Acute Heart Failure & Pulmonary Oedema

Acute heart failure — especially pulmonary oedema — is one of the most important night-shift emergencies you will manage in the NHS.

Patients deteriorate quickly, nurses become understandably worried, and early treatment makes a dramatic difference.

Your goal is simple:

👉 Improve oxygenation
👉 Reduce fluid overload
👉 Reduce cardiac workload
👉 Escalate early if failing

This is a condition where early bedside management matters more than investigations.

What is acute pulmonary oedema?

Fluid accumulates in the lungs due to raised cardiac filling pressures, usually from left ventricular failure.

Gas exchange worsens → hypoxia → respiratory distress.

Patients often look very unwell.

Common NHS triggers

Always ask: Why did this happen now?

Typical causes:

  • Acute MI / ischaemia
  • Fast AF or arrhythmia
  • Uncontrolled hypertension
  • Fluid overload (IV fluids!)
  • Infection/sepsis
  • Renal failure
  • Medication non-compliance
  • Valvular disease

Treating the trigger is essential.

Typical presentation

Patients often appear distressed.

Symptoms

  • Severe breathlessness
  • Orthopnoea
  • Sudden overnight deterioration
  • Pink frothy sputum (late sign)
  • Anxiety/restlessness

Signs

  • Tachypnoea
  • Hypoxia
  • Bilateral crackles
  • Raised JVP
  • Peripheral oedema (may be absent)
  • Hypertension initially (common)

They usually look sick at the end of the bed.

First step = A–E assessment

Do this immediately.

Red flags

  • Exhaustion
  • Altered consciousness
  • Silent chest
  • Hypotension
  • Rising CO₂ (on ABG)

These patients may need ICU support.

Immediate management (do immediately)

Treat while assessing.

1️⃣ Sit patient upright

Simple but powerful.

Reduces venous return and improves breathing.

2️⃣ Oxygen

Give oxygen if sats <94%
(Target 88–92% if COPD risk)

Do not delay.

3️⃣ Monitoring

  • Continuous monitoring
  • BP frequently
  • Cardiac monitor
  • IV access

4️⃣ IV Furosemide

Typical starting dose:
👉 40–80 mg IV

Higher if already on chronic diuretics.

Expect diuresis within 30–60 minutes.

5️⃣ Nitrates (if BP adequate)

Very effective but often underused.

If SBP >100–110:

  • GTN spray or infusion

Reduces preload and pulmonary congestion quickly.

Avoid if hypotensive.

6️⃣ Consider CPAP/NIV early

If persistent hypoxia or distress:

👉 Call outreach/ICU early.

NIV dramatically improves outcomes.

Do not wait until exhaustion.

Investigations (after stabilisation)

  • ECG (look for MI/arrhythmia)
  • Bloods:
    • FBC
    • U&E
    • BNP (if diagnostic uncertainty)
    • Troponin
  • CXR (supports diagnosis)
  • ABG if unwell

But remember:
👉 treatment comes before imaging.

When patient worsens

Watch for:

  • Falling BP
  • Reduced urine output
  • Drowsiness
  • Rising oxygen requirement

This may indicate cardiogenic shock.

Escalate urgently.

When to escalate early

  • Need for NIV
  • Persistent hypoxia
  • Hypotension
  • Suspected MI
  • Severe acidosis
  • No improvement after initial therapy

Never manage severe pulmonary oedema alone overnight.

Common on-call mistakes

  • Keeping patient lying flat
  • Giving IV fluids reflexively
  • Delaying nitrates
  • Waiting for CXR before treatment
  • Under-dosing diuretics
  • Late escalation

Pulmonary oedema is primarily a clinical diagnosis.

Practical ward mindset

When bleeped:

“Patient suddenly very breathless”

Think immediately:

  1. Sit up
  2. Oxygen
  3. IV access
  4. Furosemide
  5. Nitrates (if BP allows)
  6. Call senior if severe

Act first. Investigate after.

Take-home concept

Acute pulmonary oedema is a treat-now condition.

Simple early actions — positioning, oxygen, diuretics, nitrates — often produce rapid improvement.

Delay is the main enemy.