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Pulmonary Edema (CHF)

Date Last Search Run: Apr 18, 2021
Table last updated: May 05, 2021
Data last added: May 02, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)
3 (weak evidence exists)


Interventions

12-Lead ECG
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Prediction of all-cause mortality Process Gouda P., Brown P., Rowe BH., McAlister FA., Ezekowitz JA. Insights into the importance of the electrocardiogram in patients with acute heart failure. European journal of heart failure 2016;18(8):1032-40. Medline

Beta Agonist-MDI
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Hospital Mortality Patient PH-Paramedic Singer AJ., et al. Bronchodilator therapy in acute decompensated heart failure patients without a history of COPD. Ann Emerg Med 2008; 51:25-34. Medline

Beta Agonist-Nebulized
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Hospital mortality Patient PH-Paramedic Singer AJ., et al. Bronchodilator therapy in acute decompensated heart failure patients without a history of COPD. Ann Emerg Med 2008; 51:25-34. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Stiell IG., et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. NEJM 2007; 356:2156-64. Medline

Beta Agonist-Parenteral
Level Direction Primary Outcome Patient/Process Setting Reference

Diuretic
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Mortality, Mechanical ventilation, Myocardial Infarction Patient PH-Paramedic Cotter G., Metzkor E., Kaluski E., et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. The Lancet 1998; 351:389-3. Medline
II Supportive (Green) All cause in hospital mortality Patient Matsue Y, Damman K, Voors AA, Kagiyama N, Yamaguchi T, Kuroda S, et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. J Am Coll Cardiol 2017; 69(25):3042-51. Medline
II Supportive (Green) Increase in creatinine Patient PH-Paramedic Nieves LC., Mehrtens GM., Pores N., et al. The effect of furosemide dose administered in the out-of-hospital setting on renal function among patients with suspected acute decompensated heart failure. Prehosp Disaster Med 2015; 30(1):38-45. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Stiell IG., et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. NEJM 2007; 356:2156-64. Medline
II Neutral (Yellow) Mortality Patient Gardtman M., Waagstein L., Karlsson T., Herlitz J. Has an intensified treatment in the ambulance of patients with acute severe left heart failure improved the outcomes? European Journal of Emer Med 2000; 7:15-24. Medline
II Neutral (Yellow) 7 day mortality Patient ED-MD Gray A., Goodacre S., Seah M., Tilley S. Diuretic, opiate and nitrate use in severe acidotic acute cardiogenic pulmonary oedema: Analysis from the 3CPO trial. QJM 2010; 103(8):573-81. Medline
II Opposes (Red) 1) CHF diagnosis 2) BNP level 3) Death Patient PH-Paramedic Jaronik J., Mikkelson P., Fales W., Overton D. Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care 2006; 10(2):194-7. Medline
III Supportive (Green) Adverse Events Patient PH-Paramedic Pan A., Stiell IG., Dionne R., Maloney J. Prehospital use of furosemide for the treatment of heart failure. Emerg Med J 2015; 32(1):36-43. Medline
III Neutral (Yellow) Improvement in vital signs Patient PH-Paramedic Sporer KA., et al. Do medications affect vital signs in the prehospital treatment of acute decompensated heart failure? Prehosp Emer Care 2006; 10:41-5. Medline
III Neutral (Yellow) Survival, Length of stay Patient PH-Paramedic Wuerz RC., Meador SA. Effects of prehospital medications on mortality and length of stay in congestive heart failure. Ann Emerg Med 1992; 21(6):669-674. Medline

Humidified oxygen
Level Direction Primary Outcome Patient/Process Setting Reference

Narcotic
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) 7 day mortality Patient ED-MD Gray A., Goodacre S., Seah M., Tilley S. Diuretic, opiate and nitrate use in severe acidotic acute cardiogenic pulmonary oedema: Analysis from the 3CPO trial. QJM 2010; 103(8):573-81. Medline
II Neutral (Yellow) Mortality Patient PH-Paramedic Stiell IG., et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. NEJM 2007; 356:2156-64. Medline
II Opposes (Red) 30-day all cause mortality Patient ED-MD Miro Ô, Gil V, Martín-Sánchez FJ, Herrero-Puente P, Jacob J, Mebazaa A, et al. Morphine Use in the ED and Outcomes of Patients With Acute Heart Failure: A Propensity Score-Matching Analysis Based on the EAHFE Registry. Chest 2017; 152(4):821-32. Medline
III Neutral (Yellow) Appropriate administration, complications Process PH-Paramedic Bruns BM., Dieckmann R., Shagoury C., et al. Safety of prehospital therapy with morphine sulfate. Am J Emerg Med 1992; 10(1):53-7. Medline
III Neutral (Yellow) Survival Patient PH-Paramedic Wuerz RC., Meador SA. Effects of prehospital medications on mortality and length of stay in congestive heart failure. Ann Emerg Med 1992; 21(6):669-674. Medline

