Professional Documents
Culture Documents
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!
Dilation
– Frank Starling = Contractility
Neurohormonal
– Redistribution of Blood to the Brain
CHF Vicious Cycle
Low Output
Renin
Angiotension I
Angiotension II
Aldosterone
Decompensation
Increased Pulmonary Venous Pressure (PAWP)
Interstitial Edema
Alveolar Edema
Infiltration of Interstitial Space
Normal
Micro-anatomy
Micro-anatomy
with fluid
movement.
Acute
Pulmonary
Edema
a true life-
threatening
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 GI Symptoms
Nocturia Chest Pain
DOE Orthopnea
PND Profound Dyspnea
Physical Exam
Anxious Rales
Pale Rhonchi
Clammy Tachycardia
Tachypnea S3 Gallop
Confusion JVD
Edema Pink Frothy Sputum
Hypertension Cyanosis
Diaphoretic 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
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
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
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
on/off Flow O2
turns counterclockwise (50-60% 02).
•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 turn the
ON/OFF valve fully off (clockwise).
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.
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 Intubation
– Non-invasive – Invasive
– Easily – Usually don’t
extubate in field
discontinued
– Potential for
– Easily adjusted infection
– Does not require – Traumatic
sedation
– Comfortable
CPAP Study
1996 – 1997 1997 – 1998
September – May September – May
Intubated 22 8
CPAP 0 50