Acute Heart Failure / Pulmonary Oedema

Acute HF presents with breathlessness, orthopnoea, fine crepitations, and sometimes frothy sputum. Classify by haemodynamic profile: warm & wet (most common — diurese), cold & wet (cardiogenic shock — cautious diuresis, consider inotropes), warm &…

LMNOP / AHF Protocol

The pathway

1 · A-E & diagnosis

SpO₂, RR, HR, BP, JVP, peripheral oedema, lung auscultation. Sitting upright. 12-lead ECG, CXR (bat-wing oedema, Kerley B lines, cardiomegaly). BNP/NT-proBNP, troponin, U&E, FBC.

2 · LMNOP mnemonic

L-Lasix (furosemide 40–80mg IV)
M-Morphine — not routine; only for distressing pain or palliation
N-Nitrates (GTN SL or IV if SBP >100)
O-Oxygen (titrate to SpO₂ 94–98%)
P-Position (sit upright, legs down)

3 · CPAP consideration

If SpO₂ <92% despite O₂ and diuresis, or RR >25 and fatiguing — start CPAP 5–10 cmH₂O. CPAP reduces preload, improves oxygenation, and avoids intubation. CI: haemodynamic instability, vomiting, reduced GCS.

4 · Furosemide dosing

If already on oral furosemide: give IV dose equal to or double the oral dose. Monitor UO hourly — target 0.5–1ml/kg/hr. If no response after 1 hour, escalate to HDU/nephrology. Check U&E at 4–6 hours.

5 · Precipitant identification

Find and treat the cause: ACS (troponin/ECG), AF (rate/rhythm control), hypertensive emergency (IV antihypertensives), infection (antibiotics), medication non-compliance (patient history), fluid overload (dietary salt).

6 · Escalation thresholds

SBP <90 despite treatment = cardiogenic shock: stop nitrates and furosemide, call ITU/cardiology, consider inotropes (dobutamine). Worsening despite CPAP = intubation. New wall motion abnormality → primary PCI pathway.

Drugs

Drug	Dose	Route	Notes
Furosemide	40–80mg	IV bolus	Double oral dose if already on it. Repeat at 1h if poor UO.
GTN spray	400–800mcg (1–2 sprays)	Sublingual	400mcg per metered spray — two sprays is 800mcg. Only if SBP >100. Repeat every 5 min. Switch to IV infusion for sustained effect.
Morphine	Not routinely recommended	IV slow	Not routine in acute heart failure — associated with more ventilation and ITU admission. Reserve for distressing pain or palliative breathlessness, small dose, watching for respiratory depression.
CPAP	5–10 cmH2O	Non-invasive	Start if SpO₂ <92% or RR >25 and fatiguing despite O₂ + furosemide.

When to escalate

SBP <90 after initial treatment → cardiogenic shock protocol, ITU,SpO2 <92% on CPAP → anaesthetics for intubation,New STEMI or worsening troponin → cardiology/cath lab,No urine output after IV furosemide → AKI, nephrology input,AF with haemodynamic compromise → DC cardioversion

Reference: ESC Acute Heart Failure Guidelines 2021 / NICE NG106

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