Identify cardinal findings that increase the pretest probability of pulmonary edema

❑ Anxiety, restlessness
❑ Dyspnea
❑ Cool extremities/Warm extremities
❑ Cough, particularly coughing up blood or bloody froth
❑ Excessive sweating or diaphoresis
❑ Grunting or gurgling sounds with breathing
❑ Pale or blue skin
❑ Blue or cyanotic lips
❑ Orthopnea
❑ Wheezing
❑ Peripheral edema
❑ Decreased urine output
❑ Pulmonary crepitations/rales/crackles
❑ Third heart sound (S3) ❑ Past medical history of heart failure
❑ History of opioid and aspirin overdose
❑ History of rapidly ascend to altitudes above 12,000 to 13,000 feet
❑ History of recent pulmonary embolism
❑ History of infections
❑ History of head injury, intracranial surgery, grand mal seizures, subarachnoid or intracerebral hemorrhage, and electroconvulsive therapy

❑ History of paroxysmal nocturnal dyspnea

Does the patient have any of the following findings that require hospitalization and urgent management?

❑ Hypotension (SBP < 90 mmHg or drop in MAP >30 mmHg) and/or cardiogenic shock

❑ Altered mental status

❑ Cold and clammy extremities

❑ Urine output <0.5mL/kg/hr

❑ Dyspnea at rest manifested by tachypnea or oxygen saturation <90%
❑ Atrial fibrillation with a rapid ventricular response resulting in hypotension

❑ Acute coronary syndrome

Yes

Admit to to a level of care that allows for constant ECG monitoring given the risk of arrhythmia and order a stat chest X-ray

Initial stabilization:
❑ Assess the airway
❑ Position the patient upright at an angle of 45 degrees, with legs dangling off the bedside (decrease preload)
❑ Monitor heart rate and blood pressure continuously
❑ Monitor oxygen saturation continuously
❑ If hypoxemia is present (Sa02 < 90% or Pa02 <60 mmHg), administer oxygen with/without noninvasive ventilation
❑ Morphine to decrease symptoms and Afterload (avoid IV morphine, may increase mortality / duration of intubation, generally not advisable, may relieve refractory symptoms)
❑ Secure intravenous access with 18 gauge cannula
❑ Monitor fluid intake and urine output carefully (guide the adjustment of the diuretics dose)

Assess congestion and perfusion:
Congestion at rest (dry vs. wet)
“Wet” suggested by orthopnea, ↑JVP, rales, S3, pedal edema
Low perfusion at rest (warm vs. cold)
“Cold” suggested by narrow pulse pressure, cool extremities, hypotension
The patient is:
❑ Warm and dry, OR
❑ Warm and wet, OR
❑ Cold and dry, OR
❑ Cold and wet

Identify precipitating factor and treat accordingly:
Click on the precipitating factor for more details on the management
❑ Myocardial infarction
❑ Myocarditis
❑ Renal failure
❑ Hypertensive crisis
❑ Non adherence to medications
❑ Worsening Aortic stenosis
❑ Drugs (NSAIDS, thiazides, calcium channel blocker, beta blockers)
❑ Toxins (alcohol, anthracyclines)
❑ Atrial fibrillation

Rate control of atrial fibrillation is the mainstay of arrhythmia therapy. Avoid the use of drugs with negative inotropic effects such as beta blockers and non-dihydropyridine calcium channel blockers e.g., verapamil in the treatment of acute decompensated systolic heart failure

Consider cardioversion if the patient is in cardiogenic shock or if new onset atrial fibrillation is the clear precipitant of the hemodynamic decompensation

❑ COPD
❑ Pulmonary embolism
❑ Anemia
❑ Thyroid abnormalities
❑ Systemic infection
❑ Opioid and aspirin overdose
❑ Recent pulmonary embolism
❑ Recent ascend from high altitude
❑ Head injury, intracranial surgery, grand mal seizures, subarachnoid or intracerebral hemorrhage, and electroconvulsive therapy

Treat congestion and optimize volume status:
Diuretics
❑ Administer IV loop diuretics as intermittent boluses or continuous infusion (I-B)

❑ If patient is already on loop diuretics: IV dose ≥ home PO dose (I-B); rule of thumb: IV dose =

2.5x equivalent oral daily dose

❑ If patient is not already on loop diuretics, administer IV starting dose:

Furosemide 20 to 40 mg, OR

Torsemide 5 to 10 mg, OR

Bumetanide 0.5 to 1 mg

❑ Adjust dose according to volume status (I-B)

