Congestive Heart Failure, Pulmonary Edema, and CPAP
Objectives Review cardiac physiology and pathophysiology of CHF ● Early recognition of CHF ● Management of CHF ● Use of CPAP ●
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)
Etiology ●
Arteriosclerotic Cardiovascular Ischemia – Acute MI – Ischemic Cardiomyopathy (Dilated Cardiomyopathy)
Hypertension ● Miscellaneous ●
Acute Myocardial Infarction People Live With Atherosclerosis – But Die of Thrombosis! Arteriosclerotic plaques gradually narrow the coronary arteries, but it is a rupture of the plaque and subsequent platelet aggregation and thrombosis that occludes the artery.
Hypertension ●
Hypertrophic Cardiomyopathy
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Heart Failure Concepts Frank-Starling Length: Tension Ratio
Ejection Fraction ● Cardiac Output ● Preload ●
– Primarily a venous and diastolic function ●
Afterload – Primarily arterial and systolic function
Three Pathophysiological Causes of Failure ●
Increased work load (HTN)
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Myocardial Dysfunction (ASCVD)
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Decreased Ventricular Filling (Valvular, cardiomyopathy, etc.)
Compensatory Mechanisms ●
Increased Heart Rate – Sympathetic = Norepinephrine
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Dilation – Frank Starling = Contractility
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Neurohormonal – Redistribution of Blood to the Brain
CHF Vicious Cycle Low Output
Increased Preload Norepinephrine
Increased Afterload
Increased Salt Vasoconstriction Blood Flow
Renin Angiotension I Angiotension II Aldosterone
Renal
Decompensation Increased Pulmonary Venous Pressure (PAWP)
Interstitial Edema
Alveolar Edema
Infiltration of Interstitial Space ●
Normal Micro-anatomy
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Micro-anatomy with fluid movement.
Acute Pulmonar y Edema a true lifethreatening emergency
Precipitating Causes Non Compliance with Meds and Diet ● Acute MI ● Arrhythmia (e.g. AF) ● Pneumonia ● Increased Sodium Diet (Holiday Failure) ● Anxiety ● Pregnancy ●
Symptoms Fatigue ● Nocturia ● DOE ● PND ●
GI Symptoms ● Chest Pain ● Orthopnea ● Profound Dyspnea ●
Physical Exam ● ● ● ● ● ● ● ●
Anxious Pale Clammy Tachypnea Confusion Edema Hypertension Diaphoretic
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Rales Rhonchi Tachycardia S3 Gallop JVD Pink Frothy Sputum Cyanosis Displaced PMI
EMS Management ● ● ● ● ● ●
Sit upright High Flow O2 NTG (If SBP > 100) Diuretics (furosemide) – use care Morphine (base consult) Ventilatory Support – BVM – CPAP – intubation/ventilation
CPAP - Introduction ●
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CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfort. CPAP is an established therapeutic modality, recently introduced into the prehospital setting. In the primary phase CPAP application in cardiogenic pulmonary edema, thus far, appears to be beneficial to patient outcome.
Key Points of CPAP ●
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CPAP has been successfully demonstrated as an effective adjunct in the management of pulmonary edema secondary to congestive heart failure. CPAP may prove to be a viable alternative in many patients previously requiring endotracheal intubation by prehospital personnel.
CPAP Mechanism ● ●
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Increases pressure within airway. Airways at risk for collapse from excess fluid are stented open. Gas exchange is maintained Increased work of breathing is minimized
Prehospital Indications Congestive Heart Failure ● Pulmonary Edema associated with volume overload ●
– renal insufficiency, iatrogenic volume overload, liver disease , etc. ●
Near Drowning
Prehospital Indications Patient Assessment ●
Patient, age > 8, in severe respiratory distress who meets one of the following criteria: – Medical history and presenting complaints consistent with cardiogenic pulmonary edema – Near drowning
Absolute Contraindications ● ● ● ● ● ● ● ● ●
Age < 8 Respiratory or Cardiac Arrest Agonal Respirations Severely depressed LOC Systolic Blood Pressure < 90 Pneumothorax Major Trauma, esp. head injury with increased ICP or significant chest trauma Facial Anomalies (e.g. burns, fractures) Vomiting
Relative Contraindications ● ● ● ●
History of Asthma/COPD History of Pulmonary Fibrosis Decreased LOC Claustrophobia or unable to tolerate mask (after initial 1-2 minutes)
Complications Hypotension ● Pneumothorax ● Corneal Drying ●
Using the Machine
Turn all three control knobs fully clockwise to the OFF position Turn the ON/OFF valve counter-clockwise to the ON position Turn the Flow Adjustment Valve about 5 complete turns counter-clockwise to the completely open position to provide full flow. Turn the Oxygen Control Valve 5 complete turns counterclockwise (50-60% 02).
on/off Flow
O2
•You may deliver higher oxygen concentrations (up to 100%) by turning the valve farther counterclockwise. •In the closed position (completely clockwise) the unit will deliver a minimum 28-29% oxygen to the patient.
Verify that air is flowing to the mask. Leave the oxygen and flow controls as you have just set them, then
Important Points ●
Pulmonary edema patients, properly selected, quickly improve with CPAP in a matter of minutes. – CPAP is to CHF like D50 is to insulin shock.
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Visual inspection of chest wall movement demonstrates improved respiratory excursion.
Important Points (cont.) ●
COPD and Asthmatic patients do NOT respond predictably to CPAP. – They have a higher risk of complications such as pneumothorax, and thus should not be treated in the field with CPAP
CPAP vs. Intubation ●
CPAP – Non-invasive – Easily discontinued – Easily adjusted – Does not require sedation – Comfortable
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Intubation – Invasive – Usually don’t extubate in field – Potential for infection – Traumatic
CPAP Study 1996 – 1997
1997 – 1998
September – May
Intubated CPAP
22 0
8 50
Hospital Stay(d) 14.8 ICU Admission
September – Ma
8 100%
48%
Alameda County Data ● ● ●
22 Patients 19 lived / 3 died / 2 patients to ICU Respiratory Rate: – Range: 42 - 16 / Mean Change: 7.25 (n=16)
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SPO2: – Range: 30 - 100 / Mean Change: 19.5 (n=18)
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RDS: – Range: 10 - 3 / Mean Change: 4 (n=15) – Unable to obtain RDS in 2 patients
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2 pts intubated / 1 intubated pt died
Alameda County CPAP Policy
Summary CPAP provides an adjunct between oxygen by NRB mask and endotracheal intubation ● Eliminates trauma of intubation ● Reduces length of hospital stay ● Reduces costs of care ●