Review

Cardiogenic Pulmonary Edema in Emergency Medicine

Christian Zanza 1,2, *,† , Francesco Saglietti 3,† , Manfredi Tesauro 1,4 , Yaroslava Longhitano 5,6 ,
Gabriele Savioli 7 , Mario Giosuè Balzanelli 2 , Tatsiana Romenskaya 8 , Luigi Cofone 9 , Ivano Pindinello 9 ,
Giulia Racca 10 and Fabrizio Racca 10

1 Post Graduate School of Geriatric Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
2 Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
3 Department of Emergency and Critical Care, Santa Croce and Carle Hospital, 12100 Cuneo, Italy
4 Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
5 Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh,
Pittsburgh, PA 15261, USA
6 Department of Emergency Medicine, Humanitas University Hospital, 20089 Rozzano, Italy
7 Emergency Department, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
[email protected]
8 Department of Physiology and Pharmacology, Sapienza University of Rome, 00185 Rome, Italy
9 Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy;
[email protected] (L.C.); [email protected] (I.P.)
10 Division of Anesthesia and Critical Care Medicine, AO Ordine Mauriziano, 10128 Turin, Italy;
[email protected] (G.R.)
* Correspondence: [email protected]
† These authors contributed equally to this work.

Highlights:
What are the main findings?
• Cardiogenic pulmonary edema is the most common cause of respiratory failure and results from
increased cardiac filling pressure and alveolar-epithelial barrier breakdown due to factors like
Citation: Zanza, C.; Saglietti, F.; inflammation, leukocyte infiltration, procoagulant processes, and ion channel modification by
Tesauro, M.; Longhitano, Y.; reactive oxygen and nitrogen species.
Savioli, G.; Balzanelli, M.G.;
• Rapid evaluation of the patient with cardiogenic pulmonary edema and appropriate treatment
Romenskaya, T.; Cofone, L.;
are necessary to reduce mortality and morbidity.
Pindinello, I.; Racca, G.; et al.
Cardiogenic Pulmonary Edema in What is the implication of the main finding?
Emergency Medicine. Adv. Respir. • Bedside tests, especially ultrasound, help us to quickly identify and to understand the need
Med. 2023, 91, 445–463. of amine support. Optimal therapy for patients with cardiogenic pulmonary edema hinges
https://doi.org/10.3390/ on precise phenotypic identification and etiological assessment, with early consideration of
arm91050034
non-invasive ventilation and diuretics.
Academic Editor: Tadeusz • Hypoperfusion necessitates inotropes and, at times, vasopressors, while individuals exhibiting
Maria Zielonka persistent symptoms and diuretic resistance may benefit from vasodilators and additional
therapeutic strategies, including beta-agonists, underscoring the need for further studies to
Received: 5 July 2023
explore medical interventions in mitigating pulmonary damage in CPE patients.
Revised: 6 October 2023
Accepted: 10 October 2023
Published: 13 October 2023 Abstract: Cardiogenic pulmonary edema (CPE) is characterized by the development of acute res-
piratory failure associated with the accumulation of fluid in the lung’s alveolar spaces due to an
elevated cardiac filling pressure. All cardiac diseases, characterized by an increasing pressure in
the left side of the heart, can cause CPE. High capillary pressure for an extended period can also
Copyright: © 2023 by the authors.
cause barrier disruption, which implies increased permeability and fluid transfer into the alveoli,
Licensee MDPI, Basel, Switzerland.
leading to edema and atelectasis. The breakdown of the alveolar-epithelial barrier is a consequence
This article is an open access article
distributed under the terms and
of multiple factors that include dysregulated inflammation, intense leukocyte infiltration, activation
conditions of the Creative Commons of procoagulant processes, cell death, and mechanical stretch. Reactive oxygen and nitrogen species
Attribution (CC BY) license (https:// (RONS) can modify or damage ion channels, such as epithelial sodium channels, which alters fluid
creativecommons.org/licenses/by/ balance. Some studies claim that these patients may have higher levels of surfactant protein B in
4.0/). the bloodstream. The correct approach to patients with CPE should include a detailed medical

Adv. Respir. Med. 2023, 91, 445–463. https://doi.org/10.3390/arm91050034 https://www.mdpi.com/journal/arm

Adv. Respir. Med. 2023, 91 446

history and a physical examination to evaluate signs and symptoms of CPE as well as potential
causes. Second-level diagnostic tests, such as pulmonary ultrasound, natriuretic peptide level, chest
radiograph, and echocardiogram, should occur in the meantime. The identification of the specific CPE
phenotype is essential to set the most appropriate therapy for these patients. Non-invasive ventilation
(NIV) should be considered early in the treatment of this disease. Diuretics and vasodilators are
used for pulmonary congestion. Hypoperfusion requires treatment with inotropes and occasionally
vasopressors. Patients with persistent symptoms and diuretic resistance might benefit from additional
approaches (i.e., beta-agonists and pentoxifylline). This paper reviews the pathophysiology, clinical
presentation, and management of CPE.

Keywords: cardiogenic pulmonary edema; capillary permeability; pulmonary surfactant-associated

protein B; non-invasive ventilation

1. Introduction
Cardiogenic pulmonary edema (CPE) can be a life-threatening condition leading
to compromised gas exchange and acute respiratory failure (ARF) associated with high
mortality. Without prompt recognition and treatment, a severe form can deteriorate rapidly,
resulting in severe hypoxia [1,2]. Prognosis mainly depends on the underlying medical
conditions, but generally, these patients have a poor prognosis with an in-hospital death
rate of 15–20%, a rate of survival of 50% after one year [3], and a mortality rate of 85% at
6 years follow-up [4].
CPE is defined as pulmonary edema caused by the accumulation of excessive fluid in
the lung’s interstitial and alveolar spaces due to increased capillary hydrostatic pressure
secondary to elevated pulmonary venous pressure, which is the result of elevated cardiac
filling pressures [5]. All the cardiac diseases that contribute to increased pressure in the
left side of the heart can cause CPE [6]. However, there are many other clinical conditions
of non-cardiological origin (i.e., primary fluid overload, severe hypertension, and severe
renal disease) that may be responsible for CPE causing elevated cardiac filling pressures
without heart disease. Noncardiogenic pulmonary edema (NCPE) is a distinct form of
pulmonary edema caused by increased permeability of the pulmonary endothelium without
elevated capillary hydrostatic pressure. The most frequent cause of NCPE (also called
Adult Respiratory Distress Syndrome (ARDS)) is due to direct (e.g., pneumonia) or indirect
lung injury (e.g., sepsis). Increased alveolar-capillary permeability may also occur in
CPE, especially in some patients with abrupt, severe increases in pulmonary capillary
pressure [7]. This associated barrier dysfunction was defined as “stress failure” [8] and may
lead to more edema formation [9].
Rapid identification of the specific heart failure (HF) is essential to set up the ap-
propriate therapy. Diuretics are considered the cornerstone of CPE treatment [10], and
non-invasive ventilation (NIV) should be considered in an early stage [11]. Vasodilators
may also be required to decrease elevated filling pressures and/or left ventricle (LV) af-
terload. In addition, patients with persistent symptoms might benefit from additional
approaches, including beta-agonists and pentoxifylline, which may be effective in patients
with “stress failure” [9]. Elevated serum levels of surfactant protein B levels could be used
to identify CPE patients with associated barrier damage [12].
This paper reviews the pathophysiology and management of CPE.

