Management of Acute Pulmonary Oedema / Heart Failure

Introduction

Acute pulmonary oedema may be the first presentation of heart failure or an exacerbation of existing known heart failure. It also may be secondary to another cause e.g. atrial fibrillation (AF), other tachycardias or bradycardia, critical cardiac ischaemia, valvular disease or renal artery stenosis.

Acute management of pulmonary oedema

For early or mild pulmonary oedema (crackles and upper lobe venous diversion): give high flow oxygen (5-10L/minute; also refer to Guidelines on Oxygen and Oximetry), loop diuretic (furosemide IV or oral 40mg) and review precipitating factors.

For severe pulmonary oedema follow advice below:

• Sit patient upright and give high flow oxygen (5-10L/minute). Also refer to Guidelines on Oxygen and Oximetry.
• Consider IV opiate for distress or dyspnoea.
• IV loop diuretic (furosemide IV 40-80mg or higher if previously on diuretic). If no diuresis and patient not improving 30 minutes post-IV diuretic:
  • Repeat diuretic (if necessary consider furosemide infusion).
  • Give IV nitrate if blood pressure permits.
  • Consider IV dobutamine (5-10micrograms/kg/min) under senior/specialist advice - discuss with cardiologist or consultant.
• Review precipitating factors, especially rhythm.
• If arterial saturations are poor, consider CPAP.
• In patients unable to maintain respiratory effort ventilation should be considered and where appropriate discussed with consultant and ITU.

N.B. Once the acute episode is resolved and the patient is more stable consider long-term management below.

Diagnosis of heart failure

See the below flowchart for the management pathway in the diagnosis of heart failure.

• FlowchartDiagnosing Heart Failure

Ongoing management of heart failure

Follow the links below for drug therapy and treatment options in HFrEF, HFmrEF and HFpEF respectively.

• Heart Failure with REDUCED Ejection Fraction (HFrEF)
• Heart Failure with MILDLY REDUCED Ejection Fraction (HFmrEF)
• Heart Failure with PRESERVED Ejection Fraction (HFpEF).

Sick day rules

There are several classes of drug that should be stopped if the patient is at risk of dehydration due to acute illness (see table below).

Patients should be counselled to seek medical advice if they have diarrhoea or vomiting for more than 48 hours.

N.B. NSAIDS are contraindicated in all types of heart failure and should only be used in exceptional circumstances.

Lifestyle Advice

Vaccination and lifestyle advice should be provided to all heart failure patients.

Alcohol is contraindicated in those with alcoholic cardiomyopathy. Otherwise, can be taken in small quantities (1 or 2 units/day).

All patients with heart failure should be strongly advised not to smoke and should be offered smoking cessation advice and support.

Heart failure liaison nurse service (HFLNS) contact details

To arrange HFLNS follow up, see contact details below.

Tel: 01563 825772

Email: aa.clinical_HeartfailurePathway_xh@aapct.scot.nhs.uk 

When heart failure symptoms are stable, treatment optimised and appropriate self-management and social needs are met then patients will no longer receive planned HFLNS support. Any patient who develops worsening symptoms however, may re-access the service through their GP using the contact details above.