The Movahed protocol and algorithm for preventing intubation in patients with acute or sympathetic crashing acute pulmonary edema (SCAPE) without cardiogenic shock by repeated administration of buccal nitroglycerin ointments.

Patients presenting with severe acute cardiogenic pulmonary edema with hypoxia commonly require intubation until heart failure treatments take effect. A new term describing similar condition is called sympathetic crashing acute pulmonary edema (SCAPE). It is also called Flash pulmonary edema. Immediate pre- and afterload reduction can abort intubation. Using rapid repeated buccal administrations of nitroglycerin ointments can prevent intubation by rapidly reducing pre- and afterload as long as systolic blood pressure remains adequate without cardiogenic shock. A case series of 6 patients who needed intubation due to severe cardiogenic pulmonary edema and hypoxia despite 100% O2 administration without the presence of cardiogenic shock were successfully treated with repeated buccal administration of nitroglycerin ointments. Approximately half of an inch of nitroglycerin ointment (nitropaste) was buccally administrated every 60 seconds as long as repeated blood pressure measurements every minute before each repeated administration remained above 120 mmHg. Complete response with resolution of dyspnea with minimal oxygen requirement achieved in less than 30 minutes in all patients. Intubation was prevented in all 6 patients. No adverse events occurred in any of the patients. A treatment protocol and algorithm are developed based on these patients and reported cases in the literature for prevention of intubation in these patients. Rapid repeated buccal administration of nitroglycerin ointment is highly effective in preventing intubation and mechanical ventilation in patients with any acute pulmonary edema or SCAPE and hypoxia without cardiogenic shock.