2. Pathophysiology of Pulmonary Edema

Pulmonary edema refers to excessive fluid accumulation in the interstitial and alveolar
spaces of the lungs due to an imbalance among the “Starling forces”, an increase of alveolar-
capillary barrier permeability, or a blockage of the draining lymphatic system. [6].
Fluid balance between the interstitium and vascular bed in the lung, as in other microcircu-
lations, is determined by the Starling relationship, which predicts the net flow of liquid across a
 [6].
Fluid balance between the interstitium and vascular bed in the lung, as in other mi-
crocirculations, is determined by the Starling relationship, which predicts the net flow of
liquid across a membrane. This is represented in the following equation: Net filtration =
Kf × (Δhydrostatic pressure − Δoncotic pressure), where Kf is the filtration coefficient.
Adv. Respir. Med. 2023, 91 In normal circumstances, the pulmonary capillary hydrostatic pressure ranges from 447
6 to 13 mmHg. The oncotic pressure is determined by proteins in human plasma; the nor-
mal mean value is 21.1 mmHg in those younger than 50 years old and significantly lower
atmembrane.
19.7 mmHg in is
This those betweeninages
represented 70 and 89.equation:
the following The interstitium is generally
Net filtration kept “dry”
= Kf × (∆hydrostatic
pressure − ∆oncotic pressure), where Kf is the filtration coefficient.
by the balance of these forces. Moreover, an initial rise in the amount of fluid moving from
the pulmonary
In normalcapillaries
circumstances, to thethe
interstitial
pulmonary spaces can behydrostatic
capillary balanced by the lymphatic
pressure ranges sys-
from
tem.
6 to 13 mmHg. The oncotic pressure is determined by proteins in human plasma; the
In a mean
normal healthy lung,isthe
value 21.1 alveolar
mmHgepithelium is a tightthan
in those younger barrier that prevents
50 years old and the passage
significantly
oflower
water,atelectrolytes,
19.7 mmHg and hydrophilic
in those betweensolutes
ages 70 toand
the air
89. spaces; likewise, the
The interstitium capillary kept
is generally en-
dothelium constitutes a semipermeable barrier to fluid exchange
“dry” by the balance of these forces. Moreover, an initial rise in the amount of fluid [13]. To avoid a build-
up of fluid
moving in the
from the lungs,
pulmonary the alveolar epithelial
capillaries cells actively
to the interstitial transfer
spaces can besodium (Na)byand
balanced the
lymphatic
chloride (Cl)system.
ions. Through sodium-selective cation channels and cycling nucleotide-un-
gated In a healthy
channels, lung,
both TypetheI alveolar
and Typeepithelium
II alveolarisepithelial
a tight barrier thatinprevents
cells take Na ions,the passage
which are
of water,
then extrudedelectrolytes,
across the and hydrophilic
basolateral solutes to
membrane by the air spaces; likewise,
an energy-dependent the capillary
Na/K- ATPase
endothelium
[14]. constitutes
This vectorial transport a semipermeable
of Na ions and barrier to fluid exchange
the concomitant movement [13]. of
To Cl
avoid
ionsaleads
build-
up of fluid in the lungs, the alveolar epithelial cells actively
to the reabsorption of fluid across both normal and damaged lungs. Figure 1 shows thetransfer sodium (Na) and
chloride
ion transport(Cl)between
ions. Through sodium-selective
alveolar epithelial cation
cells, which channelsfor
is essential and cycling nucleotide-
maintaining the fluid
ungated channels, both Type I and Type II alveolar epithelial cells take in Na ions, which are
balance.
thenPulmonary
extruded across
stress,the basolateral
either membrane
via direct damageby oran energy-dependent
mediated by ReactiveNa/K-Oxygen ATPase
And Ni-[14].
trogen Species (RONS), can modulate the activity of these channels [14–16]. Indeed, oneto
This vectorial transport of Na ions and the concomitant movement of Cl ions leads
the reabsorption
possible etiology ofofalveolar
fluid across both normal
permeability to plasmaandproteins
damaged lungs. Figure
is oxidant injury. In1 shows the
this case,
ion transport between alveolar epithelial cells, which
RONS can modify or damage epithelial sodium channels, altering fluid balance is essential for maintaining the
fluid balance.

Iontransport
Figure1.1.Ion
Figure transportacross
acrossalveolar
alveolarepithelial
epithelial cells. Na++and
cells. Na andCl Cl− −ions
ionsenter
enterthe
theapical
apicalmembranes
membranes
(lumen)
(lumen)ofofalveolar
alveolarepithelial
epithelialcells
cells(both
(bothType
TypeI Iand
andType
TypeII)
II)via
viaEpithelial
Epithelialsodium
sodiumchannels
channels(ENaC)
(ENaC)
and −−
and Cl channels such as cystic fibrosis transmembrane conductance regulator (CFTR) locatedininthe
Cl channels such as cystic fibrosis transmembrane conductance regulator (CFTR) located the
apical
apicalface
faceofofthe
thecell
cell(interstitium).
(interstitium).The
TheNaNa+ions
+
ionsare
aredriven
drivenbybyananelectrochemical
electrochemicalgradient
gradientcreated
created
by the energy-dependent Na/K-ATPase. K+ +ions, brought in by the Na/K-ATPase pump in exchange
by the energy-dependent Na/K-ATPase. K ions, brought in by the Na/K-ATPase pump in exchange
for the Na+ +ions, leave the cell passively through K+ +channels located in the basolateral membrane.
for the Na ions, leave the cell passively through K channels located in the basolateral membrane.
CFTR: Cystic fibrosis transport regulator; ENaC: Epithelial sodium channel.
CFTR: Cystic fibrosis transport regulator; ENaC: Epithelial sodium channel.