❑ Perform serial assessment of fluid intake and output, vital signs, daily body weight (measured every day, with the same scale, at the same time, after first void) and symptoms

❑ Order daily electrolytes, BUN, creatinine (I-C)

❑ Low sodium diet (<2 g daily)
❑ In case of persistent symptoms:

❑ Increase dose of IV loop diuretics (I-B)- double dose at 2 hour interval up to maximal daily dose

Furosemide maximal dose: 40 to 80 mg

Torsemide maximal dose: 20 to 40 mg

Bumetanide maximal dose: 1 to 2 mg

OR

❑ Add a second diuretics, such as thiazide (I-B)

❑ Consider low dose dopamine infusion for improved diuresis and renal blood flow (IIb-B)
❑ Consider renal replacement therapy/ultrafiltration in obvious volume overload (IIb-B) refractory to higher dose/combination of IV diuretics

Venodilators
❑ Consider IV nitroglycerin, nitroprusside, or nesiritide as add-on to diuretics to relieve dyspnes (IIb-A)

Do not administer vesodilators among patients with hypotension.

Treat low perfusion:
❑ Inotropes (click here for details)

If the total body and intravascular volumes are overloaded and the patient is normotensive, then diuresis alone should be undertaken. If the patient is volume overloaded but hypotensive, then inotropes must be administered in addition to diuretics.

Invasive hemodynamic monitoring:
❑ Consider pulmonary artery catheterization in case of failure to respond to medical therapy, respiratory distress, shock, uncertainty regarding volume status, or increase in creatinine; assess the following parameters:

❑ PCWP

❑ Cardiac output

❑ Systemic vascular resistance

Pulmonary embolism:
❑ Anticoagulation in the absence of contraindications (I-B)

Aspirin toxicity:
❑ Sodium bicarbonate is the treatment for aspirin toxicity, usually common in elderly

Opioid overdose treatment
❑ Naloxone is used to reverse for opioid overdose

Infections treatment
❑ Start antibiotics depending upon the type of infections

Chronic medical therapy:
❑ Chronic ACE inhibitor: Hold if patient is hemodynamically unstable
❑ Chronic beta blocker:

❑ Hold if patient is hemodynamically unstable and/or in need or inotropes

❑ Decrease dose by ≥ half if patient is in moderate heart failure

❑ DO NOT INITIATE ACE INHIBITORS during an acute decompensation
❑ DO NOT INITIATE BETA BLOCKER during an acute decompensation; initiate beat blockers at a low dose in stable patients following optimization of volume status and D/C IV diuretics and inotropes (I-B)

Monitor laboratory tests:
❑CBC with differentials
❑ESR
❑Lactate
❑Urine toxins
❑Albumin
❑ BUN
❑ Creatinine
❑ Sodium (to detect hyponatremia which carries a poor prognosis), chloride, bicarbonate (to detect contraction alkalosis), serum potassium (to detect hypokalemia as a result of diuresis and which can precipitate arrhythmias), and magnesium

Management of hyponatremia:
❑ Water restriction

❑ <2 L/day if the Na is < 130 meq/L

❑ < 1 L/day or more if the Na is < 125 meq/L

Keep in mind that juices are essentially free water with sugar.

In the hyponatremia patient, drips should not be in D5W.

❑ Optimization of chronic home medications

❑ Persistent hyponatremia and risk of cognitive impairment: vasopressin antagonist for short term (hypervolemic)

Characterize the symptoms:

Symptoms of Cardiogenic pulmonary edema
❑ Anxiety, restlessness
❑ Dyspnea

❑ At rest

❑ Exertional

❑ Paroxysmal nocturnal dyspnea
❑ Orthopnea
❑ Cough
❑ Excessive sweating or diaphoresis
❑ Grunting or gurgling sounds with breathing
❑ Pale or blue skin
❑ Blue or cyanotic lips

Symptoms of Noncardiogenic pulmonary edema
❑ Symptoms of noncardiogenic pulmonary edema are similar to cardiogenic pulmonary edema, the only difference is the acute onset of symptoms after inciting event

Symptoms suggestive of precipitating events
❑ Chest pain (suggestive of myocardial ischemia)
❑ Palpitations (suggestive of arrhythmias)
❑ Fever (suggestive of infection)
❑ Seizures (suggestive of CNS insult)

Nonspecific symptoms
❑ Nausea
❑ Weight gain

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Obtain a detailed history:
❑ Past medical history

