1 The Patient with Heart Failure CPAP as an Intervention April 2011 CE Condell Medical Center EMS System Site Code #107200E -1211 Prepared by: Lt. William

11

The Patient with Heart The Patient with Heart FailureFailure

CPAP as an InterventionCPAP as an Intervention

April 2011 CEApril 2011 CECondell Medical CenterCondell Medical Center

EMS SystemEMS SystemSite Code #107200E -1211Site Code #107200E -1211

Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire DistrictReviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

22

ObjectivesObjectives

Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS provider will be able to: provider will be able to:

Define heart failure and congestive heart Define heart failure and congestive heart failure.failure.

Identify causes of heart failure.Identify causes of heart failure. Identify symptoms of heart failure.Identify symptoms of heart failure. Identify patterns of medical history related to Identify patterns of medical history related to

the patient with heart failure.the patient with heart failure. Identify current home medications typically Identify current home medications typically

taken by the patient with congestive heat taken by the patient with congestive heat failure.failure.

33

Objectives cont’dObjectives cont’d

Identify the difference between the patient with Identify the difference between the patient with congestive heart failure and pneumonia.congestive heart failure and pneumonia.

Identify the assessment of the patient with Identify the assessment of the patient with congestive heart failure.congestive heart failure.

Identify the proper procedure for assessing breath Identify the proper procedure for assessing breath sounds.sounds.

Identify treatment goals and options for congestive Identify treatment goals and options for congestive heart failure following Region X SOP’s.heart failure following Region X SOP’s.

Define CPAP as used by EMS for the patient with Define CPAP as used by EMS for the patient with pulmonary edema.pulmonary edema.

44

Objectives cont’dObjectives cont’d Describe how CPAP will benefit the patient with Describe how CPAP will benefit the patient with

pulmonary edema.pulmonary edema. State indications, contraindications and State indications, contraindications and

medications used with CPAP.medications used with CPAP. Describe the process of setting up the CPAP Describe the process of setting up the CPAP

device.device. Describe the process of adding in-line Albuterol Describe the process of adding in-line Albuterol

with CPAP.with CPAP. Describe patient assessment while delivery Describe patient assessment while delivery

CPAP.CPAP. State components to document when using State components to document when using

CPAP.CPAP.

55

Objectives cont’dObjectives cont’d

Demonstrate the set up of CPAP.Demonstrate the set up of CPAP. Demonstrate the set-up of regular and Demonstrate the set-up of regular and

in-line Albuterol.in-line Albuterol. Demonstrate adding in-line Albuterol Demonstrate adding in-line Albuterol

with CPAP.with CPAP. Actively participate in case scenario Actively participate in case scenario

discussion.discussion. Successfully complete the post quiz with a Successfully complete the post quiz with a

score of 80% or better.score of 80% or better.

66

What is Heart Failure?What is Heart Failure?

A clinical syndromeA clinical syndrome Heart’s mechanical performance (ie: Heart’s mechanical performance (ie:

pumping action) is compromisedpumping action) is compromised Cardiac output unable to meet the demands Cardiac output unable to meet the demands

of the body’s needsof the body’s needs Generally divided into backward Generally divided into backward

ventricular failure (right heart failure) and ventricular failure (right heart failure) and forward ventricular failure (left heart forward ventricular failure (left heart failure)failure)

Can be of a chronic or acute natureCan be of a chronic or acute nature

77

Heart FailureHeart Failure

Variety of causesVariety of causes Valve diseaseValve disease Heart diseaseHeart disease

Contributing factors to heart failureContributing factors to heart failure Diet - excess fluid or salt intakeDiet - excess fluid or salt intake HypertensionHypertension Pulmonary embolismPulmonary embolism Excessive alcohol or drug usageExcessive alcohol or drug usage Progression of an underlying diseaseProgression of an underlying disease

88

What is CHF?What is CHF? Congestive heart failure = CHFCongestive heart failure = CHF

Condition of excess build-up of fluid in the Condition of excess build-up of fluid in the lungs and/or other body parts/organslungs and/or other body parts/organs

Fluid build-up causes congestion in the Fluid build-up causes congestion in the organs seen as edemaorgans seen as edema

May be brought on by diseased heart May be brought on by diseased heart valves, hypertension, or some form of valves, hypertension, or some form of obstructive pulmonary diseaseobstructive pulmonary disease

Often a complication of AMIOften a complication of AMI

99

Fluid build-up in CHF may be Fluid build-up in CHF may be pulmonary, peripheral, sacral, or ascitespulmonary, peripheral, sacral, or ascites

1010

Understanding CHFUnderstanding CHF

A failure of the pumping action of the heartA failure of the pumping action of the heart

Heart is a 2 sided pumpHeart is a 2 sided pump Right side of heart is a low pressure Right side of heart is a low pressure

systemsystem Left side of heart is a high pressure Left side of heart is a high pressure

systemsystem

1111

Heart as a PumpHeart as a Pump

Left side of heart muscular Left side of heart muscular Needs to overcome pressure in the arteries to Needs to overcome pressure in the arteries to

push/pump blood push/pump blood Pumps blood flow to the bodyPumps blood flow to the body

Right side of heart less muscularRight side of heart less muscular Pumps blood to the lungsPumps blood to the lungs

• Does not need to be a very aggressive Does not need to be a very aggressive pump with a lot of forcepump with a lot of force

1212

Starling’s LawStarling’s Law

The more the myocardial muscle is The more the myocardial muscle is stretched, the greater the force of stretched, the greater the force of contraction (the greater the recoil)contraction (the greater the recoil) Greater the preload (amount of blood Greater the preload (amount of blood

returned to the right heart), the farther the returned to the right heart), the farther the myocardium is stretched and the more myocardium is stretched and the more forceful a contraction that results leading to forceful a contraction that results leading to an increased cardiac outputan increased cardiac output

