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.