Pulmonary stress, either via direct damage or mediated by Reactive Oxygen And
Nitrogen Species (RONS), can modulate the activity of these channels [14–16]. Indeed, one
possible etiology of alveolar permeability to plasma proteins is oxidant injury. In this case,
RONS can modify or damage epithelial sodium channels, altering fluid balance.
In patients with CPE, an increase in pulmonary venous and left atrial (LA) pressure,
which most frequently occurs from an elevated LV filling pressure, causes the rise in pul-
monary capillary of the hydrostatic pressure. According to the Starling law, the pressure
must increase higher than the normal value of the plasma colloid osmotic pressure for
edema to occur [12,17,18]. The functional capacity of the lymphatic system to remove the
extra fluid is different from patient to patient and with the severity of the disease. These
characteristics influence the rate of accumulation of lung fluid at a given elevation in pul-
Adv. Respir. Med. 2023, 91 448

monary capillary pressure [19]. An acute rise in pulmonary arterial capillary pressure (i.e.,
to >18 mm Hg) may increase fluid filtration into the lung interstitium, but the lymphatic
removal does not increase correspondingly. As a result, pulmonary edema may occur at pul-
monary capillary pressures as low as 18 mmHg. In contrast, in the presence of chronically
elevated LA pressure, the rate of lymphatic removal can be as high as 200 mL/h, which
protects the lungs from CPE. Thus, these patients do not develop CPE until significantly
higher pulmonary capillary pressures are reached.
Adv. Respir. Med. 2023, 91 The most common cause of NCPE (i.e., ARDS) is characterized by the presence 449 ofof
463
the injury of the alveolar-capillary barrier in the absence of elevated pulmonary capillary
pressures. It is caused by direct (e.g., pneumonia) or indirect lung injuries (e.g., sepsis)
(Figure 2). Other conditions
Pulmonary edema leads thattomay cause NCPE
progressive include decreased
deterioration oncotic
of alveolar pressureand
gas exchange of
the plasma (caused by hypoalbuminemia), increased negativity of interstitial pressure
respiratory failure. The pathophysiology of respiratory failure includes an increase in ex- (e.g.,
rapid removal
travascular of pneumothorax),
lung water, a reduction and
in lymphatic
pulmonaryinsufficiency
compliance, (e.g.,
and anfrom lymphangitic
increase in airway
carcinomatosis,
resistance. Thesefibrosing
eventslymphangitis, or lung work
result in increased transplantation). Hypoalbuminemia
breathing. Moreover, they alsooccurs
cause
inchanges
several diseases, including malabsorption and malnutrition, renal disease, where
in the ventilation-perfusion ratio and in intrapulmonary shunting, which lead the lossto
ofarterial
albumin occurs across the glomerulus (e.g., nephrotic syndrome), or
hypoxemia. Finally, increased work of breathing may induce rapid shallow hepatic diseases,
where there leading
breathing, is inadequate albumin synthesis.
to hypercapnia.

Figure2.2.Physiology
Figure Physiologyof of Microvascular
Microvascular Fluid
Fluid Exchange
Exchange in Lung.
in the the Lung. Innormal
In the the normal lungfluid
lung (a), (a), mo-
fluid
moves continuously outward from the vascular to the interstitial space according to the net differ-
ence between hydrostatic and protein osmotic pressures, as well as to the permeability of the capil-
lary membrane, according to the Starling equation. When hydrostatic pressure increases in the mi-
crocirculation (cardiogenic pulmonary edema), the rate of transvascular fluid filtration rises (b).
Noncardiogenic pulmonary edema (c) occurs when the permeability of the microvascular mem-
brane increases because of direct or indirect lung injury (including acute respiratory distress syn-
drome), resulting in a marked increase in the amount of fluid and protein leaving the vascular space.
Noncardiogenic pulmonary edema has a high protein content because the more permeable micro-
vascular membrane has a reduced capacity to restrict the outward movement of larger molecules
such as plasma proteins.

3. Etiology of Cardiogenic Pulmonary Edema

Patients with CPE represent a heterogeneous population. CPE is most commonly due
Adv. Respir. Med. 2023, 91 449

ves continuously outward from the vascular to the interstitial space according to the net difference
between hydrostatic and protein osmotic pressures, as well as to the permeability of the capillary
membrane, according to the Starling equation. When hydrostatic pressure increases in the mi-
crocirculation (cardiogenic pulmonary edema), the rate of transvascular fluid filtration rises (b).
Noncardiogenic pulmonary edema (c) occurs when the permeability of the microvascular membrane
increases because of direct or indirect lung injury (including acute respiratory distress syndrome),
resulting in a marked increase in the amount of fluid and protein leaving the vascular space. Noncar-
diogenic pulmonary edema has a high protein content because the more permeable microvascular
membrane has a reduced capacity to restrict the outward movement of larger molecules such as
plasma proteins.

Although CPE usually occurs in the absence of change in the permeability of the
alveolar-capillary barrier [20], the capillary wall’s permeability may also be affected during
CPE. A sudden increase in pulmonary capillary hydrostatic pressure (i.e., flash pulmonary
edema) [7] can cause mechanical damage on the alveoli–capillary barrier through a process
known as “stress failure” [8]. Renal artery stenosis, particularly when bilateral, has been
identified as a common cause of flash pulmonary edema [7]. In case of stress failure, both
hydrostatic pressures and raised permeability increase fluid transfer into alveolar spaces.
Finally, inflammation associated with stress failure may cause surfactant alterations [7,8,21].
As a result, there is an increase in permeability due to the loss of tight junction-mediated
cell-to-cell contact, changes in extracellular matrix (ECM), and surfactant dysfunction. This
acute tissue injury is also characterized by the over-activation of leukocytes and platelets
and a dysregulated inflammatory response with an increased level of tumor necrosis factor-
alpha (TNF-alpha), synthesized by macrophages, endothelial cells, and alveolar type II
epithelial cells [22,23]. In addition, in patients presenting with CPE associated with stress
failure, surfactant protein levels in the serum (i.e., surfactant protein-A and surfactant
protein-B) may be elevated [12].
From a molecular point of view, another important aspect to consider is the downregu-
lation of the epithelial Sodium channels (ENaC) due to hypoxia and hypercapnia [24,25]. In
addition, cell necrosis and fluid accumulation could trigger an inflammatory response. Pro-
apoptotic cellular factors, including Bax, Caspase-3, and p53, are activated in the lung along
with the apoptotic alterations, as can be seen with a bronchoalveolar lavage (BAL) [26,27].
Another important mechanism underlying pulmonary edema is the activation of the pro-
apoptotic Fas/FasL pathway. It has been demonstrated that blocking the activation of
this pathway may reduce alveolar damage and the formation of pulmonary edema [28,29].
Several studies show that cytokines, including interleukin (IL)-1β, IL-8, and TNF-α, are
involved in alveolar injury and the reduction of alveolar fluid clearance (AFC) [30–32].
Further studies are needed to investigate the pathophysiology of alveoli–capillary bar-
rier mechanical injury, which may contribute to the development and maintenance of
pulmonary edema in some patients with CPE.
Pulmonary edema leads to progressive deterioration of alveolar gas exchange and
respiratory failure. The pathophysiology of respiratory failure includes an increase in
extravascular lung water, a reduction in pulmonary compliance, and an increase in airway
resistance. These events result in increased work breathing. Moreover, they also cause
changes in the ventilation-perfusion ratio and in intrapulmonary shunting, which lead
to arterial hypoxemia. Finally, increased work of breathing may induce rapid shallow
breathing, leading to hypercapnia.

