ACUTE PULMONARY OEDEMA

• ECG monitoring
• Oxygen high flow 15L/min non-rebreather mask maintaining SaO2 > 93%
• IV access x 2
• 600 mcg anginine S/L
• 12 lead ECG to exclude myocardial infarction
• IV GTN 5-10mcg/min and titrate to BP
• Frusemide 80mg stat IV (or equal to patient's usual dose)
• Administer CPAP if unable to maintain oxygenation
• If hypotensive then commence adrenaline 1-10mcg/min +/- dobutamine 1-10mcg/kg/min
• Intubate with positive pressure ventilation if unable to maintain oxygenation or patient is moribund

Avoid morphine - worsens respiratory depression

Assess for cause

• Acute myocardial ischaemia / infarction
• Arrhythmia
• Acute valvular dysfunction
• Infection
• Anaemia
• Renal failure
• Pulmonary embolism
• Fluid overload (UNCOMMON)

Consider

• Aspirin, Heparin for myocardial ischaemia or pulmonary embolism
• Angioplasty/Intraaortic balloon pump for acute myocardial infarction
• Antibiotics for infection
• Dialysis in acute renal failure
• Slow transfusion in severe anaemia
• Antiarrhythmic therapy for tachyarrhythmias
• Urgent cardiothoracic opinion for acute valvular lesion

CPAP

Indications

• Unable to maintain oxygenation with high flow oxygen
• Decreased ventilation (rising CO2)

Contraindications

• Pneumothorax
• Loss of airway reflexes

Complications

• Hypotension
• Barotrauma - pneumothorax
• Gastric aspiration

Administration

• Apply tight fitting mask
• Begin settings of 100% FiO2 and 5cm CPAP
• Increase CPAP slowly to a maximum of 15cmH2O continually noting changes in BP
• Titrate FiO2 to maintain SaO2 at 95%

Weaning

• Decrease CPAP slowly back to 5cm H2O whilst monitoring clinical condition of patient and gas exchange
• Decrease FiO2 to maintain SaO2 at 95%
• Decrease GTN 5mcg/min every 5-10 min
• Switch to CIG mask once FiO2 < 50% and CPAP < 5 cmH2O

DOBUTAMINE

Mechanism of action

• Cardiac inotropy
• Vasodilatation and reduced preload and afterload

Adverse reactions

• Arrhythmias
• Hypotension

Administration

• Dobutamine 250mg/50ml solutions
• Administered by syringe driver (1ml/hr = 1 mcg/kg/min)
• Commence at 1-10ml/hr (=1-10mcg/kg/min) and titrate to adequate BP

ADRENALINE

Mechanism of action

• Cardiac inotropy
• Vasoconstriction

Adverse reactions

• Arrhythmias
• Worsening ischaemia

Administration

• Adrenaline  6 mg/100ml solutions
• Administered by infusion pump (1ml/hr = 1 mcg/kg/min)
• Commence at 1-10ml/hr (=1-10mcg/min) and titrate to adequate BP