When Starling’s Law fails, the patient is When Starling’s Law fails, the patient is no longer able to compensateno longer able to compensate

1313

HypertensionHypertension

B/P is a measurement B/P is a measurement of force against the wall of the of force against the wall of the arteries arteries

When vessels stiffen due to calcium build-When vessels stiffen due to calcium build-up (arteriosclerosis) and plaque develops up (arteriosclerosis) and plaque develops (atherosclerosis), vessels are less (atherosclerosis), vessels are less compliantcompliant

Higher pressures are needed to pump Higher pressures are needed to pump blood through stiffer vesselsblood through stiffer vessels

1414

Right Ventricular FailureRight Ventricular Failure Failure of right ventricle as a forward pumpFailure of right ventricle as a forward pump Back pressure of blood into systemic Back pressure of blood into systemic

venous circulation systemvenous circulation system Common causesCommon causes

Left ventricular failure (AMI)Left ventricular failure (AMI) Systemic hypertensionSystemic hypertension Pulmonary hypertensionPulmonary hypertension Cor pulmonale – heart disease Cor pulmonale – heart disease

due to pulmonary disease due to pulmonary disease (ie; effects of COPD) (ie; effects of COPD)

1515

Progression of Right Heart FailureProgression of Right Heart Failure

Right ventricle cannot eject all of the blood Right ventricle cannot eject all of the blood outout Fluid/pressure builds upFluid/pressure builds up

• In right atriumIn right atriumBacks up into the venous systemBacks up into the venous system

Results in pedal/dependentResults in pedal/dependent edemaedema Visible as JVDVisible as JVD

1616

Right Right Sided Sided Heart Heart

Failure -Failure -

A A Systemic Systemic PicturePicture

1717

Left Ventricular FailureLeft Ventricular Failure Failure of left ventricle to function as a forward Failure of left ventricle to function as a forward

pumppump Back pressure of blood into pulmonary circulationBack pressure of blood into pulmonary circulation

Often causes pulmonary edemaOften causes pulmonary edema Common causesCommon causes

Various types of heart disease Various types of heart disease • Ischemia / acute MIIschemia / acute MI• Coronary artery disease Coronary artery disease

(CAD)-arteriosclerosis/atherosclerosis(CAD)-arteriosclerosis/atherosclerosis• Valve diseaseValve disease• Chronic hypertension - Chronic hypertension - afterload afterload• DysrhythmiasDysrhythmias

1818

Progression of Progression of Left Ventricular FailureLeft Ventricular Failure

Left ventricle cannot eject all the blood Left ventricle cannot eject all the blood delivered from the right heart via the delivered from the right heart via the lungslungs

Left atrial pressure rises and transmitted Left atrial pressure rises and transmitted to pulmonary veins and capillariesto pulmonary veins and capillaries

These high pressures force blood plasma These high pressures force blood plasma into alveoli (ie: pulmonary edema)into alveoli (ie: pulmonary edema)

Oxygen capacity of lungs reduced Oxygen capacity of lungs reduced Hypoxia developsHypoxia develops Acidosis developsAcidosis develops

1919

Pulmonary Pulmonary EdemaEdema

Severest form Severest form of congestive of congestive heart failureheart failure Left ventricular forward failureLeft ventricular forward failure

Think Think lleft/eft/llungsungs Patient develops respiratory distress due to Patient develops respiratory distress due to

fluid in the lungsfluid in the lungs Note: Note: extremelyextremely rare to have unilateral pulmonary rare to have unilateral pulmonary

edema; then related to unusual pathology/med hxedema; then related to unusual pathology/med hx

2020

Pathophysiological Changes in Pathophysiological Changes in Pulmonary EdemaPulmonary Edema

Left ventricle cannot empty effectivelyLeft ventricle cannot empty effectively Fluid moves from capillary beds into Fluid moves from capillary beds into

surrounding interstitial tissue surrounding interstitial tissue alveoli alveoli Fluid in alveoli impedes oxygen exchangeFluid in alveoli impedes oxygen exchange

Surfactant lining alveoli washes outSurfactant lining alveoli washes out Alveoli stiffenAlveoli stiffen Alveoli collapse after each breath and are harder to Alveoli collapse after each breath and are harder to

openopen Lungs develop Lungs develop compliance, airflow compliance, airflow

obstruction, hyperinflationobstruction, hyperinflation to workload of breathingto workload of breathing

2121

Symptoms of CHFSymptoms of CHF

In the more chronic setting of In the more chronic setting of right heart right heart failurefailure, symptoms usually related to , symptoms usually related to excess fluids in organs and other body excess fluids in organs and other body partsparts

In the more acute In the more acute left heart failureleft heart failure, , symptoms usually related to excess fluid in symptoms usually related to excess fluid in the lungs and therefore respiratory the lungs and therefore respiratory distressdistress

2222

Signs and Symptoms Signs and Symptoms Right Heart FailureRight Heart Failure

Dependent edemaDependent edema Peripheral edemaPeripheral edema HepatomegalyHepatomegaly SplenomegalySplenomegaly Jugular vein Jugular vein

distension (JVD)distension (JVD) AscitesAscites Weight gainWeight gain

DysrhythmiasDysrhythmias Nausea/vomitingNausea/vomiting FatigueFatigue DizzinessDizziness Syncopal episodesSyncopal episodes WeaknessWeakness

2323

Signs and Symptoms Signs and Symptoms Left Heart FailureLeft Heart Failure

Shortness of breathShortness of breath DyspneaDyspnea OrthopneaOrthopnea CracklesCrackles WheezingWheezing HypoxiaHypoxia Respiratory acidosisRespiratory acidosis Chest painChest pain