3. Etiology of Cardiogenic Pulmonary Edema

Patients with CPE represent a heterogeneous population. CPE is most commonly
due to left cardiac dysfunction. However, a variety of other conditions may promote
the development of CPE, causing elevated cardiac filling pressures even without heart
disease. They include primary fluid overload, severe hypertension (particularly renovas-
cular hypertension), and severe renal disease. In patients with hemodialysis-dependent
Adv. Respir. Med. 2023, 91 450

renal failure, CPE is often the result of noncompliance with dietary restrictions or with
hemodialysis sessions.
Left cardiac dysfunction resulting in CPE includes the following conditions: (i) systolic
heart failure, (ii) diastolic heart failure, (iii) heart failure related to left-sided valvular
disease, and (iv) heart failure related to arrhythmias [33].
Approximately 50 percent of patients hospitalized for HF are characterized by a
preserved left ventricular ejection fraction (LVEF) (LVEF > 50 percent); the remaining
patients have HF with reduced ejection fraction (LVEF ≤ 40 percent) or HF with mid-range
ejection fraction (LVEF 41 to 50 percent).
Systolic heart failure is characterized by reduced LVEF. Common causes of reduced
LVEF include coronary artery disease, long-standing hypertension, idiopathic dilated
cardiomyopathy, viral myocarditis, progressive valvular heart disease (i.e., aortic and
mitral regurgitation, aortic stenosis), takotsubo cardiomyopathy and toxins such as alcohol,
cocaine, and chemotherapeutic agents (Table 1).

Table 1. Cancer treatments may cause cardiomyopathy.

X Anthracyclines chemotherapies: doxorubicin (Adriamycin® Doxil ® and Rubex® ),

daunorubicin (Cerubidine® ), epirubicin (Ellence® ), Valrubicin (Valstar® ), idarubicin
(Idamycin® )
X Other chemotherapy drugs: Trastuzumab (Herceptin® ) Mitoxantrone (Novatrone® ),
tucatinib (Tukysa® )
X Cisplatin (Platinol® ) can cause severe high blood pressure, which can lead to heart
impairment.
X Radiation therapy to the chest: a combination of radiation therapy and chemotherapy
can increase this risk

The cardiotoxic effects of the anthracyclines are not completely understood. The
most widely accepted theory is the formation of anthracycline–iron complexes, which
stimulate free-radical formation. The pathogenesis of trastuzumab cardiotoxicity appears
to be related to blockage of Human Epidermal Growth Factor Receptor 2 (HER2) signals in
cardiac myocytes, which are essential for cardiac myocyte repair [34]. Cisplatin can cause
severe high blood pressure, which can lead to heart problems.
Diastolic dysfunction refers to an increase in ventricular stiffness and impaired relax-
ation, which prevents ventricular filling during diastole. Due to this decreased compliance,
a heightened diastolic pressure is required to achieve a similar stroke volume. The LVEF is
often preserved. Despite normal LV contractility, cardiac output may be reduced.
The most common causes of diastolic dysfunction are chronic disorders, such as hyper-
tension and left ventricular hypertrophy. Other causes include hypertrophic cardiomyopa-
thy and infiltrative diseases (i.e., sarcoidosis and amyloidosis). Diastolic abnormalities can
also be caused by constrictive pericarditis and tamponade. Myocardial ischemia can acutely
worsen diastolic dysfunction and cause systolic dysfunction. With a similar mechanism,
myocardial contusion induces systolic and diastolic dysfunction.
Left-sided valvular disease that can cause CPE include both stenosis and regurgitation.
Critical aortic stenosis results in chronic LV outflow obstruction associated with LV hyper-
trophy, which decreases ventricular compliance and can eventually cause diastolic and
systolic dysfunction. The chronic obstruction to atrial outflow due to mitral stenosis leads
to elevated left atrial pressure. Patients with mild or moderate mitral stenosis are frequently
asymptomatic due to the slow progression of this condition, which allows patients to adapt
to this pathology. However, conditions that cause an elevated heart rate and decreased
diastolic filling time, such as exercise or atrial fibrillation with rapid ventricular response,
can result in abrupt elevations of left atrial pressures and CPE. Both chronic and acute aortic
or mitral insufficiency cause LV volume overload, which raises LV end-diastolic pressure
and LA pressure that may result in CPE. Ventricular septal rupture may cause CPE by the
same mechanism.
Adv. Respir. Med. 2023, 91 451

Tachyarrhythmias may promote the development of CPE. New-onset rapid atrial

fibrillation and ventricular tachycardia can be responsible for CPE decreasing diastolic
filling time, which may lead to an abrupt elevation of LA pressure.
While the largest proportion of patients with CPE are admitted due to worsening
chronic HF, others present with HF for the first time. Decompensation of chronic HF can
occur without known precipitant factors but more often occurs with one or more factors.
Several precipitating factors can coexist and interact with one another, exacerbating the
episode of CPE [35]. In Table 2 are listed the major precipitant factors. Major causes of
new-onset CPE are reported in Table 3.

Table 2. Common and uncommon precipitating factors associated with cardiogenic pulmonary edema.

X Uncontrolled hypertension
X Myocardial ischemia
X Arrhythmias (i.e., atrial fibrillation with a rapid ventricular response, ventricular tachycardia)
X Systemic infection (especially pulmonary infection)
X Severe emotional or physical stress
X Vigorous intravenous fluid administration
X Worsening renal failure
X Severe anemia
X Noncompliance with medications (e.g., diuretics)
X Thyrotoxicosis
X Medications that reduce contractility (i.e., antiarrhythmic drugs, calcium channel blockers,
beta-adrenergic blocking agents, anthracyclines, and other chemotherapeutic agents)
X Cardiac toxins (i.e., alcohol, cocaine)
X Use of sodium retaining medications (anti-inflammatory drugs, steroids)
X Excessive salt or water intake

Table 3. Common causes of new-onset cardiogenic pulmonary edema.

X Coronary artery disease (i.e., myocardial infarction, unstable angina)

X Arrhythmias (i.e., atrial fibrillation, atrial flutter, ventricular tachycardia)
X Myocarditis
X Non-cardiac infections (they may cause fever, which leads to tachycardia)
X Acute valve syndromes (i.e., acute mitral or aortic regurgitation secondary to infective
endocarditis, ischemic papillary muscle rupture, or aortic dissection, thrombosed
mechanical aortic or mitral valve, tear or perforation of a bioprosthetic aortic or mitral
valve leaflet)
X Ventricular septal rupture
X Stress(takotsubo) cardiomyopathy
X Volume overload (e.g., in renal failure)
X Hypertensive crisis

4. Clinical Manifestations and Diagnostic Process

Clinical presentations of acute decompensated HF can be categorized according to the
adequacy of peripheral perfusion (“warm” versus “cold”) and the presence of congestion
(“dry” or “wet”) [36]. Such categorization predicts prognosis and facilitates clinical manage-
ment. A minority of patients with acute decompensated HF (less than 20 percent) present
with a “cold and wet” clinical profile characterized by CPE associated with cardiogenic
shock. This category of patients has a higher risk of death.

