Introduction:
Acute cardiogenic pulmonary edema is related to left ventricular failure
leading to increases in the feeling pressure and pulmonary congestion.
If not rapidly treated, severe hypoxia will develop, and mechanical
ventilation will be necessary until congestion is resolved. Rapid pre-
and afterload reduction can lead to a very quick reversal of pulmonary
edema and hypoxia 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 has
the best pharmacodynamic and pharmacokinetic properties for this purpose
as it is widely available and rapidly absorbed by buccal administration.
The successful use of buccal nitroglycerin ointment in patients with
severe cardiogenic pulmonary edema has been used successfully in many
published case reports but is rarely utilized and hardly known in the
medical community. Hereby, six cases of successful buccal nitroglycerin
ointment administration are reported in patients suffering from severe
cardiogenic pulmonary edema with hypoxia on maximal oxygen therapy thus
preventing intubation and the need for mechanical ventilation in all of
these patients. This report is followed by a review of the literature.
Furthermore, a treatment protocol and algorithm are developed based on
our patients and reported cases in the literature for the prevention of
intubation in these patients. Figure 1 summarizes the clinical
characteristics of these patients.