A 75yF presents to your ED acutely short of breath. Two hours prior to ED arrival, she became suddenly short of breath. Her family tried administering her salbutamol (Ventolin) to no avail. She was driven to the ED. Her PHx includes hypertension and asthma, the former poorly controlled recently despite amlodopine, HCTZ and ramipril. She denies chest pain, N/V or diaphoresis. She had a minor surgical procedure a few days prior.
At triage her vitals included a RR of 45, pulse 100 and O2 sat 70%. BP is unobtainable. She is rushed to your resuscitation area. Her exam reveals an alert and oriented woman in extemis who is able to speak 1-2 word sentences with a lot of accessory muscle use. On a NRB mask she manages an O2 sat of 94%. The lack of BP makes you worry about a large PE with hypotension. The nurses try again. Her JVP cannot be seen. There are diffuse crackles to the scapulae and wheezes bilaterally. Heart sounds are normal and regular without murmurs. There is no peripheral edema or leg swelling. The BP finally registers – 280/150!
Her EKG is below:
Sinus tachycardia with signs of LVH and strain (inverted T’s). Comparison to her recent pre-op EKG shows no significant new findings.
Her CXR is below.
Consistent with pulmonary edema.
What is this patient?
You could call her a hypertensive emergency with CHF. You could call her acute cardiogenic pulmonary edema. You could call her a SCAPE
patient (Sympathetic Crashing Acute Pulmonary Edema, trademark Scott Weingart – EMCrit podcast episode #1
). As long as you label it something and identify how to treat it, then you’ve achieved goal #1. Not to be confused with the hypotensive patient of cardiogenic shock – that’s a different discussion altogether.
So what is the best way to treat this patient? The approach must address the vicious cycle of catecholamines driving increased afterload, leading to pulmonary edema, leading to more fear/stress-induced catecholamine surge. Most would agree that NIPPV and nitrates are key. But what is the starting dose for nitroglycerine? How should it be administered: IV. SL, patch? What about loop diuretics like furosemide/Lasix?
An interesting Twitter conversation was started by Brian Hayes (@PharmERToxGuy)stating that although most drug refs suggest a starting dose of 10 mcg/min, the initial dose for IV Nitro in acute pulmonary edema should be 50 mcg/min. Zach Kiker (@zpkiker) and Haney Mallemat (@Criticalcarenow) also got in on the conversation. See excerpts below:
So there is variability out there. This much we know. What is best practice?
(This discussion will focus mainly on Nitrates and Furosemide. References for ACEi and NIPPV are below.)
High dose nitrates:
A 2007 Ann Emerg Med
feasibility study by Levy et al demonstrated safety of a protocol using high dose nitrates (2 mg bolus q 3min prn). The protocol was “…associated with endotracheal intubation, BiPAP, and ICU admission less frequently than expected to occur without high-dose nitroglycerin, and adverse events were uncommon.”
This 1998 Lancet study
showed that for in patients with acutely decompensated CHF in severe pulmonary edema, high-dose nitrates (3 mg bolus administered intravenously every 5 min) plus furosemide 40 mg IV was superior to low-dose nitrates isosorbide dinitrate 1 mg/h, increased every 10 min by 1 mg/h) and high-dose furosemide (80 mg q 15 min). Less mechanical ventilation and less myocardial infarctions.
What about furosemide?
Loop diuretics aim to reduce volume overload. In patients with chronic fluid overload and acute exacerbations of CHF, diuresis is still a mainstay. In acutely decompensated cardiogenic pulmonary edema, flush pulmonary edema or your SCAPE/hypertensive pulmonary edema, this patients may actually be volume deplete, in part due to the immense work of breathing required to overcome the acute shortness of breath.
According to this Emedicine article
, loop diuretics may require up to 90 minutes to take effect, especially if there is intravascular depletion and reduced GFR.
This Ann Int Med 1985 study
demonstrated that in severe CHF, furosemide activates the neurohormonal axis, leading to at least a short-lived surge of catecholamines.
Diuretics should perhaps be considered in the acutely decompensated pulmonary edema patient after an hour of treatment if there is evidence of overall volume overload.
NIPPV and Afterload reduction:
It is generally well accepted that positive pressure ventilation via CPAP or BiPAP is beneficial in acute cardiogenic pulmonary edema. There is variability between which modality is used. Both however reduce work of breathing and also reduce preload and may help avert intubation. A 1997 RCT in Crit Care Med
showed that vitals and ventilation were improved more rapidly in BiPAP vs CPAP but that MI rate was higher in the BiPAP group. Subsequent meta-analyses in Ann Intern Med 2010
showed that BiPAP may trend towards lower mortality and that CPAP was associated with lower mortality.
Often agents such as ACEi (captopril 25 mg po or enalapril 1.25 mg IV) can be considered for afterload reduction. Effect is often within 10 minutes. This, however, is not often my practice as I find patients often settle down very quickly with NIPPV and nitrates. The Crashing Patient
website provides a small breakdown of doses and studies if you wish to read further.
What do some of the experts preach?
Scott Weingart’s legendary SCAPE podcast
(Emcrit Episode #1) urges a protocol of 400 mcg/min for 2 min followed by 100 mcg/min and titration + NIPPV. “This first thing you do is get your lasix, and throw it in the trash!”
As you can also see from the above Twitter discussion, some well-respected physicians are proponents of high-dose Nitro while others stay more conservative. Clearly there is practice variation. It seems a lot of this may be influenced by personal experience, as the literature (at least by my search) doesn’t have a plethora of exceptionally good studies.
The patient was given 2 sprays of SL Nitro 0.4mg/spray (for a load of 800 mcg over about ? 5-10 min – ½ life according to Epocrates is 1-3min) while the IV Nitro was being hung. She was also placed on BIPAP. The IV solution was started at 30 mcg/min and within 15 minutes her sats were 98% on an FIO2 of 40% and her breathing less laboured. BP came down steadily to 160/90 and pulse in the 80’s. Repeat CXR less than one hour showed the following:
As you can see, substantially improved. She was admitted to the ward several hours later and did well.
What practice pattern do you follow? Do you agree with the discussion above? Comments encouraged and welcome! Either below or via Twitter.
Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Cotter et al. Lancet. 1998 Feb 7;351(9100):389-93.
Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis.
Levy et al. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23.
Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema.
Weng et al. Ann Intern Med. 2010;152(9):590.
Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema.
Mehta S et al. Crit Care Med. 1997 Apr;25(4):620-8.
EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema
Great Acute Pulmonary Edema summary at: The Crashing Patient
Cardiogenic Pulmonary Edema (at Emedicine)
Acute Vasoconstrictor Response to Intravenous Furosemide in Patients with Chronic Congestive Heart Failure: Activation of the Neurohumoral Axis.
Low-Dose Atrial Natriuretic Factor and Furosemide in Experimental Acute Congestive Heart Failure.
Some additional articles not referenced above:
Bolus i.v. nitroglycerin treatment of ischemic chest pain in the ED.
Nashed et al. Am J Emerg Med. 1994 May;12(3):288-91.
Intravenous nitroglycerin boluses in treating patients with cardiogenic pulmonary edema.
Nashed et al. Am J Emerg Med. 1995 Sep;13(5):612-3.
Intravenous nitrates in the prehospital management of acute pulmonary edema.
Bertini et al. Ann Emerg Med. 1997 Oct;30(4):493-9.
A Protocol of Bolus-Dose Nitroglycerin and Non-Invasive Ventilation to Avert Intubation in Emergency Department Acute Pulmonary Edema
Mallick et al. Prepublication abstract.
Available at EMCrit website http://emcrit.org/podcasts/scape/