Pulmonary Oedema

Question 1

When is CPAP used in treating APO?

Answer 1

CPAP is an appropriate treatment for respiratory failure associated with APO while underlying causes are addressed. It may be required in patients unresponsive to nitrates or where respiratory failure is significant enough to require immediate treatment concurrent with nitrates

Question 2

Nitrates in APO

Answer 2

Nitrates treat the underlying cause of cardiogenic APO and should be administered to all patients presenting in symptomatic cariogenic APO unless contraindicated

Question 3

Frusemide in APO?

Answer 3

Frusemide in not an appropriate first line treatment in hypertensive patients with a sympathetically driven APO. Nitrates and SPAP should be the initial priority. Where the patient is normotensive, or hypertension has been corrected with nitrates, frusemide may be considered.

Question 4

What is cardiogenic APO?

Answer 4

Symptomatic cardiogenic pulmonary oedema, secondary to LVF or CCF

Question 5

What causes non-cardiogenic APO?

Answer 5

smoke/toxic gas inhalation, near drowning (aspiration) and anaphylaxis. In these cases the pulmonary oedema is likely a result of altered permeability and should be treated with supplemental oxygen and assisted ventilation where indicated. They do not require nitrates.

Question 6

If a patient with pulmonary oedema presents with a wheeze, how should you treat them?

Answer 6

With the asthma CPG

Question 7

Can you give salbutamol in the setting of pulmonary oedema?

Answer 7

Avoid where possible

Question 8

What are the contraindications to CPAP?

Answer 8

Airway
- Inability to manage own airway (e.g. altered conscious state, active vomiting, excessive secretions)
- upper airway obstruction
Breathing
- Hypoventilation (patient must have adequate spontaneous respirations)
- Untreated tension pneumothorax (tension pneumothorax must be treated prior to considering CPAP)
Circulation
- Haemodynamic instability (severe hypotension, ventricular arrhythmia etc. should be treated prior to considering CPAP)
Other
- Injuries precluding mask application

Question 9

How do we initially treat symptomatic cardiogenic pulmonary oedema?

Answer 9

• GTN 600mcg S/L (if SBP >110mmHg)
  OR
• GTN 300 mcg S/L (if no prev admin, borderline BP or small (<60kg), elderly or frail pts
• repeat 300 or 600 mcg @ 5 minute intervals titrated to pain or side effects
• GTN Patch 50mg (0.4mg/hr) upper torso/arms
• remove patch if BP falls <90mmHg

If no improvement or full field APO

• CPAP
• Suction and assisted ventilation if required
• escalate to MICA for consideration of ETT and/or frusemide.