11/13/24, 7\:38 PM Guide | Pulmonary oedema
Pulmonary oedema
Table of contents
Introduction
Pulmonary oedema involves the accumulation of
result of heart failure and/or
This guide provides an overview of the recognition and immediate management of pulmonary oedema using
an ABCDE approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working
through the following steps\:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not
intended to be relied upon for patient care.
Clinical features
Symptoms
Typical symptoms of pulmonary oedema include\:
Shortness of breath
Pink frothy sputum
Signs
Typical clinical signs of pulmonary oedema include\:
Tachypnoea
Decreased oxygen saturations
Raised jugular venous pressure (JVP)
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include\:
Treat all problems as you discover them.
Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
Make use of the team around you by delegating tasks where appropriate.
All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
Clearly communicate how often would you like the patient’s observations relayed to you by other sta
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If you require senior input, call for help early using an appropriate SBARR handover structure.
Review results as they become available (e.g. laboratory investigations).
Make use of your local guidelines and algorithms in managing speci
Any medications or will need to be prescribed at the time (in some cases you may be able to delegate this to another
member of sta
Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical
assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing sta
name, age, background and the reason the review has been requested.
You may be asked to review a patient with pulmonary oedema due to shortness of breath.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
An inability to speak in full sentences indicates signi
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of sta
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Clinical assessment
Can the patient talk?
Yes\: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No\:
Look for signs of airway compromise\: these include cyanosis, see-saw breathing, use of accessory muscles, diminished
breath sounds and added sounds.
Open the mouth and inspect\: look for anything obstructing the airway such as secretions or a foreign object.
Causes of airway compromise
There is a wide range of possible causes of airway compromise including\:
Inhaled foreign body\: symptoms may include sudden onset shortness of breath and stridor.
Blood in the airway\: causes include epistaxis, haematemesis and trauma.
Vomit/secretions in the airway\: causes include alcohol intoxication, head trauma and dysphagia.
Soft tissue swelling\: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).
Local mass e
Laryngospasm\: causes include asthma, gastro-oesophageal re
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Depressed level of consciousness\: causes include opioid overdose, head injury and stroke.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the
emergency medical team (often referred to as the 'crash team'). In the meantime, you can perform some basic airway
manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient's airway using a head-tilt chin-lift manoeuvre\:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a
remove it.
Jaw thrust
If the patient is suspected to have su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible.
2. With your index and other
lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and in some cases essential to maintain a patient's airway. They should be used in
conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the
airway aligned.
An oropharyngeal airway is a curved plastic tube with a
relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may
induce gagging and aspiration.
To insert an oropharyngeal airway\:
1. Open the patient's mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is
present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which
point you should rotate it 180°
. The reason for inserting the airway upside down initially is to reduce the risk of pushing the
tongue backwards and worsening airway obstruction.
3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient's airway by looking, listening and feeling for
signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a
tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients
who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the
NPA.
To insert a nasopharyngeal airway\:
1. Check the patency of the patient's right nostril and if required (depending on the model of NPA) insert a safety pin through
the
2. Lubricate the NPA.
3. Insert the airway bevel-end
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4. If any obstruction is encountered, remove the tube and try the left nostril.
Other interventions
anaphylaxis guide.
If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute.
Tachypnoea is a common feature of pulmonary oedema and indicates signi
Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.
Review the patient’s oxygen saturation (SpO )\:
2
A normal SpO 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk
of CO retention.
2
Hypoxaemia is a typical clinical feature of pulmonary oedema.
See our guide to performing observations/vital signs for more details.
Inspection
Observe for evidence of respiratory distress including the use of accessory muscles and cyanosis.
Palpation
Assess the position of the patient's trachea to identify deviation which may indicate underlying tension pneumothorax.
Locate the apex beat, which is typically located in the 5th intercostal space in the midclavicular line. A large pleural e
tension pneumothorax or right ventricular hypertrophy can cause a displaced apex beat.
Assess chest expansion, which may be reduced in the context of a pleural e
Auscultation
Auscultate both lungs\:
Reduced breath sounds and/or coarse crackles are associated with pulmonary oedema.
Wheeze can also be associated with pulmonary oedema and is referred to as 'cardiac asthma'
.
Percussion
Percuss the patient's chest to identify areas of dullness which may be associated with pleural e
Investigations
Arterial blood gas
Take an ABG if indicated (e.g. low SpO ) to quantify the degree of hypoxia.
2
Typical ABG 2 2 2
and low PaCO. A normal or raised PaCO is concerning as it
indicates that the patient is tiring and failing to ventilate e
Chest X-ray
A chest X-ray may reveal typical radiological signs of pulmonary oedema including\:
Bilateral peri-hilar shadowing
Blunting of the costophrenic angles
Fluid in the
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Kerley B lines
A chest X-ray is also useful for ruling out other lung pathology (e.g. pneumonia).
See our chest X-ray interpretation guide for more details.
Interventions
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-
rebreathe mask with an oxygen
assessment.
If the patient is conscious, sit them upright as this can also help with oxygenation.
