LMH ER Rounds Prepared by Shane Barclay Acute Pulmonary Edema LMH ER Rounds Prepared by Shane Barclay

Acute Pulmonary Edema Two Variations Acute Pulmonary edema with adequate perfusion. Patients usually hypertensive. 2. Acute Pulmonary edema with inadequate perfusion – ie cardiogenic shock. Patient’s BP usually low or ‘normal’.

The ‘Old Way’ Traditionally the thought was that CHF was simply extra fluid in the lungs from cardiac decompensation. Treatment of CHF was to give a ton of Lasix IV, then some morphine to ‘open up’ the airways and relax the patient. If they were hypotensive you could use dopamine in low doses to ‘renodilate’ the renal arteries, then give Dobutamine to increase the blood pressure and once that happened then give a ton of Lasix and some morphine. That view has all changed.

Mechanism of CHF/Acute Pulmonary Edema It is now felt that in APE the lungs develop some fluid due to a variety of causes – acute Afib, MI, PE etc. When that happens the bodies senses fluid in the lungs and the response is that “I am drowning”. This in turn causes a huge catecholamine release – ‘fight or flight response’, which causes massive peripheral vasoconstriction. The vasoconstriction in turn causes more resistance for the heart, which in turn can cause more fluid building up in the lungs and so goes the cycle.

Mechanism of CHF/Acute Pulmonary Edema So now the treatment is to splint the alveoli open to help clear the lungs. This is done with non invasive ventilation and the use of PEEP. Then Nitroglycerin can be given to peripherally dilate the arteries which in turn reduces the afterload. Finally you can give ‘anxiolytics’ usually in the form of Fentanyl to help take away some of the catecholamine surge. As a result, most patients with APE can improve within minutes of having NIV applied.

Treatment of APE The treatment of APE depends on the cardiovascular status. Is the patient hemodynamically stable or not?

IF Adequate Perfusion (i.e. systolic BP > 100 mmHg, MAP >65) 1. Oxygen only if hypoxic 2. Position patient upright. 3. Non-invasive positive pressure ventilation (NIPPV), PEEP 6-8, quickly titrate up to 10-12. 4. Search for causes (ACS, HTN, arrhythmia, acute aortic or mitral valve regurgitation, aortic dissection, sepsis, renal failure or anemia) and treat appropriately. 5. Intubate ONLY if apneic/agonal respirations. 6. Vasodilators – Nitroglycerin S/L x 4 sprays, then IV infusion starting at 40 mcg/min, quickly increase by 40-50 mcg/min q 2-4 min up to 200mcg/min. 7. If Pt in extremis, bolus Nitro loading dose of 400mcg/min x 2 min, then drop to 100 mcg/min. Titrate up prn 8. +/- ACE Inhibitor – SL Captopril 12.5 – 25 mg

IF Hypotensive (decompensated CHF) (systolic BP < 100) 1. Oxygen, vital signs and monitor. 2 IVs large bore. 2. Most of these Pts are complex, call ICU on call physician. 3.Provide non-invasive positive pressure ventilation (NIPPV) unless immediate intubation is needed. 4. Search for causes (ACS, HTN, arrhythmia, acute aortic or mitral valve regurgitation, aortic dissection, sepsis, renal failure or anemia) and treat appropriately. 5. Consider Fluid challenge, 250 cc N/S over 5 minutes. 6. If known systolic heart failure - -Use Inotrope: Dobutamine 2 mcg/Kg/min and increase to a max. 20 mcg/Kg/min. 7. If known diastolic heart failure with signs of hypotension/shock – - Use IV Vasopressor - Phenylephrine 0.5mcg/kg/min and titrate. (NOT inotrope) 8. If unknown cardiac status and signs of hypotension/shock – -Use Inotrope – Dobutamine 2 mcg/Kg/min and titrate up.

IF Hypotensive (decompensated CHF) (systolic BP < 100) 9. Once BP restored, then you can add IV Nitroglycerin.

Case 1 EHS has brought in a 66 year old female, Noreen Rhales, with acute SOB. Vitals BP 96/40 HR 170 RR 40 Sats 91% on 5 liters

Ms. Noreen Rhales Increasing SOB for 2 days Felt “unwell”, lethargic for 2 days, noted ‘palpitations’. Awaiting “valve replacement surgery” in 8 weeks Has been in CHF twice in past year. Meds: Ramipril 5 mg bid, Metoprolol 25 mg bid, Lasix 20 mg od, Aldactone 50 mg od, ASA 81 mg od, Synthroid 125 mcg od, Naprosyn 500 bid, K dur Exam: BP 90/50, HR 170, RR 38, Sats 90%, Looks terrified, can’t speak more than 2 words without gasping for breath. Course creps heard up to upper lung fields.

What are you going to do?

Case 2 EHS calls saying 72 year old woman with SOB Vitals: BP 172/90 HR 180/min Sats 93% Resp Rate 25/min Will be arriving in 2 minutes.

Mrs. Heidi Whetlung 78 year old woman with increasing SOB Began with ‘flu’ 3 days ago. History of HTN, RA, Diverticulosis, depression. Medication: Ramipril 2.5 mg od HCTZ 12.5 mg od Quinine 200 mg hs Tylenol ES tid Mirtazapine 15 mg

Mrs. Heidi Whetlung

What are you going to do?