apo
Table of Contents
acute pulmonary oedema (APO)
see also:
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
- 12 lead ECG to help exclude acute myocardial infarction (AMI/STEMI/NSTEMI)
- 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 08:13 by 127.0.0.1