Acute Pulmonary Edema: Myths and Facts

16 Nov
A Storify report by: Anand Swaminathan @EMSwami  from

 

  • Preamble:

Minimal change in therapeutic approach to APE over 40 years despite modern evidences.

In APE (Acute Pulmonary Edema), the first ten minutes of management dictate the course of the patient. This is where we can save a life.


 

  • Pathophysiology

Cardiorenal model basis for use of furosemide is mechanistically flawed and outdated.

Cardiocirculatory model: peripheral vasoconstriction leads to decrease in  cardiac function.

Neurohormonal model: build on increased norepinephrine levels and renin-angiotensin-aldosterone system activation


 

Urban Legend #1 – Loop diuretics are 1st line therapy in treatment of APE

The Truth #1 – Loop diuretics are not recommended as 1st line treatment in APE

References:

Urban Legend #2 – Patients presenting with APE are volume overloaded

The Truth #2 – Most patients with APE are not fluid overloaded and thus, do not require diuresis. Vascular Congestions DOES NOT equal fluid overload

References:
  • bit.ly/1gC5DMr  most pt w/ APE have incr cardiac filling pressure but minimal change in baseline/dry weight
  • 1.usa.gov/1gC5HvQ  > 50% pt w/ APE had weight gain < 2 lbs on presentation
  • bit.ly/1bO3DeU  Pulm edema results from fluid shifts not fluid gain

 

Urban Legend #3 – Loop diuretics are harmless in APE treatment so just give them

The Truth #3 – Loop diuretics are harmful early in the management of APE and should be withheld

References:

 

Urban Legend #4– Morphine should be part of the initial APE algorithm

The Truth #4– Morphine is harmful in APE and should be completely dropped from treatment algorithm

References:

 

Bottom line:

Myths

  • Loop diuretics are 1st line therapy in treatment of APE

  • Patients presenting with APE are volume overloaded

  • Loop diuretics are harmless in APE treatment so just give them

  • Morphine should be part of the initial APE algorithm

Facts

  • Loop diuretics are not recommended as 1st line treatment in APE

  • Most patients with APE are not fluid overloaded and thus, do not require diuresis

  • Loop diuretics are harmful in early phases of the management of APE and should be withheld

  • There is no role for furosemide in the management of APE

  • Morphine is harmful in APE and should be completely dropped from treatment algorithm

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