SweatingSweating Productive coughProductive cough Blood tinged sputumBlood tinged sputum CyanosisCyanosis PalpitationsPalpitations DysrhythmiasDysrhythmias HypertensionHypertension Anxiety/restlessnessAnxiety/restlessness

2424

Typical medical history pattern of Typical medical history pattern of patient with CHFpatient with CHF

HypertensionHypertension Cardiovascular Cardiovascular

disease (CVD)disease (CVD) Myocardial infarction Myocardial infarction

(MI)(MI) Coronary artery Coronary artery

disease (CAD)disease (CAD) ArteriosclerosisArteriosclerosis AtherosclerosisAtherosclerosis

SmokerSmoker Excessive alcohol or Excessive alcohol or

drug usedrug use CocaineCocaine MethamphetamineMethamphetamine Inhaled solventsInhaled solvents PCPPCP

Dietary intake excess Dietary intake excess fluids, excess saltfluids, excess salt

High cholesterolHigh cholesterol

2525

Typical home medication history Typical home medication history pattern of patient with CHFpattern of patient with CHF

DiureticDiuretic Digoxin Digoxin

contractility force of the contractility force of the heart (inotropic)heart (inotropic)

Home oxygen therapyHome oxygen therapy Anti-hypertensiveAnti-hypertensive

ACE inhibitors (end in “pril”)ACE inhibitors (end in “pril”) Beta blockersBeta blockers

heart rate & force of heart rate & force of contractions contractions B/P B/P

• Often end in “olol”Often end in “olol”

Calcium channel Calcium channel inhibitorsinhibitors• Slows movement of Slows movement of

calcium into small calcium into small muscles wrapped muscles wrapped around blood around blood vessels relaxing vessels relaxing blood vesselsblood vessels

peripheral peripheral vascular resistance vascular resistance relaxing blood relaxing blood vesselsvessels

2626

Herbal remedies that may be harmful Herbal remedies that may be harmful when mixed with heart failurewhen mixed with heart failure

St. John’s wortSt. John’s wort EphedraEphedra Gingko bilobaGingko biloba KavaKava LicoriceLicorice GinsengGinseng AconiteAconite

Alisma plantagoAlisma plantago Bearberry buchuBearberry buchu Couch grassCouch grass DandelionDandelion Horsetail rushHorsetail rush JuniperJuniper

2727

EvaluationEvaluation CHF/PECHF/PE PneumoniaPneumonia COPDCOPD

HistoryHistory HTN, heart HTN, heart problemsproblems

n/an/a Lung problemsLung problems

DyspneaDyspnea Orthopnea, Orthopnea, PNDPND

Orthopnea Orthopnea possiblepossible

Chronic; Chronic; pursed lipspursed lips

Recent hxRecent hx Acute weight Acute weight gain, dependent gain, dependent edemaedema

Fever, malaiseFever, malaise Gradual Gradual weight lossweight loss

CoughCough Frothy Frothy sputumsputum

Productive thick Productive thick greengreen

Chronic; Chronic; productiveproductive

OnsetOnset RapidRapid GradualGradual GradualGradual

B/PB/P HighHigh NormalNormal NormalNormal

MedsMeds Dig, anti-HTN, Dig, anti-HTN, diureticdiuretic

Antibiotic, cold prepAntibiotic, cold prep BronchodilatorsBronchodilators, , steroidssteroids

TxTx OO22, NTG, , NTG,

lasix, MSlasix, MSOO22, neb, fluids, neb, fluids OO22, neb, neb

2828

Separating Signs/SymptomsSeparating Signs/SymptomsSymptomSymptom CHF/PECHF/PE PneumoniaPneumonia COPDCOPD

SOBSOB YesYes YesYes YesYes

CoughCough MaybeMaybe YesYes Early a.m.Early a.m.

SputumSputum Frothy pinkFrothy pink Yellow/greenYellow/green Thick brownThick brown

FeverFever NoNo YesYes NoNo

SkinSkin Cold/clammyCold/clammy Hot/dryHot/dry Normal or duskyNormal or dusky

Chest painChest pain PossiblePossible MaybeMaybe NoNo

Smoking hxSmoking hx PossiblePossible PossiblePossible UsuallyUsually

WheezingWheezing Maybe; Maybe; bilateralbilateral

Maybe; Maybe; same same side as diseaseside as disease

Usually, Usually, bilateralbilateral

CracklesCrackles Yes; bilateralYes; bilateral Maybe; Maybe; same same side as diseaseside as disease

NoNo

2929

A Note…A Note…

““Old geezers don’t become new Old geezers don’t become new wheezers!”wheezers!”

COPD develops over a long period of time. If COPD develops over a long period of time. If an elderly person does not have a history of an elderly person does not have a history of COPD and they are suddenly wheezing, think a COPD and they are suddenly wheezing, think a cardiac problem or pulmonary edema.cardiac problem or pulmonary edema.

Assume the worst, Assume the worst, hope for the besthope for the best

3030

Patient Assessment - CHFPatient Assessment - CHF

Acute findingsAcute findings Recent trouble sleepingRecent trouble sleeping

trips to the bathroom at nighttrips to the bathroom at night• Orthopnea with Orthopnea with number of pillows number of pillows• Sleeping in the reclinerSleeping in the recliner• New episodes of paroxysmal nocturnal New episodes of paroxysmal nocturnal

dyspnea (PND)dyspnea (PND) use of nitroglycerin to stop chest painuse of nitroglycerin to stop chest pain use of oxygen use of oxygen

3131

Patient Assessment - CHFPatient Assessment - CHF General impressionGeneral impression

