Manejo del Edema Pulmonar Agudo

Introducción

El tratamiento del edema pulmonar agudo debe incluir oxigenoterapia, CPAP con oxígeno para mantener saturaciones de 94-98% en pacientes que no responden al tratamiento estándar, diuréticos intravenosos, vasodilatadores y morfina, con monitorización continua de signos vitales y saturación de oxígeno, según recomiendan la European Heart Journal y el Journal of the American College of Cardiology 1, 2, 3

Administrar oxígeno para corregir la hipoxemia, manteniendo SpO2 >90%, como recomienda la European Heart Journal 4
Posición semisentada para mejorar la ventilación, según sugieren la European Heart Journal 3, 5
Monitorización continua de ECG, presión arterial, frecuencia cardíaca y saturación de oxígeno, como recomiendan el Journal of the American College of Cardiology 6, 7
Canalizar acceso venoso para administración de medicamentos, según sugiere el Journal of the American College of Cardiology 6

Nitroglicerina sublingual o intravenosa como tratamiento de primera línea, especialmente efectiva en edema pulmonar asociado a síndrome coronario agudo, según recomiendan la European Heart Journal y el Journal of the American College of Cardiology 3, 5, 6
Dosis de nitroglicerina: titular hasta obtener respuesta hemodinámica adecuada, manteniendo PAS >85 mmHg, como sugiere el Journal of the American College of Cardiology 6
Morfina 3-5 mg IV, reduce la ansiedad, disminuye la precarga y mejora la disnea, según recomienda el Journal of the American College of Cardiology 6

CPAP con oxígeno para mantener saturación 94-98% en pacientes que no responden al tratamiento estándar, como recomiendan la Thorax 1, 2
Ventilación mecánica invasiva indicada en pacientes con hipoxemia grave que no responde rápidamente a la terapia o con acidosis respiratoria, según sugieren el Journal of the American College of Cardiology 6, 7

En edema pulmonar cardiogénico, identificar y tratar la causa subyacente, como síndrome coronario agudo o arritmias, según recomiendan la European Heart Journal y el Journal of the American College of Cardiology 5, 6
En edema pulmonar no cardiogénico, identificar y tratar la causa desencadenante, como post-obstructivo o SDRA, según sugieren la Anaesthesia 8, 9

Evaluar respuesta al tratamiento mediante parámetros clínicos, como frecuencia respiratoria y uso de musculatura accesoria, según recomiendan la European Heart Journal y el Journal of the American College of Cardiology 5, 6
Monitorizar saturación de oxígeno, gases arteriales, función renal y electrolitos, como sugieren el Journal of the American College of Cardiology 6, 7

The European Respiratory Society recommends applying CPAP early in patients with cardiogenic acute pulmonary edema who present with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) in the prehospital setting 10, 11, 12
Apply CPAP when patients with suspected cardiogenic pulmonary edema present with respiratory distress with respiratory rate >25 breaths/min 13, 10
Apply CPAP when patients with suspected cardiogenic pulmonary edema present with oxygen saturation (SpO2) <90% despite conventional oxygen therapy 13, 12

Do not apply CPAP in patients with hypotension (systolic blood pressure <90 mmHg) 13

CPAP in the prehospital setting has been shown to decrease the need for endotracheal intubation (RR 0.31, 95% CI 0.17-0.55) 10, 11
CPAP in the prehospital setting may potentially decrease mortality 11

Ensure adequate training of prehospital personnel in CPAP application, as recommended by the European Respiratory Society 10, 11

Despite CPAP therapy, consider intubation if there is persistent hypoxemia (low oxygen levels) despite CPAP 13
Despite CPAP therapy, consider intubation if there is hypercapnia (high carbon dioxide levels) with acidosis (low pH) 13
Despite CPAP therapy, consider intubation if there is deteriorating mental status or inability to protect airway 13
Despite CPAP therapy, consider intubation if there is hemodynamic instability despite appropriate interventions 13

The British Thoracic Society and European Heart Society recommend CPAP as the preferred initial therapy over high-flow nasal cannula in patients with acute pulmonary edema presenting with severe respiratory distress 14, 15
The European Society of Cardiology recommends using CPAP (5-15 cmH₂O) as adjunctive treatment in patients with cardiogenic pulmonary edema who have respiratory distress or who fail to respond to standard pharmacological therapy 14, 15
Target oxygen saturation of 94-98% (or 88-92% if at risk of hypercapnia) should be maintained during CPAP therapy, as recommended by the British Thoracic Society and European Heart Society 14, 15

The British Thoracic Society guidelines explicitly recommend CPAP or high-flow humidified nasal oxygen as adjunctive treatment, but the evidence base for CPAP is substantially stronger 14
The European Society of Cardiology guidelines recommend CPAP or non-invasive positive pressure ventilation for patients with pulmonary edema and respiratory distress, with no mention of high-flow nasal cannula as an alternative 15, 16

CPAP improves lung elasticity and decreases resistance at pressures of 10 cmH₂O, as demonstrated in a study published in the Annals of Emergency Medicine 17

The British Thoracic Society recommends not using CPAP if the patient has systolic blood pressure <90 mmHg (hypotension), active vomiting or inability to protect airway, depressed consciousness, or suspected pneumothorax 14, 15

The European Heart Society recommends starting CPAP at 5-10 cmH₂O and titrating up to 15 cmH₂O based on clinical response, and ensuring FiO₂ is entrained to maintain target saturations 14, 15

The European Respiratory Society guidelines suggest that high-flow nasal cannula may be considered only as a second-line option when the patient cannot tolerate CPAP interface or in post-operative settings, but there is no high-quality evidence supporting its use specifically for acute cardiogenic pulmonary edema 14, 18

The Annals of Emergency Medicine recommend continuous monitoring of respiratory rate, heart rate, blood pressure, and pulse oximetry targeting 94-98% during CPAP therapy 14, 15, 17