Takeaways
- Cardiogenic pulmonary edema can occur secondary to acute decompensated heart failure.
- Treatment should focus on reducing preload and afterload.
Albert Jones*, age 65, is admitted to the progressive care unit from the emergency department when he tests positive for sepsis, secondary to a urinary tract infection. He receives 30 mL/kg of fluid replacement as part of the hospital’s sepsis protocol.
*Name is fictitious
History and assessment
Mr. Jones has type 2 diabetes, morbid obesity, heart failure (HF) New York Heart Association Class III, hypertension (HTN), chronic obstructive pulmonary disease, and peripheral vascular disease. Initial vital signs are blood pressure (BP) 108/70 mmHg, heart rate (HR) 110 beats per minute (bpm), temperature 96.8°F (36°C), and respiration rate (RR) 26 breaths per minute.
Mr. Jones tells his nurse, Bridgett Anderson, that he’s short of breath. Bridgett notes that he appears anxious and is in the tripod position. She hears diffuse crackles on lung auscultations and obtains vital signs: BP 190/110 mmHg, HR 115 bpm, RR 36 breaths per minute, and oxygen saturation 85% with a nonrebreather mask. Bridgett calls the rapid response team (RRT) and Mr. Jones’s provider.
On the scene
The RRT and provider arrive. The provider orders a stat chest X-ray, bedside lung ultrasound, 12-lead ECG, arterial blood gases (ABG), cardiac enzymes, serum chemistry panel, and brain natriuretic peptide. The ECG shows no evidence of acute myocardial infarction, and electrolyte results indicate hyponatremia that’s likely dilutional due to hypervolemia. The ABG reveals acute-on-chronic respiratory acidosis and hypoxia: pH 7.24, Paco2 88 mmHg, Pao2 55 mmHg, and bicarbonate 33 mEq/L. The X-ray indicates pulmonary edema, and the bedside ultrasound reveals diffuse B-lines, another sign of pulmonary edema.
The respiratory therapist initiates noninvasive ventilation (NIV), and the provider prescribes furosemide 40 mg I.V. push, followed by a furosemide infusion to begin at 5 mg/hour and titrated (maximum dose 10 mg/hour) to a urinary output of 150 to 200 mL/hour. In addition, Mr. Jones is placed on a nitroglycerin infusion at 5 mL/min I.V. titrated to a systolic BP < 140 mmHg. The infusion can be increased by 5 mL/min every 3 to 5 minutes until systolic BP is 140 mm Hg or below (maximum 20 mL/min). Bridgett suggests serial electrolytes while the patient is on the furosemide infusion, and the team agrees.
Outcomes
Mr. Jones responds well to NIV, furosemide, and nitroglycerin. His Paco2 stabilizes at around 65 mmHg, and his Pao2 increases to 62 mmHg. A repeat ultrasound shows decreased B-lines. Mr. Jones won’t require ultrafiltration, which is recommended for patients who don’t respond to pharmacologic therapy. His sepsis resolves with antibiotic therapy.
Education and follow-up
Cardiogenic pulmonary edema can occur secondary to acute decompensated HF, as was the case with Mr. Jones. His rapidly developing HTN led to increased cardiac filling pressure, shifting fluid into the pulmonary capillaries, a common reason for pulmonary edema. The fluid settled in the alveoli and diminished gas exchange at the alveolar level, leading to hypoxia. Bridgett responded quickly to the situation, getting Mr. Jones the help he needed. Treatment goals included reducing preload and afterload. Furosemide and nitroglycerine reduced preload (nitroglycerine also reduced afterload). Before Mr. Jones is discharged, Bridgett will review his knowledge of his treatment plan, including medications, diet, and daily weights and provide patient education as needed.
Alysia D. Adams is the director of trauma services at Owensboro Health in Owensboro, Kentucky.
References:
Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486-552.
Sovari AA. Cardiogenic pulmonary edema. Medscape. December 21, 2017. emedicine.medscape.com/article/157452-overview
Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137-61.
