Pulmonary Edema ("Flash")

Physiology and Managment of Acute Cardiogenic "Flash" Pulmonary Edema:

• pathophysiology involves a rapid increase in systemic resistance and subsequently in the LVEDP.  A patient with diastolic dysfuction, or a "stiff" ventricle, cannot appropriately compensate for the dramatic increase in the LVEDP. 
• goals of treatment include aggressive BP control, venodilation and diuresis, as well as management of respiratory distress with either non-invasive positive pressure ventilation (NPPV) or mechanical ventilation, if necessary
• assuming the BP is normal to high, the best approach is to start with a rapid-acting venodilator, such as nitroglycerin SL.  The next step is to initiate a briding therapy to control the BP and continue venodilation, with either a nitroglycerin gtt or nitroprusside gtt.  Remember, nitoprusside has significant arteriolar vasodilation as well, so can result in precipitous drop in BP (these patients need to have arterial lines and close monitoring).
• nesiritide, a recominant BNP, is another option for venodilation and theoretically decreases Na and water reabsorbition.  Clinical outcomes have been variable, with concern for renal dysfunction and end-organ damage. See trials below.

(Victoria Kelly MD, 8/3/10)