Pulmonary Edema

Acute systolic heart failure is useful

for hospital billing, but pulmonary
edema is more descriptive.
Pulmonary Edema
Learning Goals
Management of symptomatic
pulmonary edema
Management of cardiogenic shock

Not in this talk:

Chronic outpatient systolic and diastolic
failure
Case #1
72 W with dilated ischemic
cardiomyopathy, EF=45 %, presents to
the ED after waking up at 2am from
shortness of breath.
It is now 6 days after Thanksgiving; I
didnt eat any salt, but she admits to
eating canned gravy and canned
cranberry sauce
Case #1, HPI, continued

Notes worsening in ankle swelling and

worsened orthopnea
Baseline ET 2 blocks, now 20 feet
limited by dyspnea; denies chest pain
Usually she makes copious urine after
taking furosemide, but had almost no
urine output after yesterdays dose
Case #1, ROS, continued

Denies lightheadedness and syncope

Notes a new decrease in appetite; on
further questioning she still feels hungry
and wants to eat, but feels full after only
2-3 bites of food
72 W DICM, ate too much salt
PMH: HTN, DM, CAD, CHF
PSH: Cath one year ago showed chronic total
occlusion of mid LAD; no other severe lesions
on cath; no intervention performed
Medications:
Lisinopril 10mg PO daily
Carvedilol 12.5mg PO bid
Furosemide 40mg PO daily
ASA 81, Simvastatin 40, Insulin
72 W DICM, ate too much salt

NKDA
Social: Quit tobacco one year ago,
drinks 1-2 8oz glasses of wine per
week, denies drug use
Lives next door to her daughter and
grandchildren, weighs herself and
checks her BP at home daily
Family: Father died age 63 of MI
72 W DICM, ate too much salt

150/90 P82 R28 SpO2=93% 2L T=98.4

Weight is 62kg; baseline is 57kg
Jugular venous pressure 12cmH2O
Crackles to mid lung fields bilaterally
RRR, II/VI apical holosystolic murmur
Bilateral pitting ankle edema;
extremities warm
72 W DICM, ate too much salt

CBC normal, coags normal

Na=129 K=4.9 BUN=18 Cre=1.1
Albumin=3.6, LFTs otherwise normal
EKG shows normal sinus rhythm, left
atrial enlargement, left ventricular
hypertrophy, and poor R-wave
progression, all unchanged from routine
EKG taken three months ago
Chest X-Ray
72 W pulmonary edema

ED Course
Receives furosemide 40mg IV once,
makes 1.5L urine
Reports complete resolution of her
shortness of breath; now feels normal
BP 130/80 P80 R21 SpO2=98% 2L
JVP=10; ankle edema persists
72 W pulmonary edema

What to do next?
Emergent cardiac catheterization
Transfer to CCU, consider inotropes
Admit to telemetry, rule out MI
Discharge home with close clinic f/u
Intestinal edema
Early satiety is one of the most sensitive and
specific symptoms of heart failure
exacerbation
Jakob SM. Clinical review: splanchnic ischemia. Crit Care.
2002;6:306312.15.
Higgins CB, Vatner SF, Franklin D, et al. Pattern of differential
vasoconstriction in response to acute and chronic low-output
states in the conscious dog. Cardiovasc Res. 1974;8:9298.16.
Zelis R, Nellis SH, Longhurst J, et al. Abnormalities in the
regional circulation accompanying congestive heart failure. Prog
Cardiovasc Dis. 1975;18:181199.
 Ate salt

Cannot
absorb
PO meds
Central venous
pressure
increases;
mesenteric venous
Intestinal pressure increases
edema
72 W pulmonary edema

What to do next?
Emergent cardiac catheterization
Transfer to CCU, consider inotropes
Admit to telemetry, rule out MI
Discharge home with close clinic f/u
And increase furosemide dose from 40mg PO
daily to 80mg PO bid for five days; instruct pt.
to return to clinic immediately if weight fails to
return to baseline
72 W pulmonary edema

