Acute pulmonary oedema

Furosemide 20mg to 80mg IV, repeated in 20 minutes if necessary

Glyceryl trinitrate 10mcg/min IV, increase by doubling infusion rate every 5 minutes based on clinical
condition and systolic blood pressure over 90mmgHg
NIV using 100% oxygen (CPAP at 10cm water pressure)
Morphine 1 to 2.5mg IV single dose
If patient has AF with RVR contributing to poor cardiac output, consider adding:
Amiodarone 300mg IV infusion over 30-60 minutes
If patient not responding to above measures plus signs of hypotension, consider adding:
Dobutamine 2.5 to 15 mcg/kg/minute by IV infusion

Precautions:
Furosemide:
- Loop diuretic allergy, prostatic obstruction (precipitate urinary retention), gout aggravation, co-
administration with otoxic drugs (increases risk)
- Contraindicated in severe sodium or fluid depletion, treatment with potassium lowering drugs
(risk of hypokalaemia)
- Contraindicated in anuria, higher doses in renal impairment, co-administration with
nephrotoxic drugs (increases risk)
- Hepatic impairment: electrolyte imbalance can precipitate hepatic encephalopathy
- Elderly: more susceptible to hypokalaemia or orthostatic hypertension
- Children: no known data
- Pregnancy: avoid use
- Breast feeding: cautionary

Glyceryl trinitrate:
- Contraindications: hypervolemia/hypotension, raised intracranial pressure, treatment with
PDE5 inhibitor, significant anaemia, HOCM, cardiac tamponade, aortic/mitral stenosis/RHF
- pregnancy: considered safe

Morphine:
- Careful use in: endocrine dysfunction, renal impairment (avoid chronic use), epilepsy,
hypotension
- Avoid in: raised intracranial pressure, phaeochromocytoma, hepatic impairment
Amiodarone:
- Contraindicated in 2nd and 3rd degree heart block, sympatomatic bradycardia, sick sinus
syndrome
- Avoid: thyroid dysfunction (hyper/hypo thyroid effects), lung disease (with reduced diffusion
capacity), electrolyte disturbance (increased arrhythmia risk)
- Careful use: hepatic impairment (increased metabolite accumulation), elderly (GIT issues,
susceptible to bradycardia)
- Pregnancy: avoid 3 months before or during, can cause thyroid dysfunction and bradycardia
in fetus, do not breastfeed

Dobutamine:
- Contraindicated: phaeochromocytoma, ventricular arrhythmias, rapid AF and hypovolemia
Not for children (may be used in intensive care), inadequate information regarding pregnancy or
breastfeeding