Pulmonary Edema

Table of Contents

Aliases

Congestive heart failure, respiratory distress, respiratory failure, acute respiratory distress syndrome, myocardial infarct, pulmonary embolism, COPD, asthma, anaphylaxis

Patient Care Goals

  1. Decrease respiratory distress and work of breathing
  2. Maintaining adequate oxygenation and perfusion
  3. Direct supportive efforts towards decreasing afterload and increasing preload

Patient Presentation

Inclusion Criteria

  1. Respiratory distress with presence of rales
  2. Clinical impression consistent with congestive heart failure

Exclusion Criteria

  1. Clinical impression consistent with infection (e.g. fever)
  2. Clinical impression consistent with asthma/COPD

Patient Management

Assessment

  1. History
    1. Use of diuretics and compliance
    2. Weight gain
    3. Leg swelling
    4. Orthopnea
  2. Exam
    1. Breath sounds – crackles/rales
    2. Lower extremity edema
    3. JVD
    4. Cough and/or productive cough with pink/frothy sputum
    5. Diaphoresis
    6. Chest discomfort
    7. Hypotension
    8. Shock
    9. Respiratory distress, assess:
      1. Patient’s ability to speak in full sentences
      2. Respiratory accessory muscle use

Treatment and Interventions

  1. Manage airway as necessary
  2. Administer oxygen as appropriate with a target of achieving 94-98% saturation
  3. Initiate monitoring and perform 12-lead EKG
  4. Establish IV access
  5. Nitroglycerin
    1. SBP 100 – 149 mmHg: 0.4 mg SL
    2. SBP 150 – 199 mmHg: 0.8 mg SL
    3. SBP 200 or greater: 1.2 mg SL
    4. Repeat every 3 minutes as long as SBP greater than 100 mmHg
    5. The use of nitrates should be avoided in any patient who has used a phosphodiesterase inhibitor within the past 48 hours
    6. Administer nitrates with extreme caution, if at all, to patients with inferior-wall STEMI or suspected right ventricular (RV) involvement because these patients require adequate RV preload
  6. For moderate to severe respiratory distress, CPAP
    1. Max of 10 cm H2O with commercial device or 20 cm H2O with BVM and PEEP valve
    2. Discontinue if SBP < 100 mmHg
  7. Consider advanced airway for severe distress or if not improving with less invasive support
    1. Etomidate is preferred for sedative-assisted advanced airway placement
    2. If PEEP valve available, titrate valve to oxygen saturation between 94-98%

Notes – Pulmonary Edema