Pulmonary Oedema Summary

Definition

  • Rapid onset worsening of heart failure symptoms
  • Requires urgent evaluation and treatment
  • Results from cardiac structure/function abnormality

Key Symptoms

  • Breathlessness (orthopnea, PND)
  • Cough with pink frothy sputum
  • Edema
  • Lightheadedness/syncope

Key Signs

  • Tachycardia/tachypnea
  • Basal crepitations/wheeze
  • Raised JVP
  • Heart murmur
  • Poor peripheral circulation

Investigations

  • ECG: ACS/arrhythmia detection
  • CXR: Upper lobe diversion, edema
  • ABG: Type-1 respiratory failure
  • BNP: Heart failure marker
  • ECHO: Valve function assessment

Management - ABCDE

  • Airway/Breathing: NIV, O2 94-98%
  • Circulation: Diuretics, nitrates, inotropes
  • Disability: IV opiates for pain
  • Exposure: Upright positioning

Medications

  • Furosemide: Diuresis
  • Nitrates: Vasodilation
  • Dobutamine: Inotrope support
  • Opiates: Pain relief

Common Causes

  • Coronary artery disease
  • Hypertension
  • Valvular heart disease
  • Cardiomyopathy
  • High output states

Cardiogenic Pulmonary Oedema

Definition

Heart failure is defined clinically as a syndrome in which patients have signs and symptoms resulting from abnormality of cardiac structure or function. Acute HF refers to rapid onset worsening of the symptoms and signs of the HF, requiring urgent evaluation and treatment.

Causes

Cardiac disease

  • Coronary artery disease (most common)
  • Hypertension
  • Cardiomyopathy
  • Valvular heart disease
  • Congenital heart disease
  • Pericardial disease

Others

  • High cardiac output state:
    • Thyrotoxicosis
    • Anaemia
    • Pheochromocytoma
    • Liver failure
    • Septicaemia
  • Drugs:
    • Cocaine
    • Alcohol
    • NSAIDs
    • Beta-blockers
    • Calcium channel blockers

Clinical Approach

Distinguishing CPO from other pathologies

Key symptoms

  • Breathlessness (orthopnoea, paroxysmal nocturnal dyspnoea)
  • Coughing (pink frothy sputum)
  • Edema
  • Lightheadedness (syncope)

Key signs

  • Tachycardia
  • Tachypnoea (basal crepitations, wheeze, pleural effusion)
  • Hypertension
  • Raised JVP
  • Heart murmur
  • Ascites
  • Poor peripheral circulation

Investigations

ECG

May reveal precipitating causes such as ST segment changes associated with ACS or arrhythmia

CXR features

  • Upper lobe diversion
  • Alveolar edema
  • Pleural effusion
  • Cardiomegaly

ABG

Type-1 respiratory failure (if with COPD then type-2)

Venous blood tests

  • FBC
  • U&E
  • LFTs
  • Troponin
  • TSH

BNP

Brain natriuretic peptide

ECHO

Evaluate for valve dysfunction, tamponade, ventricular rupture

Management

The priorities are to relieve symptoms and to restore haemodynamic stability and tissue perfusion.

Follow ABCDE approach:

Airway & Breathing

  • If the airway is compromised, intervene as required
  • BTS suggests maintaining oxygen 94-98% in acute HF (if HF coexists with COPD then 88-92%)
  • Start with NIV on high flow oxygen 15L/min

Circulation

  • Diuretics (furosemide)
  • Nitrates (initially sublingual then IV infusion 10-20mcg/min)
  • Nitroprusside (the ESC suggests commencing at the rate of 0.3-0.5 mcg/min). Contraindicated if SBP < 90mmHg
  • Inotropes (dobutamine as a first-line agent)

Disability

IV opiate for chest pain

Exposure

Position the patient sitting upright supported with pillows as appropriate for their conscious level.