NiPPV
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Hospital mortality Patient ED-MD Collins SP., Mielniczuk LM., Whittingham HA., Boseley ME., Schramm DR., Storrow AB. The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: a systematic review. Ann Emerg Med 2006; 48(3):260-9. Medline
I Supportive (Green) Death within 7 days Patient ED-MD Gray A., et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. NEJM 2008; 359:142-51. Medline
I Supportive (Green) Inhospital mortality Patient PH-Paramedic Mal S., McLeod S., Iansavichene A., Dukelow A., Lewell M. Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: A systematic review and meta-analysis. Ann Emerg Med 2014; 63(5):600-7. Medline
I Supportive (Green) Mortality Patient ED-MD Masip J., Roque M., Sanchez B., Fernadez R., Subirana M., Exposito JA. Noninvasive ventilation in acute cardiogenic pulmonary edema. JAMA 2005; 294:3124-30. Medline
I Supportive (Green) Combined criterion of ETI, death, or MI in first 24h Patient ED-MD Moritz F., Brousse B., Gellee B., et al. Continuous positive airway pressure versus bilevel noninvasive ventilation in acute cardiogenic pulmonary edema: A randomized multicenter trial. Ann Emerg Med 2007; 50(6):666-75. Medline
I Supportive (Green) need for endotracheal intubation Patient ED-MD Nava S., Carbone G., DiBattista N., et al. Noninvasive ventilation in cardiogenic pulmonary edema: A multicenter randomized trial. Am J Respir Crit Care Med 2003; 168(12):1432-7. Medline
I Supportive (Green) Mortality Patient PH-Paramedic Park M., et al. Randomized, prospective trial of oxygen, continuous positive airway pressure, and bi-level positive airway pressure by face mask in acute cardiogenic pulmonary edema. Crit Care Med 2004; 32:2407-15. Medline
I Supportive (Green) Mortality Patient ED-MD Peter JV., et al. Effect of noninvasive positive-pressure ventilation on mortality in patients with acute pulmonary oedema: a meta-analysis. The Lancet 2006; 367:1155-63. Medline
I Supportive (Green) Need for tracheal intubation Patient PH-Paramedic Thompson J., Petrie DA., Ackroyd-Stolarz S., Bardua DJ. Out-of-hospital continuous positive pressure ventilation vs usual care in acute respiratory failure: a RCT. Ann Emerg Med 2008; 52(3):232-41. Medline
I Supportive (Green) need for intubation Patient ED-MD Thys F., Roeseler J., Reynaert M., Liistro G., Rodenstein DO. Noninvasive ventilation for acute respiratory failure: A prospective randomised placebo-controlled trial. Eur Respir J 2002; 20(3):545-555. Medline
I Supportive (Green) Oxygen saturation Patient PH-Paramedic Weitz G., Struck J., Zonak A., Balnus S., Perras B., Dodt C. Prehospital noninvasive pressure support ventilation for acute cardiogenic pulmonary edema. Eur J Emerg Med 2007; 14(5):276-279. Medline
I Supportive (Green) Mortality, Intubation Patient PH-Paramedic Williams TA., Finn J., Perkins GD., Jacobs IG. Prehospital continuous positive airway pressure for acute respiratory failure: a systematic review and meta-analysis. Prehosp Emerg Care 2013; 17(2):261-273. Medline
I Neutral (Yellow) Placement detection Process Frontin P., Bounes V., Houze-Cerfon CH., Charpentier S., Houze-Cerfon V., Ducasse JL. Continuous positive airway pressure for cardiogenic pulmonary edema: A randomized study. Am J Emerg Med 2011; 29(7):775-81. Medline
I Neutral (Yellow) 7-day mortality Patient ED-MD Gray AJ., Goodacre S., Newby DE., Masson MA., Sampson F., Dixon S., et al. A multicentre randomised controlled trial of the use of continuous positive airway pressure and non-invasive positive pressure ventilation in the early treatment of patients presenting to the emergency department with severe acute cardiogenic pulmonary oedema: the 3CPO trial. Health Technol Assess 2009; 13(33):1-106. Medline
I Neutral (Yellow) Hospital death and ETI Patient ED-MD Nouira S., Boukef R., Bouida W., Kerkeni W., Beltaief K., Boubaker H., et al. Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department. Intensive Care Med 2011; 37(2):249-56. Medline
II Supportive (Green) Oxygen Saturation, Intubation Process PH-Paramedic Craven RA., Singletary N., Bosken L., et al. Use of bilevel positive airway pressure in out-of-hospital patients. Acad Emerg Med 2000; 7(9):1065-8. Medline
II Supportive (Green) Prehospital endotracheal intubation rate Process PH-Paramedic & MD Gartner BA., Fehlmann C., Suppan L., Niquille M., Rutschmann OT., Sarasin F. Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study. European journal of emergency medicine 2019. Medline
II Supportive (Green) Adherence to treatment Process PH-Paramedic Nielsen VM., Madsen J., Aasen A., Toft-Petersen AP., Lubcke K., Rasmussen BS., et al. Prehospital treatment with continuous positive airway pressure in patients with acute respiratory failure: a regional observational study. Scand J Trauma Resusc Emerg Med 2016; 24(1):121. Medline
II Supportive (Green) Mortality Patient ED-MD Pagano A, Numis FG, Rosato V, Russo T, Porta G, Bosso G, et al. Pressure support ventilation vs Continuous positive airway pressure for treating of acute cardiogenic pulmonary edema: A pilot study. Respiratory physiology & neurobiology 2018; 255:7-10. Medline
II Supportive (Green) SpO2, RR Patient Sahu N, Matthews P, Groner K, Papas MA, Megargel R. Observational Study on Safety of Prehospital BLS CPAP in Dyspnea. Prehosp Disaster Med 2017; 32(6):610-4. Medline
II Supportive (Green) Mortality, Time to intubation Patient ED-MD Wood KA., Lewis L., Von Harz B., Kollef MH. The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial. Chest 1998; 113(5):1339-1346. Medline
II Neutral (Yellow) Intubation rate Process PH-Paramedic Cheskes S., Turner L., Thomson S., Aljerian N. The Impact of Prehospital Continuous Positive Airway Pressure on the Rate of Intubation and Mortality from Acute Out-of-hospital Respiratory Emergencies. Prehosp Emerg Care 2013; 17(4):435-41. Medline
II Neutral (Yellow) Mortality Patient Gardtman M., Waagstein L., Karlsson T., Herlitz J. Has an intensified treatment in the ambulance of patients with acute severe left heart failure improved the outcomes? European Journal of Emer Med 2000; 7:15-24. Medline
II Neutral (Yellow) Adverse events including death Patient PH-Paramedic Sharon A., Shpirer I., Kaluski E., Moshkovitz Y., Milovanov O., Polak R., et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. JAC 2000; 36(3):832–7. Medline
III Supportive (Green) Respiratory Rate and SpO2 Patient PH-Paramedic Bledsoe BE., Anderson E., Hodnick R., Johnson L., Johnson S., Dievendorf E. Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. Prehosp Emerg Care 2012; 16(2):217-21. Medline
III Supportive (Green) Cost effectiveness Process PH-Paramedic Hubble MW., Richards ME., Wilfong DA. Estimates of cost-effectiveness of prehospital CPAP in the management of acute pulmonary edema. Prehosp Emerg Care 2008; 12:277-85. Medline
III Supportive (Green) Feasibility Patient PH-Paramedic Kosowsky JM., Stephanides SL., Branson RD., Sayre MR. Prehospital use of CPAP for presumed pulmonary edema: a preliminary case series. Prehospital Emer Care 2001; 5:190-6. Medline
III Supportive (Green) Feasibility Process ED-MD Pollack CV., Torres MT., Alexander L. Feasibility study of the use of bi-level positive airway pressure for respiratory support in the emergency department. Ann Emerg Med 1996; 27:18-92. Medline
III Supportive (Green) avoidance of ETI Patient ED-MD Sacchetti AD., Harris RH., Paston C., Hernandez Z. Bi-level positive airway pressure support system use in acute congestive heart failure: Preliminary case series. Acad Emerg Med 1995; 2(8):714-8. Medline
III Supportive (Green) Number of B lines Process Strnad M., Prosen G., Borovnik Lesjak V. Bedside lung ultrasound for monitoring the effectiveness of prehospital treatment with continuous positive airway pressure in acute decompensated heart failure. Eur J Emerg Med 2016; 23(1):50-55. Medline
III Supportive (Green) Oxygenation Patient PH-Paramedic Tarja K, et al. The Use of Prehospital Continuous Positive Airway Pressure Treatment of Presumed Acute Severe Pulmonary Edema. PEC 2003; 7(2):209-13. Medline
III Supportive (Green) Effectiveness Patient ED-MD Widger HN., Hoffman P., Mazzolini D., Stone A., Scholly S., Clark J. Pressure support noninvasive positive pressure ventilation treatment of acute cardiogenic pulmonary edema Am J Emerg Med 2001; 19(3):179-81. Medline
III Neutral (Yellow) Number of patients who could benefit from NiPPV Patient PH-Paramedic Taylor DM., Bernard SA., Masci K., MacBean CE., Kennedy MP. Prehospital noninvasive ventilation: A viable treatment option in the urban setting. Prehosp Emer Care 2008; 12:42-5. Medline
III Opposes (Red) Need for intubation Patient ED-MD Yosefy C., Hay E., Ben-Barak A., Derazon H., Magen E., Reisin L., et al. BiPAP ventilation as assistance for patients presenting with respiratory distress in the department of emergency medicine. Am J Respir Med 2003; 2(4):343-347. Medline

