Acute Pulmonary Edema

ERWIN MULIA
JETTY RH SEDYAWAN

Acute Pulmonary Edema

Part of Acute Heart Failure
Respiratory distress
Short of Breath
Hypoxia desaturation
Overt Lung Congestion and
alveolar edema

Pathophysiology
Increased LV workload (LVEDP)
Increased LA pressure
Increased Pulmonary wedge pressure
Interstitial and alveolar congestion
Clinically symptomatic

Predisposing Factors

Volume overload or acute BP elevation in patients

with Hypertensive Heart Disease

De Novo due to Acute Coronary Syndrome

INITIAL MANAGEMENT
Begin treatment with the ABCs.
Administer oxygen, 100% non-rebreather facemask.
Cardiac monitoring and continuous pulse oxymetry.
Intravenous access
Medication and non medication treatment

Goal of treatment: Preload and afterload reduction to decrease

LV workload

TREATMENT OF ACUTE PULMONARY EDEMA

Non Medication
Elevate the head of the bed.
Patients may be most comfortable in a sitting position with

their legs dangling over the side of the bed, which allows for
reduced venous return and decreased preload.

Treatment of Acute Pulmonary Edema

Medication :
Administer :
Nitrat 5 mg SL, continued with
nitroglycerine IV drip as long as systolic
BP > 100 mmHg
Furosemide IV 0,5 to 1,0 mg/kg
Morphine IV 2 to 4 mg

Tanda
Tandaklinis
klinisShock,
Shock,hipoperfusi,
hipoperfusi,
Gagal
Jantung
Kongestif,
Edema
Gagal Jantung Kongestif, EdemaParu
ParuAkut
Akut
Permasalahan
yang
menyerupai
?
Permasalahan yang menyerupai ?

Edema
EdemaParu
ParuAkut
Akut

Gangguan
GangguanVolum
Volum

Gangguan
GangguanPompa
Pompa Gangguan
GangguanLaju
Laju

Bradikardi
Takikardi
Bradikardi
Takikardi
lihat
algorithm
lihat
lihat algorithm lihatalgorithm
algorithm
11Edema
Berikan
EdemaParu
ParuAkut
Akut
Berikan: :
Furosemide iv 0.5 1.0 mg/kg
Cairan
Furosemide iv 0.5 1.0 mg/kg
Cairan
Morphine iv 2 4 mg
Transfusi darah
Morphine iv 2 4 mg
Transfusi darah
Nitroglycerin SL
Intervensi penyebab spesifik
Nitroglycerin SL
Intervensi penyebab spesifik
Oxygen/intubasi sesuai kebutuhan Pertimbangkan vasopressin
Oxygen/intubasi sesuai kebutuhan Pertimbangkan vasopressin

Tekanan
Tekanan
darah?
darah?

Tanda
Tandaklinis
klinisShock,
Shock,hipoperfusi,
hipoperfusi,
Gagal
Jantung
Kongestif,
Edema
Gagal Jantung Kongestif, EdemaParu
ParuAkut
Akut
Permasalahan
yang
menyerupai
?
Permasalahan yang menyerupai ?

4
Edema
EdemaParu
ParuAkut
Akut

1
Gangguan
GangguanVolum
Volum

Gangguan
GangguanPompa
Pompa Gangguan
GangguanLaju
Laju

Bradikardi
Takikardi
Bradikardi
Takikardi
lihat
algorithm
lihat
lihat algorithm lihatalgorithm
algorithm
11Edema
Berikan
EdemaParu
ParuAkut
Akut
Berikan: :
Furosemide iv 0.5 1.0 mg/kg
Cairan
Furosemide iv 0.5 1.0 mg/kg
Cairan
Morphine iv 2 4 mg
Transfusi darah
Morphine iv 2 4 mg
Transfusi darah
Nitroglycerin SL
Intervensi penyebab spesifik
Nitroglycerin SL
Intervensi penyebab spesifik
Oxygen/intubasi sesuai kebutuhan Pertimbangkan vasopressin
Oxygen/intubasi sesuai kebutuhan Pertimbangkan vasopressin

Tekanan
Tekanan
darah?
darah?

