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