Cardiogenic pulmonary edema (CPE) presents a significant clinical challenge due to impaired gas exchange and potential acute respiratory failure. Diuretic therapy is foundational, yet optimal dosing requires individualized assessment of patient response. A recent prospective observational study explored the utility of the Reverse-FALLS protocol, an ultrasound-guided approach, in monitoring diuretic efficacy in the emergency department.
Cardiogenic pulmonary edema (CPE) is a serious condition associated with impaired gas exchange and acute respiratory failure, carrying high mortality. Diuretics are considered the cornerstone of CPE treatment, with furosemide doses requiring individualization based on patient status and response. Lung ultrasonography has emerged as a reliable bedside tool for diagnosing and monitoring pulmonary congestion. By assessing extravascular lung water and inferior vena cava (IVC) size, clinicians can obtain objective data to guide diuretic therapy for safe and effective treatment of pulmonary edema. However, data on structured ultrasound protocols, such as the Reverse-FALLS protocol, for guiding and monitoring diuretic therapy in the emergency department are limited.1,2,3
The Reverse-FALLS Protocol Study
A prospective, single-center observational study was conducted between April 1 and June 30, 2023, in an emergency department to evaluate the Reverse-FALLS protocol.1 Adult patients diagnosed with acute CPE were included. Bedside lung ultrasonography and IVC measurements were performed using the Reverse-FALLS protocol both before and after intravenous loop diuretic therapy. The study recorded the number of B-lines in four lung regions and changes in IVC diameter. The primary outcome was the change in B-line counts following diuretic treatment. Secondary outcomes included IVC diameter changes and clinical outcomes.1
A total of 40 patients were included in the study, with a mean age of 73.7 ± 12.7 years; 65% of the participants were female. Following diuretic therapy, 82.5% of patients demonstrated a significant reduction in B-lines on lung ultrasonography. B-line counts decreased significantly in all lung regions: right upper (P=.005), right lower (P=.013), left upper (P<.001), and left lower (P<.001). The mean interval between ultrasound assessments was 6.2 ± 3.4 hours. Changes in IVC diameter were not statistically significant (P=.061). Higher brain natriuretic peptide levels were significantly associated with worse clinical outcomes (P=.021).1
The study concluded that bedside lung ultrasonography using the Reverse-FALLS protocol effectively demonstrated a reduction in pulmonary congestion following diuretic therapy in patients with CPE. Monitoring B-line changes may allow individualized diuretic management without significant intravascular volume depletion, thereby supporting the clinical utility of ultrasound-guided treatment in the emergency department.1
The utility of the Reverse-FALLS protocol in guiding diuretic therapy for cardiogenic pulmonary edema offers a practical, evidence-based approach for emergency department clinicians. Relying solely on clinical signs or fixed diuretic doses often leads to suboptimal fluid management, risking either under-diuresis and persistent congestion or over-diuresis and renal injury. The ability to objectively quantify pulmonary congestion via B-lines and monitor their reduction provides a tangible metric for treatment response, moving beyond subjective assessments. This individualized approach could refine diuretic strategies, potentially reducing hospital readmissions and improving patient outcomes by preventing both fluid overload and depletion.
While the study is observational and single-center, the findings underscore the growing role of point-of-care ultrasound in acute care. For medical device manufacturers, this highlights a clear market for user-friendly, integrated ultrasound systems that can easily implement protocols like Reverse-FALLS. Training for GPs and specialists in these protocols will be essential to translate this research into widespread clinical practice. The lack of significant IVC diameter changes as a marker of response, contrasted with the clear B-line reduction, suggests that B-lines may be a more sensitive indicator of pulmonary decongestion in this acute setting.
Patients stand to benefit from more precise and personalized care. The risk of adverse events associated with diuretic therapy, such as electrolyte imbalances or acute kidney injury, could be mitigated by a guided approach that aims for optimal rather than maximal diuresis. This precision medicine approach, even for a common condition like CPE, represents a step forward in optimizing resource utilization and enhancing patient safety within the emergency department setting.
- The Pivot Structured ultrasound protocols, specifically Reverse-FALLS, can guide and monitor diuretic therapy in acute CPE.
- The Data 82.5% of patients demonstrated a significant reduction in B-lines following diuretic therapy, with p-values ranging from P=.005 to P<.001 across lung regions.
- The Action Clinicians may consider incorporating bedside lung ultrasonography with the Reverse-FALLS protocol to individualize diuretic management in CPE, potentially mitigating intravascular volume depletion.
ART-2026-041
Cite This Article
Team TLSFE. Reverse-falls protocol reduces pulmonary congestion in cpe patients. The Life Science Feed. Updated May 19, 2026. Accessed May 20, 2026. https://thelifesciencefeed.com/cardiology/coronary-artery-disease/reverse-falls-protocol-reduces-pulmonary-congestion-in-cpe-patients.
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References
1. Koç ÖF, Balci EB, Cander B. Evaluation of diuretic therapy response in patients with pulmonary edema in the emergency department using the Reverse-FALLS protocol: A prospective observational study. Medicine (Baltimore) 2026;105(1):e42152292. doi:10.1097/MD.000000000042152292
2. Huang X, Hou X, Wang M. Intravascular Ultrasound-Guided Local Theranostics Enables Precise Treatment of Atherosclerotic Plaques. ACS Nano 2026;20(1):1-10. doi:10.1021/acsnano.5b07484
3. Tomar S, Abbasi A, Chandan S. Management of parastomal variceal bleeding with endoscopic ultrasound-guided coiling and human thrombin/fibrinogen injection. VideoGIE 2026;11(1):1-3. doi:10.1016/j.vgie.2025.07.001