Labored respirationsLabored respirations Audible noisy respirationsAudible noisy respirations Tripod positioningTripod positioning Frothy sputum productionFrothy sputum production work of breathing – retractions, tachypneawork of breathing – retractions, tachypnea Wheezing/crackles bilaterallyWheezing/crackles bilaterally DiaphoreticDiaphoretic Change in skin color from normChange in skin color from norm Severe anxiety/restlessnessSevere anxiety/restlessness Severe hypertension may be presentSevere hypertension may be present

3232

Patient Assessment - CHFPatient Assessment - CHF Signs and symptoms pulmonary edemaSigns and symptoms pulmonary edema

TachypneaTachypnea OrthopneaOrthopnea PNDPND Noisy labored respirationsNoisy labored respirations Fine crackles/ralesFine crackles/rales Wheezing – “cardiac asthma”Wheezing – “cardiac asthma” Coarse crackles/rhonchi larger airwaysCoarse crackles/rhonchi larger airways Coughing with frothy blood tinged sputumCoughing with frothy blood tinged sputum

3333

Obtaining Breath SoundsObtaining Breath Sounds Use flat diaphragm surface of stethoscopeUse flat diaphragm surface of stethoscope Rub stethoscope head between hands to Rub stethoscope head between hands to

warm it up before placing on patient’s skinwarm it up before placing on patient’s skin If audible sounds are heard, ask patient to If audible sounds are heard, ask patient to

cough gently to clear upper airwaycough gently to clear upper airway Auscultate side to side and top to bottomAuscultate side to side and top to bottom Anterior: Posterior:Anterior: Posterior:

3434

Adventitious (Extra) Breath Adventitious (Extra) Breath SoundsSounds

Check for asymmetryCheck for asymmetry Crackles: high pitched, continuous sounds Crackles: high pitched, continuous sounds

like rubbing hair between fingerslike rubbing hair between fingers Wheezes: generally high pitched, of musical Wheezes: generally high pitched, of musical

qualityquality Stridor: Harsh inspiratory wheeze indicating Stridor: Harsh inspiratory wheeze indicating

upper airway obstruction upper airway obstruction Rhonchi: snoring or gurgling qualityRhonchi: snoring or gurgling quality

Any extra sound not a crackle or wheeze Any extra sound not a crackle or wheeze is usually rhonchi is usually rhonchi

3535

Decision Making –What to Do?Decision Making –What to Do? Use critical thinking skillsUse critical thinking skills Decide if patient is sick or notDecide if patient is sick or not Obtain current and past historyObtain current and past history Obtain vital signsObtain vital signs LookLook

Skin (wet/dry; color; temp)Skin (wet/dry; color; temp) JVD present or notJVD present or not Peripheral / dependent edema presentPeripheral / dependent edema present Subtle signsSubtle signs

ListenListen Breath soundsBreath sounds

3636

Making the Right DecisionMaking the Right Decision

Does the medical history include Does the medical history include cardiovascular disease?cardiovascular disease?

Does the physical examination/patient Does the physical examination/patient assessment paint a picture of CHF?assessment paint a picture of CHF?

Use critical thinking skillsUse critical thinking skills Not treating pulmonary edema means the Not treating pulmonary edema means the

body becomes more hypoxic and acidoticbody becomes more hypoxic and acidotic Miss diagnosis (ie: pneumonia) could prove Miss diagnosis (ie: pneumonia) could prove

lethallethal This patient will arrest This patient will arrest

3737

Treatment Goals for CHFTreatment Goals for CHF

Decrease myocardial workloadDecrease myocardial workload Decrease oxygen demandDecrease oxygen demand Decrease fluid retentionDecrease fluid retention Correct hypoxiaCorrect hypoxia Correct acidosisCorrect acidosis

3838

Treating CHF/Pulmonary Treating CHF/Pulmonary EdemaEdema

Decrease myocardial workloadDecrease myocardial workload No physical activity (they don’t walk to the No physical activity (they don’t walk to the

rig)rig) Sitting the patient upright; dangle feetSitting the patient upright; dangle feet Administering oxygen – non-rebreatherAdministering oxygen – non-rebreather CPAP to increase oxygen absorption CPAP to increase oxygen absorption

surface of lungssurface of lungs Medications to Medications to preload and afterload preload and afterload

NitroglycerinNitroglycerinMorphineMorphineLasix – additionally works as diureticLasix – additionally works as diuretic

3939

Treatment Goals for PneumoniaTreatment Goals for Pneumonia

Supply supplemental oxygen as neededSupply supplemental oxygen as needed Treat the bacterial infectionTreat the bacterial infection Hydrate the patientHydrate the patient

• Usually found in the elderlyUsually found in the elderly• Often vague symptoms; use to feeling illOften vague symptoms; use to feeling ill• Immune system often already weakened Immune system often already weakened

so mortality rate is high with this diagnosisso mortality rate is high with this diagnosis

4040

Region X SOP- Acute Region X SOP- Acute Pulmonary EdemaPulmonary Edema

Begin Routine Medical CareBegin Routine Medical Care Take standard precautionsTake standard precautions Perform assessmentsPerform assessments Identify priority patient and make transport Identify priority patient and make transport

decisionsdecisions• Stay and play?Stay and play?• Load N go?Load N go?

Perform routine tasksPerform routine tasks• IV-OIV-O22-monitor-monitor

4141

What About the IV and What About the IV and Nitroglycerin?Nitroglycerin?

