Acute Pulmonary Oedema

Question 1

What are the short term therapeutic goals of managing APO?

Answer 1

• Decrease distress by managing dyspnoea and anxiety
• Manage tachycardia
• Promote venodilation
• Prevent complications by increase tissue oxygenation and reducing symptoms
• Consider ceasing Na+ and H20 retention drugs

Question 2

What drugs can cause fluid retention and ppt APO and acute on chronic heart failure?

Answer 2

• NSAIDs

- Corticosteriods

Question 3

What are the non-drug treatment options?

Answer 3

• If O2 saturation is below 90%, administer high flow oxygen - 15L face mask. If no quick response, add CPAP or BiPAP
• Sit patient upright
• Decrease fluid intake
• Decrease salt intake

Question 4

Outline the initial standard management of a patient with APO.
Outline cardiac management if patient is stable.
Outline cardiac management if patient is unstable.

Answer 4

Initial:

1. Sit patient UP
2. Maximal O2 (CPAP or BiPAP if required)
3. Nitrates to decrease systolic BP 100-120mmHg
4. Obtain 12 lead ECG

Cardiac management if patient is stable:
a. IV frusemide 40mg in a “diuretic naive patient”/
NB: if pt normally is on a higher dose, match that with IV
b. IV morphine
c. Again: Sublingual nitrate to titrate carefully until systolic BP is 100-120mg (unless already hypotensive)
d. remove cause

Cardiac management if patient is unstable:

1. Inotropic support for cardiogenic shock: dobutamine, adrenaline
2. If AF, treat AF and rule out its causes (sepsis, loss of blood, uncontrolled failure, PE)

Question 5

What needs to be monitored during the hospital stay?

Answer 5

• arterial O2 sats
• arterial BP
• fluid balance
• Sx of dyspnoea
• regular lung auscultation

Question 6

What are the precipitant of APO?

Answer 6

MAD HATTER
􏰀 Myocardial infarct,
􏰀 Anaemia,
􏰀 Drugs or dietary high fluid or salt intake,
􏰀 Hypertension,
􏰀 Arrhythmias,
􏰀 Thyrotoxicosis,
􏰀 Toxic i.e. infection,
􏰀 Endocarditis or embolism (pulmonary),
􏰀 Renal failure or pregnancy (‘ruptured placenta’)

Question 7

Why are loop diuretics preferred for diuretics than K sparing or thiazide diuretics?

Answer 7

Loop diuretics (frusemide) have symptom control and decrease fluid overload. However, important to note that its immediate effect is from vasodilation rather from its diuretic effect that takes place later on.

K sparing diuretics have little efficacy in APO due to the latency of the diuretic effect. However, it is can be paired with loop diuretic in long term treatment due to K sparing.

Thiazide diuretics are NOT appropriate for APO because they are considered as weak diuretics.

Question 8

When is digoxin indicated for APO?

Answer 8

When AF is the cause of the APO

Question 9

When are sympathomimetics indicated for APO?

Answer 9

In the case of severe refractory heart failure where CO is critically low

Question 10

Why are opioid analgesics indicated in APO?

Answer 10

Morphine is a temporary venodilator, as well as decreasing distress and anxiety

Question 11

Which anticoagulant is used in APO for VTE prophylaxis?

Answer 11

• Enoxaparin is marketed especially for bed ridden patients due to acute illness

Question 12

What is the major contraindication of nitrates?

Answer 12

PDE5 inhibitors! Such as sildanefil, tadalfil and vardenafil. They potentiate hypotensive effects of both acute and chronic nitrate treatments

Question 13

What is the role of B Blockers in APO?

Answer 13

there is NO role of B blockers in acute situations. If it is administered too rapidly, then it can precipitate HF or severe hypotension.

B blockers play a role in chronic management of CHF though

Question 14

How do we prevent recurrence of APO - communication to patient?

Answer 14

1. Pt education: educate about Rx and APO itself (Heart Foundation information referral)
2. Advise that rapid fluctuations in weight are reasonable measurement of oedema and pulmonary congestion
   Therefore if > 2kg change in one day, increase frusemide dose

Question 15

How do we prevent recurrence of APO - discharge summary to health professionals?

Answer 15

Discharge summary should include:

1. Rx that exacerbate APO (NSAIDs and Corticosteroids)
2. Drugs pt was discharged on
3. Review of pt Rx to ensure pt is on optimal Rx for CHF
4. Increase frusemide dose if pt gains > 2kg in one day