Management of Pulmonary Edema

Diagnostic Considerations

Bilateral interstitial opacities on chest imaging can represent pulmonary edema, which may be either hydrostatic (cardiac or renal failure) or permeability-related, characterized by expansion of connective tissue space around conducting airways, accompanying vessels, and interlobular septa 1, 2
Radiographic findings of pulmonary edema include hazy opacities, Kerley lines, and batwing appearance in hydrostatic edema, and patchy and widespread areas of parenchymal opacities in permeability edema 2

The American College of Cardiology recommends a Level B approach: patients with moderate-to-severe pulmonary edema resulting from acute heart failure should be treated with furosemide in combination with nitrate therapy, which has been associated with the highest frequency of clinical improvement in pulmonary edema 3, 4
Nitrates, such as sublingual nitroglycerin 0.4-0.6 mg repeated every 5-10 minutes, should be considered as initial therapy alongside furosemide 5

Aggressive diuretic monotherapy is unlikely to prevent the need for endotracheal intubation compared with aggressive nitrate monotherapy (Level C recommendation), and diuretics should be administered judiciously due to potential association with worsening renal function 3, 4
Patients receiving furosemide may experience transient worsening of hemodynamics for 1-2 hours after treatment, and hypotension is a potential adverse effect 3