FOCUS

Chronic heart failure

Andrew Baird

Acute pulmonary
oedema
Management in general practice

Background
Acute pulmonary oedema is a life threatening emergency
that requires immediate intervention with a management
plan and an evidence based treatment protocol.

Objective
This article describes the features, causes, prevalence and
prognosis of heart failure and the management of acute
pulmonary oedema.

Discussion
Presentations of acute pulmonary oedema and acute heart
failure to general practice require a coordinated and urgent
response. Initial assessment, management and monitoring
should occur concurrently and must be modified in
response to clinical changes.

Keywords: heart failure; pulmonary oedema; emergencies

910 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010

Acute heart failure (AHF) is a clinical syndrome

characterised by the rapid onset and progression of
breathlessness and exhaustion. There is usually fluid
overload.1 Acute heart failure typically occurs as acute
decompensated heart failure (ADHF) either secondary to
chronic heart failure (CHF) or de novo. The more severe
presentations of acute heart failure are acute pulmonary
oedema (APO) and cardiogenic shock. In the EuroHeart
Failure Survey II2 of patients hospitalised with AHF, 37% had
de novo acute heart failure and 16% had APO.

General practitioners are familiar with the clinical presentation of APO
severe dyspnoea, distress, pallor, sweating, tachycardia and poor
peripheral perfusion. However, in general practice, the presentation of
AHF may be less dramatic than APO and the clinical features may be
atypical (eg. delirium or falls in the elderly). Differential diagnoses and
potential precipitants for APO are listed in Table 1.
The most common cause of heart failure is impaired myocardial
function (cardiomyopathy) secondary to one or more of the following1:
hypertension (>60% of patients with heart failure)
ischaemic heart disease (>50% of patients with heart failure)
idiopathic dilatation (10% of patients with heart failure)
diabetes
alcohol excess
obesity
drug toxicity.
Other cardiac causes of heart failure include arrhythmias, valve
dysfunction and pericardial disease. Noncardiac causes of heart failure
are hypovolaemia (dehydration or haemorrhage), pulmonary embolism
and high output states (anaemia, septicaemia and thyrotoxicosis).
On echocardiographic criteria, about one-third to one-half of patients
with a diagnosis of CHF have normal ventricular systolic function with
a left ventricular ejection fraction >40%.1 There is impaired relaxation
of the ventricle in diastole, which is termed diastolic heart failure or
synonymously heart failure with normal systolic function (HFNSF). The
significance of HFNSF as a distinct clinical entity is uncertain. However,
patients with HFNSF do seem particularly dependent on ventricular filling
for cardiac output and are very sensitive to overdiuresis.3

Table 1. Acute pulmonary oedema differential diagnoses and potential precipitants

Consider and manage the following as appropriate
Differential diagnoses of acute dyspnoea

Precipitants of acute pulmonary oedema

Primary respiratory causes

Exacerbation of chronic obstructive pulmonary
disease (COPD)
Acute asthma
Pneumothorax
Pneumonia

Primary cardiac causes

Acute coronary syndrome/myocardial infarction
Arrhythmia
Pericarditis
Acute valve dysfunction (aortic stenosis, mitral regurgitation)
Endocarditis

Anaphylaxis

Fluid overload

Hyperventilation

Drugs (eg. nonsteroidal anti-inflammatory drugs [NSAIDs],

nondihydropyridine calcium channel blockers)

Noncardiogenic acute pulmonary oedema

Drowning
Laryngospasm/upper airway obstruction
Toxic inhalation

Noncompliance with:
heart failure management medications
restrictions on fluid intake or alcohol intake

Pulmonary embolus

Pulmonary embolus

Acute renal failure

Acute renal failure

High output states

Septicaemia
Anaemia
Thyrotoxicosis

High output states

Septicaemia
Anaemia
Thyrotoxicosis

Prevalence
The prevalence of CHF increases with age. In Australia, the prevalence
in the 5564 years age group is estimated at 2.5%, in the over 75
years age group it is 8.2%. There are twice as many women as men
with CHF.4 At the age of 40 years, the lifetime risk of developing heart
failure is about 20% in both men and women.1 There are no data on
the incidence of APO, but it is estimated that most patients with CHF
will have at least one episode of ADHF or APO.1

