Acute Pulmonary Edema: Myths and Facts

A Storify report by: Anand Swaminathan @EMSwami  from #AAME14 #emconf

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Cardiorenal model basis for use of furosemide is mechanistically flawed and outdated.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

• ACEP clinical policy http://1.usa.gov/JyiSSN  states aggressive diuretic monotherapy unlikely to be beneficial

• Good overview of APE treatment http://1.usa.gov/1koxlBf  – “diuretics are not the ideal 1st-line therapy for most patients

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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:

• Furosemide alone caused increased PCWP in first 20 minutes http://1.usa.gov/19C4Tmc 

• bit.ly/1aEzyyI  furosemide activates renin-angiotensin-aldosterone system + sympathetic nervous system

• 1.usa.gov/1gdZfKt  furosemide decr GFR (assoc w/ worse outcomes), cardiac output (up to 20%) and incr afterload

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:

• ADHERE analysis http://1.usa.gov/KAtOjL  morphine assoc w/ incr mech vent (15.4% vs 2.8), incr ICU admit + mortality

• Morphine in APE assoc w/ incr ICU admit (OR 3.08) and intubation (OR 5.04). Mechanistically flawed http://1.usa.gov/17t6M4X 

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

[View the story “Acute Pulmonary Edema” on Storify]

 

Tags: acute pulmonary edema, edema polmonare, edema polmonare acuto cardiogeno, emergency medicine, medicina d'urgenza