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Key Findings

  • Acute onset or worsening of dyspnea at rest

  • Tachycardia, diaphoresis, cyanosis

  • Pulmonary rales, rhonchi, expiratory wheezes

  • Chest radiograph shows interstitial and alveolar edema with or without cardiomegaly

  • Arterial hypoxemia

  • Cardiac causes include

    • Acute myocardial infarction (MI) or ischemia

    • Acute severe hypertension

    • Acute kidney injury

    • Heart failure (HF)

    • Valvular regurgitation

    • Mitral stenosis

  • Noncardiac causes include

    • Injection drug (opioid) use

    • Increased intracerebral pressure

    • High altitude

    • Sepsis

    • Medications

    • Inhaled toxins

    • Transfusion reactions

    • Shock

    • Disseminated intravascular coagulation

Clinical Findings

  • Severe dyspnea

  • Pink, frothy sputum

  • Diaphoresis

  • Cyanosis

  • Rales, wheezing, or rhonchi in all lung fields

  • Sudden onset in acute exacerbations of HF or acute MI

Diagnosis

  • Characteristic clinical findings

  • Chest radiograph

    • Pulmonary vascular congestion

    • Increased interstitial markings

    • Butterfly pattern of alveolar edema

    • Heart enlarged or normal in size

  • Echocardiography: assesses ejection fraction, atrial pressure

  • B-type natriuretic peptide (BNP) is elevated

  • Pulmonary capillary wedge pressure

    • Always elevated (usually > 25 mm Hg) in cardiogenic pulmonary edema

    • Normal or even low in noncardiogenic pulmonary edema

Treatment

  • Place patient in a sitting position with legs dangling over the side of the bed

  • Give oxygen by mask for PaO2 < 60 mm Hg

  • Noninvasive pressure support ventilation or endotracheal intubation and mechanical ventilation for respiratory distress

  • Morphine, 4–8 mg intravenously or subcutaneously, repeated as needed after 2–4 hours (avoid in patients with opioid-induced and neurogenic pulmonary edema)

  • Diuretic (furosemide, 40 mg intravenously, or bumetanide, 1 mg intravenously—or higher doses if the patient has been receiving long-term diuretic therapy)

  • Nitroglycerin sublingually, orally, or intravenously

  • Inhaled β-adrenergic agonists or intravenous aminophylline for bronchospasm

  • Intravenous nesiritide

    • Reserved for patients who continue to be symptomatic after initial treatment with diuretics and nitrates

    • Hemodynamic effects resemble those of intravenous nitroglycerin with a more predictable dose–response curve and a longer duration of action

    • Dosage: 2 mcg/kg by intravenous bolus injection followed by an infusion of 0.01 mcg/kg/min, which may be up-titrated if needed

    • Primary adverse effect is hypotension, which may be symptomatic and sustained

  • Positive inotropic agents

    • Reserved for patients with refractory symptoms and signs of low cardiac output, particularly if life-threatening vital organ hypoperfusion, such as deteriorating kidney function, is present

    • In some cases, dobutamine or milrinone may help maintain patients who are awaiting cardiac transplantation

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