❑ Atrial fibrillation

❑ Cardiomyopathy

❑ Diabetes mellitus

❑ Hypertension

❑ Myocarditis

❑ Previous myocardial infarction

❑ Prior heart failure

❑ COPD

❑ Valvular heart disease

❑ Central nervous system injury

❑ Medication history

❑ Noncompliance with previously prescribed medications for heart failure

❑ Intake of the following drugs:

❑ Anticoagulants

❑ Aspirin

❑ Narcotics

❑ Heroin

❑ NSAID

❑ Morphine

❑ Methadone

❑ Dextropropoxyphene

❑ Family history

❑ History of dilated cardiomyopathy

❑ Radiation to the chest

❑ Surgical history

❑Recent surgery

❑Valve replacement surgeries

❑Recent history

❑ Opioid and aspirin overdose

❑ High altitudeascend

❑ Pulmonary embolism

❑ Head injury

❑ Seizures

❑ Electroconvulsive therapy

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Examine the patient:

General appearance:
❑ Ill-looking
❑ In respiratory distress
❑ Inability to speak in full sentences

Vitals:
❑ Temperature

❑ Fever (suggestive of underlying infection)

❑ Pulse

❑ Tachycardia

❑ Narrow pulse pressure (<25% of SBP)

❑ Blood pressure

❑ Hypotension (suggestive of circulatory collapse)

❑ Hypertension

❑ Respiration

❑ Tachypnea (most common symptom)

❑ Pulse oximetry (maintain oxygen sat ≥ 94% unless COPD)

Weight:
❑ Measure weight daily at the same time after the first void
❑ Subtract ‘dry weight’ from current weight to estimate extent of volume overload and edema

Skin
❑ Cool and clammy (suggestive of hypoperfusion)
❑ Cyanosis (suggestive of severe hypoxemia)
❑ Anasarca
❑ Jaundice (suggestive of liver dysfunction secondary to right-sided fluid overload)

Neck examination:
❑ Jugular vein distention (suggestive of right-sided fluid overload)
❑ Positive hepatojugular reflux (suggestive of right-sided fluid overload)

Respiratory examination
❑ Tachypnea
❑ Wheeze
❑ Dullness at lung bases (suggestive of pleural effusion, may be present in chronic HF secondary to lymphatic compensation)
❑ Crackles/crepitations/rales (suggestive of pleural effusion)
❑ Cheyne-stokes respiration

Cardiovascular examination
❑ Displaced apex beat (suggestive of enlarged left ventricle)
❑ Parasternal heave (suggestive of elevated right ventricular pressure)
❑ S3 (typical) or S4 or both
❑ Soft S1
❑ Pulsus alternans
❑ S4 (suggestive of diastolic dysfunction)
❑ New or changed murmur (suggestive of an underlying valvular heart diseases)

❑ Mitral regurgitation – Holosystolic murmur

❑ Aortic regurgitation – Decrescendo diastolic murmur

❑ Aortic stenosis – Crescendo-decrescendo systolic ejection murmur with ejection click

Abdominal examination
The following findings suggest volume overload and / or poor forward cardiac output:
❑ Hepatojugular reflux
❑ Hepatomegaly
❑ Ascites

Extremity examination
❑ Pedal edema

Neurological examination
❑ Altered mental status
❑ Syncope (suggestive of aortic stenosis or pulmonary embolism)

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Determine status of congestion and perfusion based on physical exam:
Congestion at rest (dry vs. wet)

“Wet” suggested by orthopnea, ↑JVP, positive hepatojugular reflux, abnormal valsalva response, rales, dullness upon percussion in bases, S3, peripheral edema, hepatomegaly, ascites, jaundice

Low perfusion at rest (warm vs. cold)

“Cold” suggested by narrow pulse pressure, cool extremities, hypotension, soft S1, pulsus alternans, decreased urinary output

The patient is:
❑ Warm and dry, OR
❑ Warm and wet, OR
❑ Cold and dry, OR
❑ Cold and wet

Order tests:

Routine (Class I, level of evidence C)

❑ CBC with differentials(rule out anemia and infections)

❑ ESR

❑ Lactate

❑ Urine toxicology

❑ Troponin

❑ Elevated in myocardial ischemia and acute cardiogenic pulmonary edema, particularly if creatinine clearance (CrCl) is reduced

❑ Troponin T ≥ 0.1 ng/mL (associated with poor survival)^[2]