Continuous positive airway pressure
Continuous positive airway pressure (CPAP) should be considered for patients who do not improve after supplemental oxygen
and intravenous diuretics (see below). Commencing CPAP is a skill beyond the scope of most junior doctors and should always
involve more senior doctors.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Pulse
Patients with pulmonary oedema may be tachycardic.
Blood pressure
Patients with acute heart failure may be hypotensive and for this reason, it is important to check blood pressure before
administering medications such as diuretics which can worsen hypotension.
Additionally,
oedema.
As a result, patients who are hypotensive with pulmonary oedema need immediate critical care input, as they'll likely require
continuous monitoring and potentially vasopressors to maintain adequate blood pressure whilst treating their pulmonary
oedema.
Capillary re
Capillary re
Fluid status assessment
Assess the patient's
Fluid status assessment involves\:
Inspecting the oral mucosa for hydration
Capillary re
Assessment of jugular venous pressure (JVP)
Review of the patient's
An elevated jugular venous pressure indicates hypervolaemia which may be the reason for pulmonary oedema.
Cardiac auscultation
Auscultate the patient's praecordium to assess heart sounds\:
Soft or mu
A gallop rhythm is a feature of congestive heart failure which is a cause of pulmonary oedema.
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Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Collect blood tests after cannulating the patient including\:
FBC\: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
U&Es\: to assess renal function and rule out electrolyte disturbances.
LFTs\: to assess albumin levels (hypoalbuminaemia can result in oedema).
CRP\: to screen for evidence of in
Troponin\: if considering acute myocardial infarction as the cause of acute heart failure.
Plasma BNP\: helpful if the diagnosis of heart failure is unclear as it has a high negative predictive value.
ECG
An ECG should be performed to look for\:
evidence of acute myocardial ischaemia
ventricular hypertrophy
arrhythmias
An ECG should not delay the treatment of pulmonary oedema.
Interventions
Diuretics
Consider administration of intravenous furosemide to treat pulmonary oedema\:
Furosemide will increase the patient's urine output and help to shift
Larger doses of furosemide may be required in renal failure for a similar response.
As mentioned previously, if the patient is hypotensive then diuretics can precipitate hypovolaemic shock, therefore critical
care input should be sought to decide on the most appropriate management strategy.
Vasodilators and opiates
Recent NICE guidelines warn against the routine use of vasodilators (e.g. glyceryl trinitrate) and opiates (e.g. morphine) in the
context of pulmonary oedema. Specialist advice should be sought prior to prescribing these classes of medication.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
In the context of pulmonary oedema, a patient's consciousness level may be reduced secondary to hypoxia or hypovolaemia.
Assess the patient's level of consciousness using the AVPU scale\:
Alert\: the patient is fully alert, although not necessarily orientated.
Verbal\: the patient makes some kind of response when you talk to them (e.g. words, grunt).
Pain\: the patient responds to a painful stimulus (e.g. supraorbital pressure).
Unresponsive\: the patient does not show evidence of any eye, voice or motor responses to pain.
If a more detailed assessment of the patient's level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
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Assess the patient's pupils\:
Inspect the size and symmetry of the patient's pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology.
Drug chart review
anxiolytics).
Review the patient's drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives,
Investigations and procedures
Blood glucose and ketones
Measure the patient's capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g.
hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
Hypoglycaemia is de≤4.0
mmol/L should be treated if the patient is symptomatic.
If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis
(DKA).
See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.
Imaging
Request a CT head if intracranial pathology is suspected after discussion with a senior.
See our guide on interpreting a CT head for more details.
Interventions
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants
urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient's airway as
explained in the airway section of this guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Exposure
It may be necessary to expose the patient during your assessment\: remember to prioritise patient dignity and conservation of
body heat.
Clinical assessment
Inspection
Inspect the legs for pedal oedema suggestive of heart failure.
Note any unilateral leg swelling and palpate for tenderness suggestive of deep vein thrombosis.
Review the output of the patient's catheter and any surgical drains. High output from ascitic drains can result in
pulmonary oedema.
Temperature
Assess the patient's temperature\: fever may indicate an underlying infection (e.g. pneumonia).
Investigations and procedures
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If a DVT is suspected, calculate the patient's DVT Wells score to determine if an ultrasound scan or D-dimer test should be
performed to con
Interventions
Allergen removal
If a potential allergen is identi
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Re-assess ABCDE
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such as a nurse, who can perform
observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior sta
about your patient.
Use an eSBARR handover to communicate the key information e
Next steps
Well done, you've now stabilised the patient and they're doing much better. There are just a few more things to do...
Take a history
Revisit history taking to identify risk factors for pulmonary oedema and explore relevant medical history. If the patient is
confused you might be able to get a collateral history from sta
See our history taking guides for more details.
Review
Review the patient's notes, charts and recent investigation results.
Review the patient's current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the
patient's response.
See our documentation guides for more details.
Discuss
Discuss the patient's current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
Should any changes be made to the current management of their underlying condition(s)?
Handover
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The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.
References
1. Acute heart failure\: diagnosis and management. Clinical guideline [CG187] Published date\: October 2014. Available from\: [LINK].
Source\: geekymedics.com
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