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.