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apo

acute pulmonary oedema (APO)

Rx aims

  • improve cardiac function:
    • correct hypoxaemia
      • supplemental oxygen
      • correct acute respiratory failure
    • promote coronary blood flow
    • reduce LV diastolic pressure via:
      • decreasing systemic vascular resistance
      • improve systolic and diastolic functional reserve

Rx principles

  • supplemental oxygen
  • sit patient up to ensure optimised lung function
  • continuous cardiac monitor
  • iv access and send bloods for usual FBE, U&E, cardiac enzymes, glucose
  • consider nitrates including GTN (eg. GTN) if systolic BP > 110mmHg
    • results in rapid venodilatation and reduces LV afterload as well as promotes coronary blood flow
    • BUT watch for excessive drop in BP!
  • most ED physicians now avoid iv frusemide / furosemide / Lasix:
    • most patients are euvolaemic or hypovolaemic and thus a diuretic is probably not in their best interest
    • efficacy not proven and may in fact decrease cardiac output, but is still often given judiciously (eg bd bolus dosing)
    • no clear benefit of continuous infusion vs bolus vs high dose vs low dose strategies
    • high dose bolus strategy is associated with greater diuresis and more rapid relief of dyspnoea, but with transent worsening of renal function, and may be the preferred option1)
  • do not give morphine as tends to worsen outcomes
  • avoid ACEI's in acute setting as may cause dramatic fall in BP
  • commence noninvasive positive pressure ventilation (NPPV or NIPPV) early as this reduces need for intubation and apears to reduce mortality by ~40%
  • patients in extremis or not able to tolerate NIPPV generally require intubation.
  • consider inotropic support if hypotensive but inotropes increase myocardial oxygen demand and may cause further deterioration, particularly if there is underlying myocardial ischaemia or acute infarct.
1)
NEJM 364:9 March 3 2011 p797-805
apo.txt · Last modified: 2014/06/04 18:13 (external edit)