Pulmonary edema medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farnaz Khalighinejad, MD [2]
|
Pulmonary edema Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Pulmonary edema medical therapy On the Web |
|
Risk calculators and risk factors for Pulmonary edema medical therapy |
Overview
Medical Therapy
Pulmonary edema classified into cardiogenic and non-cardiogenic pulmonary edema, each requires different management and has a different prognosis.[1]
Cardiogenic pulmonary edema:
The main goal of management is to alleviate symptoms and stabilize patient as well as to improve outcome.[2]
Oxygen therapy
- Administer oxygen as early as possible
- Achieve 95% arterial oxygen saturation (90% in COPD patients)
- Caution should be taken in patients with severe airway obstruction to avoid hypercapnia
Drug therapy
- loop diuretics
- Recommended in the case of congestion and volume overload as the underlying cause of pulmonary edema
- The recommended initial dose is bolus furosemide 20 – 40 mg i.v. (0.5 – 1 mg bumetanide; 10 -20 mg torasemide)
- Total dose of furosemide is100 mg in the first 6 hours and 240 mg for the first 24 hours
- Thiazides combined with loop diuretics can be useful in cases resistant to diuretics
- In cases of acute cardiogenic pulmonary edema with volume overload, thiazides and aldosterone antagonists can be used in combination with loop diuretics
- A combination of drugs in low doses is more effective and has less side effects than the use of higher doses of a single drug
- Side Effects of Loop diuretics include:
- Hypokalemia
- Hyponatremia
- Hyperuricemia
- Hypovolemia
- Dehydration
- Urine output should be evaluate as frequent as possible
- Morphine and Its Analogues
- May be given in the early stage of the treatment in patient with severe acute heart failure, especially if they present with restlessness, dyspnea, anxiety, or chest pain[3]
- Relieves dyspnea and other symptoms
- Bolus of morphine 2.5 – 5 mg may be administered
- Respiration should be monitored
- Nausea often occurs and antiemetics therapy may be necessary
- Extra caution when giving morphine in following conditions:
- Hypotension
- Bradycardia
- Advanced AV block
- CO2 retention
- Vasopressin Antagonists
- Types of vasopressin receptors include:[3][4]
- V1a receptor which mediates vasoconstriction
- V2 receptor in the kidneys which induce water reabsorption
- Two most studied vasopressin antagonists are:
- Conivaptan (dual V1a/v2 AVP receptor antagonist)
- Tolvaptan (selective oral antagonist of V2 receptor)
- Tolvaptan relieves symptoms associated with acute heart failure but it does not reduce mortality or morbidity at 1 year
- Vasodilators
- Vasodilators are recommended at initial phase of acute cardiogenic pulmonary edema[5]
- Intravenous nitrate
- The initial recommended dose is 10 – 20 ug/minutes, which can be increased to 5 – 10 ug/minute every 3 – 5 minutes if required
- Sodium nitroprusside
- The Initial infusion rate is 0.3 ug/kg/minute with titration up to 5 ug/kg/minute
- Intravenous nitrate
- Vasodilators effects include:
- lowering systolic blood pressure
- Reducing left and right-heart filling pressure
- Reducing systemic vascular resistance
- Relieving dyspnea
- Use vasodilators in acute cardiogenic pulmonary edema when:
- SBP > 110 mmHg
- Side effects of Vasodilators include:
- Headache
- Tachyphylaxis
- Hypotension
- Titrating nitroglycerin i.v. gradually and monitoring blood pressure regularly to prevent sudden decrease in systolic blood pressure
- Inotropic agents
- Inotropic agents should be considered in patients with following conditions:
- low output condition with signs of hypoperfusion
- Congestion despite vasodilators and/or diuretics
- Should be given in patients with hypokinetic and enlarged ventricle
- Should be given immediately and stop rapidly when hemodynamic condition of patients improve
- May acutely improve hemodynamic and clinical condition of patients with acute cardiogenic pulmonary edema
- May lead to further myocardial injury and increased short-term and long-term mortality
- Dobutamine
- Positive inotropic agent acting through stimulation of β1-receptors[6]
- Given with an infusion rate of 2-3 ug/kg/min without a loading dose
- The elimination of the drug is rapid after ending of infusion
- Blood pressure must always be monitored
- Used with caution in patients with heart rate of 100 times/min
- Dobutamine
- Dopamin
- Stimulates the beta adrenergic receptor both directly and indirectly[6]
- Must be used with caution in patients with heart rate of 100 times/min
- Low dose dopamine infusion (2-3 ug/kg/min) stimulates dopaminergic receptor
- At higher dose may stimulate a-adrenergic through vasoconstriction may be used to maintain the systolic blood pressure, but there is an increasing risk of tachycardia and arrhythmia
- Dopamin
- Vasopressor
- Vasopressors (i.e. norepinephrine) are not recommended for first-line therapy
- Indicated in cardiogenic shock when the use of an inotropic agent combined with fluid challenge fail to restore systolic blood pressure over 90 mmHg
- Milrinone and Enoximone
- Cardiac Glycosides
References
- ↑ Murray JF (February 2011). "Pulmonary edema: pathophysiology and diagnosis". Int. J. Tuberc. Lung Dis. 15 (2): 155–60, i. PMID 21219673.
- ↑ Alwi I (July 2010). "Diagnosis and management of cardiogenic pulmonary edema". Acta Med Indones. 42 (3): 176–84. PMID 20973297.
- ↑ 3.0 3.1 Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL (April 2008). "Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis". Emerg Med J. 25 (4): 205–9. doi:10.1136/emj.2007.050419. PMID 18356349.
- ↑ Konstam MA, Gheorghiade M, Burnett JC, Grinfeld L, Maggioni AP, Swedberg K, Udelson JE, Zannad F, Cook T, Ouyang J, Zimmer C, Orlandi C (March 2007). "Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial". JAMA. 297 (12): 1319–31. doi:10.1001/jama.297.12.1319. PMID 17384437.
- ↑ Moazemi K, Chana JS, Willard AM, Kocheril AG (2003). "Intravenous vasodilator therapy in congestive heart failure". Drugs Aging. 20 (7): 485–508. PMID 12749747.
- ↑ 6.0 6.1 Bayram M, De Luca L, Massie MB, Gheorghiade M (September 2005). "Reassessment of dobutamine, dopamine, and milrinone in the management of acute heart failure syndromes". Am. J. Cardiol. 96 (6A): 47G–58G. doi:10.1016/j.amjcard.2005.07.021. PMID 16181823.