Management of severe acute pulmonary oedema, from expert guidelines to bedside strategies: multidisciplinary survey involving 1048 physicians
Authors: Muller G , Laribi S , Delmas C , Puymirat E , Chouihed T , Danchin N , Aissaoui N , Angoulvant D 
Published: November 2023

Abstract

Introduction
Current recommendations regarding the management of severe acute pulmonary oedema (APE) have low levels of recommendation and/or evidence (LOR/E) that may lead to high heterogeneity in clinical practice 1–3. We hypothesized that practice may diverge from guidelines and differ according to medical specialty and level of expertise. The objective of this survey was to evaluate the clinical management of 4 phenotypes of APE by physicians of 3 specialties and their divergence from guidelines.

Methods
Four vignettes were designed by a scientific committee representing the French scientific societies of cardiology, emergency medicine, and intensive care (Table 1). In addition, 20 experts in the field of APE care were enrolled. Target participants and designated experts were French physicians of the 3 specialties. From 06/2022 to 09/2022, the vignettes were submitted to the physicians and experts using an open online survey.

Results
Among the 1048 respondents, 781 completed the 4 cases whereas all 20 experts completed the whole survey (Table 1). Accordance with international guidelines was heterogenous (Table 2). Compliance with SpO2&lt;90% threshold for O2 administration (LOE/R: I-C 1): 22% of physicians and 53% of experts were in accordance with the guidelines. Initiation of non-invasive ventilation (NIV) for respiratory distress (LOE/R: IIa-B 1): concordance was 54% and 93%, respectively. Intubation for progressive respiratory failure despite O2 or NIV (LOE/R: I-C 1): in case of pre-hospital NSTEMI worsening despite NIV and medications, compliance was 55% among physicians and 85% among experts. In case of STEMI with worsening respiratory failure, compliance was respectively 44% and 70%. Intravenous (iv) loop diuretics indications and choice of a loop diuretic (LOE/R: I-C 1): 91% of physicians and 95% of experts were in accordance. For the systolic blood pressure&gt;110 mmHg threshold for iv vasodilators (LOE/R: IIb-C 1) and iv nitrates during NSTEMI with signs of APE (LOE/R: I-C 2): concordance was respectively 8% and 96% among physicians, 32% and 100% among experts. For reperfusion strategies, 20% of physicians and experts acted according to the guidelines. For early PCI within 24h of NSTEMI (LOE/R: I-A 2) and immediate strategy (&lt; 2 hours) for very high-risk NSTEMI (LOE/R: I-C 2): concordance was respectively 62% and 12% among physicians, 80% and 10% among experts. Except for indications of mechanical ventilation and NSTEMI early invasive strategy, results were homogenous among medical specialties (Table 2).

Conclusion
Our data show that therapeutic strategies regarding classical clinical cases of severe APE often diverge from guidelines with expected differences between specialties. The low level of evidence fuelling the Guidelines may explain these heterogeneities 4. There is a need for more clinical investigation to fill the current gap in evidence and strengthen future guidelines that may reduce heterogeneity in care.Table 1Table 2