What to do next?
Emergent cardiac catheterization
Transfer to CCU, consider inotropes
Admit to telemetry, rule out MI
Discharge home with close clinic f/u
This is not a heart failure exacerbation,
its Lasix deficiency syndrome.
Case #2

71W with a one-year history of asthma

treatment from a community physician,
presents to the ED after waking up at
2am with shortness of breath.
Case #2, HPI, continued

Often awakens in the middle of the

night; gets up and takes albuterol,
usually feels good enough to go back to
sleep
Baseline ET 1 block, now has dyspnea
at rest; denies chest pain
Sometimes feels lightheadedness and
palpitation after taking albuterol
71 W asthma
PMH: HTN, DM, CHOL, asthma (PFTs never done)
PSH: None
Medications:

Amlodipine 10mg PO daily

Aliskiren 300mg PO daily
HCTZ 25mg PO daily
Albuterol PRN; using 6-8 puffs a day now
Advair 500/50 2 puffs PO bid
ASA 81, Pravastatin 10, Insulin
71 W asthma

NKDA
Social:Smokes 1/2 ppd x50 years, no
EtOH, denies drug use
Family: Father died age 63 of MI
71 W asthma
102/64 P118 R32 SpO2=91% 4L T=99.4
Diaphoretic
Jugular venous pressure 12cmH2O
Expiratory wheeze from lung bases to mid
lung fields bilaterally
Rapid rate, regular rhythm, III/VI apical
holosystolic murmur
Bilateral pitting ankle edema; extremities
warm
71 W asthma

Labs drawn; results pending

EKG shows sinus tachycardia, left atrial
enlargement, left ventricular
hypertrophy with ST-T changes that
could be due to hypertrophy or
ischemia, and poor R-wave progression
No prior EKG for comparison
Chest X-Ray
71 W pulmonary edema

ED Course
Doctor. Please help me. (Gasp.) I feel
terrible.
What do you do?
71 W pulmonary edema
Albuterol? Intubation? Levophed?
Xopenex? IABP? Dopamine?
Furosemide? Morphine? Dobutamine?
Tirofiban? Nitroglycerin? Nesiritide?
ASA? Simvastatin? Nexium?
Plavix? BiPAP? Hydralazine?
Metoprolol? Diltiazem? Lisinopril?
Heparin? Digoxin? Captopril?
71 W pulmonary edema
Albuterol? Intubation? Levophed?
Xopenex? IABP? Dopamine?
Furosemide? Morphine? Dobutamine?
Tirofiban? Nitroglycerin? Nesiritide?
ASA? Simvastatin? Nexium?
Plavix? BiPAP? Hydralazine?
Metoprolol? Diltiazem? Lisinopril?
Heparin? Digoxin? Captopril?
Here, have a mnemonic

Lasix IV (high dose if pt. prev. on it)

Morphine (at least 4mg IV to start)
Nitroglycerin (SL, paste, or drip)
Oxygen (100% NRBM, then PAP)
Positive pressure ventilation
(noninvasive bilevel positive airway
pressure BiPAP or intubation)
Someone comes rushing in.

The labs came back! The troponin is

elevated. We have our diagnosis: This
is a NSTEMI! Rush the patient to the
cath lab!
Laboratory Values

CBC normal, coags normal

Na=126 K=5.1 BUN=28 Cre=1.3
Albumin=3.4, mildly elevated
transaminases, LFTs otherwise normal
Troponin I=0.13, CK=164
Physical examination now
98/62 P96 R26 SpO2=99% on Bilevel PAP set
at IPAP=10, EPAP=5, FiO2=60%
Diaphoretic
Bilateral pitting ankle edema; extremities
warm
Yikes! We have troponin!
You shout: Are you having any chest
discomfort at all? She shakes her head no.
How is your breathing? She indicates
through the mask that she is starting to feel
better.
Repeat EKG shows normal sinus rhythm,
otherwise unchanged (LVH, LAE, ST-T wave
changes of hypertrophy or ischemia)
72 W pulmonary edema

