Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 10-41: Acute Heart Failure & Pulmonary Edema + Key Findings Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 beta-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