Region X Medical Directors discussion:Region X Medical Directors discussion: Majority of patients in pulmonary edema will be Majority of patients in pulmonary edema will be

hypertensivehypertensive Nitroglycerin will help reduce preload which will Nitroglycerin will help reduce preload which will

lower blood pressure (beneficial)lower blood pressure (beneficial) Do not delay NTG dose, if no contraindications, Do not delay NTG dose, if no contraindications,

to start the IVto start the IV• If patient deteriorates before IV established, If patient deteriorates before IV established,

can always place an IOcan always place an IO

4242

Region X SOP- Acute Region X SOP- Acute Pulmonary EdemaPulmonary Edema

Determine if the patient is Determine if the patient is stablestable or or unstableunstable Stability guided by status of perfusion Stability guided by status of perfusion

B/P and level of consciousnessB/P and level of consciousness If stable, the patient can receive more If stable, the patient can receive more

aggressive care including medications and aggressive care including medications and procedures (ie: CPAP)procedures (ie: CPAP)

If unstable, Medical Control needs to If unstable, Medical Control needs to coordinate degree of care provided in the coordinate degree of care provided in the field (ie: meds and CPAP)field (ie: meds and CPAP)

4343

Region X SOP- Acute Region X SOP- Acute Pulmonary Edema - StablePulmonary Edema - Stable

NitroglycerinNitroglycerin Nitrate vasodilatorNitrate vasodilator Decreases myocardial workloadDecreases myocardial workload

• Dilates arterial and venous systemsDilates arterial and venous systems preloadpreload afterloadafterload

Carefully monitor blood pressureCarefully monitor blood pressure Screen for concomitant use of sexual Screen for concomitant use of sexual

enhancement drugenhancement drug• Viagra or Levitra in last 24 hoursViagra or Levitra in last 24 hours• Cialis in past 48 hoursCialis in past 48 hours

4444

Stable Pulmonary Edema SOPStable Pulmonary Edema SOP

LasixLasix Loop diureticLoop diuretic Moves sodium (NAMoves sodium (NA++) out of blood vessels) out of blood vessels

• Water follows sodiumWater follows sodium• Potassium (KPotassium (K++) also pulled out) also pulled out

Vasodilation effects within 5 minutesVasodilation effects within 5 minutes• Decreases preloadDecreases preload

Diuresis within 20-30 minutesDiuresis within 20-30 minutes Peaks within 30 minutesPeaks within 30 minutes

4545

Stable Pulmonary Edema SOPStable Pulmonary Edema SOP

Morphine sulfateMorphine sulfate Narcotic analgesicNarcotic analgesic

• Reduces anxietyReduces anxiety Dilates venous and arterial systemsDilates venous and arterial systems

preloadpreload afterloadafterload blood pressureblood pressure

Stimulates nausea center in the brainStimulates nausea center in the brain Slows respiratory rate in medullaSlows respiratory rate in medulla

4646

Region X SOP – Pulmonary Edema Region X SOP – Pulmonary Edema Medication RegimenMedication Regimen

Stable patientStable patient Nitroglycerin 0.4 mg slNitroglycerin 0.4 mg sl

• One every 3-5 minutes to max dose of 3One every 3-5 minutes to max dose of 3 Begin CPAPBegin CPAP Lasix 40 mg IVP (80 mg if taken at home)Lasix 40 mg IVP (80 mg if taken at home) Morphine 2 mg IVP slow over 2 minutesMorphine 2 mg IVP slow over 2 minutes

• May repeat 2 mg every 2 minutes to max of 10mgMay repeat 2 mg every 2 minutes to max of 10mg If wheezing, contact Medical Control for If wheezing, contact Medical Control for

possible Albuterol neb treatmentpossible Albuterol neb treatment

4747

CPAPCPAP

CContinuous ontinuous ppositive ositive aairway irway ppressureressure Delivered throughout the respiratory cycleDelivered throughout the respiratory cycle

Noninvasive ventilatory supportNoninvasive ventilatory support Most beneficial when initiated earlyMost beneficial when initiated early Maintains airway in open positionMaintains airway in open position intrathoracic pressure which intrathoracic pressure which venous venous

return to the heartreturn to the heart Preload and afterload both decrease Preload and afterload both decrease

4848

Benefits of Benefits of CPAPCPAP

Increases amount of inspired oxygenIncreases amount of inspired oxygen Decreases work load of breathingDecreases work load of breathing Reduces need for intubationReduces need for intubation

Intubation requires ICCU stayIntubation requires ICCU stay

• Increased exposure to risks associated Increased exposure to risks associated with complications due to intubationwith complications due to intubation

• Increases overall hospital length of stayIncreases overall hospital length of stay

4949

Redistribution of extravascular lung Redistribution of extravascular lung water during use of CPAPwater during use of CPAP

Without CPAP With CPAPWithout CPAP With CPAP

5050

5151

Indications for CPAPIndications for CPAP

Patient in acute pulmonary edema with Patient in acute pulmonary edema with stable blood pressurestable blood pressure Stable B/P = >100mmHg systolicStable B/P = >100mmHg systolic

FYI – with revised 2011 SOP’s, blood FYI – with revised 2011 SOP’s, blood pressure levels will be shifting to systolic pressure levels will be shifting to systolic of 90 as a consistent guideline throughout of 90 as a consistent guideline throughout the SOP’sthe SOP’s

5252

Contraindications for CPAPContraindications for CPAP

Decreased or altered level of consciousnessDecreased or altered level of consciousness Inability of patient to protect their airway from Inability of patient to protect their airway from

aspirationaspiration Persistent nausea/vomitingPersistent nausea/vomiting Need for immediate intubationNeed for immediate intubation Hemodynamic instability (B/P<100)Hemodynamic instability (B/P<100)

Note: B/P guideline will be changing to <90 with Note: B/P guideline will be changing to <90 with revised 2011 SOPrevised 2011 SOP

Penetrating chest traumaPenetrating chest trauma

5353

Medications Simultaneous With Medications Simultaneous With CPAPCPAP

Medications should be started Medications should be started NTG slNTG sl

Then begin CPAP Then begin CPAP Then continue medication administration as indicatedThen continue medication administration as indicated

Lasix – 40mg or 80mg IVPLasix – 40mg or 80mg IVP Morphine – 2 mg IVP repeated every 2 minMorphine – 2 mg IVP repeated every 2 min

CPAP will buy time for the medications to workCPAP will buy time for the medications to work

5454

Did you know…Did you know…

It is not It is not either / oreither / or (CPAP or meds)(CPAP or meds)

CPAP works CPAP works WITHWITH medications medications in tandemin tandem

Lift the mask to continue administration of Lift the mask to continue administration of more NTGmore NTG

5555

CPAP EquipmentCPAP Equipment

Fixed whisper Fixed whisper flowflow Connects to Connects to

your oxygen your oxygen sourcesource

5656

OO22 Tank Duration Tank Duration

Approximate time at 30% FIOApproximate time at 30% FIO22

D tankD tank 30 min. 30 min.

