Management Of Acute Pulmonary Edema Research Articles

Guideline adherence in the management of acute pulmonary oedema: Study protocol for a French survey involving cardiologists, emergency physicians and intensivists

BackgroundBecause of their high morbidity and mortality, patients with acute pulmonary oedema (APE) require early recognition of symptoms, identification of precipitating factors and admission to specialized care units (cardiac critical care or intensive care). APE is at the crossroads of different specialties (cardiology, emergency medicine and intensive care medicine). Although multidisciplinary expertise and management may be a strength, it can also be a source of confusion, with unexpected heterogeneity in patient care. We hypothesized that the management of severe APE may be heterogeneous between specialties and, in some situations, may differ from international recommendations. AimWe designed a survey to compare management of different APE phenotypes according to the physicians’ medical specialty, and to compare the results with what experts would do and European guidelines. MethodsFour clinical cases of typical APE with questions pertaining to the latest guidelines were designed by a Scientific Committee designated by the French Scientific Societies for Cardiology, Emergency Medicine and Intensive Care Medicine. We focused on oxygenation and ventilation strategies, management of precipitating factors, including timing of coronary revascularization, use of diuretics and management of diuretic resistance, and discharge coverage. From 20 June 2022 until 09 September 2022, the four cases of APE (two during hypertensive crises, two during acute coronary syndromes) were proposed to French physicians involved in APE care, and to experts, using an open online survey. To avoid any diagnostic ambiguity, the diagnosis of APE was given at the beginning of each clinical case. ResultsThe intention is to present the results at national and international conferences and publish them in a peer-reviewed journal. ConclusionsThe results of this survey are intended to pave the way for the generation of novel hypotheses for future clinical trials in case of equipoise between subsets of therapeutic procedures in APE.

Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review.

Heart failure affects nearly 65million people globally, resulting in recurrent hospital admissions and substantial healthcare expenditure. The use of morphine in the management of acute pulmonary oedema remains controversial, with conflicting guidance and significant variation in practice. Synthesised evidence is needed to inform standard treatment guidelines and clinical practice. To determine whether morphine should be used in the treatment of acute pulmonary oedema (APE) in adults. A rapid review of systematic reviews of randomised controlled trials or observational studies, and then randomised controlled trials, was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on 12February 2022. We used a prespecified protocol following Cochrane rapid review methods and aligned to the National Standard Treatment Guidelines and Essential Medicines List methodology. We first considered relevant high-quality systematic reviews of randomised controlled trials or observational studies, then (if required) randomised controlled trials to inform time-sensitive or urgent evidence requests, clinical practice, policy, or standard treatment guidelines. We identified four systematic reviews of observational studies. The two most relevant, up-to-date, and highest-quality reviews were used to inform evidence for critical outcomes. Morphine may increase in-hospital mortality (odds ratio (OR) 1.78; 95% confidence interval (CI) 1.01 - 3.13; low certainty of evidence; six observational studies, n=151735 participants), resulting in 15 more per 1000 hospital deaths, ranging from 0 to 40 more hospital deaths. Morphine may result in a large increase in invasive mechanical ventilation (OR 2.72; 95% CI 1.09- 6.80; low certainty of evidence; four observational studies, n=167847 participants), resulting in 45 more per1000 ventilations, ranging from 2 more to 136 more. Adverse events and hospital length of stay were not measured across reviews ortrials. Based on the most recent, relevant and best-available quality evidence, morphine use in adults with APE may increase in-hospital and all-cause mortality and may result in a large increase in the need for invasive mechanical ventilation compared to not using morphine. Recommending against the use of morphine in pulmonary oedema may improve patient outcomes. Disinvesting in morphine for this indication may result in cost savings, noting the possible accrued benefits of fewer patients requiring invasive ventilation and management of morphine-related side-effects.

A case of severe non-cardiogenic pulmonary edema in a woman treated with atosiban for preterm labor.

A 27-year-old primigravid woman with a triamniotic pregnancy presented with preterm labor at 29 weeks of gestation and acute severe pulmonary edema after treatment with atosiban. The severe symptoms and hypoxemia of the patient led to emergency hysterotomy and intensive care unit hospitalization. This clinical case prompted us to review the existing literature to examine studies on differential diagnoses in pregnant women with acute dyspnea. The possible pathophysiological mechanisms of this condition and the management of acute pulmonary edema are worth discussing.