Nitroglycerin-IV
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Mortality, Mechanical ventilation, Myocardial Infarction Patient PH-Paramedic Cotter G., Metzkor E., Kaluski E., et al. Randomized trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. The Lancet 1998; 351:389-3. Medline
II Supportive (Green) Adverse events including death Patient PH-Paramedic Sharon A., Shpirer I., Kaluski E., Moshkovitz Y., Milovanov O., Polak R., et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. JAC 2000; 36(3):832–7. Medline
II Supportive (Green) ICU admission Process Wilson SS., Kwiatkowski GM., Millis SR., Purakal JD., Mahajan AP., Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med 2017; 35(1):126-131. Medline
II Neutral (Yellow) 7 day mortality Patient ED-MD Gray A., Goodacre S., Seah M., Tilley S. Diuretic, opiate and nitrate use in severe acidotic acute cardiogenic pulmonary oedema: Analysis from the 3CPO trial. QJM 2010; 103(8):573-81. Medline
II Neutral (Yellow) Effectiveness and safety Patient ED-MD Levy P., Compton S., Welch R., et al. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: A feasibility and outcome analysis. Ann Emerg Med 2007; 50(2):144-152. Medline
III Supportive (Green) Vital Signs Patient PH-Paramedic & CCT Perlmutter MC, Cohen MW, Stratton NS, Conterato M. Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin. Prehosp Disaster Med 2020:1-6. Medline

