Pulmonary Oedema

Hi All,

I'm currently a nursing student who lives with severe chronic asthma and just spent a weeks clinical on a respiratory ward in a major teaching hospital. However, I'm short on knowledge on the topic I'm curious about and I'm hoping that the wealth of knowledge that exists here with the pulmo nurses might be of help.

CASE STUDY:
My great-aunt is 84 years old and living at home with her sister, my gran. Neither of them are confused or demented - they've both got their marbles about them. However both of them are increasingly and more severely, incapacitated with respiratory and cardiac problems. My concern currently lies with my aunt.

Hx: of mild COPD, coronary artery disease, atrial fibrillation, cardiac failure and one past MI.

Medications: digoxin (62.5mcg), lasix (40mg), aspirin (100mg), lipex (10mg)

Presenting symptoms: severe increase in peripheral oedema, nocturnal dyspnea, tachyopnea, orthopnea, pale skin, mild anxiety/apprehension, possible chest pain and otherwise mild dyspnea.

Provisional diagnosis: Pulmonary oedema (by GP)

Treatment: Increase Lasix by 20mg (i.e. half a tablet.) If breathlessness does not abate, trial 5mg ventolin by neb for effect

My question is this: is this treatment aggressive enough to a) treat the problem and b) avoid a medical emergency?

I understand that the reason for only increasing the Lasix mildly was to prevent precipitating renal failure, however I wonder if another 20mg is enough to treat the problem when 40mg never reduced the peripheral oedema significantly in the first place. My concern is that this treatment isn't aggressive enough to avoid a medical emergency, considering her already very unsteady state of health (we recently had a trip to the ER and a subsequent 1 week hospital admission for unstable AF, chest pain and breathlessness) and poor self-care.

It's my understanding that pulmonary oedema has the potential to be fatal. Should I be taking my aunt back to the doctor sooner rather than later or straight to the ER - or should I try and take off my worried nurse cap and let the Lasix do it's work?

What sort of treatment plan would you suggest for this pt?