E tankE tank 50 min. 50 min.

M tankM tank 253 min.253 min.

H tankH tank 508 min.508 min.*based on 50 psi output*based on 50 psi output

5757

CPAP CPAP CircuitCircuitSet-upSet-up

Package Package includes: includes:

Mask Mask TubingTubingHead Head strapstrapCPAP CPAP valvevalveAirAirentrainmententrainment filterfilter

Filter

CPAPvalve

5858

Most patients need a lot of coaching to Most patients need a lot of coaching to initially tolerate the tight fitting maskinitially tolerate the tight fitting mask

5959

If The Patient is WheezingIf The Patient is Wheezing Contact Medical Control to consider an Contact Medical Control to consider an

order for Albuterol via nebulizerorder for Albuterol via nebulizer Medical Control needs to give this Medical Control needs to give this

physician’s orderphysician’s order Contact ECRN on radio Contact ECRN on radio

• Needs to give the ED MD a report Needs to give the ED MD a report • Obtains MD’s order Obtains MD’s order • Relays the response to EMSRelays the response to EMS

If Albuterol is given, monitor for cardiac If Albuterol is given, monitor for cardiac side effects (ie: tachycardia)side effects (ie: tachycardia)

6060

In-line Albuterol Set-up with In-line Albuterol Set-up with CPAPCPAP

Cut the CPAP corrugated tubing as close to patient Cut the CPAP corrugated tubing as close to patient as possible in smooth area of tubingas possible in smooth area of tubing

Splice Albuterol kit T piece in-lineSplice Albuterol kit T piece in-line Remove the mouthpiece and place the adaptor (used for Remove the mouthpiece and place the adaptor (used for

in-line Albuterol)in-line Albuterol) Connect adaptor to distal cut end of corrugated CPAP Connect adaptor to distal cut end of corrugated CPAP

tubingtubing Remove Albuterol corrugated tubing and connect Remove Albuterol corrugated tubing and connect

proximal end of CPAP tubing to T piece of Albuterolproximal end of CPAP tubing to T piece of Albuterol Keep Albuterol cup uprightKeep Albuterol cup upright Albuterol kit still needs to be hooked to OAlbuterol kit still needs to be hooked to O22

6161

CPAP With In-line Albuterol Set-upCPAP With In-line Albuterol Set-up

6262

Criteria to Discontinue CPAPCriteria to Discontinue CPAP

Development of hemodynamic instabilityDevelopment of hemodynamic instability B/P drops below 100 systolicB/P drops below 100 systolic

• Revised 2011 SOP B/P level will be 90 systolicRevised 2011 SOP B/P level will be 90 systolic

Inability of patient to tolerate tight fitting Inability of patient to tolerate tight fitting maskmask

Emergent need to intubate the patientEmergent need to intubate the patient

6363

Patient Monitoring During Use Patient Monitoring During Use of CPAPof CPAP

Constant reassessment required:Constant reassessment required: Patient tolerancePatient tolerance Mental statusMental status Respiratory patternRespiratory pattern

Rate, depth, subjective feeling of Rate, depth, subjective feeling of improvementimprovement

Blood pressure, pulse, SaOBlood pressure, pulse, SaO22, EKG rhythm, EKG rhythm ComplicationsComplications

Gastric distension, nausea, vomitingGastric distension, nausea, vomiting

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Monitoring Improvement With Monitoring Improvement With CPAPCPAP

It’s working when:It’s working when: Level of distress decreasesLevel of distress decreases Respiratory rate is returning toward normalRespiratory rate is returning toward normal Pulse oximetry (SaOPulse oximetry (SaO22) increasing) increasing Pulse rate decreasing toward normalPulse rate decreasing toward normal Decrease in use of accessory musclesDecrease in use of accessory muscles Ability to speak in fuller sentences returningAbility to speak in fuller sentences returning

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Contacting Medical ControlContacting Medical Control

Remember:Remember: Early communication with receiving Early communication with receiving

hospitalhospital Hospital needs to get their regulator for Hospital needs to get their regulator for

oxygen source connectionoxygen source connection

• Usually not kept in each roomUsually not kept in each room

6666

Documentation With CPAPDocumentation With CPAP

Assessment leading your general Assessment leading your general impression to a diagnosis of pulmonary impression to a diagnosis of pulmonary edemaedema

CPAP level provided (10cmHCPAP level provided (10cmH22O)O) FiOFiO22 provided (100%) provided (100%) SaOSaO22 serial levels serial levels Vital signs over timeVital signs over time Response to treatmentResponse to treatment Any adverse reactions notedAny adverse reactions noted

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So, What’s Different About BiPAP?So, What’s Different About BiPAP?