Low- versus high-dose nitroglycerin infusion in the management of acute pulmonary edema

BackgroundNitroglycerin (NTG) is commonly used for the management of pulmonary edema in acute heart failure presentations. Although commonly initiated at low infusion rates, higher infusion rates have favorable pharmacodynamic properties and may improve outcomes in the management of acute pulmonary edema. ObjectivesTo characterize the clinical outcomes including the time to resolution of severe hypertension when using an initial low dose (<100 μg/min) versus high-dose (≥100 μg/min) strategy. MethodsThis was a retrospective study performed at a single, tertiary academic emergency department in Atlanta, GA. We describe the blood pressure effects and key safety outcomes (intubation, hypotension, intensive care unit admissions) during the first hour of treatment of acute pulmonary edema. Results41 patients were included in the final sample. 27 (66%) received low dose NTG and 14 (34%) received high dose NTG. The high dose group reached their blood pressure faster on average (hazard ratio = 3.5, 95% CI: 1.2–10.1). 8/14 (57%) of patients in the high dose group reached their BP target within the first hour of treatment, compared to 6/27 (22%) in the low dose group. Observed incidence of safety outcomes were similar between the two groups. ConclusionsHigher initial NTG doses may be an effective way to decrease times to achieve blood pressure targets and should be the focus of future trials.

Management of respiratory distress following prehospital implementation of noninvasive ventilation in a physician-staffed emergency medical service: a single-center retrospective study

BackgroundNoninvasive ventilation (NIV) is recognized as first line ventilatory support for the management of acute pulmonary edema (APE) and chronic obstructive pulmonary disease (COPD) exacerbations. We aimed to study the prehospital management of patients in acute respiratory distress with an indication for NIV and whether they received it or not.MethodsThis retrospective study included patients ≥18 years old who were cared for acute respiratory distress in a prehospital setting. Indications for NIV were oxygen saturation (SpO2) <90% and/or respiratory rate (RR) >25/min with a presumptive diagnosis of APE or COPD exacerbation. Study population characteristics, initial and at hospital vital signs, presumptive and definitive diagnosis were analyzed. For patients who received NIV, dyspnea level was evaluated with a dyspnea verbal ordinal scale (D-VOS, 0-10) and arterial blood gas (ABG) values were obtained at hospital arrival.ResultsAmong the 187 consecutive patients included in the study, most (n = 105, 56%) had experienced APE or COPD exacerbation, and 56 (30%) received NIV. In comparison with patients without NIV, those treated with NIV had a higher initial RR (35 ± 8/min vs 29 ± 10/min, p < 0.0001) and a lower SpO2 (79 ± 10 vs 88 ± 11, p < 0.0001). The level of dyspnea was significantly reduced for patients treated with NIV (on-scene D-VOS 8.4 ± 1.7 vs 4.4 ± 1.8 at admission, p < 0.0001). Among the 131 patients not treated with NIV, 41 (31%) had an indication. In the latter group, initial SpO2 was 80 ± 10% in the NIV group versus 86 ± 11% in the non-NIV group (p = 0.0006). NIV was interrupted in 9 (16%) patients due to either discomfort (n = 5), technical problem (n = 2), persistent desaturation (n = 1), or vomiting (n = 1).ConclusionsThe results of this study contribute to a better understanding of the prehospital management of patients who present with acute respiratory distress and an indication for NIV. NIV was started on clinically more severe patients, even if predefined criteria to start NIV were present. NIV allows to improve vital signs and D-VOS in those patients. A prospective study could further elucidate why patients with a suspected diagnosis of APE and COPD are not treated with NIV, as well as the clinical impact of the different strategies.Trial registrationThe study was approved by our institutional ethical committee (CER-VD 2020-01363).

Protocol-based management of acute pulmonary edema in pregnancy in a low-resource center