What to do next?
Emergent cardiac catheterization
Transfer to CCU, consider inotropes
Admit to telemetry, continue LMNOP
Call the cardiology fellow to ask Should
we give heparin?
Pt. goes to the CCU: Best case

Pt. continues to feel better with repeat

furosemide dosing. Blood pressure
improves. Stops BiPAP. Echo shows
EF=35%, mod MR. Weight drops 4kg in
two days; edema resolves. Cardiac
catheterization two days later shows
chronic total occlusion of mid LAD. No
other significant lesions noted.
Best case scenario, continued

Pt. sent home on ACE, beta blocker,

diuretic, statin, aspirin, insulin. Quits
smoking. Fires her old internist and
chooses a physician at Jacobis internal
medicine continuity clinic. Echo 3
months later shows EF=45%, mild MR.
Doesnt go to the ED again until shortly
after Thanksgiving of the following year.
The worst outcome

Pulmonary edema is not treated

promptly. Patient has RR=44,
SpO2=89%, then starts to become
lethargic.
Intubated for hypoxic respiratory failure.
(After all, intubation is the ultimate form
of positive pressure ventilation.)
Why this is bad

This is not bad because of the patients

long-term prognosis--its bad because we
physicians failed the patient.
This patient can still recover and turn out
just as well as in the best-case scenario
long-term (so long as she doesnt
develop ventilator complications). She
just had to suffer needlessly to get there.
Pt. goes to the CCU:
Intermediate outcome, case #2
Despite LMNOP, the patient continues
to complain of shortness of breath in
the CCU. Extremities become cooler.
BP drops to 92/52, HR=112. Echo
shows EF=30%, mod MR. Pt. cannot lie
flat for cardiac catheterization; she
continues to deny chest pain.
Whats the term for this?

Theres a name for this cluster of findings:

Hypotension
Elevated JVP
Pulmonary edema
Cool extremities
What to do now?
Albuterol? Intubation? Levophed?
Xopenex? IABP? Dopamine?
Furosemide Morphine Dobutamine?
Tirofiban? Nitroglycerin Nesiritide?
ASA Simvastatin Nexium
Plavix? BiPAP Hydralazine?
Metoprolol? Diltiazem? Lisinopril?
Heparin? Digoxin? Captopril?
Cardiogenic shock:
Principles of Therapy
Palliate symptomatic pulmonary edema
Confirm diagnosis
Reduce afterload
Remove edema fluid
Increase inotropy

This discussion does not apply to the septic

(distributive shock) patient who also has
heart failure
Cardiogenic shock:
Principles of Therapy
First, exclude surgical emergency:
To cardiac cath lab stat if etiology is acute
coronary syndrome
If acute structural heart disease is etiology
(e.g. endocarditis, ventricular septal wall
rupture), consider IABP and OR stat

Get EKG and auscultate; check emergent

echo if concerns persist
Cardiogenic shock:
Principles of Therapy
Palliate
symptomatic pulmonary edema
Confirm diagnosis
Reduce afterload
Remove edema fluid
Increase inotropy
Cardiogenic shock:
Principles of Therapy
Palliate
symptomatic pulmonary edema
Confirm diagnosis
Reduce afterload
Remove edema fluid
Increase inotropy
Afterload reduction options
Hydralazine
ACE/ARB
Dobutamine/Milrinone
Nesiritide

Diuresis/Ultrafiltration
Phlebotomy
Hydralazine (with nitrates)
Hydralazine 10mg PO tid is a reasonable
starting dose
Titrate upward every day as BP tolerates;
goal systolic BP is usually 95-100
Maximum dose is 300mg daily
Drug-induced lupus is dose-dependent

