Severe Pulmonary Oedema

Question 1

Causes:

Answer 1

1. CV - LVF (post MI or IHD), VHD, arrhythmias, malignant HPT
2. ARDS - trauma, malaria, drugs
3. Fluid overload
4. Neurogenic

Question 2

Diff Dx:

Answer 2

1. Asthma/COPD
2. Pneumonia
3. Pulmonary oedema

Question 3

How to Mx if unsure of Diff Dx?

Answer 3

Mx all 3:

1. Salbutamol nebulizer
2. Furosemide IV,
3. Diamorphine
4. Amoxicillin

Question 4

Sx:

Answer 4

1. Dyspnoea
2. Orthopnoea (eg paroxysmal)
3. Pink frothy sputum

Question 5

Signs:

Answer 5

1. Distressed
2. Usually sitting up and leaning forward
3. Tachypnoea
4. Pink frothy sputum
5. Raise JVP
6. Fine lung crackles
7. Triple/gallop rhythm
8. Wheeze (cardiac asthma)

Question 6

Investigations:

Answer 6

1. CXR - cardiomegaly, signs of pulmonary oedema: look for shadowing
   (usually bilateral), small effusions at costophrenic angles, fluid in the lung fissures, Kerley B lines (linear opacities)
2. ECG - signs of MI, dysrhythmias.
3. Bloods - BNP, U&E, troponin, ABG
4. Consider echo

Question 7

Mx of acute HF:

Answer 7

1. Sit the patient upright
2. O2 - 100% if no pre-existing lung disease
3. IV access
4. Investigations - ECG, CXR, Bloods, Echo
5. Diamorphine 1.25–5mg IV slowly Caution in liver failure and COPD
6. Furosemide 40–80mg IV slowly
7. GTN spray 2 puffs SL or 2 x 0.3mg tablets SL - Don’t give if systolic BP < 90
8. If systolic BP ≥100, start a nitrate infusion - isosorbide dinitrate 2–10mg/h IVI; keep systolic BP ≥90
9. Further dose of furosemide 40–80mg
10. Consider CPAP
11. Increase nitrate infusion if able to do so without dropping systolic BP < 100
12. If systolic BP < 100, treat as cardiogenic shock - ICU

Question 8

Role of CPAP in acute severe pulmonary oedema:

Answer 8

1. Improves ventilation by recruiting more alveoli
2. Driving fluid out of alveolar spaces and into vasculature