Nitroglycerin-SL
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Mortality Patient PH-Paramedic Stiell IG., et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. NEJM 2007; 356:2156-64. Medline
II Neutral (Yellow) Mortality Patient Gardtman M., Waagstein L., Karlsson T., Herlitz J. Has an intensified treatment in the ambulance of patients with acute severe left heart failure improved the outcomes? European Journal of Emer Med 2000; 7:15-24. Medline
II Neutral (Yellow) 7 day mortality Patient ED-MD Gray A., Goodacre S., Seah M., Tilley S. Diuretic, opiate and nitrate use in severe acidotic acute cardiogenic pulmonary oedema: Analysis from the 3CPO trial. QJM 2010; 103(8):573-81. Medline
III Neutral (Yellow) Adverse events, ECG rhythm change Process PH-Paramedic Wuerz R., Swope G., Meador S., et al. Safety of prehospital nitroglycerin. Ann Emerg Med 1994; 23(1):31-36. Medline
III Neutral (Yellow) Survival, Length of stay Patient PH-Paramedic Wuerz RC., Meador SA. Effects of prehospital medications on mortality and length of stay in congestive heart failure. Ann Emerg Med 1992; 21(6):669-674. Medline

Oxygen
Level Direction Primary Outcome Patient/Process Setting Reference
III Opposes (Red) Cardiac output Process ED-MD Haque WA., Boehmer J., Clemson BS., et al. Hemodynamic effects of supplemental oxygen administration in congestive heart failure. J Am CC 1996; 27(2):353-7. Medline

Oxymetry Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Detection of hypoxemia Patient PH-Paramedic Bota GW., Rowe BH. Continuous monitoring of oxygen saturation in prehospital patients with severe illness: the problem of unrecognized hypoxemia. J Emerg Med 1995; 13:305-11. Medline

PEEP
Level Direction Primary Outcome Patient/Process Setting Reference

Ultrasound
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Feasibility Process Laursen CB., Hänselmann A., Posth S., Mikkelsen S., Videbaek L., Berg H. Prehospital lung ultrasound for the diagnosis of cardiogenic pulmonary oedema: a pilot study. Scand J T R EM 2016; 24:96. Medline


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