Context: Acute pulmonary oedema (APO) in pregnant women is associated with increased maternal morbidity and mortality. Aim: The aim of this study was to evaluate the risk reduction strategy by a protocol-based approach to the management of APO in pregnancy in a low-resource center. Settings and Design: The study was conducted in a single obstetric tertiary care public sector hospital for 12 months. Materials and Methods: The pregnant women admitted with acute shortness of breath (SOB) were divided into two groups based on the implementation of pulmonary edema protocol. The data before protocol (Group A) and after (Group B) were compared. Results: A total of 38 patients were admitted with acute SOB. The incidence of APO was 0.10% (95% CI: 0.08,0.14). Majority (Group A: 92.87%; Group B: 81.25%) were admitted in the third trimester. Hypertension was the most common etiology (71.42% in Group A; 81.25% in Group B), followed by cardiovascular causes (42.85% in Group A; 6.25% in Group B) and sepsis (21.42% in Group A; 18.75% in Group B). Caesarean section was carried out in 57.14% in Group A; 62.5% in Group B. Noninvasive Ventilation (NIV) was started in 8 of 16 cases in Group B. Regional anesthesia was used in 87.5% in Group A and 100% in Group B. The maternal mortality was 9 (64.28%) in Group A as compared to 1 (6.25%) in Group B; P = 0.001. Conclusion: The protocol-based algorithm for APO in pregnancy decreases the maternal mortality. Hypertensive disorders of pregnancy are the most common cause followed by cardiac disease. NIV is useful in APO.

Acute pulmonary oedema.

What was the nature of the CPD activity, practice-related feedback and/or event and/or experience in your practice? The article provided information about the pathology, recognition, assessment and management of acute pulmonary oedema.

Formas de presentación de la insuficiencia cardíaca aguda: edema agudo de pulmón y shock cardiogénico

Acute cardiogenic pulmonary edema and cardiogenic shock are two of the main forms of presentation of acute heart failure. Both entities are serious, with high mortality, and require early diagnosis and prompt and aggressive management. Acute pulmonary edema is due to the passage of fluid through the alveolarcapillary membrane and is usually the result of an acute cardiac episode. Correct evaluation and clinical identification of the process is essential in the management of acute pulmonary edema. The initial aim of treatment is to ensure hemodynamic stability and to correct hypoxemia. Other measures that can be used are vasodilators such as nitroglycerin, loop diuretics and, in specific instances, opioids. Cardiogenic shock is characterized by sustained hypoperfusion, pulmonary wedge pressure > 18mmHg and a cardiac index < 2.2l/min/m2. The process typically presents with hypotension (systolic blood pressure < 90mmHg or a decrease in mean arterial pressure > 30mmHg) and absent or reduced diuresis (< 0.5ml/kg/h). The most common cause is left ventricular failure due to acute myocardial infarction. Treatment consists of general measures to reverse acidosis and hypoxemia, as well as the use of vasopressors and inotropic drugs. Early coronary revascularization has been demonstrated to improve survival in shock associated with ischaemic heart disease.

Management of pre‐eclampsia: issues for anaesthetists

Pre-eclampsia is a leading cause of maternal morbidity and mortality. Substandard care is often present and many deaths are preventable. The aim of this review is to summarise the key management issues for anaesthetists in the light of the current literature. A systematic literature search of electronic databases was undertaken including MEDLINE, EMBASE and the Cochrane Library using the key words obstetrics, pregnancy, pregnancy complications, maternal, pre-eclampsia, preeclampsia, cardiac function, haemodynamics, haemolysis, elevated liver enzymes, low platelets (HELLP), eclampsia, anaesthesia, anesthesia, neuraxial. Relevant Colleges and Societies websites were examined for pertinent guidelines. The disease is defined within the context of hypertensive diseases, and early recognition of pre-eclampsia and its complications, as well as multidisciplinary expert team management is highlighted. Accurate monitoring and recording of observations including the use of transthoracic echocardiography is discussed. The importance of the treatment of systolic blood pressure>180 mmHg and the use of intravenous antihypertensive medication as well as the use of parenteral magnesium sulphate for the treatment and prevention of eclampsia is emphasised . Restricted intravenous fluid therapy and avoidance of ergometrine is discussed. Neuraxial analgesia and anaesthesia, and general anaesthesia for birth is summarised as well as postpartum management including analgesia, thromboprophylaxis, management of acute pulmonary oedema and the use of pharmacological agents in the setting of breastfeeding.

Acute pulmonary oedema in pregnant women

Acute pulmonary oedema in pregnant women is an uncommon but life-threatening event. The aims of this review are to address why pulmonary oedema occurs in pregnant women and to discuss immediate management. We performed a systematic literature search of electronic databases including MEDLINE, EMBASE and the Cochrane Library, using the key words obstetrics, pregnancy, acute pulmonary oedema, pregnancy complications, maternal, cardiac function and haemodynamics. We present a simple clinical classification of acute pulmonary oedema in pregnancy into pulmonary oedema occurring in normotensive or hypotensive women (i.e. without hypertension), and acute pulmonary oedema occurring in hypertensive women, which allows focused management. Pre-eclampsia remains an important cause of hypertensive acute pulmonary oedema in pregnancy and preventive strategies include close clinical monitoring and restricted fluid administration. Immediate management of acute pulmonary oedema includes oxygenation, ventilation and circulation control with venodilators. Pregnancy-specific issues include consideration of the physiological changes of pregnancy, the risk of aspiration and difficult airway, reduced respiratory and metabolic reserve, avoidance of aortocaval compression and delivery of the fetus.