Prognosis
Overall, CHF has a poor prognosis with about 50% mortality 5 years
from diagnosis.57 In-hospital mortality from ADHF ranges from
2.121.9%, depending on mortality risk stratification.8
Clinical decision tools to predict mortality in ADHF have been
developed based on the following recognised indicators of poor
prognosis: renal impairment, low systolic blood pressure, tachypnoea,
hyponatraemia, anaemia and comorbidities.8,9

Management
The management of ADHF and APO is largely based on clinical
experience rather than prospective randomised controlled trials.1,57,10
Current management described in this article is informed by guidelines
from Australia,3,6 Europe,5 the United States of America7 and by
a review.10 The therapeutic interventions recommended by these
authorities differ in approach and emphasis but the principles are similar.

Table 2 summarises the assessment and management steps for APO.

There are no guidelines or studies which specifically address the
management of APO in the primary care setting. A PubMed search
on all fields using the MeSH terms acute heart failure and family
practice produced only one relevant article.11
The goals of APO management are symptom relief, reduction
of extracellular fluid excess, improved haemodynamics, improved
arterial oxygenation and satisfactory perfusion of the vital organs.1
General guidelines, approaches and goals must be modified
according to clinical setting (eg. rural or metropolitan) and context
(eg. APO in an elderly patient with end stage CHF as opposed to a
previously healthy patient 50 years of age).
The prerequisites for successful management of APO include
appropriate:
systems (triage, crisis resource management plans, organisation,
leadership, teamwork, documentation)
resources (personnel, equipment and drugs)
knowledge and skills.
Assessment, management and definitive therapy are concurrent,
continuous and iterative. All patients require hospital admission
for stabilisation and monitoring unless inappropriate, such as in
the palliative care context. Definitive therapy for acute pulmonary
oedema is outlined in Table 3.
Once the patient is stable, management progresses to postacute
care planning.

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FOCUS Acute pulmonary oedema management in general practice

Table 2. Assessment and management of acute pulmonary oedema

Initial

Call for help (other GPs, nurses, clinic staff, dial 000)
Commence oxygen
Insert 16 gauge intravenous cannula
Commence definitive treatment while assessing patient

History

Focused cardiorespiratory history (Note: nocturnal dyspnoea and orthopnoea are

specific but not sensitive for heart failure)
Check past medical history, medications, compliance
Consider third party information

Examination

Five vital signs

temperature
pulse (rate, rhythm)
blood pressure
respiration (rate, pattern)
oxygen saturation
Focused cardiorespiratory examination, particularly:
colour
diaphoresis
jugular venous pulse
apex beat (shift, loading)
heart sounds (gallop rhythm?)
Murmurs (eg. mitral regurgitation, aortic stenosis)
Peripheral perfusion and oedema
Air entry, crepitations, rhonchi

Monitoring

Blood pressure
Continuous ECG (lead II) if available
Oxygen saturation
Automated external defibrillator on standby
Consider urinary catheter if managing in rural hospital

Investigations
(depending on availability)

12 lead electrocardiogram (ECG) as soon as possible (APO is an acute coronary

syndrome until proven otherwise)
Chest X-ray (portable, if available)
Point-of-care pathology tests (if available)
troponin
B-type natriuretic peptide (BNP)*
Other pathology tests: urea and electrolytes, liver function tests, glucose, urinalysis, full
blood examination (FBE), arterial blood gases
Echocardiogram at earliest opportunity (depending on access and patient stability)

Reassurance
and explanation

Patient and relatives

* Useful negative predictive value (if BNP lower than 100 pg/mL, dyspnoea is unlikely to be cardiogenic). This test costs
about $50 and there is a Medicare rebate for the diagnosis of dyspnoea in hospital emergency departments. The role
and utility of this test in APO and in primary care settings is not yet well defined

912 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010

Acute pulmonary oedema management in general practice FOCUS

Table 3. Definitive therapy for acute pulmonary oedema

Therapy (action)
Posture
Oxygen
(corrects hypoxaemia)
(align centre of flowmeter ball to
required flow rate)

Glyceryl trinitrate
(venodilator, reduces preload)

