Pulmonary edema resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief:

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Life threatening cause 1
• Life threatening cause 2
• Life threatening cause 3

Common Causes

• Common cause 1
• Common cause 2
• Common cause 3
• Common cause 4
• Common cause 5

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients of pulmonary edema in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

Abbreviations: BU: Blood urea nitrogen; COPD: Chronic obstructive pulmonary disease; D5W: 5% dextrose solution in water ; HF: Heart failure; IV: Intravenous; MAP: Mean arterial pressure; Na: Sodium; NSAID: Non steroidal anti-inflammatory drug; SBP: Systolic blood pressure; S3: Third heart sound;

Identify cardinal findings that increase the pretest probability of acute decompensated heart failure ❑ Dyspnea ❑ Cool extremities ❑ Peripheral edema ❑ Decreased urine output ❑ Past medical history of heart failure ❑ History of orthopnea and paroxysmal nocturnal dyspnea ❑ Pulmonary crepitations/rales/crackles ❑ Third heart sound (S3)

Does the patient have any of the following findings that require hospitalization and urgent management? ❑ Severe decompendated HF: ❑ Hypotension (SBP < 90 mmHg or drop in MAP >30 mmHg) and/or cardiogenic shock ❑ Altered mental status ❑ Cold and clammy extremities ❑ Urine output <0.5mL/kg/hr ❑ Dyspnea at rest manifested by tachypnea or oxygen saturation <90% ❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension ❑ Acute coronary syndrome

Yes

No

Admit to to a level of care that allows for constant ECG monitoring given the risk of arrhythmia

Proceed to complete diagnostic approach

Initial stabilization: ❑ Assess the airway ❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside (decrease preload) ❑ Monitor heart rate and blood pressure continuously ❑ Monitor oxygen saturation continuously ❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation ❑ Morphine to decrease symptoms and Afterload (avoid IV morphine, may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms) ❑ Secure intravenous access with 18 gauge cannula ❑ Monitor fluid intake and urine output carefully (guide the adjustment of the diuretics dose) Assess congestion and perfusion: Congestion at rest (dry vs. wet) "Wet" suggested by orthopnea, ↑JVP, rales, S3, pedal edema Low perfusion at rest (warm vs. cold) "Cold" suggested by narrow pulse pressure, cool extremities, hypotension The patient is: ❑ Warm and dry, OR ❑ Warm and wet, OR ❑ Cold and dry, OR ❑ Cold and wet Identify precipitating factor and treat accordingly: Click on the precipitating factor for more details on the management ❑ Myocardial infarction ❑ Myocarditis ❑ Renal failure ❑ Hypertensive crisis ❑ Non adherence to medications ❑ Worsening Aortic stenosis ❑ Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers) ❑ Toxins (alcohol, anthracyclines) ❑ Atrial fibrillation Rate control of atrial fibrillation is the mainstay of arrhythmia therapy. Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure Consider cardioversion if the patient is in cardiogenic shock or if new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation ❑ COPD ❑ Pulmonary embolism ❑ Anemia ❑ Thyroid abnormalities ❑ Systemic infection Treat congestion and optimize volume status: Diuretics ❑ Administer IV loop diuretics as intermittent boluses or continuous infusion (I-B) ❑ If patient is already on loop diuretics: IV dose ≥ home PO dose (I-B); rule of thumb: IV dose = 2.5x equivalent oral daily dose ❑ If patient is not already on loop diuretics, administer IV starting dose: Furosemide 20 to 40 mg, OR Torsemide 5 to 10 mg, OR Bumetanide 0.5 to 1 mg ❑ Adjust dose according to volume status (I-B) ❑ Perform serial assessment of fluid intake and output, vital signs, daily body weight (measured every day, with the same scale, at the same time, after first void) and symptoms ❑ Order daily electrolytes, BUN, creatinine (I-C) ❑ Low sodium diet (<2 g daily) ❑ In case of persistent symptoms: ❑ Increase dose of IV loop diuretics (I-B)- double dose at 2 hour interval up to maximal daily dose Furosemide maximal dose: 40 to 80 mg Torsemide maximal dose: 20 to 40 mg Bumetanide maximal dose: 1 to 2 mg OR ❑ Add a second diuretics, such as thiazide (I-B) ❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B) ❑ Consider renal replacement therapy/ultrafiltration in obvious volume overload (IIb-B) refractory to higher dose/combination of IV diuretics Venodilators ❑ Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnes (IIb-A) Do not administer vesodilators among patients with hypotension. Treat low perfusion: ❑ Inotropes (click her for details) If the total body and intravascular volumes are overloaded and the patient is normotensive, then diuresis alone should be undertaken. If the patient is volume overloaded but hypotensive, then inotropes must be administered in addition to diuretics. Invasive hemodynamic monitoring: ❑ Consider pulmonary artery catheterization in case of failure to respond to medical therapy, respiratory distress, shock, uncertainty regarding volume status, or increase in creatinine; assess the following parameters: ❑ PCWP ❑ Cardiac output ❑ Systemic vascular resistance VTE prevention: ❑ Anticoagulation in the absence of contraindications (I-B) Chronic medical therapy: ❑ Chronic ACE inhibitor: Hold if patient is hemodynamically unstable ❑ Chronic beta blocker: Hold if patient is hemodynamically unstable and/or in need or inotropes Decrease dose by ≥ half if patient is in moderate heart failure ❑ DO NOT INITIATE ACE INHIBITORS during an acute decompensation ❑ DO NOT INITIATE BETA BLOCKER during an acute decompensation; initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B) Monitor laboratory tests: ❑ BUN ❑ Creatinine ❑ Sodium (to detect hyponatremia which carries a poor prognosis), chloride, bicarbonate (to detect contraction alkalosis) and serum potassium (to detect hypokalemia as a result of diuresis and which can precipitate arrhythmias), potassium, magnesium Management of hyponatremia: ❑ Water restriction ❑ <2 L/day if the Na is < 130 meq/L ❑ < 1 L/day or more if the Na is < 125 meq/L Keep in min that juices are essentially free water with sugar. In the hyponatremia patient, drips should not be in D5W. ❑ Optimization of chronic home medications ❑ Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)