Acute pulmonary edema due to stress cardiomyopathy in a patient with aortic stenosis: a case report.

IntroductionStress cardiomyopathy is a condition of chest pain, breathlessness, abnormal heart rhythms and sometimes congestive heart failure or shock precipitated by intense mental or physical stress.Case presentationA 64-year-old male with a known diagnosis of moderate-to-severe aortic stenosis and advised that valve replacement was not urgent, presented with acute pulmonary edema following extraordinary mental distress. The patient was misdiagnosed as having a "massive heart attack" and died when managed by a traditional protocol for acute myocardial infarction/coronary artery disease, irrespective of his known aortic stenosis.ConclusionIntense mental stress poses a considerable risk, particularly to patients with significant aortic stenosis. As described here, it can precipitate acute pulmonary edema. Importantly, effective management of acute pulmonary edema due to stress cardiomyopathy in patients with known aortic stenosis requires its distinction from acute pulmonary edema caused by an acute myocardial infarction. Treatment options include primarily urgent rhythm and/or rate control, as well as cautious vasodilation.

Estimates of Cost-Effectiveness of Prehospital Continuous Positive Airway Pressure in the Management of Acute Pulmonary Edema

Objective. To estimate the cost-effectiveness of continuous positive airway pressure (CPAP) in managing prehospital acute pulmonary edema in an urban EMS system. Methods. Using estimates from published reports on prehospital andemergency department CPAP, a cost-effectiveness model of implementing CPAP in a typical urban EMS system was derived from the societal perspective as well as the perspective of the implementing EMS system. To assess the robustness of the model, a series of univariate andmultivariate sensitivity analyses was performed on the input variables. Results. The cost of consumables, equipment, andtraining yielded a total cost of $89 per CPAP application. The theoretical system would be expected to use CPAP 4 times per 1000 EMS patients andis expected to save 0.75 additional lives per 1000 EMS patients at a cost of $490 per life saved. CPAP is also expected to result in approximately one less intubation per 6 CPAP applications andreduce hospitalization costs by $4075 per year for each CPAP application. Through sensitivity analyses the model was verified to be robust across a wide range of input variable assumptions. Conclusion. Previous studies have demonstrated the clinical effectiveness of CPAP in the management of acute pulmonary edema. Through a theoretical analysis which modeled the costs andclinical benefits of implementing CPAP in an urban EMS system, prehospital CPAP appears to be a cost-effective treatment.

High hopes at high altitudes: pharmacotherapy for acute mountain sickness and high-altitude cerebral and pulmonary oedema

The pharmacotherapy of prevention and treatment of acute altitude- related problems – acute mountain sickness, high-altitude cerebral oedema and high-altitude pulmonary oedema – is reviewed. Drug therapy is only part of the answer to the medical problems of high altitude; prevention should include slow ascent and treatment of the more severe illnesses should include appropriate descent. Carbonic anhydrase inhibitors, in particular acetazolamide, remain the most effective drugs in preventing, to a large extent, the symptoms of acute mountain sickness, and can be used in the immediate management of the more severe forms of altitude-related illnesses. Glucocorticoids in relatively large doses are also effective preventative drugs, but at present are largely reserved for the treatment of the more severe acute mountain sickness and acute cerebral oedema. Calcium channel blockers and PDE-5 inhibitors are effective in the management of acute pulmonary oedema. Further work is required to establish the role of antioxidants and anticytokines in these syndromes.

