Medical

Flash pulmonary edema / SCAPE

Before / During / After / Pitfalls

Before

• Aggressive NIV/CPAP is often the key pre-intubation intervention when mental status and airway protection allow.
• Treat afterload and sympathetic surge per local protocol; prepare for intubation only if failing NIV or unable to protect airway.
• Preoxygenate with PEEP; have suction ready for frothy secretions.

During

• Use PEEP from the start; avoid derecruitment during transition.
• Anticipate hemodynamic changes from induction and positive pressure.
• Confirm tube and quickly transition to ventilator with adequate PEEP.

After

• Titrate PEEP/FiO2 and reassess BP/afterload strategy.
• Look for myocardial ischemia, arrhythmia, renal failure, or valvular trigger.
• Avoid leaving FiO2 at 100% once stabilized.

Pitfalls

• Intubating before a real NIV/afterload-reduction trial when NIV is safe.
• Dropping PEEP during transitions.
• Post-intubation hypotension from induction/PPV.