Background:
Acute pulmonary edema is related to left ventricular failure leading to
increases in the feeling pressure and pulmonary congestion. If not
rapidly treated, mechanical ventilation is necessary until congestion is
resolved. Rapid preload and afterload reduction can lead to a very quick
reversal of pulmonary edema thus preventing intubation. Nitroglycerin
has been safe in reducing pre – and afterload as long as blood pressure
can tolerate it. Rapid administration of high doses of nitroglycerin is
crucial in order to reverse acute congestion. Nitroglycerin ointment can
rapidly absorbed by buccal administration with some success but is a
totally underutilized and relatively unknown method to the medical
community. Hereby, six cases of successful buccal nitroglycerin
administration are reported in severe pulmonary edema successfully
preventing mechanical ventilation in all of these patients. This report
is followed by a review of the literature.
Case 1: A 70-year-old male was admitted with diastolic heart failure.
Had normal ejection fraction. After transfer to the medical floor, the
patient suffered from severe pulmonary edema with oxygenation dropping
to the mid-80s. examined revealed severe bilateral rales all the way to
the upper lung. He was immediately put on 100% oxygen but did not
improve in his respiratory effort. His BOP was 160/90Respiratory
therapist was called for immediate intubation while receiving 40 mg of
IV furosemide. Immediate ¼ of an inch of buccal nitroglycerin ointment
from available nitro paste was applied to his oral mucosa every 60
seconds. Within 15 minutes of treatment, respiratory distress resolved,
O2 sat increased to 100% on 2 liters and intubation was avoided.
Further diuretic and BP treatment gradually resolved his heart failure
over the next couple of days.
Case 2: A 72-year-old female patient presenting with unstable angina
underwent coronary angiography and stenting. Post-procedure, the patient
developed acute contrast-induced nephropathy leading to severe
congestive heart failure and pulmonary edema with hypoxia and 02
saturation in 80s. While the respiratory therapist was underway to
perform intubation, the pt received a quarter of an inch of buccal
nitroglycerin ointment every minute while checking BP before each
administration. Systolic BP dropped gradually from 170 to 120 and within
30 minutes, respiratory distress and pulmonary edema resolved, and
intubation was avoided with raise of O2 sat to 100% on 4-liter O2.
Case 3: 75 years 75-year-old male was admitted with congestive heart
failure secondary to severe aortic valve regurgitation. After admission
to the medical floor, while receiving IV diuretic therapy, the patient
suffered from severe respiratory distress and pulmonary edema. O2 sat
dropped to 70s. The pt was put on 100% non-rebreather and respiratory
care was called for intubation. The pat was immediately treated with
repeated doses of ¼ of an inch of buccal nitroglycerin ointment every 60
seconds with repeated BP measurements before each administration to make
sure hypotension was not occurring. SBP from 190 gradually was reduced
to 120 and within 20 minutes, respiratory distress resolved with a rise
of O2 saturation to 100%. Intubation was avoided and the pt did well
with diuresis.
Case 4: 46 years 46-year-old male was admitted to ICU with worsening
renal failure leading to congestive heart failure, He had swan ganze
insertion showing wedge pressure in his 30s. He failed diuretic therapy
and developed worsening heart failure and pulmonary edema. His O2 sat
dropped to the 80s and his wedge raised to 45. The patient was prepared
for intubation. He immediately received ¼ of an inch of buccal
nitroglycerin paste every 60 seconds. His wedge pressure was decreasing
with each treatment with a final wedge of 18 in 30 minutes. Within 20-30
minutes, respiratory distress resolved. O22 sat improved to 100% on 4
liters, and his SBP normalized from 170 to 120. Iv nitro was started to
keep his pre and after-load low and intubation was aborted.
Case 5: a 78-year-old male underwent PCI to his LAD for unstable angina.
Post PCI, he suffered from respiratory distress and severe pulmonary
edema. While awaiting intubation, ¼ of an inch of buccal nitroglycerin
was administrated every 60 seconds with resolution of respiratory
distress and pulmonary edema and normalization of his BP. Intubation was
avoided
Case 6: A 68-year-old male on dialysis presented with acute anterior
STEMI. He underwent successful PCI to 100% occluded proximal LAD. Post
PCI, he developed severe pulmonary edema. His o2 sat dropped to 83%
with severe hypertension with SBP in the 180 range. Immediate buccal ¼
of an inch nitroglycerin ointment was administered every 60 seconds with
blood pressure measurement before each repeat administration. His BP
gradually dropped to the 130 range with a resolution of hypoxia and
respiratory distress. Urgent dialysis was started later to prevent
recurrent pulmonary edema. Intubation was avoided.