  • Time to initiation of non-invasive positive pressure ventilation
  • Number of CPAP patients who require intubation
  • Time to clinical improvement
  • Assessment/auscultation of lung sounds before and after each intervention

References

  1. Clemency BM, Thompson JJ, Tundro GN, Lindstrom HA. Prehospital high-dose nitroglycerin rarely causes hypotension. Prehosp Disaster Med. 2013;Oct:28(5):477-81.
  2. Gheorghiade M, Zannad F, Sopko G, et al. Acute heart failure syndromes: current state and framework for future research. Circulation. 2005;112:3958-68.
  3. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2010;16(6):e1-194.
  4. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(4):e391-479.
  5. Hubble MW, Richards ME, Jarvis R, et al. Effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care. 2006;10(4):430-9.
  6. Mosesso VN, Dunford J, Blackwell T, Griswell JK. Prehospital therapy for acute congestive heart failure: state of the art. Prehosp Emerg Care. 2003;(7):13-23.
  7. Spijker EE, de Bont M, Bax M, et al. Practical use, effects and complications of prehospital treatment of acute cardiogenic pulmonary edema using the Boussignac CPAP system. Int J Emerg Med. 2013;6(1):8.
  8. Thompson J, Petrie D, Ackroy, Stolarz S, et al. Out of hospital continuous positive airway pressure ventilation versus usual care for acute respiratory failure: A randomized controlled trial. Ann of Emerg Med. 2008;52(3):232-41.
  9. Williams TA, Finn J, Celenza A, et al. Paramedic identification of acute pulmonary edema in a metropolitan ambulance service. Prehosp Emerg Care. 2013;17(3):339-47.