De Los Reyes, Kristine Joy Emanuelle B.

Group 5-B
WORKSHEET#1 For Clerks - Topic: ADHF

1. Please differentiate dyspnea, or difficulty of breathing, that is cardiac versus respiratory in

origin, in terms of history and physical examination.
• Pulmonary Origin:
o History:
▪ Dyspnea with rest and exertion
▪ Presence of cough with sputum production
▪ (+) Wheezing
▪ (+) Pleuritic chest pain
▪ History of tobacco use
o Physical Examination:
▪ Resonant in percussion
▪ (+) expiratory wheezes and rales
▪ Decreased air movement
• Cardiac Origin:
o History:
▪ Dyspnea on exertion
▪ History of high blood pressure
▪ Associated chest pain
▪ (+) Orthopnea and Paroxysmal nocturnal dyspnea
o Physical Examination:
▪ Hypertension
▪ Presence of pleural effusion
▪ Cardiomegaly
▪ S3 gallop
▪ Jugular venous distention
▪ Peripheral edema

2. What ancillary procedures can you request in order to differentiate cardiac versus
pulmonary dyspnea?
• Complete pulmonary function testing
• Exercise treadmill testing
• Complete blood count
• ECG
• Chest X-ray
• Pulse oximetry
• Arterial blood gas
• Spirometry

3. What is pulmonary congestion? Describe its pathophysiology.

Pulmonary congestion is an accumulation of fluid in the lungs, resulting in impaired gas
exchange and arterial hypoxemia.
De Los Reyes, Kristine Joy Emanuelle B.
Group 5-B
• Cardiogenic Pathophysiology:
o Due to the dysfunction of the left side of the heart which leads to increased
pulmonary capillary hydrostatic pressure
• Non-Cardiogenic Pathophysiology:
o Direct injury in the alveolar epithelium or capillary endothelium.
o Exogenous through aspirations, breathing of noxious substances, and trauma.
The injury will lead to rapid leakage of interstitial protein and fluids
o Endogenous through pneumonia and sepsis - sepsis causes damage to the
alveolar capillaries as a consequence the neutrophils leak out to the interstitium.
These neutrophils will cause damage to the alveolar membrane and the proteins
and fluid will leak out to the alveoli and will cause pulmonary edema.

4. How can you identify congestion in a patient coming in the ER with DOB in terms of
history and PE?
• History:
o Dyspnea that worsens when lying down
o A feeling of suffocation or drowning
o Wheezing or gasping for breath
o Cough with frothy sputum that may be tinged with blood
o Excessive sweating
o Pale/bluish skin color
o Chest pain (cardiogenic)
• Physical Examination:
o Tachypnea, tachycardia, agitated, diaphoretic, hypertension, hypotension
indicates severe LV systolic dysfunction and the possibility of cardiogenic shock,
cool extremities may indicate low cardiac output and poor perfusion

5. What ancillary procedures would you request to help you identify pulmonary congestion?
Describe.
• Complete Blood Count - It can quantify the severity of suspected anemia
• Chest X-ray - Clue in where congestion is cardiac in origin or not. In cardiogenic origin,
cephalization of the pulmonary vessels, Kerley B lines or septal lines, patchy shadowing
with air bronchograms, and increased cardiac size will be seen.
• Pulse oximetry - to determine the hemoglobin oxygen saturation.
• ECG - can show abnormalities of the heart rate and rhythm, or evidence of ischemia,
injury or infarction.
• Arterial Blood Gases - can provide information about altered pH, hypercapnia,
hypocapnia or hypoxemia. Used for the evaluation of acute dyspnea but it can also be
used in the evaluation of patients who have gradually become dyspneic or who are
chronically dyspneic.

6. How can heart failure cause pulmonary congestion?

De Los Reyes, Kristine Joy Emanuelle B.
Group 5-B
• When the left ventricle is unable to pump blood to the aorta properly, the pressure
within the left ventricle and atrium will increase which will increase the pressure within
the pulmonary veins.
• So blood that is going back up will lead to increase in the hydrostatic pressure in a
pulmonary capillaries, this pressure pushes the proteins and fluid out of the capillaries
and will shift to interstitial space then to the alveoli leading to alveolar pulmonary
edema.

7. What is Acute Decompensated Heart Failure (ADHF)? Identify the triggers.

• It characterized by the development of dyspnea, generally associated with rapid
accumulation of fluid within the lung's interstitial and alveolar spaces, which is the result
of acutely elevated cardiac filling pressures (cardiogenic pulmonary edema).
• ADHF can also present as elevated left ventricular filling pressures and dyspnea without
pulmonary edema.
• Triggers:
o Smoking
o Excessive alcohol use
o Obesity
o Sedentary lifestyle
o High salt intake (more fluid retention)
o Noncompliance with medications
o Cardiac ischemia, dysrhythmias
o Pulmonary embolus
o Physical or environmental stresses
o Iatrogenic volume overload.
o Pregnancy
o Hyperthyroidism

8. How can you manage ADHF in a patient coming at the emergency room with DOB?
• Check ABCs
• Establish air supply
• Cardiac monitoring and vitals monitoring
• Reduce venous return, elevate feet
• Start patient on nitrates and diuretics if stable
• Treat underlying cause if there is any
• Diet: Restrict Na and fluid intake
• Give prophylaxis against venous thromboembolism with Heparin
• Patients with respiratory failure who fail to improve with NIV (within 30 minutes-2
hours) or do not tolerate or have contraindications with NIV should be intubated for
conventional mechanical ventilation.