Acute pulmonary edema is a sudden buildup of fluid in the lungs, most often from heart failure, that makes breathing very hard. In hospital patients it is often triggered by too much IV fluid, a heart attack, a fast rhythm or very high blood pressure.
Key symptoms
- Sudden severe shortness of breath
- Unable to lie flat; needs to sit up
- Cough with pink, frothy sputum
- Anxiety, sweating and a feeling of drowning
What you find on exam
- Fast breathing, low oxygen saturation, often high blood pressure
- Crackles in both lungs, sometimes wheeze
- Raised jugular venous pressure, S3 gallop, leg edema
- Review fluid balance and recent IV fluids or transfusions
Tests
- Chest X-ray: bilateral fluid, enlarged heart, pleural effusions
- BNP or NT-proBNP, troponin, electrolytes and kidney function
- ECG for ischemia or arrhythmia
- Bedside echocardiogram or lung ultrasound (B-lines)
- Arterial blood gas if severe
Treatment basics
- Sit the patient up and give oxygen; stop IV fluids
- Noninvasive ventilation (CPAP or BiPAP) for distress or low oxygen
- IV furosemide
- Nitroglycerin when blood pressure is high
- Treat the trigger: heart attack, arrhythmia, hypertension; intubate if failing
Red flags
- Low blood pressure or signs of cardiogenic shock
- Falling consciousness or rising carbon dioxide
- Chest pain or ECG changes of a heart attack
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NCSBN 2026 NCLEX-RN Test Plan. Written by Making Synapses. Making Synapses is not affiliated with these organizations.