Cardiogenic pulmonary oedema

Question 1

Describe the pathophysiolgy of cardiogenic pulmonary oedema.

Answer 1

Left HF –> inc. LVEDP –> inc. pulmonary capillary hydrostatic pressure.

Fluid collects in extravascular pulmonary tissues faster than it is cleared by the lymphatic system

Question 2

What are the main causes of cardiogenic pulmonary oedema?

Answer 2

Often an acute complicaiton of MI / IHD, or exacerbation of existing cardiac disease

Arrhythmia
Failure of prosthetic valve
Cardiomyopathy
Negative inotropes
Myocarditis / pericarditis

Question 3

What pertient information must you gather from your history?

Answer 3

Likely difficult history –> dypnoea + distress

Length of symptoms + ? CP

Current drugs / allergies + PHEM treatment given

Question 4

What would you expect find on examination?

Answer 4

Obs –> tachycardia, tachypnoea +- hypotension

Inspection –> ?pacemaker, ?midline sterno, cool peripheries

Cardio –> murmurs, gallop rhythm, inc. JVP

Other –> crackles + wheeze (base > apex), cool peripheries

Question 5

What urgent treatment do these patients require?

Answer 5

ABCDE + senior

Check airway clear, sit patient up, HFO2 by tight-fitting face mask

SBP > 90 –> 2 puffs of GTN SL (monitor BP closely)

FUROSEMIDE IV 50mg –> titrate as needed

CP / ditress –> small dose IV opioid + anti-emetic¹

? catheter + urine output

Treat underlying cause

¹ do NOT give opioids to patients who are drowsy or confused, as can preciptate respiratory arrest

Question 6

After initial urgent treatment, what investigations would you order?

Answer 6

Attach to cardiac monitor, pulse ox, and 15min BP

ECG + attempt to find an old ECG

Bloods –> FBC, U&E, glucose (VBG), troponin

V ill or SpO₂ < 94% –> ABG

Imaging –> CXR +- echocardiogram

Question 7

What features would you expect to see on CXR?

Answer 7

ABCDE

Alveolar oedema –> ‘bat wings’
Kerley B lines
Cardiomegaly
Upper lobe Diversion
Pleural Effusion

Other –> interlobar fluid, peribronchial cuffing

Question 8

How would you continue to manage this patient?

Answer 8

Monitor SpO₂ and clinical response to initial treatment –> rapid improvement may occur due to venodilatation and reduction of preload

If not improving, repeat ABG and consider:

1. Non-invasive ventilation –> CPAP or BiPAP
2. ?Hypotensive –> involve ICU –> likely to need ART line, S-G catheter, and inotropic support

Question 9

How would your management change if presentation is due to prosthetic valve failure?

Answer 9

Exam –> dramatic onset with +++ murmurs

Resus –> as normal, but may not respond as well to medical Rx

Call for expert help –> ICU, cardiology, CTS

Urgent –> TTE / TOE + replacement