BiBi-level -level ppositive ositive aairway irway ppressureressure Uses 2 levels of pressureUses 2 levels of pressure

Helps move more air into lungs without need Helps move more air into lungs without need to exhale against higher pressuresto exhale against higher pressures

CPAP is a larger & noisier machineCPAP is a larger & noisier machine Uses extra effort to exhale and can be tiringUses extra effort to exhale and can be tiring

Both can be used for sleep apneaBoth can be used for sleep apnea BiPAP easier on those with COPD and BiPAP easier on those with COPD and

neuromuscular diseasesneuromuscular diseases

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Case ScenariosCase ScenariosSmall Group and Large Group Small Group and Large Group

DiscussionsDiscussions Read the presentationRead the presentation Form a general impressionForm a general impression Discuss treatment optionsDiscuss treatment options Discuss what/how/when to reassess the Discuss what/how/when to reassess the

patientpatient Decide what treatment to continue or what Decide what treatment to continue or what

adjustments need to be madeadjustments need to be made Note: Additional questions are asked on ppt that can be Note: Additional questions are asked on ppt that can be

discussed during group presentations.discussed during group presentations.

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Case Scenario #1Case Scenario #1

Dispatch: You are called to a 70 y/o man c/o breathing problems

HPI: Increasing shortness of breath for 1 day despite the use of inhalers

PmHx: COPD, Hypertension, and Diabetes Medications: Albuterol Inhaler, Lasix, and

Aspirin Allergies: Penicillin

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Physical Exam: Thin white man on home oxygen breathing through pursed lips sitting in a tripod position

Vital Signs: B/P 180/90; HR 120 sinus tachycardia; RR 30; SaO2 88%; LOC alert; airway patent

Head & neck: Perioral cyanosis, no JVD Pulmonary: Lung auscultation reveals

inspiratory and expiratory wheezes Extremities: Cyanotic, no pedal edema

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What is your general impression?What is your general impression? Are assessment findings stronger for Are assessment findings stronger for

exacerbation of COPD or for acute exacerbation of COPD or for acute pulmonary edema?pulmonary edema?

COPD supportedCOPD supported HistoryHistory AppearanceAppearance Lung soundsLung sounds

What treatment is indicated?What treatment is indicated?

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IV – O2, monitor

Albuterol nebulizer started:

• 5 min Vital Signs: B/P 160/90; HR 130; RR 24; SaO2 92%, LOC Alert; lung sounds unchanged

• 10 min Vital Signs: B/P 120/90; HR 120, RR, 24, SaO2 92%, LOC Alert; lung sounds less prominent wheezing; subjectively patient breathing easier

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Case Scenario #2 Case Scenario #2

Dispatch: 65 y/o woman c/o of shortness of breath

HPI: 1 week history of progressive dyspnea with exertion. Unable to lay down flat without shortness of breath, no chest pain or cough

PmHx: Hypertension, Diabetes Medications: Lasix, Atenolol, and

Glucaphage

7474


Physical Exam: 260 lb woman sitting in recliner.

Vital Signs: B/P 160/80; HR 140 sinus tachycardia; RR 30; SaO2 78%, LOC follows commands; airway patent

Head & neck: Cyanosis, JVD present Pulmonary: Crackles in all lung fields Extremities: Cyanotic, 3+ pedal edema

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exacerbation of COPD or for acute pulmonary exacerbation of COPD or for acute pulmonary edema?edema?

Pulmonary edema supportedPulmonary edema supported HistoryHistory AppearanceAppearance Lung soundsLung sounds


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Need to move rapidlyNeed to move rapidly Minimize scene time as much as possibleMinimize scene time as much as possible

IV-OIV-O22-monitor-monitor Start nonrebreather until switched to CPAPStart nonrebreather until switched to CPAP Consider AMI so obtain 12 lead EKGConsider AMI so obtain 12 lead EKG

Any contraindications to treatment?Any contraindications to treatment? Nitroglycerin?Nitroglycerin? CPAP?CPAP? Lasix?Lasix? Morphine?Morphine?

NO

NO

NO

NO

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After CPAP started:

5 min Vital Signs: B/P 100/60; HR 100; RR 24; SaO2 84%; LOC: responds to verbal stimuli

10 min Vital Signs: B/P 60/40; HR 30; RR 6; SaO2 60%; LOC unresponsive

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What is your general impression now?What is your general impression now? Patient is deterioratingPatient is deteriorating

What is your treatment now?What is your treatment now? CPAP needs to be discontinuedCPAP needs to be discontinued Patient needs to be bagged and intubatedPatient needs to be bagged and intubated

• One breath every 5-6 seconds before intubationOne breath every 5-6 seconds before intubation• One breath every 6-8 seconds after intubationOne breath every 6-8 seconds after intubation

Hold further repeats of medications usedHold further repeats of medications used Consider need for dopamine infusionConsider need for dopamine infusion

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Case Scenario #3 DocumentationCase Scenario #3 Documentation

Initial impression was acute pulmonary edemaInitial impression was acute pulmonary edema Based on physical assessment; history; Based on physical assessment; history;

recent hospitalization for CHFrecent hospitalization for CHF Treatment was routine medical careTreatment was routine medical care

IV – OIV – O22 non-rebreather- monitor non-rebreather- monitor CPAP started after ordered by Medical CPAP started after ordered by Medical

ControlControl 2 sets of vital signs documented2 sets of vital signs documented

Initial vital signs (B/P 170/98 – 92 – 32)Initial vital signs (B/P 170/98 – 92 – 32) Second reading at the hospital Second reading at the hospital

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Case Scenario #3 Comments Case Scenario #3 Comments DocumentedDocumented

Upon arrival patient found sitting upright, Upon arrival patient found sitting upright, agitated, complaining of chest pain and agitated, complaining of chest pain and difficulty breathing. Audible congested difficulty breathing. Audible congested breathing standing next to patient. Unable to breathing standing next to patient. Unable to complete a full sentence. Bilateral pedal edema complete a full sentence. Bilateral pedal edema noted. Began oxygen via nonrebreather. IV noted. Began oxygen via nonrebreather. IV started. Moved patient to ambulance. Medical started. Moved patient to ambulance. Medical Control contacted and ordered CPAP to be Control contacted and ordered CPAP to be started. Patient becoming more agitated. After started. Patient becoming more agitated. After 5 minutes, SaO5 minutes, SaO22 increasing. Patient stated increasing. Patient stated breathing was becoming easier.breathing was becoming easier.

