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Fluid Overload Subacute Pulmonary Edema

(FOSPE) vs. Sympathetic Crashing Acute
Pulmonary Edema (SCAPE)

Abstract:

Fluid overload subacute pulmonary edema (FOSPE) and sympathetic crashing acute
pulmonary edema (SCAPE) are critical conditions with overlapping clinical features. This
article provides a detailed analysis of these conditions, focusing on their identification,
differentiation, and management in the intensive care unit (ICU). Subheadings cover the
clinical presentation, diagnostic criteria, treatment algorithms, and key differences between
FOSPE and SCAPE. Specific guidance is given to aid rapid identification and appropriate
intervention in an ICU setting.

Fluid Overload Subacute Pulmonary Edema (FOSPE):

Identification and Clinical Presentation

FOSPE is characterized by fluid overload resulting in gradual pulmonary edema. Patients may
exhibit dyspnea, orthopnea, increased respiratory rate, and bilateral crackles on auscultation.
Symptoms typically develop over hours to days, making FOSPE a subacute condition.

Diagnostic Criteria

Diagnostic criteria for FOSPE include evidence of fluid overload, such as peripheral edema,
weight gain, and elevated jugular venous pressure. Chest X-ray may reveal bilateral infiltrates
and Kerley B lines. Echocardiography may show left ventricular dysfunction or increased
filling pressures.

Treatment Algorithm for FOSPE

Diuretics / Dialysis: Initiate loop diuretics to reduce fluid overload and alleviate pulmonary
congestion.

Oxygen Therapy: Administer supplemental oxygen to maintain oxygen saturation levels.

Fluid Restriction: Limit fluid intake to prevent exacerbation of fluid overload.

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Nitrates: Consider nitroglycerin to reduce preload and improve cardiac output. (See SCAPE
below for dosage)

Positive Pressure Ventilation if indicated: (See SCAPE)

Inotropic Support: If cardiac output remains compromised, consider inotropic support.

Sympathetic Crashing Acute Pulmonary Edema (SCAPE):

Identification and Clinical Presentation

SCAPE is characterized by rapid-onset severe pulmonary edema often associated with

sympathetic overactivity. Patients exhibit severe dyspnea, tachypnea, hypoxia, and profound
anxiety. The rapid onset and severity of symptoms distinguish SCAPE from other forms of
pulmonary edema.

Diagnostic Criteria

Diagnostic criteria for SCAPE include sudden development of severe respiratory distress,
tachycardia, and hypertension. Chest X-ray may reveal diffuse alveolar infiltrates.

A bedside ultrasound is crucial and will show dilated Inferior Vena Cava (IVC), Pleural
Effusion, B-lines (vertical comet-tail artifacts that arise from the pleural line and extend to
the bottom of the screen. They represent increased interstitial fluid and thickened pulmonary
septa). The presence of multiple B-lines in multiple lung fields is a hallmark of pulmonary
edema.

Treatment Algorithm for SCAPE

Oxygen Therapy: Administer high-flow oxygen to correct hypoxia.

Positive Pressure Ventilation/BiPAP: Initiate non-invasive positive pressure ventilation

(NIV) or invasive mechanical ventilation as needed.

BiPAP is identified to be the most ideal choice of management in SCAPE. Increasing the
airway pressure can lead to an immediate decrease in both preload and afterload, potentially
yielding quicker and more consistent results compared to medication.

Adjusting BiPAP setting to the respiratory demands of the patient is important. May titrate
pressure support from 12 to up to 18. the upper limit for bi-level positive airway pressure (PAP)
is 30 cm H2O for IPAP, and the minimum difference between IPAP and EPAP should be at
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least 4 cm H2O. As CPAP approaches 15 cm H2O, transitioning to bi-level PAP is generally

recommended.

Nitroglycerin: The initiation of a nitroglycerine (NTG) infusion is typically commenced at a

rate ranging from approximately 100-300 mcg/min (1.2-3 ml/hr). Achieving arterial
vasodilation often necessitates the administration of a high dose of nitroglycerine, possibly
reaching at least around 150 mcg/min (1.8 ml/hr).

Considering the underlying vicious-spiral physiology associated with SCAPE, it is generally

recommended to initiate treatment with a higher dose of nitroglycerine, promptly achieve
blood pressure control, and subsequently titrate the dosage downwards. In scenarios where
rapid blood pressure control is not attained, a more assertive titration of nitroglycerine may
be required. On certain occasions, considerably elevated doses (e.g., 800 mcg/min) might be
indicated for limited intervals to effectively disrupt the cycle of progressive hypertension.

It is imperative to acknowledge that the use of nitroglycerine is contraindicated in patients

who have recently received phosphodiesterase type-5 inhibitors (e.g., sildenafil, tadalafil,
vardenafil). In such instances, the consideration of nicardipine or clevidipine may be
appropriate. Additionally, nitroglycerine has the potential to elevate intracranial pressure
(ICP) and has been documented to exacerbate Posterior Reversible Encephalopathy
Syndrome (PRES).

In situations where access to an NTG infusion is restricted, an alternative approach could

involve the administration of 3-5 sublingual tablets containing 400 mcg (0.4 mg) each every 5
minutes.

Diuretics: Use loop diuretics cautiously to avoid exacerbating hypoperfusion.

Sedation and Anxiolysis: Administer benzodiazepines to alleviate anxiety and counteract

sympathetic surge.

Hemodynamic Monitoring: Use invasive monitoring to guide fluid management and titration
of vasodilators.

Inotropic Support: If cardiac output remains compromised, consider inotropic agents.

Rapid Identification in the ICU:

Clinical Presentation: SCAPE typically presents with extreme respiratory distress, anxiety,
and tachycardia, while FOSPE may manifest as slower-onset dyspnea and fluid accumulation.
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Table 1 Image Credits to EMCRIT.org & Dr. Josh Farkas.

Conclusion:

Fluid overload subacute pulmonary edema (FOSPE) and sympathetic crashing acute
pulmonary edema (SCAPE) are critical conditions that demand prompt recognition and
intervention. Understanding their clinical presentations, diagnostic criteria, and
management algorithms is essential for delivering optimal care in the ICU. Distinguishing
between these two conditions is vital for guiding appropriate interventions and improving
patient outcomes.

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