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Acute pulmonary oedema

Emergencies

Sit up, oxygen to target, IV loop diuretic — then find out why it happened.

NICE advises against routine nitrates, opioids and NIV; each has specific uses below.

Act now

  1. 1

    Sit the patient upright.

  2. 2

    Oxygen to target: 94–98%, or 88–92% if at risk of hypercapnia.

  3. 3

    Stop IV fluids.

  4. 4

    IV furosemide.

  5. 5

    12-lead ECG and continuous monitoring.

Assess

  • ABCDE: RR, SpO₂, BP, crackles, JVP, oedema, fluid balance.
  • Trigger: ACS, new AF or other arrhythmia, hypertension, valve disease, IV fluid overload, missed diuretics, NSAIDs, infection.
  • Cardiogenic shock (low BP, cold, confused, low urine output) changes everything — senior now.

Investigations

  • Blood gas, CXR, ECG, troponin, U&E, FBC, LFT, TFTs, NT-proBNP.
  • Echocardiogram within 48 hours for new suspected heart failure.
  • Catheter for hourly urine output if unwell.

Manage

  • Repeat the diuretic dose if response is poor; monitor U&E and weight daily.
  • Nitrates: consider only with myocardial ischaemia, severe hypertension, or aortic or mitral regurgitation — and only if systolic BP is adequate.
  • NIV: consider if severe breathlessness with acidaemia.
  • Continue a regular beta-blocker unless HR under 50, second- or third-degree AV block, or shock.
  • Treat the trigger: ACS pathway, rate control for AF.

Escalate when

  • Cardiogenic shock, not improving, rising CO₂ or acidaemia, or needing NIV: senior, cardiology and critical care.

Doses and prescribing

Furosemide

40–80 mg IV slowly. If already on a loop diuretic, give at least the usual daily oral dose IV.

Glyceryl trinitrate

10–200 micrograms/minute IV infusion, titrated, if a nitrate is indicated and systolic BP is over 90 mmHg.

Check the BNF and your local formulary before prescribing.

Written to current guidance (NICE CG187) · sources checked 14 Nov 2026. We watch NICE for updates weekly.

Sources (3)

Reviewed by Aboodee Alhasso, MPharm MRCPharm IP on 14 Nov 2026

Calculators for this

For healthcare professionals, as an aid to clinical judgement — not a substitute for it. Follow your local policy and ask a senior when in doubt.