Dose
Patient supported in sitting up
position
1015 L/min via Hudson type
mask and reservoir bag12
(This is initial treatment even
in patients with known COPD
who are at risk of hyperoxic
hypercapnia as oxygenation is
the priority. Monitor conscious
state, respiratory rate and
oxygenation)
400 g sublingual every 5
minutes (up to three doses)

Intravenous infusion
commencing at 10 g/min
Positive airway pressure
support (continuous [CPAP]
or bi-level [BiPAP] if available)
reduces alveolar and pulmonary
interstitial oedema; reduces
venous return and preload

Continuous positive airway

pressure 10 cmH20
BiPAP: inspiratory pressure
15 cmH20, expiratory pressure
5 cmH20

Frusemide
(loop diuretic, reduces fluid
overload; possible vasodilator
effect)

2080 mg IV bolus
After bolus, consider continuous
IV infusion at 510 mg/hour (total
dose <100 mg in first 6 hours,
and <240 mg in the first 24 hours)
12 mg IV

Morphine (reduces sympathetic

nervous activity; possible
venodilator effect)

Notes
Supine position if unconscious or in cardiogenic
shock
When stable, reduce to 26 L/min via nasal
prongs or 510 L/min via Hudson mask
Patients with COPD should ideally receive
controlled oxygen therapy via a 28% Venturi
mask (flow rate 4 L/min)12
Titrate to achieve oxygen saturation of 9496%
(non-COPD) or 8892% (COPD)12

Maintain systolic blood pressure (SBP) above

100 mmHg
Contraindicated within 48 hours of PDE5
inhibitor
Double infusion rate every 5 minutes according
to clinical response (maintain SBP above 90
mmHg)
Contraindicated if:
SBP <90 mmHg
reduced consciousness
Clinical improvement may occur within 10
minutes. Duration of use depends on efficacy
and tolerability. Some evidence BiPAP may be
superior
Consider repeating a bolus dose after
3060 minutes if there has been no clinical
improvement and no diuresis
Risk of hypovolaemia; avoid if no clear fluid
overload
Does not improve pulmonary oedema or cardiac
output
Anxiolytic
Reduces respiratory work

Other drugs that may be used

Low molecular weight heparin
(venous thromboembolism
prophylaxis)

Eg. enoxaparin 40 mg SC daily

Commence if available

Digoxin

500 g IV (over 5 or more

minutes)

Only for digoxin nave patients with rapid atrial

fibrillation

Spironolactone

2550 mg orally stat

Consider in volume overloaded patient with

poor response to IV frusemide5

Other therapies that may be used in intensive care unit

Adrenaline infusion
Vasopressin antagonists (conivaptan, tolvaptan)
Vasodilators (sodium nitroprusside)
Inotropes (for cardiogenic shock or hypoperfused state with SBP <90 mmHg)
beta-adrenergic stimulators (dobutamine, dopamine)
phosphodiesterase inhibitors (milrinone, enoximone)
Ultrafiltration
Mechanical support (eg. intra-aortic balloon pump) for cardiogenic shock

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FOCUS Acute pulmonary oedema management in general practice

