Pulmonary Edema, Acute

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

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

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

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