Discussion:
Acute pulmonary edema is a life-threatening condition requiring
immediate treatment. Usual treatment such as intravenous diuretic
therapy will take time to reduce congestion. Morphine administration can
be helpful but by suppressing respiratory drive it can worsen
respiratory failure and hypoxia. It is also not very effective in severe
pulmonary edema needing intubation. Any agent that can rapidly and
safely reduce pre and afterload is ideal for this situation.
Nitroglycerin is an ideal drug in this setting. However, sublingual
nitroglycerin will take a while to resolve. High-dose IV nitroglycerin
has been effective in patients with acute pulmonary edema (1-3)
including in pre-hospital settings (4) but is not rapidly available at
the bedside. Furthermore, pharmacists and nursing staff are resistant to
supply providers with high doses of IV nitroglycerin as they are not
familiar with such dosing which is usually over 2-3 mg. Nitro ointment
commonly called nitro paste is widely available with excellent rapid
resorption if it is administrated buccally. Buccal administration of
nitro ointment has been shown to be superior compared to other
nitroglycerin agents in patients with angina (5-8) In patients with
chronic congestive heart failure buccal administration of nitroglycerin
ointment has shown superior response in comparison to other forms of
nitroglycerines for rapid onset, longer duration of drug effect and
hemodynamic response using its effect on wedge pressure. (9-16 ).
Nitroglycerin ointment contains 15 mg of nitroglycerin per one inch of
paste that can rapidly absorbed by buccal application simulating
intravenous nitroglycerin administration. Starting with a quarter of an
inch of buccal nitroglycerin ointment, about 3-4 grams of nitroglycerin
can be given rapidly with each administration which can lead to rapid
pre- and afterload reduction thus dramatically reducing pulmonary
congestion. An important part of this treatment is the presence of
adequate blood pressure. This is the reason that this type of treatment
should not be initiated in patients with cardiogenic shock and BP has to
be rechecked before each buccal administration.
In the setting of acute pulmonary edema without cardiogenic shock, there
are limited case reports and case series that have demonstrated the
effectiveness of buccal nitroglycerin application. (17-19). However,
this very effective treatment of patients with acute pulmonary edema
without cardiogenic shock is hardly utilized as the medical community is
not aware of this lifesaving treatment. Every time I have used this
method, every single medical staff including nurses, residents, fellows,
and cardiology attendings were unaware of this treatment and were
surprised about its usage and effectiveness. This case series is the
largest reported case series in this regard showing very effective and
safe use of buccal nitroglycerin ointment. Due to ease of use, safety,
and efficacy, the use of buccal nitroglycerin ointment should be the
standard of care in patients presenting with severe pulmonary edema
without cardiogenic shock in order to avoid imminent intubation and
mechanical ventilation.