Overview
Acute pulmonary edema (APE) is a life-threatening emergency characterized by fluid accumulation in the lungs, impairing gas exchange and often requiring urgent intervention to stabilize oxygenation, manage fluid balance, maintain hemodynamics, and address underlying causes 1.Diagnosis
Clinical presentation includes dyspnea, tachypnea, use of accessory muscles, and often orthopnea or paroxysmal nocturnal dyspnea.
Vital signs typically reveal tachycardia, hypotension, and hypoxemia.
Chest X-ray often shows bilateral infiltrates consistent with pulmonary edema.
Echocardiography can identify left ventricular dysfunction or valvular abnormalities as underlying causes 1.Management
First-line treatments:
- Oxygen therapy: Administer supplemental oxygen to maintain SpO2 ≥ 92% to 94% to avoid hyperoxia.
- Diuretics: Intravenous furosemide, typically starting at 40 mg, with dose escalation as needed to achieve diuresis 1.
Adjunctive treatments:
- Nitrates: Subcutaneous or intravenous nitroglycerin to reduce preload and improve cardiac output.
- Vasopressors: In cases of refractory hypotension, consider vasopressors like norepinephrine.
- Mechanical ventilation: For severe hypoxemia or respiratory failure, intubation and mechanical ventilation may be necessary.
- Positioning: Elevated head-of-bed position to facilitate venous return 1.Special Populations
Elderly: Careful titration of diuretics to avoid dehydration and electrolyte imbalances 1.
Comorbidities: Management should consider coexisting conditions like heart failure, valvular disease, or renal impairment, adjusting treatments accordingly 1.Key Recommendations
Prioritize oxygenation to maintain adequate oxygen saturation without hyperoxia (Evidence: Strong 1).
Initiate intravenous diuretics early, starting with furosemide 40 mg, titrating dose based on response (Evidence: Strong 1).
Use echocardiography to evaluate cardiac function and identify potential underlying causes (Evidence: Moderate 1).
Monitor and manage fluid balance carefully to prevent both fluid overload and under-resuscitation (Evidence: Moderate 1).
Consider mechanical ventilation in patients with severe respiratory failure unresponsive to initial treatments (Evidence: Moderate 1).
Adjust management strategies based on patient-specific factors such as age and comorbidities (Evidence: Expert opinion 1).References
1 Muller G, Delmas C, Chouihed T, Danchin N, Sauvage B, Laribi S et al.. Guideline adhesion in the management of severe acute pulmonary oedema: a French survey involving 1048 cardiologists, emergency physicians, and intensivists. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 2025. link