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Congestive Heart Failure and Pulmonary Edema Nestor Nestor, MD June 21, 2006.

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Presentation on theme: "Congestive Heart Failure and Pulmonary Edema Nestor Nestor, MD June 21, 2006."— Presentation transcript:

1 Congestive Heart Failure and Pulmonary Edema Nestor Nestor, MD June 21, 2006

2 Goals and Outline 1.Pathophysiology of Congestive Heart Failure (CHF) 2.Recognizing CHF and Pulmonary Edema (PE) 3.Prehospital Treatment

3 1. Pathophysiology

4 Terminology 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)

5 tissue CO 2 O2O2 RV LA The Heart is Two Pumps in Series

6 Like any pump: The heart generates pressure to deliver blood to the body Therefore it also must…

7 Pull blood out of the veins

8 Fluid (and some cells) from stagnating blood leak out… alveolus lymphatic capillary

9 Three Pathophysiological Causes of Failure Increased work load (HTN) Myocardial Dysfunction (ASCVD) Decreased Ventricular Filling (Valvular, cardiomyopathy, etc.)

10 Normal Heart LV RV

11 Infarction Myocardial Infarction

12 Hypertension

13 Dilated Cardiomyopathy

14 Heart 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

15 CHF: A Vicious Cycle Low Output Increased Preload Increased Afterload Norepinephrine Increased Salt Vasoconstriction Renal Blood Flow Renin Angiotension I Angiotension II Aldosterone

16 Gas exchange Airway flow CO 2 O2O2 no gas exchange

17 Infiltration of Interstitial Space Normal Micro-anatomy Micro-anatomy with fluid displacement

18 Normal lung Early pulmonary edema Perivascular cuffs in early pulmonary edema cuff

19 The ultimate insult: alveolar flooding flow

20 Precipitating Causes Non-Compliance with Meds and Diet Increased Sodium Diet (Holiday Failure) Acute MI Arrhythmia (e.g. AF) Infection (pneumonia, viral illness) Pregnancy

21 2. Recognizing CHF and Pulmonary Edema

22 Acute Pulmonary Edema

23 History, History, History Acute or chronic onset Prior episodes Weight gain Medications

24 Symptoms Fatigue Nocturia DOE PND GI Symptoms Chest Pain Orthopnea Profound Dyspnea

25 Vitals Tachypnic Tachycardic Hypoxic Hypertensive (even “normal” may be too high) or Hypotensive in severe failure

26 Physical Exam Anxious Pale Clammy Confusion Edema Diaphoretic Rales Rhonchi S 3 Gallop JVD Pink Frothy Sputum Cyanosis

27 Pitting Edema

28 JVD

29 3. Prehospital 3. Prehospital Treatment

30 EMS Management Sit upright High Flow O 2 Nitroglycerine (If SBP > 100) Morphine Diuretics (furosemide) Ventilatory Support –CPAP –BVM –Intubation and ventilation

31 Relaxes arteries and veins Relaxes arteries and veins 0.4 mg sub lingual or 1 spray 0.4 mg sub lingual or 1 spray Repeat x2 every 5 min if SBP > 100 Repeat x2 every 5 min if SBP > 100 Consider 1” NTG paste to CW Consider 1” NTG paste to CW Pharmacological Treatment: Nitroglycerine (NTG)

32 Also relaxes arteries and veins Also relaxes arteries and veins Reduces anxiety and O 2 demand Reduces anxiety and O 2 demand 2-4 mg IV 2-4 mg IV Pharmacological Treatment: Morphine

33 A diuretic, reducing fluid overload A diuretic, reducing fluid overload Requires good enough cardiac output to reach the kidneys Requires good enough cardiac output to reach the kidneys 40mg IV 40mg IV May require more if already taking Lasix May require more if already taking Lasix Pharmacological Treatment: Furosemide (Lasix)

34 Not useful in acute CHF Not useful in acute CHF Decrease HR and output, worsening failure Decrease HR and output, worsening failure May cause/worsen bronchoconstriction May cause/worsen bronchoconstriction However they are used in stable, compensated failure so they may be on a pt’s med list However they are used in stable, compensated failure so they may be on a pt’s med list Pharmacological Treatment: Beta Blockers (Lopressor)???

35 Continuous Positive Airway Pressure Ventilatory Support: CPAP

36 CPAP is oxygen therapy in its most efficient form.  Simple Masks  Venturi Masks  CPAP

37 Why does oxygen pass into the blood? The Pressure Gradient Deoxygenated blood has a lower partial pressure of oxygen so oxygen transfers from the air into the blood.

38 CPAP and Patient Airway Pressure ‘The application of positive airway pressure throughout the whole respiratory cycle to spontaneously breathing patients.

39 CPAP increases the pressure gradient 7.5cm H 2 O 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.

40 Physiological 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

41 Application

42 CPAP And Pulmonary Edema  CPAP increases transpulmonary pressure  CPAP improves lung compliance  CPAP improves arterial blood oxygenation  CPAP redistributes extravascular lung water

43 Redistribution Of Extravascular Lung Water With CPAP

44 CPAP And Acute Respiratory Failure  CPAP prevents airway collapse during exhalation  CPAP overcomes inspiratory work imposed by auto-peep (pursed lip breathing)  CPAP may avoid intubation and mechanical ventilation

45 Caution COPD and Asthmatic patients do not respond predictably to CPAP Higher risk of complications such as pneumothorax

46 When Not To Use Mask CPAP  Pneumothorax (evolve into tension)  Hypovolemia (further limit preload)  Severe facial injuries  Patients at risk of vomiting

47 Common Complications With CPAP  Gastric distension  Pulmonary barotrauma  Reduced cardiac output  Hypoventilation

48 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,

49 Ventilatory Support: Intubation Definitive (but not first) treatment of pulmonary edema Definitive (but not first) treatment of pulmonary edema Positive pressure redistributes edema fluid as in CPAP but to a greater extent Positive pressure redistributes edema fluid as in CPAP but to a greater extent Mechanical ventilation greatly reduces O2 demand Mechanical ventilation greatly reduces O2 demand Sedation/paralysis also reduces O2 demand and increases compliance Sedation/paralysis also reduces O2 demand and increases compliance

50 Ultimate Therapies If pt stabilizes: long term therapy with beta blockers and ACE inhibitors If cardiac output remains unacceptable: –Beta agonists –LVAD –Transplant

51 In 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

52 Thank You


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