Background:
Acute pulmonary edema is related to left ventricular failure leading to increases in the feeling pressure and pulmonary congestion. If not rapidly treated, mechanical ventilation is necessary until congestion is resolved. Rapid preload and afterload reduction can lead to a very quick reversal of pulmonary edema thus preventing intubation. Nitroglycerin has been safe in reducing pre – and afterload as long as blood pressure can tolerate it. Rapid administration of high doses of nitroglycerin is crucial in order to reverse acute congestion. Nitroglycerin ointment can rapidly absorbed by buccal administration with some success but is a totally underutilized and relatively unknown method to the medical community. Hereby, six cases of successful buccal nitroglycerin administration are reported in severe pulmonary edema successfully preventing mechanical ventilation in all of these patients. This report is followed by a review of the literature.
Case 1: A 70-year-old male was admitted with diastolic heart failure. Had normal ejection fraction. After transfer to the medical floor, the patient suffered from severe pulmonary edema with oxygenation dropping to the mid-80s. examined revealed severe bilateral rales all the way to the upper lung. He was immediately put on 100% oxygen but did not improve in his respiratory effort. His BOP was 160/90Respiratory therapist was called for immediate intubation while receiving 40 mg of IV furosemide.  Immediate ¼ of an inch of buccal nitroglycerin ointment from available nitro paste was applied to his oral mucosa every 60 seconds. Within 15 minutes of treatment, respiratory distress resolved, O2 sat increased to 100% on 2 liters and intubation was avoided. Further diuretic and BP treatment gradually resolved his heart failure over the next couple of days.
Case 2: A 72-year-old female patient presenting with unstable angina underwent coronary angiography and stenting. Post-procedure, the patient developed acute contrast-induced nephropathy leading to severe congestive heart failure and pulmonary edema with hypoxia and 02 saturation in 80s. While the respiratory therapist was underway to perform intubation, the pt received a quarter of an inch of buccal nitroglycerin ointment every minute while checking BP before each administration. Systolic BP dropped gradually from 170 to 120 and within 30 minutes, respiratory distress and pulmonary edema resolved, and intubation was avoided with raise of O2 sat to 100% on 4-liter O2.
Case 3: 75 years 75-year-old male was admitted with congestive heart failure secondary to severe aortic valve regurgitation. After admission to the medical floor, while receiving IV diuretic therapy, the patient suffered from severe respiratory distress and pulmonary edema. O2 sat dropped to 70s. The pt was put on 100% non-rebreather and respiratory care was called for intubation. The pat was immediately treated with repeated doses of ¼ of an inch of buccal nitroglycerin ointment every 60 seconds with repeated BP measurements before each administration to make sure hypotension was not occurring. SBP from 190 gradually was reduced to 120 and within 20 minutes, respiratory distress resolved with a rise of O2 saturation to 100%. Intubation was avoided and the pt did well with diuresis.
Case 4: 46 years 46-year-old male was admitted to ICU with worsening renal failure leading to congestive heart failure, He had swan ganze insertion showing wedge pressure in his 30s. He failed diuretic therapy and developed worsening heart failure and pulmonary edema. His O2 sat dropped to the 80s and his wedge raised to 45. The patient was prepared for intubation. He immediately received ¼ of an inch of buccal nitroglycerin paste every 60 seconds. His wedge pressure was decreasing with each treatment with a final wedge of 18 in 30 minutes. Within 20-30 minutes, respiratory distress resolved. O22 sat improved to 100% on 4 liters, and his SBP normalized from 170 to 120. Iv nitro was started to keep his pre and after-load low and intubation was aborted.
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. While awaiting intubation, ¼ of an inch of buccal nitroglycerin was administrated every 60 seconds with resolution of respiratory distress and pulmonary edema and normalization of his BP. Intubation was avoided
Case 6: A 68-year-old male on dialysis presented with acute anterior STEMI. He underwent successful PCI to 100% occluded proximal LAD. Post PCI, he developed severe pulmonary edema. His o2 sat dropped to 83% with severe hypertension with SBP in the 180 range. Immediate buccal ¼ of an inch nitroglycerin ointment was administered every 60 seconds with blood pressure measurement before each repeat administration. His BP gradually dropped to the 130 range with a resolution of hypoxia and respiratory distress. Urgent dialysis was started later to prevent recurrent pulmonary edema. Intubation was avoided.