Case descriptions:
Case 1: A 70-year-old male was admitted with diastolic heart failure from the emergency department. He had a normal ejection fraction. After transfer to the medical floor, the patient suffered from severe pulmonary edema with oxygenation dropping to the mid-80s despite 100% oxygen therapy. Physical examine revealed severe bilateral rales all the way to the upper lung. His systolic blood pressure (SBP) was in 160-180 mmHg range. The respiratory therapist was called for immediate intubation while receiving 40 mg of IV furosemide. An immediate 1/2 of an inch of buccal nitroglycerin ointment (nitropaste) was applied to his oral mucosa every 60 seconds with recheck of his SBP every minutes before each nitro ointment administration to make sure SBP remains above 120 mmHg. Within 20 minutes of treatment, respiratory distress resolved. O2 sat increased to 100% on 2 liters oxygen and intubation was avoided. Further diuretic and BP treatment gradually resolved his heart failure over the next couple of days. The patient had no adverse event to buccal nitro ointment administration.
Case 2: A 72-year-old female patient presenting with unstable angina underwent coronary angiography and stenting. Post-procedure, the patient suffered from acute contrast-induced nephropathy leading to severe congestive heart failure and pulmonary edema with hypoxia. Her O2 saturation dropped to 80s despite 100% oxygen administration. Her SBP was >140 mmHg. While the respiratory therapist was underway to perform intubation, she received an immediate 1/2 of an inch of buccal nitroglycerin ointment every minute while checking SBP before each administration. SBP dropped gradually from 170 to 120 mmHg and within 30 minutes. Her respiratory distress and pulmonary edema resolved and intubation was avoided. Her O2 saturation was raised to 100% on 4-liter O2. She had no adverse event. Later she responded to high doses of IV diuretic and IV nitro with the resolution of heart failure.
Case 3: A 75-year-old male was admitted with congestive heart failure secondary to severe aortic valve regurgitation from emergency department. Upon arrival to the medical floor, while receiving IV diuretic therapy, the patient suffered from severe respiratory distress and pulmonary edema. His O2 saturation dropped to 70s. The pt was put on 100% non-rebreather without resolution of hypoxia. A respiratory therapist was called for intubation. The patient was immediately treated with repeated doses of 1/2 of an inch of buccal nitroglycerin ointment every 60 seconds with repeated BP measurements before each administration every minute to make sure SBP remained > 120 mmHg. His SBP from 190 mmHg gradually was reduced to 120 mmHg. Within 20 minutes, respiratory distress resolved with a rise of O2 saturation to 100% on 4-liter O2. Intubation was avoided and the patient tolerated the treatment well. Later, he responded well to IV diuresis and underwent successful aortic valve surgery.
Case 4: A 46-year-old male was admitted to ICU with worsening renal failure leading to congestive heart failure. He had a normal ejection fraction. He had a swan ganze catheter in place showing a wedge pressure of 30 mmHg. He failed diuretic therapy and developed worsening heart failure and pulmonary edema. His O2 sat on 100% oxygen and BIPAP dropped to the 80s and his wedge pressure rose to 45 mmHg. The patient was prepared for intubation. He immediately received 1/2 of an inch of buccal nitroglycerin paste every 60 seconds with repeated blood pressure checks every minute. His wedge pressure decreased with each treatment with a final wedge of 18 mmHg in 30 minutes. His respiratory distress completely resolved after 30 minutes with O2 saturation improvement to 100% on 4 liters O2. His SBP normalized from 170 mmHg to 130 mmHg. Later, IV nitro was started to keep his pre- and after-load low and intubation was aborted. Later the patient underwent dialysis and did well. No adverse event occurred.
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. His SBP was 170-200 mmHg range. While awaiting intubation, 1/2 of an inch of buccal nitroglycerin ointment was administrated every 60 seconds with repeated SBP checks every minute before the next nitroglycerin ointment administration. His SBP remained above 120 mmHg. His respiratory distress and pulmonary edema gradually resolved with normalization of his SBP. Intubation was avoided. Later, he responded well to diuretics and had no adverse reaction to buccal nitroglycerin administration.
Case 6: A 68-year-old male on dialysis presented with acute anterior ST-elevation Myocardial infarction (STEM). He underwent successful PCI to 100% occluded proximal LAD. Post PCI, he developed severe pulmonary edema. His O2 saturation dropped to 83% with severe hypertension with SBP in the 170-190 mmHg range. His ejection fraction was 45%. Immediate buccal ½ of an inch nitroglycerin ointment was administered every 60 seconds with blood pressure measurement before each repeat administration every minute. His SBP gradually dropped to the 130 mmHg range with complete resolution of his hypoxia and respiratory distress within 20 minutes. Intubation was avoided. The patient had no adverse events. Urgent dialysis was started later which resolved his congestive heart failure.