Severe Pulmonary Oedema Flashcards
What are the causes of severe pulmonary oedema?
- Cardiac cause
- Adult respiratory distress syndrome
- Fluid overload
- Neurogenic
What are the cardiovascular causes of severe pulmonary oedema?
- Usually left ventricular failure, post MI or in ischaemic heart disease
- Valvular heart disease
- Arrhythmias
- Malignant hypertension
Give three examples of things that can cause adult respiratory distress syndrome
- Trauma
- Malaria
- Drugs
What can cause neurogenic pulmonary oedema?
Head injury
What are the differential diagnoses of severe pulmonary oedema?
- Asthma/COPD
- Pneumonia
What should you do in an extremely unwell patient when you cannot determine if the cause is pulmonary oedema, pneumonia, or asthma/COPD?
Consider treating all 3, e.g. with salbutamol nebulisers, furosemide IV, diamorphine, amoxicillin etc
What are the symptoms of severe pulmonary oedema?
- Dyspnoea
- Orthopnoea
- Pink, frothy sputum
What are the signs of severe pulmonary oedema?
- Distressed
- Pale
- Sweaty
- Increased pulse
- Tachypnoea
- Pulsus alterans
- Increased JVP
- Fine lung crackles
- Triple/gallop rhythm
- Wheeze
What investigations should be done in a patient presenting with severe pulmonary oedema?
- CXR
- ECG
- U&E
- Troponin
- ABG
- Consider echo
What might the chest x-ray show in severe pulmonary oedema?
- Cardiomegaly
- Shadowing, usually bilateral
- Small effusions at costophrenic angles
- Fluid in lung fissures
- Kerley B lines
How should severe pulmonary oedema be managed?
- Sit patient upright
- High flow oxygen if low sats
- IV access, and monitor ECG. Treat any arrhythmias
- Diamorphine 1.25-5mg IV slowly
- Furosemide 40-80mg IV slowly
- GTN spray 2 puffs sublingual, or 2x0.3mg tablets sublingual
- Necessary examination, investigation, and history
- If systolic BP >100mmHg, start nitrate infusion. If systolic BP <100mg, treat as cardiogenic shock and refer to ICU
Why should you avoid supplemental oxygen in those with normal saturations in severe pulmonary oedema?
Because it may cause vasoconstriction and reduce cardiac output
What should you do if a person with known COPD has reduced saturations in severe pulmonary oedema?
Still give high-flow oxygen, but monitor closely for CO2 retention (check serial ABG if needed), and reduce flow as soon as possible
When should caution be employed when giving diamorphine in severe pulmonary oedema?
- Liver failure
- COPD
When are larger doses of furosemide required in the treatment of severe pulmonary oedema?
Renal failure
What should be done if the patient is worsening after your initial acute management?
- Further dose of furosemide 40-80mg
- Consider CPAP
- Increase nitrate infusion if able to do so without dropping systolic BP >100mmHg
- Consider alternative diagnoses
How does CPAP work in severe pulmonary oedema?
It improves ventilation by recruiting more alveoli, driving fluid out of alveolar spaces and into vasculature
What alternative diagnoses can be considered if a patient continues to worsen with severe pulmonary oedema?
- Hypertensive heart failure
- Aortic dissection
- Pulmonary embolism
- Pneumonia
How should process be monitored in severe pulmonary oedema?
- BP
Pulse - Cyanosis
- Respiratory rate
- JVP
- Urine output
- ABG
- Observe on cardiac monitor or telemetry in case of arrhythmias
What should be done once a patient with severe pulmonary oedema is stable and improving?
- Daily weights
- Repeat CXR
- Modify medications
- Consider (if patient is suitable) for biventricular pacing or cardiac transplantation
- Optimise management of AF if present
What modifications to medications should be made when a patient with severe pulmonary oedema is stable and improving?
- Change to oral furosemide or bumetanide
- If on large doses of loop diuretic, consider the addition of a thiazide
- ACE inhibitor if LVEF <40%. If contraindicated, consider hydralazine and nitrate
- Consider ß-blocker and spironolactone if LVEF <35%
