A 70-year-old man with a history of stable angina and hypertension develops sudden onset breathlessness at night. He is unable to lie flat and appears, sweaty and anxious. He is brought into the resus area and the sister in charge has sat him upright and commenced high-flow oxygen. His chest X-ray is shown below:


1. What is the most likely diagnosis?

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The presentation and X-ray in this question are clearly indicative of a diagnosis of acute cardiogenic pulmonary oedema (ACPO).

Features on the chest X-ray supporting this diagnosis include:

  • Cardiac enlargement (cardiothoracic ratio >50%)
  • Upper lobe diversion (prominent upper lobe veins)
  • Bibasal lung shadowing
  • Kerley B lines (basal septal lines)


X-ray sourced from Wikipedia
Courtesy of Frank Gaillard CC BY-SA 3.0

2. Outline your immediate management of this patient.
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The management of ACPO is as follows:

  • Sit patient upright
  • High flow oxygen via reservoir mask
  • IV loop diuretic e.g. furosemide 20-80 mg (first-line pharmacological therapy)
  • Thromboprophylaxis (e.g. with low-molecular-weight heparin) is recommended in patients not already anticoagulated.


Although it is no longer recommended that nitrates are offered routinely, they are helpful in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease. If administered blood pressure should be monitored closely in a setting where at least level 2 care can be provided.

The NICE guidelines on the diagnosis and management of acute heart failure can be read in full here:


3. If his condition continues to worsen despite your above management, which other treatment modality could be initiated in the ED?
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Non-invasive ventilation could be initiated. NICE recommends that non-invasive ventilation (CPAP or NIPPV) is reserved for patients with ACPO with severe dyspnoea, acidaemia, or for patients deteriorating despite treatment.

4. Should intravenous opiates be given routinely and why?
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NICE no longer recommend the use of IV opiates following the ADHERE analysis, which demonstrated an increased incidence of mechanical ventilation, prolonged hospitalisation, ICU admission and mortality in patients with ACPO treated with them.