385: Etiology and management of acute pulmonary edema in pregnancy-postpartum: Role of echocardiography

POSTPARTUM: ROLE OF ECHOCARDIOGRAPHY MOUNIRA HABLI, ANNETTE BOMBRYS, JOHN R. BARTON, HELEN HOW, BAHA SIBAI, University of Cincinnati, Cincinnati, Ohio, Central Baptist Hospital, Lexington, Kentucky OBJECTIVE: To evaluate the role of echocardiography (ECHO)in the etiology and management of acute pulmonary edema in pregnancy. STUDY DESIGN: 59 pregnant women with acute pulmonary edema were evaluated with ECHO between 2000-2006.Women with known functional or structural heart disease were excluded. Maternal outcomes are: ECHO parameters(left ventricular end diastolic[LVED] and systolic dimension[LVES],ejection fraction[EF], % shortening and evidence of systolic diastolic dysfunction), risk factors, acute and discharge medications and major morbidities. 47(80%) patients had a follow up of 1-5 years. Data were analyzed using T-test, Chi square and Fisher exact test. RESULTS: Based on ECHO findings, patients(pts) were classified as having cardiogenic (n 36) or non-cardiogenic (n 23) etiology. There were no differences between groups regarding race, age, rate of hypertensive disorders (67% vs 58%) and admission with preterm labor (11%vs 17%). Mean gestational age at delivery was 36.4 3.25 wks. Among the cardiogenic group, 21 (58%) had peripartum cardiomyopathy, 6 (17%) had isolated systolic dysfunction, 8 (22%) had newly diagnosed valvular disease and one had pulmonary hypertension. These pts had significant impairment in left ventricular performance as compared to non-cardiogenic group (table). All pts received diuretics and oxygen.There was a difference in use of antihypertensive medications(66%,cardiogenic vs 39%,p 0.04). At discharge 28 (77%) women in the cardiogenic group received targeted medications based on ECHO findings as compared to none in the non-cardiogenic group. There were no maternal deaths. CONCLUSION: Echocardiography should be an integral part of the initial evaluation of the etiology and management of acute pulmonary edema in pregnancy. Information obtained by ECHO will assist in improvement of short and long term maternal outcomes.

Management of acute pulmonary edema in the emergency department

Noninvasive ventilation (NIV) is a safe and effective technique that can prevent side effects and complications related to endotracheal intubation. Acute cardiogenic pulmonary edema is currently the second most common indication for NIV, mainly in emergency departments. In this article we examine recent literature related to the applications of NIV in the acute setting with regard to patients with acute cardiogenic pulmonary edema. In addition, we examine the epidemiology and the pathophysiology of acute heart failure.

Effectiveness of Prehospital Continuous Positive Airway Pressure in the Management of Acute Pulmonary Edema

Objective. To compare the effectiveness of continuous positive airway pressure (CPAP) with standard pharmacologic treatment in the management of prehospital acute pulmonary edema. Methods. Using a nonrandomized control group design, all consecutive patients presenting to two participating emergency medical services (EMS) systems with a field impression of acute pulmonary edema between July 1, 2004, andJune 30, 2005, were included in the study. The control EMS system patients received standard treatment with oxygen, nitrates, furosemide, morphine, and, if indicated, endotracheal intubation. The intervention EMS system patients received CPAP via face mask at 10 cm H2O in addition to standard therapy. Results. Ninety-five patients received standard therapy, and120 patients received CPAP andstandard therapy. Intubation was required in 8.9% of CPAP-treated patients compared with 25.3% in the control group (p = 0.003), andmortality was lower in the CPAP group than in the control group (5.4% vs. 23.2%; p = 0.000). When compared with the control group, the CPAP group had more improvement in respiratory rate (−4.55 vs. −1.81; p = 0.001), pulse rate (−4.77 vs. 0.82; p = 0.013), anddyspnea score (−2.11 vs. −1.36; p = 0.008). Using logistic regression to control for potential confounders, patients receiving standard treatment were more likely to be intubated (odds ratio, 4.04; 95% confidence interval, 1.64 to 9.95) andmore likely to die (odds ratio, 7.48; 95% confidence interval, 1.96 to 28.54) than those receiving standard therapy andCPAP. Conclusion. The prehospital use of CPAP is feasible, may avert the need for endotracheal intubation, andmay reduce short-term mortality.

