Congestive Heart FailureCongestive Heart Failureand and
Pulmonary EdemaPulmonary Edema
Nestor Nestor, MDNestor Nestor, MDJuneJune 21, 2006 21, 2006
Goals and OutlineGoals and Outline
1. Pathophysiology of Congestive Heart Failure (CHF)
2. Recognizing CHF and Pulmonary Edema (PE)
3. Prehospital Treatment
1. Pathophysiology1. Pathophysiology
TerminologyTerminology• Heart Failure: The inability of the heart to
maintain an output adequate to maintain the metabolic demands of the body.
• Pulmonary Edema: An abnormal accumulation of fluid in the lungs.
• CHF with Acute Pulmonary Edema: Pulmonary Edema due to Heart Failure (Cardiogenic Pulmonary Edema)
tissue
CO2 O2
RV
LA
The Heart is Two Pumps in Series
Like any pump:Like any pump:
• The heart generates pressure to deliver blood to the body
• Therefore it also must…
Pull blood outPull blood out of the veins of the veins
Fluid (and some cells) from stagnating blood leak out…
alveolus lymphatic
capillary
Three Pathophysiological Three Pathophysiological Causes of FailureCauses of Failure
• Increased work load (HTN)
• Myocardial Dysfunction (ASCVD)
• Decreased Ventricular Filling (Valvular, cardiomyopathy, etc.)
Normal HeartNormal Heart
LV
RV
Myocardial Infarction Infarction
HypertensionHypertension
Dilated CardiomyopathyDilated Cardiomyopathy
Heart Failure - ConceptsHeart Failure - Concepts• Cardiac Output (L/min)• Afterload (BP)
– Primarily arterial and systolic function• Preload (volume)
– Primarily a venous and diastolic function• Frank-Starling Length: Tension Ratio
– Why preload effects output
CHF: A Vicious CycleCHF: A Vicious CycleLow Output
Increased Preload Increased Afterload Norepinephrine
Increased Salt Vasoconstriction Renal Blood Flow
ReninAngiotension IAngiotension II
Aldosterone
Gas exchange
Airway
flow
CO2 O2
no gas exchange
Infiltration of Interstitial SpaceInfiltration of Interstitial Space
Normal Micro-anatomy
Micro-anatomy with fluid displacement
Normal lung
Early pulmonary edema
Perivascular cuffs in early pulmonary edema
cuff
The ultimate insult: alveolar flooding
flow
Precipitating CausesPrecipitating Causes
• Non-Compliance with Meds and Diet• Increased Sodium Diet (Holiday Failure)• Acute MI• Arrhythmia (e.g. AF)• Infection (pneumonia, viral illness)• Pregnancy
2. Recognizing CHF and 2. Recognizing CHF and Pulmonary EdemaPulmonary Edema
Acute Acute Pulmonary Pulmonary
EdemaEdema
History, History, HistoryHistory, History, History• Acute or chronic onset
• Prior episodes
• Weight gain
• Medications
SymptomsSymptoms
• Fatigue
• Nocturia
• DOE
• PND
• GI Symptoms
• Chest Pain
• Orthopnea
• Profound Dyspnea
VitalsVitals• Tachypnic
• Tachycardic
• Hypoxic
• Hypertensive (even “normal” may be too high)
• or Hypotensive in severe failure
Physical ExamPhysical Exam• Anxious• Pale• Clammy• Confusion• Edema• Diaphoretic
• Rales• Rhonchi• S3 Gallop• JVD• Pink Frothy Sputum• Cyanosis
Pitting EdemaPitting Edema
JVDJVD
3. Prehospital 3. Prehospital Treatment
EMS ManagementEMS Management• Sit upright• High Flow O2
• Nitroglycerine (If SBP > 100)• Morphine• Diuretics (furosemide)• Ventilatory Support
– CPAP– BVM – Intubation and ventilation
• Relaxes arteries and veinsRelaxes arteries and veins
• 0.4 mg sub lingual or 1 spray0.4 mg sub lingual or 1 spray
• Repeat x2 every 5 min if SBP > 100Repeat x2 every 5 min if SBP > 100
• Consider 1” NTG paste to CWConsider 1” NTG paste to CW
Pharmacological Treatment:Pharmacological Treatment:Nitroglycerine (NTG)
• Also relaxes arteries and veinsAlso relaxes arteries and veins
• Reduces anxiety and OReduces anxiety and O22 demand demand
• 2-4 mg IV2-4 mg IV
Pharmacological Treatment:Pharmacological Treatment:MorphineMorphine
• A diuretic, reducing fluid overloadA diuretic, reducing fluid overload
• Requires good enough cardiac output to reach Requires good enough cardiac output to reach the kidneysthe kidneys
• 40mg IV40mg IV
• May require more if already taking LasixMay require more if already taking Lasix
Pharmacological Treatment:Pharmacological Treatment:Furosemide (Lasix)Furosemide (Lasix)
• Not useful in acute CHFNot useful in acute CHF
• Decrease HR and output, worsening failureDecrease HR and output, worsening failure
• May cause/worsen bronchoconstrictionMay cause/worsen bronchoconstriction
• However they are used in stable, compensated However they are used in stable, compensated failure so they may be on a pt’s med listfailure so they may be on a pt’s med list
Pharmacological Treatment:Pharmacological Treatment:Beta Blockers (Lopressor)???Beta Blockers (Lopressor)???
