Pulmonary edema

In addition, diuretics may worsen renal dysfunction. If pressures remain elevated, and clinical improvement is not achieved, conversion to IV nitroprusside may be required. Small studies suggest that the angiotensin-converting enzymes sublingual captopril or IV enalapril show promise.

Diuretics are used if volume overload is evident, but nitrates should be given first.

Background

• Mechanism
  • Failing heart > pulm edema > stress response > incr afterload
    • Incr afterload > incr pulm edema

• Pts often intravascularly depleted; avoid diuretics!

Diagnosis

• Crackles
• Respiratory distres

Treatment

1. CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
2. Nitroglycerin
   1. Dosing Options
      1. Loading dose: 400mcg/min x 2min
         1. Then drop to 100mcg/min and titrate up as needed
      2. Repeated sublingual 0.4 mg q1min until IV NTG (0.5-0.7 mcg/kg/min)is started
         1. Titrate IV NTG rapidly upward (200mcg/min or higher) until BP is controlled
3. ACEI
   1. After pt improves titrate off NTG as enaliprilat or captopril are started

Source

Tintinalli EMCrit Podcast 1