Hydralazine + nitrates saves lives compared

to placebo; please dont ask about BiDil
ACE/ARB
Compared to hydralazine and nitrates, ACE
or ARB therapy extends life still more
This effect is not dose-dependent (low-dose
ACE/ARB as life-extending as high dose)
In severely low output states, can cause renal
hypoperfusion and injury (evidence poor)
No evidence that adding ACE to ARB or vice
versa has any benefit
Dobutamine/Milrinone
These are inotropes, not pressors
They are both arterial vasodilators
A good combination, physiologically, for relief
of cardiogenic shock
Dobutamine/Milrinone
adverse reactions
Can cause tachyarrhythmia (AF, Afl, VT, VF)
Decrease dose in case of relentless
tachycardia or frequent nonsustained
ventricular tachycardia

If inotrope deemed necessary and unable to

control tachyarrhythmia with reduced dose:
Consider amiodarone
Consider digoxin (keep K>4, Mg>2)
Dobutamine v. Milrinone
Renal insufficiency:
Milrinone accumulates, causing worsened ability to monitor; still okay for
short-term (1-2) day use in renal dysfunction
Winner: Dobutamine

Beta blockers wanted:

Dobutamine cannot be used with a beta blocker (dobutamine is a beta
agonist); however a patient can be on milrinone with a beta blocker
Winner: Milrinone

Dopamine or Norepinephrine is in the room:

Increases afterload--usually a bad idea in heart failure, but may seem
necessary in septic shock
Loser: Dopamine and Norepinephrine
Dobutamine/Milrinone
adverse reactions
In patients with acute coronary syndrome, can worsen
infarct (increased oxygen demand)

Never shown to reduce mortality; several

studies show increase in mortality
Nesiritide
Controversial
Reduces afterload
Potentially effective in diastolic heart failure
Potentially protects kidneys
Potentially shortens life
Diuresis/Ultrafiltration
Reduce afterload by decreasing effective
circulating volume
Removes the edema

Phlebotomy used to be performed for this

until we learned that anemia worsens heart
failure
Diuresis/Ultrafiltration
Monitor urine output and daily weight
Make sure kidneys are perfused (reduce
afterload and increase inotropy as needed)
Escalate furosemide dose until brisk diuresis
is achieved; add metolazone as needed
If unable to diurese, begin ultrafiltration
What to do now?
Albuterol? Intubation? Levophed?
Xopenex? IABP? Dopamine?
Furosemide Morphine Dobutamine?
Tirofiban? Nitroglycerin Nesiritide?
ASA Simvastatin Nexium
Plavix? BiPAP Hydralazine?
Metoprolol? Diltiazem? Lisinopril?
Heparin? Digoxin? Captopril?
Intermediate outcome, cont.
Pt. is started on dobutamine
5mcg/kg/min. Furosemide changed to
continuous IV drip (10mg/hr), and
nitroglycerin changed to IV drip
(10mcg/min).
Once pulmonary edema resolves, drips
titrated off. Pt. starts beta-blocker, ACE,
diuretics; follows with cardiology.
A word about Beta Blockers in
Pulmonary Edema
Long-term heart failure management:
Yes.
Beta-blockers prolong life.

Management of patient in pulmonary

edema on the verge of intubation:
Avoid.
(Its a negative inotrope.)
Special situations: Beta Blockers
in Pulmonary Edema
Pulmonary edema due to hypertensive
emergency:
Esmolol is as good as any other hypertensive
emergency drug. (Nitroglycerin is not.)

Patient on dobutamine: Avoid.

Patient with HOCM, tachycardia, and

pulmonary edema: Use beta blockers
Choose your own adventure.

What would you like to discuss now?

Furosemide pharmacokinetics
DDx of elevated troponin
Heparin/LMWH in UA/NSTEMI
Why is this patient hyponatremic?
HOCM/ASH/IHSS/LVOT obstruction

Something completely different