Cardiogenic Pulmonary Oedema Case 3

A 76-year-old woman presents with acute onset shortness of breath a few hours after going to bed.  Her family tell you that this is the second time that she has presented in this way and that on each occasion the family were called in to be told that she ‘may not survive the night’.  She has a history of MI many years ago and now her only problem is hypertension for which she takes several different medicines.

Which of the following classical clinical findings might you expect to find in this lady with acute CPO? Select six from the list.

The ABG analysis is as follows:

ABG on 15L O₂
pH 7.29
pO2 9.9
pCO2 3.5
Bicarbonate 16
Lactate 2

Her CXR is shown. Click on the image to see a larger version:

Which of the following treatment options are required?

Despite both low dose furosemide and morphine, CPAP at 5cm H₂O and an IV nitrate infusion at 10 mcg/min there is no clinical improvement. What would you do next?