4.1. History and Physical Examination

Many patients with chronic HF report that symptoms have progressively worsened
over the previous days and weeks. In a small percentage of patients, an episode of CPE
may be the first presentation of HF.
The most frequent clinical manifestations are dyspnoea and profuse diaphoresis.
Cough is a common complaint and could be an early clue to worsening pulmonary edema.
Adv. Respir. Med. 2023, 91 452

Pink, frothy sputum may be present in patients with severe disease. Other signs of severe
hypoxemia may include neurologic symptoms such as confusion, anxiety, and disorienta-
tion. Change in mental status can also be caused by hypercapnia.
In CPE patients’ tachypnoea, tachycardia, and jugular venous distention are frequent
physical findings. Patients may be sitting upright and usually appear anxious and di-
aphoretic with cyanosis of the lips. Tachypnoea may be associated with the use of auxiliary
breathing muscles. Auscultation of the lungs generally reveals fine, crepitant rales, but
wheezes may also be present. Rales are usually heard at the bases first, and they progress to
the apices as the condition worsens. An absence of rales does not imply a lack of pulmonary
venous pressure elevation. Diminished air entry at the lung bases is usually caused by a
pleural effusion, which is often more frequent in the right pleural cavity than in the left.
Although cardiac auscultation may be challenging in an acute scenario, when valvular
abnormalities result in PCE, murmurs may be audible. Auscultation of murmurs can help
in the diagnosis of acute valvular disorders manifesting with CPE.
The initial detection of hypoxia and the patient’s response to further oxygenation
and other treatments are both identified using pulse oximetry before treatment. Oxygen
saturation in ambient air is usually less than 90 percent [37].
Hypertension is often present due to the hyperadrenergic state. However, when the
blood pressure is found to be significantly elevated, it is more likely to be an important
contributing factor to pulmonary edema rather than the consequence of the condition.
If hypotension prevails, this could indicate severe left ventricular systolic dysfunction
and cardiogenic shock must be considered. Low perfusion is also characterized by a
decline in urine output, cold extremities, skin pallor or mottling, and decreased cognitive
functioning. Skin mottling at presentation is an independent predictor of an increased risk
of in-hospital mortality [36,37].
Hepatomegaly, hepatojugular reflux, ascites, and peripheral edema may be found in
patients with concomitant right ventricular failure. In patients with chronic heart failure,
peripheral and pulmonary edema frequently coexist. Leg edema is frequently evident in
both legs, particularly in the pretibial region and ankles in ambulatory patients. Sacral and
upper thigh edema can be detected in patients who are bedridden.

4.2. Tests Available for Diagnosing Pulmonary Edema

The diagnosis of CPE is based primarily on signs and symptoms and supported by
appropriate investigations. No single definitive test is available for diagnosing CPE, but
clinically, one proceeds from simple to more complex tests while searching for the diagnosis
and the associated etiology [37].
Initial testing includes a 12-lead electrocardiogram (ECG), chest X-ray, lung ultra-
sonography, and laboratory tests comprising arterial blood gas (ABG) and cardiac enzymes.
Subsequently, a bedside echocardiogram is extremely important in determining the etiology
of CPE. A Brain natriuretic peptide (BNP) level should be obtained when the diagnosis of
HF is uncertain.
Chest radiography is one of the most important investigations required for the evalu-
ation of pulmonary edema and can help distinguish between CPE and NCPE [36,38,39].
However, the characteristic features (Table 4 and Figure 3) described in chest X-rays have
only moderate specificity (75–83%) and poor sensitivity (50–68%) in the diagnosis of
CPE [38].
 Adv. Respir. Med. 2023, 91 453

Table 4. Common radiological findings in patients with cardiogenic pulmonary edema.

X Cephalization of pulmonary vessels (i.e., pulmonary venous redistribution to the upper

lobes) correlates with a pulmonary capillary hydrostatic pressure greater than 12 mmHg

X Broad vascular pedicle (i.e., the width of the mediastinum at the level of the superior vena
cava on the right and the left subclavian artery origin on the left.) correlates with a
pulmonary capillary hydrostatic pressure greater than 12 mmHg

X Septal lines, also known as Kerley lines, are due to edema of the connective tissues of the
interlobular septa and usually occur when pulmonary capillary hydrostatic
reaches 17 mmHg

X Batwing edema (i.e., central, nongravitational distribution of alveolar edema with lung
cortex free of alveolar or interstitial fluid). It correlates with pulmonary capillary hydrostatic
greater than 25 mmHg.

X Pleural effusions and cardiomegaly (i.e., an increase of cardiothoracic ratio over 50%) are
other chest X-ray findings useful for differentiating CPE from NCPE. Of note, pleural
effusions and enlarged cardiac silhouette are frequently present in patients with acute
Adv. Respir. Med. 2023, 91 453 of 463
decompensation of chronic HF but are often absent in patients with de novo acute HF.

X Unilateral cardiogenic pulmonary edema is infrequent (2% of CPE cases in one study) and is
chiefly caused by eccentric mitral regurgitation
only moderate specificity (75–83%) and poor sensitivity (50–68%) in the diagnosis of CPE
[38].
Legend: CPE, cardiogenic pulmonary edema; NCPE, non-cardiogenic pulmonary edema; HF, heart failure.

Figure 3. Chest Radiographs representing Cardiogenic and Noncardiogenic Pulmonary Edema. Left
Figure 3. Chest Radiographs representing Cardiogenic and Noncardiogenic Pulmonary Edema.
X-ray shows an anteroposterior chest Rx with acute anterior myocardial infarction and acute cardi-
Left X-ray shows an anteroposterior chest Rx with acute anterior myocardial infarction and acute
ogenic pulmonary edema. Signs of cardiogenic pulmonary edema are peri broncho vascular spaces
cardiogenic pulmonary edema. Signs of cardiogenic pulmonary edema are peri broncho vascular
(red arrows) and the prominent septal lines (Kerley’s B lines) (blue arrows). Right X-ray shows an
spaces and the prominent septal lines (Kerleys, s B lines). Right X-ray shows an anteroposterior chest
anteroposterior chest Rx with noncardiogenic pulmonary edema, with blood culture positive for
Rx with noncardiogenic pulmonary edema, with blood culture positive for Streptococcus pneumoniae,
Streptococcus pneumoniae, causing pneumonia complicated by septic shock and acute respiratory
causing pneumonia complicated by septic shock and acute respiratory distress syndrome. Diffuse
distress syndrome. Diffuse alveolar infiltrates appear patchy and bilateral with air bronchograms
alveolar infiltrates appear patchy and bilateral with air bronchograms, findings that are charac-
(arrows), findings that are characteristics of, but not specific to, noncardiogenic edema and acute
teristics of, but not specific to, noncardiogenic edema and acute lung injury.
lung injury.
Transthoracic Pulmonary ultrasound can detect CPE by identifying B-lines, also known
Table 4. Common
as “comet radiological
tails,” findings
which represent in patients with cardiogenic
alveolar-interstitial edema [9].pulmonary
B-lines areedema.
vertical hy-
perechoic reverberation artifacts that arise at the pleural line and extend to the bottom
 of Cephalization
the screen (see of pulmonary
Figure vesselsof(i.e.,
4). The extent edema pulmonary venous
is correlated to theredistribution to the
number of B-lines.
Inupper lobes)
particular, thecorrelates
number ofwith a pulmonary
B-lines correlated withcapillary hydrostatic
extravascular pressure
lung water and greater
wedge
than 12 [40].
pressures mmHg In addition, it may predict BNP levels greater than 400 pg/mL and ad-
 Broad vascular pedicle (i.e., the width of the mediastinum at the level of the supe-
rior vena cava on the right and the left subclavian artery origin on the left.) corre-
lates with a pulmonary capillary hydrostatic pressure greater than 12 mmHg
 Septal lines, also known as Kerley lines, are due to edema of the connective tissues
Adv. Respir. Med. 2023, 91 4

