- 1 Background
- 2 Clinical Features
- 3 Differential Diagnosis
- 4 Evaluation
- 5 Management
- 6 Disposition
- 7 See Also
- 8 References
Pulmonary Edema Types
Noncardiogenic pulmonary edema
- Negative pressure pulmonary edema
- Upper airway obstruction
- Reexpansion edema
- Neurogenic causes
- Iatrogenic fluid overload
- Respiratory distress
- Increased jugular venous distension
- Signs of poor organ perfusion
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Interstitial lung disease
- Panic attack
- Pleural effusion
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- CBC (rule out anemia)
- Albumin level
- Interstitial edema
- Pulmonary venous congestion
- Pleural effusion
- Alveolar edema
- Troponin +/- BNP
- Biologically active metabolite of proBNP (released from ventricles in response to increased volume/pressure)
- Utility is controversial and may not affect patient centered outcomes
- May be trended to gauge treatment response in acute decompensated CHF
- May have false negative with isolated diastolic dysfunction
- <100 pg/mL: Negative for acute CHF (Sn 90%, NPV 89%)
- 100-500 pg/mL: Indeterminate (Consider differential diagnosis and pre-test probability)
- >500 pg/mL: Positive for acute CHF (Sp 87%, PPV 90%)
- American College of Cardiology, American Heart Association, Heart Failure Society of America guidelines as of May 2017
- BNP should be measured in patients presenting with dyspnea to help diagnose or exclude heart failure
- BNP or nt-pro-BNP should be measured to determine prognosis or disease severity in chronic heart failure
- Baseline BNP, cardiac troponin, or both should be measured upon hospital admission to determine prognosis in patients with acutely decompensated heart failure
- N-terminal proBNP (biologically inert metabolite of proBNP)
- <300 pg/mL → CHF unlikely
- CHF likely in:
- >450 pg/mL in age < 50 years old
- >900 pg/mL in 50-75 years old
- >1800 pg/mL in > 75 years old
Differential Diagnosis (Elevated BNP)
BNP In Obese Patients
- Visceral fat expansion leads to increased clearance of active natriuretic peptides
- Obese patients also frequently treated for hypertension or coronary artery disease which may also contribute to lower BNP levels
- In one study of 204 patients with acute CHF, an inverse relationship between BMI and BNP was noted. The standard cutoff of 100pg/mL resulted in a 20% false-negative rate
- Analysis of a subgroup of patients with documented BMI from the Breathing Not Properly study showed that a lower cutoff was more appropriate to maintain 90% sensitivity in obese and morbidly obese patients (54pg/mL)
- CPAP/BPAP with PEEP 6-8; titrate up to PEEP of 10-12
- Dosing Options
- Sublingual 0.4mg q5min
- Nitropaste (better bioavailability than oral Nitroglycerin)
- Intravenous: 0.1mcg/kg/min - 5mcg/kg/min
- Generally start IV Nitroglycerin 50mcg/min and titrate rapidly (150mcg/min or higher) to symptom relief as long as patient's blood pressure tolerates
- Dosing Options
- If nitroglycerin fails to reduce work of breathing, consider nitroprusside (reduces both preload and afterload) or ACE-inhibitiors (preload reducer)
- After patient improves, titrate down nitroglycerin as enaliprilat (0.625 - 1.25mg IV) or captopril are started
- Morphine is no longer recommended do to increased morbidity
- Depends on underlying cause, hemodynamic stability, and response to treatment
- Congestive Heart Failure (CHF)
- Acute Respiratory Distress Syndrome
- Sympathetic crashing acute pulmonary edema (SCAPE)
- Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161-167. doi:10.1056/NEJMoa020233.
- Carpenter CR et al. BRAIN NATRIURETIC PEPTIDE IN THE EVALUATION OF EMERGENCY DEPARTMENT DYSPNEA: IS THERE A ROLE? J Emerg Med. 2012 Feb; 42(2): 197–205.
- Yancy CW et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.
- Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006 Feb. 27(3):330-7.
- Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med. 2005 Feb 17. 352(7):666-75.
- Moe GW, Howlett J, Januzzi JL, Zowall H,. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. Circulation. 2007 Jun 19. 115(24):3103-10.
- Clerico A, Giannoni A, Vittorini S, Emdin M. The paradox of low BNP levels in obesity. Heart Fail Rev. 2011;17(1):81-96. doi:10.1007/s10741-011-9249-z.
- Krauser DG, Lloyd-Jones DM, Chae CU, et al. Effect of body mass index on natriuretic peptide levels in patients with acute congestive heart failure: A ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) substudy. Am Heart J. 2005;149(4):744-750. doi:10.1016/j.ahj.2004.07.010.
- Daniels LB, Clopton P, Bhalla V, et al. How obesity affects the cut-points for B-type natriuretic peptide in the diagnosis of acute heart failure. Results from the Breathing Not Properly Multinational Study. Am Heart J. 2006;151(5):999-1005. doi:10.1016/j.ahj.2005.10.011.
- Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008 Apr;25(4):205-9.
- Ellingsrud C, Agewall S. Morphine in the treatment of acute pulmonary oedema--Why? Int J Cardiol. 2016 Jan 1;202:870-3.