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Case Scenario #3 Documentation Case Scenario #3 Documentation cont’dcont’d

Patient transported sitting upright. Patient transported sitting upright. Continued CPAP during entire call. Continued CPAP during entire call. Transported patient into ED on portable OTransported patient into ED on portable O22

with CPAP continued.with CPAP continued.

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Case Scenario #3 Documentation Case Scenario #3 Documentation cont’dcont’d

Pt contact: 0954Pt contact: 0954 Depart scene: 1025Depart scene: 1025 ““Drugs”Drugs”

0959 - Oxygen - 15 l – non-rebreather0959 - Oxygen - 15 l – non-rebreather 1001 – 0.9 NS 1000ml – TKO – IV1001 – 0.9 NS 1000ml – TKO – IV 1005 – CPAP /oxygen – 15l – CPAP mask1005 – CPAP /oxygen – 15l – CPAP mask

““`Cardiac rhythm”`Cardiac rhythm” 0958 – sinus0958 – sinus 1035 - sinus 1035 - sinus

8383

Case Scenario #3 Documentation Case Scenario #3 Documentation DiscussionDiscussion

What went well?What went well? Recognized pulmonary edemaRecognized pulmonary edema CPAP used with positive patient CPAP used with positive patient

responseresponse

8484

Case Scenario #3 Documentation Case Scenario #3 Documentation DiscussionDiscussion

What could be improved upon?What could be improved upon? Long on-scene time (0954 – 1025 -31 mins)Long on-scene time (0954 – 1025 -31 mins) Delay in initiating ODelay in initiating O22 therapy – 5 minutes therapy – 5 minutes Waited for MC to order CPAP – 11 min delayWaited for MC to order CPAP – 11 min delay

• No Medical Control direction needed to initiateNo Medical Control direction needed to initiate No other meds given for pulmonary edemaNo other meds given for pulmonary edema Only 2 sets of vital signs taken on a critical Only 2 sets of vital signs taken on a critical

patientpatient

8585


Dispatch: You are called to a 84 year-old female c/o breathing problems

HPI: Running low grade fevers, not feeling well for 4 days

PmHx: MI, Hypertension, TIA’s Medications: Plavix, Lasix, Lisinopril Allergies: Iodine, shellfish

8686


Physical Exam: Vital Signs: B/P 142/80; HR 96 sinus

rhythm; RR 28; SaO2 92%, LOC follows commands; airway patent

Head & neck: Pale, no JVD Pulmonary: Crackles in right lower lung

field Extremities: Pale, pedal pulses palpable

8787



acute pulmonary edema or pneumonia?acute pulmonary edema or pneumonia? Pneumonia supported?Pneumonia supported?

HistoryHistory AppearanceAppearance Lung sounds not so helpfulLung sounds not so helpful


8888


What is your treatment now?What is your treatment now? IV-O2-monitorIV-O2-monitor Fluids Fluids

• Faster than keep open but not a fluid Faster than keep open but not a fluid challengechallenge

Diagnosis confirmed at the hospital with Diagnosis confirmed at the hospital with chest x-ray and labschest x-ray and labs

8989


Patients with pneumonia need fluidsPatients with pneumonia need fluids Patients with congestive heart failure need Patients with congestive heart failure need

fluid restrictionsfluid restrictions A wrong diagnosis and therefore wrong A wrong diagnosis and therefore wrong

treatment approach could be harmful for treatment approach could be harmful for both patientsboth patients

9090


Dispatch: You are called to a home for a 78 year-old male with severe SOB

HPI: Has been getting progressively SOB past 2 days; slept in recliner last night

PmHx: MI x3; hypertension, diverticulitis, seizures

Medications: Aspirin, Hydrodiuril, Verapamil, NTG PRN, Coumadin, Phenobarbital

Allergies: none

9191


Physical Exam: Vital Signs: B/P 172/96; HR 110 sinus

tachycardia; RR 36; SaO2 88%, LOC follows commands; extremely anxious; airway patent

Head & neck: JVD Pulmonary: Crackles mid way up lung fields

bilaterally Extremities: Cyanotic, pedal edema palpable

9292


What is your general impression?What is your general impression? What is your treatment plan?What is your treatment plan? Write a run report Write a run report

Include initial assessmentInclude initial assessment Document treatment interventions indicatedDocument treatment interventions indicated Document reassessment performedDocument reassessment performed

Discuss as a group what needs to be Discuss as a group what needs to be includedincluded

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BibliographyBibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Bledsoe, B., Porter, R., Cherry, R. Paramedic

Care: Principles and Practices. Brady. 2009.Care: Principles and Practices. Brady. 2009. Limmer, D., O’Keefe, M. Emergency Care, 10Limmer, D., O’Keefe, M. Emergency Care, 10 thth

Edition. Brady. 2005.Edition. Brady. 2005. Region X SOP’s March 2007; Amended Region X SOP’s March 2007; Amended

January 1, 2008.January 1, 2008. http://whisperflow.respironics.com/http://whisperflow.respironics.com/ www.emsworld.comwww.emsworld.com Variety internet websites for CPAP and Variety internet websites for CPAP and

pulmonary edemapulmonary edema

Documents

1 The Patient with Heart Failure CPAP as an Intervention April 2011 CE Condell Medical Center EMS System Site Code #107200E -1211 Prepared by: Lt. William