CHF/Pulmonary Edema & CPAP

McHenry Western Lake County EMS System Education

CHF

Common & potentially fatal condition Occurs when the left ventricle fails Pressure builds up in the ventricle This causes an overload of fluid in body When this fluid occurs in lungs it’s called

pulmonary edema CHF is on the rise in the US

CHF/Pulmonary Edema

CHF/Pulmonary Edema

When fluid saturates the interstitial spaces it will begin to accumulate in the alveoli

CHF/Pulmonary Edema

Alveoli collapse with each exhalation Fluid washes out the surfactant Alveoli can not re-expand Pink frothy sputum Acute respiratory distress Rapid deterioration

CHF/Pulmonary Edema

Signs & Symptoms – Dyspnea of varying degrees – Orthopnea – Anxiety / Restlessness – Tachypnea / tachycardia – Pink Frothy Sputum – SpO2 ≤ 94 %

CHF/Pulmonary Edema

Signs & Symptoms – Pale/Cool/Diaphoretic – Labored respirations – Severe apprehension or confusion – BP usually elevated

(Low would be ominous) – Pt not able speak normally – Lung Sounds-crackles & / or wheezes

CHF/Pulmonary Edema

Rapid Aggressive Treatment is required All that wheezes is not asthma and

should not be treated with albuterol!

Treatment for CHF

Position the patient in a sitting upright at 90* and dangle legs if possible.

If the patient is in severe distress you may have to consider DAI.

Treatment for CHF

CPAP if immediately available – Do not use C-PAP in AMI

Treatment for CHF

Monitor-from the time of pt contact

IV-tko

Pulse Ox

Treatment for CHF

ASA 324mg – (unless contraindicated)

NTG – EVERY 3-5 MIN as long as SBP remains >90. No limit

Treatment for CHF

For severe anxiety in CHF, Versed in 2mg increments every 30-60 sec IVP (0.2 mg/kg IN) up to 10mg IVP/IN.

May repeat to 20mg if SBP >90. Anxiety worsens the condition

CPAP : What it is

Applies positive pressure to the airways throughout the respiratory cycle

This keeps the alveoli open during expiration

Allows for O2 & CO2 exchange Can rapidly improve pt’s condition Frequently prevents intubation

CPAP

Why wouldn’t we want to intubate? – Mandatory ICU admission – Prolonged hospital stay & recovery – Higher potential for complications – Airway trauma possible – Infection can occur – More invasive & uncomfortable

CPAP : What it isn’t

CPAP does not maintain the airway CPAP does not allow you to assist

your pt with ventilation Pt MUST be able to maintain their

own airway Pt MUST be able to clear their own

airway

CPAP

If your pt requires ventilatory assistance with a BVM he is not a candidate for CPAP

Altered mental status – GCS ≤ 8 requires ventilatory assistance, therefore no CPAP

CPAP – Indications/Inclusions

Pulmonary Edema

Dyspnea Crackles Wheezes

At least 18 yrs old Alert with airway

intact/maintainable SBP > 90 DBP >60 Sp02 < 94%

CPAP - Contraindications

Age less than 18 AMS SBP < 90 Need for immediate airway control Unstable airway Acute MI

CPAP – May exclude

Uncooperative patient Facial hair making it impossible to obtain seal Pregnancy Inability to properly fit mask

CPAP - Procedure

Follow appropriate SOP Prepare equipment

– Connect oxygen to 15 L – Peep will be 3.0-4.0 – Have intubation equipment

available Position pt sitting up Explain procedure to pt &

reassure

CPAP - Procedure

Hold mask gently to face to allow patient to feel what the pressure will be like.

After 3-5 min. lift mask & give next NTG Now gently place head straps on patient.

CPAP - Procedure

If needed, flow can be increased to 20 lpm which will provide 6.0 -7.0 of peep

Sp02 of >95% is our goal.

CPAP - Procedure

If no improvement in 3 minutes: – Increase O2 to 25 LPM – PEEP will now be 8.5 – 10.0 – Maintain Sp02 >95%

Continuously monitor pt for S/S requiring intubation

Cardiogenic Shock

SBP < 90 MAP <60 Signs and Symptoms of hypoperfusion Dopamine 400mg/250ml

– Start at 5mcg/kg/min and titrate up to 20 mcg/kg/min until SBP is >90.

– NS 200 ml increments if lungs clear and respirations are not labored!

CPAP – D/C in field

Inability to tolerate mask (Nobody likes CPAP at first)

Need to intubate SBP falls below 90 ECG instability with evidence of

acute ischemia

CPAP

Be sure to document : – Time of initiation – Settings – Pt response-VS, color, work of

breathing, SpO2, EtC02 Continually watch pt for

improvement or deterioration

CPAP

System is dependent on a good seal Pt MUST remain on O2 & cardiac

monitor at ALL times, even when transferring pt care to hospital

Continue to give NTG SL every 3-5 min, just lift mask briefly to administer medication

Documentation

Time initiated O2 settings Patient response

– V/S-resp. rate & depth – SpO2 & mental status – Respiratory distress-WOB, comfort level – Lung sounds – Complications- gastric distention, inability to

tolerate

Additional Indications for CPAP Include

Asthma/COPD patient in severe respiratory distress

Near drowning patient who is congested has increased work of breathing who can maintain their own airwy.

Case Study

You have a 68 y/o male with sudden onset of dyspnea, coughing pink sputum. He is restless and has tachycardia. His BP is 168/94 SpO2 is 94% and pulse is 140. What should your treatment be?

Answer

Prepare equipment – Connect oxygen to 15 L – Have intubation equipment available

Position pt sitting up Explain procedure to pt & reassure

Answer

Hold mask gently to face After 5 min. lift mask & give next NTG Now gently place head straps on and

increase flow as needed.

Case Study

You have given your patient 4 ASA and 2 NTG during your treatment. His pressure remains stable at 154/78 and his pulse is still 140. SpO2 is 96%. Can you give him another NTG?

Answer

Yes…there is no limit to the NTG every 3-5 minutes as long as the patient has a SBP >90

Questions??

Color good

Alert

Good Airway

Sitting Upright

Thanks Guys! I feel much better now!!