Adv. Respir. Med. 2023, 91 pressures [40]. In addition, it may predict BNP levels greater than 400 pg/mL 454 and a

outcomes [41]. Moreover, ultrasound scans reveal whether pleural effusions are
and whether the inferior vena cava collapses, which is a reliable sign of fluid ov
verse outcomes [41]. Moreover, ultrasound scans reveal whether pleural effusions are
Limitations of this modality include technique dependence and limited specificity
present and whether the inferior vena cava collapses, which is a reliable sign of fluid over-
identification
load. Limitationsofofpulmonary
this modality edema
include[42]. Indeed,
technique a varietyand
dependence of limited
conditions, including
specificity
nary
in thefibrosis, interstitial
identification pneumonia,
of pulmonary pneumonitis,
edema [42]. and of
Indeed, a variety NCPE, mayincluding
conditions, cause diffuse b
pulmonary
B-lines. fibrosis, interstitial pneumonia, pneumonitis, and NCPE, may cause diffuse
bilateral B-lines.

Figure 4. Lung Ultrasounds (LUS). In the normal state (A), there are no B-lines. In a state of mild to
Figure
moderate 4.interstitial
Lung Ultrasounds
edema (B), an(LUS).
overall In the normal
hypoechoic state (A),
appearance there arewith
is maintained, no B-lines. In a state of
sparse B-lines
moderate
forming. As the edema progresses to become more clinically severe (C), the hypoechoic appearance with sp
interstitial edema (B), an overall hypoechoic appearance is maintained,
lines
is lost,forming.
with a highAs the edema
density progresses to become more clinically severe (C), the hypoec
of B-lines.
pearance is lost, with a high density of B-lines.
Echocardiography is recommended to evaluate LV systolic and diastolic function.
Among patients with chronic HF, management strategies differ according to whether or not
Echocardiography
the patient has HF with reduced is recommended
LVEF (i.e., LVEF ≤ to40evaluate LV systolic
percent) versus HF with and diastolic fu
preserved
Among
LVEF. Echocardiography is also recommended to evaluate valvular function and to assess to whe
patients with chronic HF, management strategies differ according
not the patient
for pericardial has HF
disease. with reduced
In addition, LVEF (i.e.,
new wall-motion LVEF ≤ 40may
abnormalities percent)
suggestversus
acute HF w
myocardial infarction.
served LVEF. Echocardiography is also recommended to evaluate valvular functi
BNP is a cardiac neurohormone that is secreted from the ventricles when they are
to assess for pericardial disease. In addition, new wall-motion abnormalities may s
under increased pressure and stress. This is one of the HF’s compensatory mechanisms;
acute myocardial
particularly, it resultsinfarction.
in renal sodium and water excretion and in the reduction of systemic
BNP
vascular is a cardiac
resistance. Severalneurohormone
observational studies thatand
is clinical
secreted from
trials have the
shownventricles
the impor-when th
tant diagnostic value of BNP measurements in differentiating HF
under increased pressure and stress. This is one of the HF’s compensatory mecha from other pulmonary
causes of dyspnoea [43]. Most dyspneic patients with HF have plasma BNP values above
particularly, it results in renal sodium and water excretion and in the reduction
400 pg/mL. The test is less reliable in cases of moderate BNP levels (approximately 200 to
temic vascular
400 pg/mL). resistance.
Indeed, Several(i.e.,
many conditions observational studies
renal dysfunction, andCOPD,
sepsis, clinical trials have sho
pulmonary
important
embolism, and diagnostic value significantly
atrial fibrillation) of BNP measurements in differentiating
increase BNP levels. On the other hand,HFlowfrom oth
monary causes
levels of BNP of pg/mL)
(<100 dyspnoea [43].rule
usually Mostoutdyspneic patients
CPE, although with HF
low values have plasma BNP
are occasionally
found in some patients with dyspnoea associated with HF [35].
above 400 pg/mL. The test is less reliable in cases of moderate BNP levels (approxi
Pulmonary arterial catheterization using a Swan-Ganz catheter helps in differentiating
200 to 400 pg/mL). Indeed, many conditions (i.e., renal dysfunction, sepsis, COP
CPE from NCPE: pulmonary capillary wedge pressure (PCWP) is generally >18 mm Hg in
monary
CPE and <18embolism,
mm Hg in and
NCPE. atrial fibrillation)
However, routinesignificantly
use of Swan-Ganz increase BNP
catheter levels. On th
in patients
hand,
with CPElowis levels of BNP
not required. It is(<100 pg/mL) usually
recommended rule out
only for patients CPE,
with CPEalthough low values
with persistent
symptoms and/or when the diagnosis is uncertain [44,45].
casionally found in some patients with dyspnoea associated with HF [35].
Pulmonary
5. Treatment arterial catheterization using a Swan-Ganz catheter helps in diffe
ing CPE fromtreatment
The initial NCPE: pulmonary capillary
of CPE is described wedge
in Table 5 [44].pressure (PCWP) is generally >
Hg in CPE and <18 mm Hg in NCPE. However, routine use of Swan-Ganz cath
patients with CPE is not required. It is recommended only for patients with CP
persistent symptoms and/or when the diagnosis is uncertain [44,45].

5. Treatment
The initial treatment of CPE is described in Table 5 [44].
Adv. Respir. Med. 2023, 91 455

Table 5. Initial treatment of cardiogenic pulmonary edema.

X Supplemental oxygen and/or non-invasive ventilatory support to assure adequate

oxygenation in case of hypoxemia

X Early intravenous loop diuretics (i.e., furosemide) therapy is considered the cornerstone of
CPE in order to decrease cardiac preload; the aggressiveness of diuretic therapy depends on
the patient’s hemodynamic and volume status

X Vasodilator therapy when the initial response to diuretics is not sufficient to decrease
cardiac preload (e.g., nitroglycerin). Early intravenous vasodilator therapy with an agent
that lowers arterial tone (e.g., nitroprusside) is suggested in patients who require a rapid
decrease in cardiac afterload (e.g., those with severe hypertension, acute mitral
regurgitation, acute aortic regurgitation).

X Management of Atrial fibrillation (AF). AF management starts with rate control (<110/min)
and early decision-making regarding the need for cardioversion. Anticoagulation prior to
cardioversion (e.g., intravenous heparin) is mandatory for patients in whom cardioversion
will take place more than 48 h after the onset of AF or when the duration is unknown. In
patients with preserved ejection fraction, rate control can be achieved with beta-blockers. In
patients who cannot receive a beta blocker, digoxin may be considered.

