Congestive Heart Failure, Pulmonary Edema, and CPAP

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Congestive Heart Failure, Pulmonary Edema, and
CPAP

• James Pointer, MD, FACEP
• Medical Director
• Alameda County EMS

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Objectives

• Review cardiac physiology and pathophysiology of
  CHF
• Early recognition of CHF
• Management of CHF
• Use of CPAP

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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)

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Etiology

• Arteriosclerotic Cardiovascular Ischemia
• Acute MI
• Ischemic Cardiomyopathy (Dilated Cardiomyopathy)
• Hypertension
• Miscellaneous

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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.
Acute Myocardial Infarction
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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

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Three Pathophysiological Causes of Failure

• Increased work load (HTN)
• Myocardial Dysfunction (ASCVD)
• Decreased Ventricular Filling (Valvular,
  cardiomyopathy, etc.)

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Compensatory Mechanisms

• Increased Heart Rate
• Sympathetic Norepinephrine
• Dilation
• Frank Starling Contractility
• Neurohormonal
• Redistribution of Blood to the Brain

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CHF Vicious Cycle

• Low Output
• Increased Preload Increased
  Afterload Norepinephrine
• Increased Salt Vasoconstriction Renal Blood
  Flow
• Renin
• Angiotension I
• Angiotension II
• Aldosterone

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Decompensation

• Increased Pulmonary Venous Pressure (PAWP)
• Interstitial Edema
• Alveolar Edema

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Infiltration of Interstitial Space

• Normal
• Micro-anatomy
• Micro-anatomy with fluid movement.

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Acute Pulmonary Edema a true life- threatening
emergency
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Precipitating Causes

• Non Compliance with Meds and Diet
• Acute MI
• Arrhythmia (e.g. AF)
• Pneumonia
• Increased Sodium Diet (Holiday Failure)
• Anxiety
• Pregnancy

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Symptoms

• Fatigue
• Nocturia
• DOE
• PND

• GI Symptoms
• Chest Pain
• Orthopnea
• Profound Dyspnea

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Physical Exam

• Anxious
• Pale
• Clammy
• Tachypnea
• Confusion
• Edema
• Hypertension
• Diaphoretic

• Rales
• Rhonchi
• Tachycardia
• S3 Gallop
• JVD
• Pink Frothy Sputum
• Cyanosis
• Displaced PMI

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EMS Management

• Sit upright
• High Flow O2
• NTG (If SBP 100)
• Diuretics (furosemide) use care
• Morphine (base consult)
• Ventilatory Support
• BVM
• CPAP
• intubation/ventilation

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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.

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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.

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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

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Prehospital Indications

• Congestive Heart Failure
• Pulmonary Edema associated with volume overload
• renal insufficiency, iatrogenic volume overload,
  liver disease , etc.
• Near Drowning

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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

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Absolute Contraindications

• Age
• Respiratory or Cardiac Arrest
• Agonal Respirations
• Severely depressed LOC
• Systolic Blood Pressure
• Pneumothorax
• Major Trauma, esp. head injury with increased ICP
  or significant chest trauma
• Facial Anomalies (e.g. burns, fractures)
• Vomiting

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Relative Contraindications

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

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Complications

• Hypotension
• Pneumothorax
• 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 turn the ON/OFF valve fully
  off (clockwise).

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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.

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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

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CPAP vs. Intubation

• CPAP
• Non-invasive
• Easily discontinued
• Easily adjusted
• Does not require sedation
• Comfortable

• Intubation
• Invasive
• Usually dont extubate in field
• Potential for infection
• Traumatic

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CPAP Study
1996 1997 1997 1998 September May
September May Intubated 22 8 CPAP
0 50 Hospital Stay(d) 14.8 8 ICU
Admission 100 48
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Alameda County Data

• 22 Patients
• 19 lived / 3 died / 2 patients to ICU
• Respiratory Rate
• Range 42 - 16 / Mean Change 7.25 (n16)
• SPO2
• Range 30 - 100 / Mean Change 19.5 (n18)
• RDS
• Range 10 - 3 / Mean Change 4 (n15)
• Unable to obtain RDS in 2 patients
• 2 pts intubated / 1 intubated pt died

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Alameda County CPAP Policy
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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

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