Acute heart failure with pulmonary oedema: urgent management
THE CONTEXT
Acute heart failure with pulmonary oedema is a medical emergency requiring urgent treatment, monitoring and escalation if initial measures fail.
Initial care and monitoring
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Keep the patient rested upright and continuously monitor cardiac rhythm, blood pressure and pulse oximetry.
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Intravenous opiates may help distressed patients, but use them sparingly because they may cause respiratory depression and worsen hypoxaemia and hypercapnia.
Measures to relieve pulmonary oedema
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Sitting the patient up reduces preload; high-flow oxygen corrects hypoxia.
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Consider continuous positive airway pressure (CPAP) at 5–10 mmHg through a tight-fitting mask to reduce preload and the pulmonary capillary hydraulic gradient.
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Intravenous glyceryl trinitrate at 10–200 μg/min reduces preload and afterload. Titrate the nitrate dose upwards every 10 minutes until improvement occurs or systolic blood pressure falls below 110 mmHg.
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A loop diuretic combats fluid overload; the listed regimen is furosemide 50–100 mg intravenously.
Escalation and subsequent care
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If initial measures are ineffective, an inotropic agent such as dobutamine at 2.5–10 μg/kg/min may be required to augment cardiac output, particularly in hypotensive patients.
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An intra-aortic balloon pump may benefit patients with acute cardiogenic pulmonary oedema and shock.
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After the acute episode is controlled, additional measures are required for longer-term control of heart failure.