Pulmonary Oedema | Acute Management | ABCDE

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Pulmonary oedema involves the accumulation of fluid in the parenchyma and air spaces of the lungs, most commonly as a result of heart failure and/or fluid overload.

This guide provides an overview of the recognition and immediate management of pulmonary oedema using an ABCDE approach.

The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.

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Clinical features of acute pulmonary oedema

Symptoms

Typical symptoms of pulmonary oedema include:

• Shortness of breath
• Pink frothy sputum

Signs

Typical clinical signs of pulmonary oedema include:

• Tachypnoea
• Decreased oxygen saturations
• Raised jugular venous pressure (JVP)

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Tips before you begin

General tips for applying an ABCDE approach in an emergency setting include:

• Treat all problems as you discover them.
• Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
• Make use of the team around you by delegating tasks where appropriate.
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
• Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
• If you require senior input, call for help early using an appropriate SBARR handover structure.
• Review results as they become available (e.g. laboratory investigations).
• Make use of your local guidelines and algorithms in managing specific scenarios.
• Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
• Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.

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Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.

You may be asked to review a patient with pulmonary oedema due to shortness of breath.

Introduction

Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.

Interaction

Introduce yourself to the patient including your name and role.

Ask how the patient is feeling as this may provide some useful information about their current symptoms.

An inability to speak in full sentences indicates significant shortness of breath.

Preparation

Make sure the patient’s notes, observation chart and prescription chart are easily accessible.

Ask for another clinical member of staff to assist you if possible.

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.

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Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

• Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
• Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.

Interventions

Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airway using a head-tilt chin-lift manoeuvre:

1. Place one hand on the patient’s forehead and the other under the chin.

2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.

Jaw thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

Other interventions

If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Breathing

Clinical assessment

Observations

Review the patient’s respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Tachypnoea is a common feature of pulmonary oedema and indicates significant respiratory compromise.
• Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.

Review the patient’s oxygen saturation (SpO₂):

• A normal SpO₂ range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO₂ retention.
• Hypoxaemia is a typical clinical feature of pulmonary oedema.

See our guide to performing observations/vital signs for more details.

Inspection

Observe for evidence of respiratory distress including the use of accessory muscles and cyanosis.

Palpation

Assess the position of the patient’s trachea to identify deviation which may indicate underlying tension pneumothorax.

Locate the apex beat, which is typically located in the 5th intercostal space in the midclavicular line. A large pleural effusion, tension pneumothorax or right ventricular hypertrophy can cause a displaced apex beat.

Assess chest expansion, which may be reduced in the context of a pleural effusion.

Auscultation

Auscultate both lungs:

• Reduced breath sounds and/or coarse crackles are associated with pulmonary oedema.
• Wheeze can also be associated with pulmonary oedema and is referred to as ‘cardiac asthma’.

Percussion

Percuss the patient’s chest to identify areas of dullness which may be associated with pleural effusion or lobar collapse.

Investigations

Arterial blood gas

Take an ABG if indicated (e.g. low SpO₂) to quantify the degree of hypoxia.

Typical ABG findings in pulmonary oedema include low PaO₂ and low PaCO₂. A normal or raised PaCO₂ is concerning as it indicates that the patient is tiring and failing to ventilate effectively.

Chest X-ray

A chest X-ray may reveal typical radiological signs of pulmonary oedema including:

• Bilateral peri-hilar shadowing
• Blunting of the costophrenic angles
• Fluid in the fissures (e.g. right horizontal fissure)
• Kerley B lines

A chest X-ray is also useful for ruling out other lung pathology (e.g. pneumonia).

See our chest X-ray interpretation guide for more details.

Interventions

Oxygen

Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. You can then trial titrating oxygen levels downwards after your initial assessment.

If the patient is conscious, sit them upright as this can also help with oxygenation.

Continuous positive airway pressure

Continuous positive airway pressure (CPAP) should be considered for patients who do not improve after supplemental oxygen and intravenous diuretics (see below). Commencing CPAP is a skill beyond the scope of most junior doctors and should always involve more senior doctors.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Circulation

Clinical assessment

Pulse

Patients with pulmonary oedema may be tachycardic.

Blood pressure

Patients with acute heart failure may be hypotensive and for this reason, it is important to check blood pressure before administering medications such as diuretics which can worsen hypotension.

Additionally, fluid resuscitation to correct the hypotension can be challenging given the potential to worsen pulmonary oedema.

