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Emergency Medicine & Critical Care

Pulmonary Oedema Management

Life-threatening condition characterized by accumulation of excess fluid in the interstitial and alveolar spaces of the lungs, impairing gas exchange. Most commonly caused by acute decompensated heart failure (cardiogenic), but can also be non-cardiogenic.

Also known as: Fluid in the Lungs, Lung Congestion, Acute Heart Failure Exacerbation (if cardiogenic)

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Referral and warning signs

When to refer

All cases of acute pulmonary oedema require immediate emergency management and urgent referral to HC4/Hospital. Specifically refer if: need for non-invasive or invasive ventilation, persistent hypoxaemia despite high-flow oxygen, hypotension or signs of shock, suspected acute MI, need for advanced diagnostics (echo) or therapies (inotropes, urgent revascularization).

Red flags

  • Severe respiratory distress unresponsive to initial treatment
  • Hypotension (Systolic BP < 90 mmHg) or signs of shock
  • Altered mental status (confusion, somnolence)
  • SpO2 remaining low (<90%) despite high-flow oxygen
  • Need for advanced airway management or ventilation

Signs and symptoms

  • Severe dyspnoea (shortness of breath), often sudden onset
  • Orthopnoea (difficulty breathing when lying flat)
  • Paroxysmal Nocturnal Dyspnoea (PND - waking up breathless at night)
  • Rapid, shallow breathing (tachypnoea)
  • Cough, potentially with frothy, pink or blood-stained sputum
  • Wheezing ('cardiac asthma')
  • Crackles (rales) heard on lung auscultation (often bibasilar initially)
  • Tachycardia
  • Pallor, sweating (diaphoresis)
  • Anxiety, feeling of suffocation
  • Signs of underlying cause: e.g., Raised JVP, peripheral oedema, S3 gallop (heart failure); Fever, purulent sputum (pneumonia); Signs of renal failure.

Risk factors

  • Cardiogenic causes: Acute myocardial infarction, Chronic heart failure exacerbation (due to non-compliance, infection, arrhythmia, ischemia), Valvular heart disease, Hypertensive crisis, Cardiomyopathy.
  • Non-cardiogenic causes: Acute Respiratory Distress Syndrome (ARDS) due to sepsis, pneumonia, aspiration, trauma; Renal failure (fluid overload); Iatrogenic fluid overload; High altitude pulmonary oedema (HAPE); Neurogenic pulmonary oedema (head injury); Inhalation of toxic gases.

Diagnosis

Clinical assessment

Based on acute onset of severe respiratory distress with characteristic signs and symptoms (dyspnoea, orthopnoea, tachypnoea, crackles, frothy sputum). Identify potential underlying cause (cardiac vs non-cardiac).

Investigations

  • Pulse Oximetry (shows hypoxaemia)
  • Chest X-ray (typically shows bilateral pulmonary infiltrates, Kerley B lines, cardiomegaly, pleural effusions in cardiogenic cause)
  • Electrocardiogram (ECG) (may show ischemia, infarction, arrhythmia, chamber enlargement)
  • Arterial Blood Gas (ABG) (shows hypoxaemia, potentially respiratory acidosis/alkalosis)
  • Consider Brain Natriuretic Peptide (BNP) or NT-proBNP levels (elevated in heart failure)
  • Echocardiography (assess cardiac structure and function - usually hospital level)
  • Renal function tests, electrolytes
  • Consider investigations for non-cardiogenic causes (e.g., sepsis workup)

Diagnostic criteria

Clinical presentation consistent with pulmonary oedema supported by investigations, particularly Chest X-ray and assessment of oxygenation (SpO2/ABG).

Management

Non-pharmacological management

  • Positioning: Sit patient upright with legs dangling over side of bed (reduces venous return, improves lung expansion).
  • Oxygen Therapy: Administer high-flow oxygen via face mask (simple or non-rebreather) to maintain SpO2 >90-92%. Consider non-invasive ventilation (CPAP/BiPAP) early if severe distress or failing oxygenation (requires appropriate equipment and expertise - HC4/Hospital).
  • Monitor vital signs (HR, BP, RR, SpO2) continuously or very frequently.

Pharmacological treatment

  • Diuretics: Furosemide 40-80 mg slow IV push (may be higher dose if patient on chronic diuretics). Child: 0.5-1.5 mg/kg IV (max 6 mg/kg/day). Repeat dose or start infusion based on clinical response (urine output, respiratory status).
  • Vasodilators (if Systolic BP > 90-100 mmHg): Nitrates - Glyceryl trinitrate (GTN) 500 micrograms sublingually, may repeat every 5-10 mins. Or IV GTN infusion (hospital setting). Reduces preload and afterload.
  • Morphine: 2-4 mg slow IV (Adult dose). Child: 0.1 mg/kg slow IV (single dose). Use cautiously (risk of respiratory depression, hypotension, vomiting). Primarily for anxiolysis and venodilation (reduces preload).
  • Treat underlying cause: e.g., Manage hypertensive emergency, treat arrhythmia, address ischemia.
  • Consider Inotropes (e.g., Dobutamine, Dopamine) if cardiogenic shock present (hypotension with signs of poor perfusion - hospital level).
  • Consider Digoxin loading dose IV ONLY if pulmonary oedema is due to rapid Atrial Fibrillation (use cautiously, monitor closely). Do not give loading dose if patient already on digoxin.
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Continuous monitoring of respiratory status (rate, effort, SpO2, auscultation), haemodynamics (HR, BP), urine output, and mental status. Monitor for side effects of medications (hypotension from nitrates/morphine, respiratory depression from morphine, electrolyte disturbance from diuretics).

Complications

  • Respiratory failure requiring mechanical ventilation
  • Severe hypoxaemia
  • Cardiogenic shock
  • Cardiac arrest
  • Flash pulmonary oedema (rapid recurrence)

Prevention

  • Optimal management of underlying chronic conditions (e.g., heart failure, hypertension, renal disease).
  • Patient compliance with medications, diet (salt restriction), and fluid restrictions if advised.
  • Avoidance of iatrogenic fluid overload.
  • Early recognition and treatment of precipitating factors (e.g., infections, arrhythmias).

Patient education

  • Explain the condition (fluid in the lungs) and likely cause.
  • Emphasize importance of adherence to treatment for underlying conditions (e.g., heart failure medications, diuretics, BP control).
  • Educate on recognizing early warning signs of worsening heart failure or fluid overload (e.g., increasing shortness of breath, weight gain, swelling).
  • Discuss dietary restrictions (salt, fluid) if applicable.

Uganda-specific notes

Common underlying causes in Uganda include hypertensive heart disease, rheumatic heart disease, cardiomyopathy. Ensure availability of IV furosemide, oxygen. Use morphine with caution due to potential for respiratory depression, especially if advanced airway support is not readily available. Consider fluid overload as a cause, especially in patients with renal impairment or receiving IV fluids.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 4, Section 4.1.4

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