X Management of hypotensive patient

◦ In patients with reduced ejection fraction, the use of an inotrope (i.e., dobutamine or
milrinone) is suggested in the presence of adequate preload. Beta-blockers should be
discontinued due to their negative inotropic effect; of note, milrinone does not act
via beta receptors; as a consequence, its effects are not as diminished as those of
dobutamine by concomitant beta-blocker therapy). In case of persistent shock, a
vasopressor (i.e., phenylephrine or norepinephrine) may be needed
◦ Patients with preserved ejection fraction may require a vasopressor and should not
receive inotropic therapy. Assessment of the intravascular volume status is critical in
such patients to determine the need for hydration. For patients with dynamic left
ventricular outflow obstruction (e.g., some patients with hypertrophic
cardiomyopathy), treatment may also include beta-blockers.

X Venous thromboembolism prophylaxis

X Sodium and fluid restriction

5.1. Supplemental Oxygen and Assisted Ventilation

Supplemental oxygen therapy and assisted ventilation should be provided as needed
to treat hypoxemia (SpO2 < 90 percent). However, oxygen is not recommended as routine
therapy in patients without hypoxemia, as it may cause vasoconstriction and reduction in
cardiac output [46–48].
In case of respiratory distress, respiratory acidosis, and/or hypoxia persists on oxygen
therapy, a trial of non-invasive ventilation (NIV) (i.e., continuous positive airway pressure
(CPAP) or bilevel NIV) is recommended if there are no contraindications to NIV. This
approach is supported by evidence from meta-analyses and small randomized trials in
patients with CPE, indicating that NIV improves clinical and laboratory indices of ARF (e.g.,
heart rate, dyspnoea, hypercapnia, acidosis) and decreases the need for intubation [49–52].
In addition, a meta-analysis of 13 trials found that patients with CPE who received NIV
plus standard care had a lower hospital mortality than those who received standard care
alone [53,54]. However, in the same analysis, treatment with NIV was only associated with
a trend toward improved mortality that did not reach statistical significance. In addition,
NIV did not have any impact on hospital length of stay of these patients.
Adv. Respir. Med. 2023, 91 456

A randomized trial comparing bilevel NIV with CPAP found no differences in mor-
tality or in the incidence of intubations despite patients’ respiratory distress appearing
to improve more quickly when receiving bilevel NIV [55–57]. Based on this evidence,
ERS/ATS guidelines recommended either bilevel NIV or CPAP for patients with ARF due
to CPE (strong recommendation, moderate certainty of evidence) [47].
In clinical practice, for patients with CPE, a trial of NIV, generally with CPAP, is
recommended as initial therapy. Bilevel NIV may be particularly beneficial in patients
with hypercapnia.
Patients with ARF should be intubated for invasive mechanical ventilation if they fail
to improve with NIV (within two hours) or they do not tolerate NIV.

5.2. Diuretic Therapy

Intravenous loop diuretics (i.e., furosemide) are considered the cornerstone of CPE
treatment. Patients with CPE are usually volume overloaded. Consequently, fluid removal
with intravenous diuretics can improve symptoms and oxygenation, even in the less typi-
cal scenario where CPE occurs without severe volume overload (e.g., with hypertensive
emergency, acute aortic or mitral valvular insufficiency). Although the safety and efficacy
of diuretic therapy have not been proved in randomized trials, extensive observational
experience has shown that they are useful for the successful treatment of most CPE pa-
tients [58]. In addition, starting intravenous diuretic treatment may also enhance hospital
outcomes [10].
Exceptions in which some delay in diuretics use may be required include patients
with severe hypotension or cardiogenic shock. Such patients may not have adequate LV
filling pressures, and an increased diuresis may have a negative effect. On the other hand,
diuresis should be increased carefully in patients with aortic stenosis and volume overload.
By reducing intravascular volume, diuresis lowers central venous and pulmonary
capillary wedge pressures. In addition, furosemide also has an initial morphine-like effect
that causes vasodilation and can decrease lung congestion before the onset of diuresis [59].
Intravenous rather than oral administration is recommended because of greater and more
consistent drug bioavailability. The doses of furosemide should be individualized according
to patient status and response [60]. Ultrafiltration (UF) or inotropes should be taken
into consideration if significant congestion continues and appropriate diuresis cannot
be accomplished.

5.3. Ultrafiltration
UF is a fluid removal procedure that is particularly useful in patients with renal
dysfunction and diuretic resistance. A randomized trial demonstrated that UF was superior
to the use of IV diuretics in controlling net fluid loss and rehospitalization in hypervolemic
patients with HF [61]. These findings suggest that UF should be considered in patients
with volume overload and CPE who have not responded well to moderate to high doses of
diuretic therapy or in whom the side effects of such treatment (e.g., renal dysfunction) do
not allow initiation of diuretics or make them ineffective.

5.4. Vasodilator Therapy

In patients with CPE, vasodilators can be needed to reduce high filling pressures
and/or LV afterload. However, the routine use of vasodilators in these patients should be
avoided because it does not improve the outcome [62].
The selection of a vasodilator depends on the underlying hemodynamics. For patients
who do not respond well to diuretics, a vasodilator therapy that primarily lowers venous
tone (such as nitroglycerin) may be administered as an addition to diuretic therapy. For
individuals who require afterload reduction, a vasodilator that lowers arterial tone (such
as nitroprusside) is advised (i.e., severe hypertension, acute mitral regurgitation, or acute
aortic regurgitation).
Adv. Respir. Med. 2023, 91 457

The dose of vasodilators should be adjusted according to the patient’s response.

In patients with right ventricular infarction or aortic stenosis, these medications should
be avoided or used with caution. They should also be lowered or stopped entirely if
symptomatic hypotension develops.

5.5. Management of Arrhythmias

Atrial fibrillation (AF) is a common arrhythmia, particularly in patients with HF.
It is often difficult to determine whether AF is the cause or result of HF. Acute HF can
precipitate AF due to increases in left atrial pressure and wall stress. AF can cause acute
HF, particularly if the ventricular response is rapid. On the other hand, AF may be chronic
and not directly related to acute HF decompensation. The treatment of AF depends upon
whether or not it is associated with significant hemodynamic instability and whether or
not it is believed to be the precipitant of HF decompensation. AF management starts
with rate control and early decision-making regarding the need for cardioversion. If we
decide to perform emergency cardioversion, the risk of a thromboembolic event needs to be
considered. If cardioversion occurs within 48 h of the onset of AF, the thromboembolic risk
appears to be very low. Anticoagulation prior to cardioversion (e.g., intravenous heparin)
is mandatory for patients in whom cardioversion will take place more than 48 h after the
onset of AF or when the duration is unknown.
In patients with preserved LVEF, rate control can be achieved with beta-blockers. In
patients who cannot receive a beta blocker or are not adequately rate controlled despite
their maximal-tolerated dose, digoxin may be considered as well as amiodarone, which
is easier to handle although with a higher risk of returning to sinus rhythm even in those
patients who should be anticoagulated [61–63].