❑ Electrolytes

❑ Sodium: hyponatermia may occur due to fluid overlaod

❑ Serum calcium

❑ Serum magnesium can be lowered by diuresis

❑ Serum bicarbonate: to monitor contraction alkalosis with diuresis

❑ BUN, creatinine: may be elevated due to poor renal perfusion

❑ Urinalysis

❑ Fasting blood sugar

❑ Fasting lipid profile

❑ Liver function tests: can be elevated secondary to peripheral hypoperfusion

❑ TSH

❑ BNP or NT-pro BNP
Heart failure is unlikely if:^[3][4]

❑ BNP ≤ 100 pg/mL, or

❑ NT-pro BNP ≤ 300 pg/mL

❑ Chest X-ray of Cardiogenic pulmonary edema (Class I, level of evidence C)

❑ Cardiomegaly (cardiothoracic ratio >50%)

❑ Cardiogenic pulmonary edema

❑ Kerley B lines

❑ Peribronchial cuffing

❑ Cephalization

❑ Chest X-ray findings of non-cardiogenic edema
❑Patchy alveolar infiltrates
❑ Air bronchograms

❑ ECG (to help identify the cause of heart failure)

❑ Low QRS voltage (suggestive of infiltrative or dilated cardiomyoapthy)

❑ Arrhythmia (atrial fibrillation carries a poor prognosis and requires slowing of the heart rate to improve filling & cardiac output)

❑ Poor R wave progression (suggestive of a prior MI)

❑ Left ventricular hypertrophy (consistent with a history of hypertension)

❑ Left bundle branch block (LBBB) due to prior MI, may result in dysynchrony)

❑ Left atrial enlargement (due to valvular disease or hypertension)

❑ Non-specific ST segment and T wave changes may suggest ischemia

❑ 2-D echocardiography with Doppler
(Class I, level of evidence C)

❑ Assess chambers size, wall thickness, wall motion, and valve function

❑ Assess ejection fraction

❑ Radionuclide ventriculography or MRI

❑ To assess LVEF and volume when echocardiography is inadequate

❑ To assess myocardial infiltrative processes or scar burden (MRI)

❑ Coronary angiography looking for CAD
❑ Comprehensive metabolic panel if no evidence of CAD on coronary angiography
❑ Consider pulmonary artery catheterization in case of failure to respond to medical therapy, respiratory distress, shock, uncertainty regarding volume status, or increase in creatinine; assess the following parameters:

❑ PCWP

❑ Cardiac output

❑ Systemic vascular resistance

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Order additional tests to rule out other etiologies:
❑ ANA and rheumatoid factor (for rheumatologic diseases)
❑ Diagnostic tests for hemochromatosis and pheochromocytoma
❑ Endomyocardial biopsy (when myocarditis is suspected)

Consider alternative diagnoses:

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Alternative diagnoses	Features
Acute asthma	❑ Wheeze ❑ Reversal of symptoms following administration of bronchodilators
COPD	❑ Increased cough ❑ Increased dyspnea ❑ Increased sputum production
ARDS	❑ Severe hypoxia ❑ Bilateral opacities on chest X-ray ❑ PCWP < 15 mmHg
Pneumonia	❑ Fever, cough, sputum ❑ Consolidation on chest X-ray
Pulmonary embolism	❑ Pleuritic chest pain, cough, S4 ❑ Risk factors: trauma, immobilization, smoking, OCPs ❑ Clot in pulmonary artery on CT pulmonary angiography

Assess the stage of heart failure using the ACCF/AHA staging system to guide chronic therapy

Prevention of pulmonary edema

❑ Encourage healthy lifestyle and exercise
❑ Prevention for pulmonary edema associated with high altitude

❑ Gradual ascent

❑ Preacclimization

❑ Avoiding alcohol and drugs like ibuprofen, acetazolamide, sumatriptan, spironolactone, and steroids

❑ Adequate hydration

❑ Treat hypertension
❑ Treat dyslipidemia
❑ Control obesity
❑ Treat DM
❑ Avoid tobacco
❑ Avoid cardiotoxic agents

❑ Encourage healthy lifestyle and exercise

Consider additional measures in selected patients: ❑ Administer ACE-I if history of MI or ACS and reduced EF to prevent symptoms and reduce mortality (I-A), in all decreased EF to prevent symptoms (I-A)
❑ Administer beta-blockers if history of MI or ACS and reduced EF to reduce mortality (I-B), in all reduced EF to prevent symptoms (I-C)
❑ Administer statins if history of MI or ACS to prevent symptoms (I-A)

❑ Consider ICD placement to prevent sudden death if asymptomatic ischemic cardiomyopathy, > 40 days post-MI, LVEF ≤30%, on adequate medical therapy, and good 1 year survival