FFinalistSouthampton · 2027
Acute care
AKT · Acute care/Cardiac & respiratory

Acute pulmonary oedema (acute LVF)

Acute left-ventricular failure → alveolar flooding

Overview

Acute left-heart failure causing fluid to flood the alveoli — severe breathlessness, hypoxia and pink frothy sputum. An emergency treated by sitting the patient up, oxygen, IV nitrates and diuretics, while seeking the precipitant (ACS, arrhythmia, fluid overload).

Recognise

  • Acute severe dyspnoea, orthopnoea, pink frothy sputum, distress
  • Bilateral basal crepitations, raised JVP, gallop rhythm, tachycardia
  • Hypoxia; CXR: upper-lobe diversion, Kerley B lines, bat-wing oedema, effusions

Red flags

  • Cardiogenic shock (hypotension + poor perfusion), exhaustion/falling consciousness → critical care, consider CPAP/ventilation

Differentials & how to tell them apart

Acute severe asthma / COPDwheeze, prior airways disease, no cardiac signs/oedema
Pneumoniafever, focal consolidation, raised CRP
Pulmonary embolismpleuritic pain, clear lungs, hypoxia with risk factors
ARDSdiffuse infiltrates with a non-cardiac precipitant

Investigations

ECG (ACS/arrhythmia trigger), CXR, ABG, BNP, troponin, U&E; echocardiogram to assess LV function.

Management

Sit up + high-flow O2 + IV furosemide + IV nitrates (if BP adequate)

  1. 1Sit the patient up, high-flow oxygen, IV furosemide, IV nitrate infusion; treat the precipitant (ACS, arrhythmia).Gate: IV nitrates are contraindicated if systolic BP is low (hypotension/cardiogenic shock) → do not give; consider inotropes/CPAP and critical care
  2. 2Refractory hypoxia → CPAP; cardiogenic shock → inotropes + critical care; address the underlying cause.
IV furosemide — loop diuretic (offload)
IV nitrates (GTN infusion) — reduce preload/afterload — if BP adequate
Oxygen ± CPAP — CPAP for refractory hypoxia

Key points

Nitrates need an adequate BP. CPAP recruits flooded alveoli. Always hunt the precipitant — a silent MI or new AF often triggers it.

Monitor & prognosis

SpO2, BP, urine output, ABG, response to diuresis; daily weights.

Good if the precipitant is treated; recurrent if chronic HF undertreated.

Source: NICE NG106 (chronic heart failure); acute HF pathways