TD
TDSystolic
Systolicnd
BP
defines
BP defines22nd
Line
Lineofofaction
action
(see
below)
(see below)

TD
TD
TDSystolic
Systolic
TDSystolic
Systolic
<<7070mmHg
70
s.d
mmHg
70 s.d100
100mmHg
mmHg
Tanda/
gejala
shock
(+)
Tanda/
gejala
Tanda/ gejala shock (+) Tanda/ gejalashock
shock(+)
(+)

Norepinephrine
Norepinephrine
iviv
0.5
0.53030mcg/min
mcg/min

Dopamine iv
Dopamine iv
551515mcg/kg/min
mcg/kg/min

TD
TDSystolic
Systolic
7070s.d
s.d100
100mmHg
mmHg
Tanda/
gejala
Tanda/ gejalashock
shock(-)(-)

Dobutamine iv
Dobutamine iv
222020mcg/kg/min
mcg/kg/min

22ndnd- -Acute
Acutepulmonary
pulmonaryedema
edema
Nitroglycerin
/
nitroprusside
Nitroglycerin / nitroprussidejika
jikaTD
TD>>100mmHg
100mmHg
Dopamine
jika
TD
70

100
mmHg,
Tanda/
Dopamine jika TD 70 100 mmHg, Tanda/gejala
gejalashock
shock(+)
(+)
Dobutamine
jika
TD
>
100
mmHg,
Tanda/
gejala
shock
(-)
Dobutamine jika TD > 100 mmHg, Tanda/ gejala shock (-)
Untuk
Untukdiagnostik/terapi
diagnostik/terapilebih
lebihlanjut
lanjutpertimbangkan
pertimbangkan: :
Kateter Arteri Pulmoner
Kateter Arteri Pulmoner
Pompa Balon Intra-aorta
Pompa Balon Intra-aorta
Angiography untuk IMA/ iskemi
Angiography untuk IMA/ iskemi
Additional diagnostic studies
Additional diagnostic studies

TD
TDSystolic
Systolic
>>100
100mmHg
mmHg

Nitroglycerin iv
Nitroglycerin iv
10102020mcg/min
mcg/min
Pertimbangkan
Pertimbangkan
Nitroprusside iv
Nitroprusside iv
0.1-5
0.1-5mcg/kg/min
mcg/kg/min

Low perfusion at rest

Congestion at rest?
No

No

Warm & dry

Cold & dry

Sign of low perfusion:

Yes

Narrow pulse pressure,cool

extremities,sleepy, suspect from
ACEI hypotension, low Na, renal
worsening

Yes

Sign of congestion:
Orthopnea, elevated JVP,
edema,pulsatile hepatomegaly,
asites, rales,louderr S3,
P2 radiation left ward,
abdomino-jugular reflex,
valsava square wave

Warm & wet

Cold & Wet

C
Fluid loading

European Heart Journal of Heart Failure,2005;

March. Vol 7:323-331

Dry

Warm

Cold

WET

Diuretic
Vasodilator

Dry

Warm

Cold

WET

Diuretikc
Vasodilator

Inotropic drugs :
Dobutamine
Milrinone
Levosimendan

Morphine
Cautious !!
It should not be given to patients with decreased
sensorium or respiratory drive, as it may bring
about respiratory arrest.
Prepare!!
Rescucitation aid, and
Antidotum: naloxone (0.8 to 2.0 mg IV bolus) .

Treatment of Acute Pulmonary Edema

with Hypotension

Systolic BP < 70 mmHg

Administer : Norepinephrine 0,5 to 30 g

Systolic BP 70 to 100 mmHg ,sign of shock
Administer : Dopamin 5 15g/kg per minute
Systolic BP 70 100 mmHg,no sign of shock
Administer : Dobutamine 2 20g/kg/minute IV

Take Home Messages

The goal of treatment is to reduce LV workload by preload

reduction strategy and the relieve of pulmonary congestion

by diuretics
In the case accompanied by shock and hypotension

maintain optimal mean arterial pressure to

preserve tissue perfusion
always assess the rhythm
The use of inotropes and vasopressors based on clinical

judgment