Congestive Heart Failure, Pulmonary Edema, and CPAP

Objectives
Review cardiac physiology and pathophysiology of CHF q Early recognition of CHF q Management of CHF q Use of CPAP
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Terminology
q Heart Failure: The inability of the heart to maintain an output adequate to maintain the metabolic demands of the body. q Pulmonary Edema: An abnormal accumulation of fluid in the lungs. q CHF

with Acute Pulmonary Edema: Pulmonary Edema due to Heart
Failure (Cardiogenic Pulmonary Edema)

Etiology
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Arteriosclerotic Cardiovascular Ischemia
– Acute MI – Ischemic Cardiomyopathy (Dilated Cardiomyopathy)

Hypertension q Miscellaneous
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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
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Hypertrophic Cardiomyopathy

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Heart Failure Concepts Ratio Frank-Starling Length: Tension
– Primarily a venous and diastolic function

Ejection Fraction q Cardiac Output q Preload
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Afterload
– Primarily arterial and systolic function

Three Pathophysiological Causes of Failure
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Increased work load (HTN) Myocardial Dysfunction (ASCVD) Decreased Ventricular Filling (Valvular, cardiomyopathy, etc.)

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Compensatory Mechanisms
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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

Renal

Renin Angiotension I Angiotension II Aldosterone

Decompensation
Increased Pulmonary Venous Pressure (PAWP)

Interstitial Edema

Alveolar Edema

Infiltration of Interstitial Space
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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 q Acute MI q Arrhythmia (e.g. AF) q Pneumonia q Increased Sodium Diet (Holiday Failure) q Anxiety q Pregnancy
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Symptoms
Fatigue q Nocturia q DOE q PND
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GI Symptoms q Chest Pain q Orthopnea q Profound Dyspnea
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Physical Exam
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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
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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 q Pulmonary Edema associated with volume overload
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– renal insufficiency, iatrogenic volume overload, liver disease , etc.
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Near Drowning

Prehospital Indications Patient Assessment
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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
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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
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History of Asthma/COPD History of Pulmonary Fibrosis Decreased LOC Claustrophobia or unable to tolerate mask (after initial 1-2 minutes)

Complications
Hypotension q Pneumothorax q Corneal Drying
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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
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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.)
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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
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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
September – May

1997 – 1998
8 50 8

September – Ma

Intubated CPAP 0

22

Hospital Stay(d) 14.8 ICU Admission 100%

48%

Alameda County Data
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22 Patients 19 lived / 3 died / 2 patients to ICU Respiratory Rate:
– Range: 42 - 16 / Mean Change: 7.25 (n=16)

SPO2:
– Range: 30 - 100 / Mean Change: 19.5 (n=18)

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 q Eliminates trauma of intubation q Reduces length of hospital stay q Reduces costs of care
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