Continuous Positive Airway PressureContinuous Positive Airway Pressure
Ventilatory Support:Ventilatory Support:
CPAPCPAP
CPAP is oxygen therapy in its CPAP is oxygen therapy in its most efficient form.most efficient form.
Simple Masks
Venturi Masks
CPAP
Why does oxygen pass into the blood?
The Pressure GradientThe Pressure Gradient
Deoxygenated blood has a lower partial pressure of oxygen so oxygen transfers from the air into the blood.
CPAP and Patient CPAP and Patient Airway PressureAirway Pressure
‘The application of positive airway pressure throughout the whole
respiratory cycle to spontaneously breathing patients.
CPAP increases the pressure gradient
• 7.5cm H2O CPAP increases the partial pressure of the alveolar air by approximately 1%.
• This increase in partial pressure ‘forces’ more oxygen into the blood.
• Even this comparatively small change is enough to make a clinical difference.
Physiological Effects Of CPAPPhysiological Effects Of CPAP
• Increases the volume of gas remaining in lungs at end-expiration
• CPAP distends alveoli preventing collapse on expiration
• Greater surface area improves gas exchange
• Reduces work of breathing
ApplicationApplication
CPAP And Pulmonary EdemaCPAP And Pulmonary Edema
CPAP increases transpulmonary pressure
CPAP improves lung compliance
CPAP improves arterial blood oxygenation
CPAP redistributes extravascular lung water
Redistribution Of Redistribution Of Extravascular Lung Water Extravascular Lung Water
With CPAPWith CPAP
CPAP And Acute Respiratory CPAP And Acute Respiratory FailureFailure
CPAP prevents airway collapse during exhalation
CPAP overcomes inspiratory work imposed by auto-peep (pursed lip breathing)
CPAP may avoid intubation and mechanical ventilation
CautionCaution
• COPD and Asthmatic patients do not respond predictably to CPAP
• Higher risk of complications such as pneumothorax
When Not To Use Mask When Not To Use Mask CPAPCPAP
Pneumothorax (evolve into tension)
Hypovolemia (further limit preload)
Severe facial injuries
Patients at risk of vomiting
Common Complications With Common Complications With CPAPCPAP
Gastric distension Pulmonary barotrauma Reduced cardiac output Hypoventilation
CPAP Flow Sheet CPAP Flow Sheet
2 or more of the following Respiratory Distress Inclusion Criteria
-Retractions of accessory muscles-Brochospasm or Rales on Exam
-Respiratory Rate > 25/min.-O2 Sat. < 92% on high flow O2
Administer CPAP using Max FIO2
-Continue CPAP-Continue COPD/Asthma/Pulmonary Edema Protocol
-Contact Medical Control with a Report
-Contact Medical Control with report-Discontinue CPAP unless advised by Medical Control-Continue Asthma/COPD/Pulmonary Edema Protocols
Stable or Improving Reassess Patient Deteriorating
No Exclusion Criteria Present
-Respiratory/Cardiac Arrest-Pt.unable to follow commands
-Unable tp maintain patent airway independently-Major Trauma
-Suspicion of a Pneumothorax-Vomiting or Active GI Bleed
-Obvious signs/Symptoms of Pulmonary infection
,
Ventilatory Support:Ventilatory Support:IntubationIntubation
• Definitive (but not first) treatment of pulmonary Definitive (but not first) treatment of pulmonary edemaedema
• Positive pressure redistributes edema fluid as in Positive pressure redistributes edema fluid as in CPAP but to a greater extentCPAP but to a greater extent
• Mechanical ventilation greatly reduces Mechanical ventilation greatly reduces O2 demandO2 demand
• Sedation/paralysis also reduces O2 demand Sedation/paralysis also reduces O2 demand and and increases complianceincreases compliance
Ultimate TherapiesUltimate Therapies
• If pt stabilizes: long term therapy with beta blockers and ACE inhibitors
• If cardiac output remains unacceptable:– Beta agonists– LVAD– Transplant
In SummaryIn Summary
1. Heart failure is the result of an acute event (MI, AF) or chronic decompensation
2. Pulmonary edema frequently results from cardiac failure but may also result from other disease processes (ARDS) or direct insult
3. Correct diagnosis is crucial and depends on good history and exam
4. Therapy is both pharmacological and ventilatory support
Thank YouThank You
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