Simple lightweight disposable continuous positive airways pressure mask to effectively treat acute pulmonary oedema: Randomized controlled trial

To compare the novel Boussignac valve continuous positive airways pressure (CPAP) delivery mask and a standard closed-circuit Drager CF800 CPAP system in the management of acute pulmonary oedema (APO) patients. This was a randomized controlled trial whereby patients presenting to the ED with APO and who met the study criteria received either CPAP via the Boussignac valve system or from a standard Drager CF800. Baseline physiological and arterial gas data were recorded and repeated at 30 and 60 min after CPAP commenced. The primary outcome was mean change in pCO2 at 60 min between the two systems. There were 39 evaluable patients (19 Boussignac, 20 Drager). The mean change in pCO2 at 60 min compared to baseline was similar in the two groups (Boussignac 0.9 kPa vs. Drager 1.2 kPa, mean difference -0.3; 95% CI -1.0-0.5, P=0.45). In addition, there were no significant differences at 60 min in regards to respiratory rate decrease, Boussignac 17.3/min versus Drager 19.6/min (mean difference 1.3; 95% CI -3.3-5.8, P=0.58) or peripheral SaO2 increase, Boussignac 10.7% versus Drager 14.6% (mean difference -3.9; 95% CI -9.9-2.1, P=0.19). There was no significant difference in disposition from the ED or the complication rate. The Boussignac valve system may be an effective lightweight disposable method of delivering CPAP to patients with APO. It appears to perform as effectively as much larger, more expensive and less transportable equipment.

Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema

Background: Nitrates are superior to furosemide in the management of acute pulmonary edema associated with myocardial infarction; however, their role in the absence of infarction is unclear. Methods and Results: A randomized comparison was undertaken of the relative effectiveness of primary therapy with either intravenous morphine/furosemide (men/women; n = 32) or nitroglycerin/ N-acetylcysteine (NTG/NAC; n = 37) in consecutive patients with acute pulmonary edema. The primary end point was change in Pao 2/Fio 2 over the first 60 minutes of therapy. Secondary end points were needed for mechanical respiratory assistance (ie, continuous positive airway pressure via mask or intubation and ventilation) and changes in other gas exchange parameters. Both treatment groups showed improvement in oxygenation after 60 minutes of therapy; however, this reached statistical significance only with NTG/ NAC therapy. There was no significant difference between groups in the assessed parameters (95% Cl for differences in Pao 2/Fio 2: furosemide/morphine −12 to 23 and NTG/NAC 4 to 44), a finding also confirmed in 32 patients presenting with respiratory failure. Only 11% of the study group required mechanical ventilatory assistance (continuous positive airway pressure in 4 patients and intubation and ventilation in 3 patients). Conclusions: NTG/NAC therapy is as effective as furosemide/morphine in the initial management of acute pulmonary edema, regardless of the presence or absence of respiratory failure. The necessity for mechanical ventilatory assistance is infrequent in these patients, regardless of the initial medical treatment regimen.

Intravenous Nitrates in the Prehospital Management of Acute Pulmonary Edema

Study objective: We sought to assess the effect of nitrates on prehospital mortality among patients with acute pulmonary edema (APE). Methods: The study involved a retrospective evaluation of the records of prehospital outcome in 640 patients with APE rescued by the mobile CCU (MCCU) of Florence, Italy, between January 1980 and December 1991. The MCCU serves an urban environment with a population of 400,000 in a 102-sq km area. In the years 1980 through 1983, patients were treated with oxygen, morphine, furosemide, digoxin, nitrates, aminophylline, or dopamine, according to the attending physician's judgment. From 1984 through 1991, new guidelines for the use of intravenous nitrates, based on differential treatment according to blood pressure, were in use. Results: Overall prehospital mortality rate for APE in all patients was 7.8% (50 of of 640 patients). Mortality after 1984 was significantly lower than before (5.3% versus 13%, P<.01). Nitrates were effective in reducing mortality, even in hypotensive patients. Multivariate analysis showed that outcome was significantly affected by two clinical features (dyspnea and low blood pressure), treatment with nitrates, and calendar period effects (before/after 1984). Conclusion: Our findings suggest that the use of intravenous nitrates improves short-term prognosis in APE. [Bertini G, Giglioi C, Biggeri A, Margheri M, Simonetti I, Sica ML, Russo L, Gensini G: Intravenous nitrates in the prehospital management of acute pulmonary edema. Ann Emerg Med October 1997;30:493-499.]

Edema pulmonar agudo. Abordagem terapêutica.

The management of acute pulmonary edema remains an interesting challenge to the clinician. The early recognition of this frequent condition, based on clinical features, must lead to the institution of general measures of therapy that can save most patients; a delay or mistake in this early treatment is lethal. The subsequent treatment depends on the characterization of the etiology and the pathophysiological characteristics of each case. The authors present a review of the management of acute pulmonary edema for the general practitioner, which includes the general first line measures and also mention some therapeutic approaches, related to different etiologies, namely those requiring intensive care units.