Pulmonary Oedema

Question 1

List the 3 care objectives in APO.

Answer 1

1. Nitrate admin to treat underlying cause of APO
2. CPAP where nitrates ineffective or respiratory failure requires immediate treatment, concurrent with nitrates
3. Furosemide for normotensive APO (MICA only)

Question 2

What type of APO does this CPG treat?

Answer 2

Symptomatic cardiogenic pulmonay oedema secondary to LVF or CCF.
Asymptomatic APO does not require treatment.

Question 3

What are some causes of non-cardiogenic APO?

Why do they occur?

Answer 3

Smoke/toxic gas inhalation
Near drowning
Anaphylaxis

Occur due to altered permeability and should be treated with supplemental O2/assisted ventilation - nitrates not required.

Question 4

Chest pain associated with APO should be managed…

Answer 4

As per ACS.

Question 5

When should patients with pulmonary oedema presenting with a wheeze be managed as asthma?

Answer 5

Only if a past history of bronchospasm can be confirmed.

Question 6

Avoid the use of … in pulmonary oedema where possible.

Answer 6

Salbutamol

Question 7

Contraindications to CPAP (7)

Answer 7

GCS <13
Facial trauma
Pneumothorax
Active vomiting
Life threatening arrhythmias
The need for a secure airway
Hypoventilation

Question 8

What symptoms are listed as symptomatic cardiogenic APO (in the setting of cardiac PHx)?

Answer 8

Short of breath, fine crackles in any lung zones.

Question 9

How is symptomatic APO managed?

Answer 9

GTN 600 or 300mcg S/L at 5 minute intervals
- titrate to pain or side effects
GTN patch 50mg

Question 10

When is CPAP or suction/ventilation indicated?

Answer 10

Full field crackles or no improvement from nitrates admin.

Question 11

What is the physiological function of CPAP?

Answer 11

1. CPAP provides PEEP, re-expands collapsed alveoli (recruitment) and prevents alveolar collapse on expiration.
2. This increases functional residual capacity and tidal ventilation, improves lung compliance and can correct VQ mismatch.
3. It can also redistribute extravascular lung water away from alveoli and endothelial cells, improving oxygen diffusion.

Question 12

What is the specific indication for CPAP?

Answer 12

Pt presenting with moderate to severe respiratory distress and audible full-field crackles due to suspected cardiogenic pulmonary oedema.

Question 13

What are the precautions for CPAP?

Answer 13

1. COPD - APO pts with COPD Hx can be cautiously managed with CPAP
2. Hypotension

Question 14

What is the minimum O2 flow for CPAP?

What is the target O2/PEEP?

Answer 14

8L/min prior to applying = PEEP 5-7cm H2O

12-14L/min after applying = PEEP 10cm H2O

Question 15

Is patient improvement an indication for CPAP removal?

Answer 15

No, continue CPAP until handed over at hospital.

Question 16

List the 4 signs of CPAP ineffectiveness

Answer 16

1. Decresing SPO2
2. Decreasing conscious state
3. Decreasing respiratory rate (fatigue)
4. Hypotension