5.6. Management of Hypotensive Patients

Patients with CPE and hypotension deserve special consideration. The goal of the
therapy is to maintain systemic perfusion and preserve end-organ performance. The
therapeutic approach differs for HF with reduced ejection fraction (i.e., ≤40 percent) and
HF with preserved ejection fraction.
In patients with reduced ejection fraction, the administration of an inotrope (i.e., dobu-
tamine and/or milrinone) is suggested in case of systolic blood pressure < 85–90 mmHg or
evidence of shock (e.g., cool extremities, narrow pulse pressure, low urine output, confu-
sion) and evidence of adequate preload [10,64]. The use of epinephrine or levosimendan
as an alternative to dobutamine and milrinone is controversial. The use of epinephrine in
the treatment of cardiogenic shock has been associated with detrimental outcomes [65,66].
Levosimendan is a calcium sensitizer that increases contractility without raising myocar-
dial oxygen demand; it is not an arrhythmogenic agent, and it also increases coronary
flow reserve. However, a randomized clinical study—the Survival of Patients With Acute
Heart Failure in Need of Intravenous Inotropic Support (SURVIVE) trial—demonstrated
no mortality benefit from levosimendan in comparison with dobutamine in patients with
acute decompensated HF [67,68].
Due to their negative inotropic impact, beta-blockers should be stopped in patients
with CPE and hypotension. In the same way, ivabradine should not be used to treat
tachycardia caused by cardiogenic shock. Since milrinone and levosimendan do not act via
beta receptors, their effects are not as diminished as those of dobutamine by concomitant
beta-blocker therapy.
In case of persistent shock, a vasopressor (i.e., norepinephrine) may be needed as a
temporizing measure to support perfusion to vital organs, though this is at the expense of
increased LV afterload. Invasive monitoring, including a pulmonary artery catheter, may
be useful in these patients.
Patients with preserved ejection fraction presenting with hypotension and evidence of
adequate preload require a vasopressor and should not receive inotropic therapy. Assess-
Adv. Respir. Med. 2023, 91 458

ment of the intravascular volume status is critical in such patients to determine the need
for diuresis and/or hydration.
For patients who develop hypotension with dynamic LV outflow obstruction (e.g.,
some patients with hypertrophic cardiomyopathy), treatment may include a beta blocker, a
vasopressor (i.e., phenylephrine or norepinephrine), and gentle hydration.
For selected patients with acute severe hemodynamic compromise despite adequate
pharmacologic therapy with vasopressor and inotropes, nondurable mechanical support
(e.g., intra-aortic balloon pump (IABP), extracorporeal circulatory membrane oxygenator
(ECMO), or extracorporeal ventricular assist devices) is an option as a “bridge to decision”
or “bridge to recovery” [10].

5.7. Additional Management Strategies

Considerations related to acute barrier disruption, which may cause more fluid for-
mation and alveolar collapse, can lead to additional management strategies, including
beta-agonists and pentoxifylline [9]. Increased levels of surfactant protein B in the circula-
tion could help to identify patients with CPE at risk for poor responses to medical therapy
due to mechanical injury to the alveoli–capillary barrier [12].
Short-acting beta-2 adrenergic agonists (e.g., albuterol) have been studied as a possible
therapeutic intervention in ARDS and in stable HF patients. Theoretically, beta-agonists
may improve fluid clearance, reduce lung vascular permeability, increase surfactant secre-
tion, and have anti-inflammatory effects. Lee et al. have summarized the mixed results of
studies treating beta-2 adrenergic agonists patients with ARDS [67]. Some studies have re-
ported improvements in edema resolution using beta-2 agonists, but others found that this
treatment may result in further tissue damage. Beta-2 agonists did not improve outcomes
in patients with ARDS. More recent studies have found that albuterol can safely reduce
extravascular lung fluid in stable HF patients without complications [69].
The principal mechanisms by which albuterol reduces lung fluid are increased lym-
phatic drainage, the activation of epithelial sodium channels on type I and II alveolar cells,
and enhanced lymphatic drainage [69]. However, beta-2 agonists have not yet been studied
in patients with CPE [9].
A recent meta-analysis of pentoxifylline administered following the diagnosis of HF
reported a 4-fold decrease in all-cause mortality from 18.3% to 5.4% [70]. The good impact
on patient outcomes was originally related to blocking the synthesis of TNF-alpha, but a
more recent review suggests that the drug’s other immunomodulatory properties explain
its benefit [14,71]. This argument is supported by a study in which idiopathic-dilated
cardiomyopathy patients with elevated baseline CRP levels were more likely to respond
to pentoxifylline [13]. However, more studies investigating the role of pentoxifylline in
reducing pulmonary damage in patients with CPE are needed [9].
Recently, sodium-glucose co-transporter 2 inhibitors (SGLT2i) have been introduced
in the treatment of heart failure. Dapagliflozin and empagliflozin reduce the risk of HF
hospitalization and cardiovascular (CV) death in HF. Their true mechanism of action in
HF is not yet defined. SGLT2i have earned their place as the fourth pillar of HF medical
therapy alongside sacubitril-valsartan, evidence-based beta-blockers, and mineralocorticoid
receptor antagonists. They should be considered for the treatment of all symptomatic
patients across the entire range of HF phenotypes, including patients hospitalized with
HF. Vericiguat benefits high-risk patients with worsening HF clinical profile. Most patients
hospitalized with HF can be up-titrated to high doses of GDMT within weeks, and this
approach reduces the likelihood of adverse HF outcomes [70–72].

6. Conclusions
Among patients, diseases causing pulmonary edema are among the most frequent
causes of respiratory failure and should be treated quickly. A faster method to recognize
and treat acute respiratory failure in an emergency department is a single breath counting
test [73].
Adv. Respir. Med. 2023, 91 459

Moreover, chest trauma must also be treated quickly and acutely because it can cause
or aggravate pulmonary edema. Certainly, chest wall blocks are revolutionizing emergency
medical practice [74].
Pleuroparenchimal patterns in ALI/ARDS do find a characterization through ultra-
sonographic lung scans. In the critically ill, the ultrasound demonstration of a dyshomoge-
neous AIS with spared areas, pleural line modifications, and lung consolidations is strongly
predictive, in an early phase, of non-cardiogenic pulmonary edema [75].
Patients with CPE represent a heterogeneous population. Appropriate therapy for
these patients requires appropriate identification of the specific CPE phenotype as well
as the potential causes and precipitants. NIV and diuretics should be considered early.
Hypoperfusion requires treatment with inotropes and occasionally vasopressors. Patients
with persistent symptoms and diuretic resistance might benefit from vasodilators and
additional approaches to management, like beta-agonists. More studies investigating
the role of medical therapy in reducing pulmonary damage in patients with CPE are
needed [76–78].

Author Contributions: Conceptualization, C.Z.; methodology, Y.L. and M.T.; software, I.P., L.C. and
G.S.; writing—original draft preparation, C.Z. and F.R.; writing—review and editing, C.Z. and Y.L.;
visualization, F.S.; project administration, M.G.B.; funding acquisition, G.R., C.Z. and T.R. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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