Checklist for postacute care

Summary of important points

Structured management plan (Medicare primary care items may

apply): patient and GP define problems, goals and actions
Team based care according to needs and access (Medicare primary
care items may apply). This may involve the GP, practice nurse,
cardiologist and/or heart failure clinic, pharmacist, Aboriginal
health worker, dietician or exercise physiologist
Education and support for patient and carers (useful resources are
available at www.heartfoundation.org.au)
Home assessment and community support
Lifestyle
smoking cessation
diet: follow Heart Foundation guidelines, no added salt
fluid restriction: maximum 2 L/day (1.5 L/day if severe CHF)
alcohol: no more than one unit per day
exercise: individualised program
Investigations
echocardiogram: mandatory for all patients post-AHF
full cardiac workup: ECG, lipid profile, glucose, renal function,
liver function, thyroid function, iron studies, FBE
Monitoring: patient self monitoring (symptoms, weight, BP)
GP review (frequency determined by severity and stability of CHF):
symptoms, weight, BP, cardiorespiratory status
risk factor management
comorbidities (especially ischaemic heart disease, diabetes,
COPD, renal impairment, sleep apnoea, obesity, depression,
osteoarthritis)
mental state
medication review (Medicare primary care items may apply)
pathology (urea, creatinine, electrolytes, FBE)
Medications indicated (*improves prognosis as well as symptoms)
angiotensin converting enzyme inhibitor (ACEI)*: all patients
with CHF (if not tolerated use angiotensin II receptor blocker)
beta blocker*: patients with systolic failure; COPD is not a
contraindication (bisoprolol, carvedilol, metoprolol, nebivolol)
frusemide: symptoms of fluid overload
spironolactone*: add on if symptom control inadequate
digoxin: consider for atrial fibrillation, or as add on therapy for
sinus rhythm with severe CHF inadequately controlled with the
above
Medications (contraindicated or caution):
verapamil and diltiazem
NSAIDs or cyclo-oxygenase-2 inhibitors
corticosteroids
Vaccinations: influenza, pneumococcal
Device therapy for patients with moderate or severe CHF
(cardiologist would assess and recommend if appropriate):
cardiac resynchronisation therapy (eg. if QRS is greater
than 120 ms)
implantable cardioverter defibrillator.

Acute pulmonary oedema is a life threatening emergency requiring

immediate intervention with a crisis resource management plan
and an evidence based treatment protocol.
The principal therapies for APO are oxygen, sitting the patient
upright, glyceryl trinitrate, positive airway pressure, frusemide,
morphine and inotropes.
A key component in the management of APO is postacute care
which presents an opportunity to optimise wellbeing and prognosis
in CHF.

914 Reprinted from Australian Family Physician Vol. 39, No. 12, december 2010

Author

Andrew Baird MBChB, FRACGP, FACRRM, is a general practitioner,

Melbourne, Victoria. [email protected].
Conflict of interest: none declared.

References

1. Krum H, Abraham W. Heart failure. Lancet 2009;373:94155.

2. Nieminen M, Brutsaert D, Dickstein K, et al, EuroHeart Failure Survey II
(EHFS II): a survey on hospitalized acute heart failure patients: description
of population. Eur Heart J 2006;27:272536.
3. Cardiovascular Expert Group. Therapeutic Guidelines: cardiovascular.
Version 5. Melbourne: Therapeutic Guidelines Limited, 2008.
4. Australian Institute of Health and Welfare. Heart failure in Australia.
Available at www.aihw.gov.au/cvd/heart_failure.cfm.
5. Dickstein K. The Task Force for the Diagnosis and Treatment of Acute and
Chronic Heart Failure of the European Society of Cardiology. ESC guidelines
for the diagnosis and treatment of acute and chronic heart failure 2008. Eur
Heart J 2008;29:2388442.
6. National Heart Foundation of Australia and the Cardiac Society of Australia
and New Zealand (Chronic Heart Failure Guidelines Expert Writing Panel).
Guidelines for the prevention, detection and management of chronic heart
failure in Australia, 2006. Available at www.heartfoundation.org.au.
7. Lindenfeld J, Albert NM, Boehmer JP, et al. Executive summary: Heart
Failure Society of America 2010 Comprehensive Heart Failure Practice
Guideline. J Card Fail 2010;16:475539.
8. Fonarow GC, Adams KF Jr, Abraham WT, et al for the ADHERE Scientific
Advisory Committee, Study Group, and Investigators. Risk stratification for
in-hospital mortality in acutely decompensated heart failure: classification
and regression tree analysis. JAMA 2005;293:57280.
9. Lee DS, Austin PC, Rouleau JL, et al. Predicting mortality among patients
hospitalized for heart failure: derivation and validation of a clinical model.
JAMA 2003;290:25817.
10. Allen LA, OConnor CM. Management of acute decompensated heart
failure. Can Med Assoc J 2007;176:797805.
11. Bosomworth J. Rural treatment of acute cardiogenic pulmonary edema:
applying the evidence to achieve success with failure. Can J Rural Med
2008;13:1218.
12. ODriscoll B, Howard L, Davison A. Emergency Oxygen Guideline Group,
British Thoracic Society. Guideline for emergency oxygen use in adult
patients. Thorax 2008;63(Suppl 6):84950.