As a result, patients who are hypotensive with pulmonary oedema need immediate critical care input, as they’ll likely require continuous monitoring and potentially vasopressors to maintain adequate blood pressure whilst treating their pulmonary oedema.

Capillary refill time

Capillary refill time may be prolonged in pulmonary oedema if the patient is hypotensive.

Fluid status assessment

Assess the patient’s fluid status to determine if they are hypervolaemic, euvolaemic or hypovolaemic.

Fluid status assessment involves:

• Inspecting the oral mucosa for hydration
• Capillary refill time assessment as above
• Assessment of jugular venous pressure (JVP)
• Review of the patient’s fluid input and output

An elevated jugular venous pressure indicates hypervolaemia which may be the reason for pulmonary oedema.

Cardiac auscultation

Auscultate the patient’s praecordium to assess heart sounds:

• Soft or muffled heart sounds may indicate the presence of pericardial effusion.
• A gallop rhythm is a feature of congestive heart failure which is a cause of pulmonary oedema.

Investigations and procedures

Intravenous cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

See our intravenous cannulation guide for more details.

Blood tests

Collect blood tests after cannulating the patient including:

• FBC: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
• U&Es: to assess renal function and rule out electrolyte disturbances.
• LFTs: to assess albumin levels (hypoalbuminaemia can result in oedema).
• CRP: to screen for evidence of inflammation (e.g. pneumonia).
• Troponin: if considering acute myocardial infarction as the cause of acute heart failure.
• Plasma BNP: helpful if the diagnosis of heart failure is unclear as it has a high negative predictive value.

ECG

An ECG should be performed to look for:

• evidence of acute myocardial ischaemia
• ventricular hypertrophy
• arrhythmias

An ECG should not delay the treatment of pulmonary oedema.

Interventions

Diuretics

Consider administration of intravenous furosemide to treat pulmonary oedema:

• Furosemide will increase the patient’s urine output and help to shift fluid out of the lungs.
• Larger doses of furosemide may be required in renal failure for a similar response.
• As mentioned previously, if the patient is hypotensive then diuretics can precipitate hypovolaemic shock, therefore critical care input should be sought to decide on the most appropriate management strategy.

Vasodilators and opiates

Recent NICE guidelines warn against the routine use of vasodilators (e.g. glyceryl trinitrate) and opiates (e.g. morphine) in the context of pulmonary oedema. Specialist advice should be sought prior to prescribing these classes of medication.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Disability

Clinical assessment

Consciousness

In the context of pulmonary oedema, a patient’s consciousness level may be reduced secondary to hypoxia or hypovolaemia.

Assess the patient’s level of consciousness using the AVPU scale:

• Alert: the patient is fully alert, although not necessarily orientated.
• Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
• Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
• Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Pupils

Assess the patient’s pupils:

• Inspect the size and symmetry of the patient’s pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
• Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology.

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Investigations and procedures

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g. hypoglycaemia or hyperglycaemia). 

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.

Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting a CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. 

Clinical assessment

Inspection

Inspect the legs for pedal oedema suggestive of heart failure.

Note any unilateral leg swelling and palpate for tenderness suggestive of deep vein thrombosis.

Review the output of the patient’s catheter and any surgical drains. High output from ascitic drains can result in flash pulmonary oedema.

Temperature

Assess the patient’s temperature: fever may indicate an underlying infection (e.g. pneumonia).

Investigations and procedures

If a DVT is suspected, calculate the patient’s DVT Wells score to determine if an ultrasound scan or D-dimer test should be performed to confirm or exclude the presence of a DVT.

Interventions

Allergen removal

If a potential allergen is identified and you suspect allergic aetiology remove the allergen (e.g. stop the antibiotic infusion).

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Reassess ABCDE

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.

Use an effective SBARR handover to communicate the key information effectively to other medical staff.

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Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Revisit history taking to identify risk factors for pulmonary oedema and explore relevant medical history. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.

See our history taking guides for more details.

Review

Review the patient’s notes, charts and recent investigation results.

Review the patient’s current medications and check any regular medications are prescribed appropriately.

Document

Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details.

Discuss

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

• Are any further assessments or interventions required?
• Does the patient need a referral to HDU/ICU?
• Does the patient need reviewing by a specialist?
• Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.

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References

1. Acute heart failure: diagnosis and management. Clinical guideline [CG187] Published date: October 2014. Available from: [LINK].

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