Therapeutic Handbook - GGC Prescribing

Management of Acute Pulmonary Oedema /Heart FailureIntroductionAcute pulmonary oedema may be the first presentation of heart failure or an exacerbation of existingknown heart failure. It also may be secondary to another cause e.g. atrial fibrillation (AF), othertachycardias or bradycardia, critical cardiac ischaemia, valvular disease or renal artery stenosis.Assessment• If critical cardiac ischaemia / infarction, see thrombolysis / PCI guideline.• Measure blood gases, record ECG and CXR and pulse oximetry.• If in fast AF / flutter, see guideline page 105.General management / drug treatment• Sit patient upright and give 100% oxygen via facemask unless CO 2retention (see page 128 forinterpretation of blood gases).• Consider slow titrated small increments of intravenous diamorphine or morphine if associatedchest pain or severe distress. Also consider antiemetic. Do not give opiate if patient is drowsy,exhausted or hypotensive. Give: furosemide IV 50 mg (or in patients already receiving oraldiuretics, give, intravenously, double the patient’s normal oral dose). Repeat bolus at 30mins to 1 hour. Double dose at first repeat. If further diuretic required - refer immediatelyto senior medical staff.• Glyceryl trinitrate IV. Commence at 0.5 mg/hour. Titrate according to BP (but only ifsystolic BP > 90 mmHg (see local dosing charts for details).• Consider CPAP (CPAP protocol on next page) or NIV if acidotic or poor response to furosemideand nitrates.• Refer to senior medical staff and intensive care for consideration of intravenous inotropes orinvasive ventilation.N.B. Once the acute episode is resolved and the patient is more stable consider long-termmanagement.Cardiovascular SystemPage 113