Treatment of acute cardiogenic pulmonary oedema in the emergency department or coronary care unit

To treat acute cardiogenic pulmonary oedema in the emergency department or coronary care unit, continue oxygen therapy and establish intravenous access and continuous monitoring of electrocardiogram (ECG), blood pressure and pulse oximetry.

If ECG reveals evidence of ST elevation myocardial infarction (STEMI), consider acute cardiac catheterisation or thrombolytic therapy according to local protocols and facilities; see ST elevation myocardial infarction for more information. Consider other precipitating factors, including non–ST elevation acute coronary syndrome (NSTEACS), hypertensive emergency, arrhythmias, mechanical cardiac causes (eg mitral regurgitation related to acute valve dysfunction, ventricular septal defect) or acute pulmonary embolism.

Treatment of acute cardiogenic pulmonary oedema in the emergency department or coronary care unit includes:

furosemide (frusemide) 20 to 80 mg intravenously, repeated 20 minutes later if necessary. furosemide (frusemide) furosemide (frusemide) furosemide (frusemide)

Consider inserting an indwelling catheter to monitor urine output.

Consider using a glyceryl trinitrate infusion (alone or in addition to furosemide). Use nitrates with caution in patients with systolic blood pressure below 100 mmHg, symptomatic hypotension or signs of poor perfusion. A suitable regimen is:

glyceryl trinitrate 10 micrograms/minute by intravenous infusion; increase by doubling the infusion rate every 5 minutes according to clinical response and maintaining systolic blood pressure at more than 90 mmHg. glyceryl trinitrate glyceryl trinitrate glyceryl trinitrate

If pulmonary oedema remains severe and does not respond promptly to the above measures, start noninvasive ventilation with 100% oxygen. Use:

continuous positive airway pressure ventilation (CPAP), starting with 10 cm of water pressure.

Acute pulmonary oedema can be associated with acute anxiety and distress. In addition, the patient may have difficulty tolerating noninvasive ventilation. In this situation, use:

morphine 1 to 2.5 mg intravenously, as a single dose. morphine morphine morphine

Use the lower end of the dose range of morphine for older patients. In all patients, monitor for sedation (an indicator of opioid-induced ventilatory impairment) with a sedation score.

If the patient has atrial fibrillation with rapid ventricular rate that is thought to be contributing to poor cardiac output, use:

amiodarone 300 mg by intravenous infusion over 30 to 60 minutes. amiodarone amiodarone amiodarone

If the atrial fibrillation is not responding to the above treatment, or if the patient is deteriorating, consider electrical cardioversion.

If pulmonary oedema is not responding to the above measures (especially if the patient is hypotensive or poorly perfused), consider adding:

dobutamine 2.5 to 15 micrograms/kg/minute by intravenous infusion. dobutamine dobutamine dobutamine

Patients who progress to this level of treatment often need invasive monitoring and management in an intensive care unit. Treat hypotensive patients as for cardiogenic shock (see Cardiogenic shock).

If the patient does not respond to the above measures, intubation is necessary. Signs of nonresponse include:

  • patient exhaustion
  • declining level of consciousness
  • increasing confusion and agitation
  • rising partial pressure of carbon dioxide (PaCO2)
  • failure to maintain an adequate partial pressure of oxygen (PaO2).