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Acute Care > Acute Cardiogenic Pulmonary Oedema > Flashcards

Acute Cardiogenic Pulmonary Oedema Flashcards

1
Q

definition

A

-Leakage of fluid from the pulmonary capillaries and venules into the alveolar space as a result of increased hydrostatic pressure

-Inability of left ventricle to effectively handle its pulmonary venous return

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2
Q

pathophysiology

A
  1. decreased CO increased PCWP (symptomatic decompensation)
  2. activation of renin angiotensin system. activation of S/S system
  3. increased HR, increased systemic vascular resistance, increased preload
  4. cardiac ischemia. decreased left ventricular function
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3
Q

causes
FAILURE

A

-F orgot medication (poor compliance)
-A rrhythmia / Anaemia
-I schaemia / Infarction / Infection
-L ifestyle: high sodium diet
-U pregulation of cardiac output: pregnancy, thyroid storm
-R enal failure / Retention of fluid: steroids, NSAIDS
-E ndocardium : valvular pathology

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4
Q

clinical features

A

SOB
Orthopnoea
PND
Tachycardia
 BP
Wheezing
Crepitations

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5
Q

relevant history

A

-Assess clinical severity by history and physical exam
-Assess cardiac structure and function
-Determine cause, pay attention to reversible causes
-Evaluate for coronary disease and myocardial ischeamia
-Evaluate risk of life threatening arrhythmia
-Identify exacerbating factors and comorbidities
-Establish treatment compliance
-Assess for exertional dyspnoea, PND and orthopnoea

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6
Q

New York Heart Association functional Classification (NYHA)

A

-Class I : No limitation of physical activity. Ordinary activity causes no undue fatigue, palpitations or dyspnoea.

-Class II : Slight limitation of physical activity. Comfortable at rest, symptomatic with ordinary activity.

-Class IIIA : Marked limitation of physical activity. Comfortable at rest, symptomatic at less than ordinary activity

-Class IIIB : Comfortable at rest, symptomatic with minimal activity.

-Class IV : symptomatic at rest, discomfort increased with any activity

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7
Q

Killip Classification – only with AMI

A

-Scoring system to assess severity of heart failure in patients with acute myocardial infarction

-Killip I: no clinical signs of heart failure,

-Killip II: crackles in the lungs, third heart sound (S3), and elevated jugular venous pressure

-Killip III: acute pulmonary oedema

-Killip IV: cardiogenic shock or arterial hypotension (measured as systolic blood pressure < 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosis, and diaphoresis)

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8
Q

physical examination

A

-Assess weight and vital signs, manage accordingly

-Presence and severity of crackles, S3 gallop, elevated JVP, hepatic enlargement and tenderness, positive hepatojugular reflex, peripheral oedema and ascites

-Thorough clinical examination on cardiovascular and respiratory systems

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9
Q

investigations

A
  1. Blood
  2. Electrocardiography
  3. Radiology – CXR, echo, bedside cardiac ultrasound
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10
Q

blood investigations

A

-Arterial Blood Gas
-FBC – anaemia, infection
-U&E
-Troponin – when indicated (suspected myocardial ischaemia or infarction)

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11
Q

ECG

A

Advisable to do an ECG on all patients presenting with acute pulmonary oedema

Possible Findings:
*Ischaemia / infarction (ST segment changes)
*Arrhythmia – atrial fibrillation, atrial flutter, SVT
*LVH
*Prolonged QRS

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12
Q

chest radiography

A

FINDINGS IN HEART FAILURE
-Cardiomegaly
-Vascular redistribution
-Interstitial oedema
-Pleural effusions (right sided/bilateral)

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13
Q

chest X ray

A

Not all patients with acute heart failure have “typical features”

*No longstanding HF- Normal size heart
*Longstanding CCF -lymphatics
*COPD – minimal findings

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14
Q

other investigations: Echo/ bedside cardiac ultrasound

A

1.Identify reversible cause eg tamponade
2.Distinguish between systolic and diastolic dysfunction
3. Assess valvular function

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15
Q

differential diagnosis

A

-Acute Renal Failure
-Acute Respiratory Distress Syndrome
-COPD
-Myocardial Infarction
-Pneumonia
-Pneumothorax
-Neurogenic Pulmonry Oedema
-Pulmonary Embolism
-Pulmonary Fibrosis

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16
Q

management

A

*ABCs
*Decrease Preload (right-sided filling)
*Increase left-sided emptying
*↓ Afterload,  Cardiac output
*± improve LV contractility – inotropes

*Main goal is to redistribute fluid out of the lungs

17
Q

initial emergency management

A

-Attach patient to monitors, acute care setting (resus)
-Address airway – ensure patency. Apply supplemental oxygen if needed. Consider non-invasive positive pressure ventilation (NPPV) or intubation if necessary

-Breathing

-Circulation – establish IV access, consider inotropes if clinically shocked or significantly hypotensive (LV contractility)

-Disability – may have reduced level of consciousness due to hypoxia

18
Q

specific management

A

-OXYGEN
-PHARMACOTHERAPY
-INOTROPIC SUPPORT (if needed)
-NONINVASIVE POSITIVE PRESSURE VENTILATION
-INVASIVE VENTILATION

19
Q

supplemental oxygen

A

-Consider in patients with sats <94% on room air, or with signs of respiratory distress
-Titrate oxygen to symptoms
-Administer via nasal cannula, facemask or partial non- rebreather mask
-Assess efficacy, determine need for NPPV or intubation

20
Q

preload reduction- give nitrates

A

*Isordil 5mg s/l or GTN spray (one dose) can be used, repeated every 5-10 minutes
*Nitrate Infusion: mix 50mg GTN (Tridil) in 200ml normal saline. Rate 0-48ml/hour, start at 20ml/hour and titrte to blood pressure.
*Avoid lowering systolic BP <90-100mmHg

Nitrates are more effective and safer than morphine or furosemide for preload reduction

21
Q

nitrates

A

NITROGLYCERIN
MECHANISM OF ACTION

-Venodilation (low dose)= ↓ PRELOAD
-Arteriolar dilatation (higher dose)= ↓ AFTERLOAD
-↓pulmonary hydrostatic pressure

22
Q

other considerations: furosemide

A

-Consider Furosemide
-Mainly indicated if pulmonary oedema due to fluid retention. No added benefit in normovolaemic patients
-Diuretic naïve: IV furosemide 1mg/kg
-Patient already on diuretics: usual dose in IV form
-Preload is decreased through diuresis, but overall effect is delayed.

23
Q

other considerations

A

furosemide
morphine

24
Q

other considerations: morphine

A

-Consider Morphine
-No good evidence to support immediate reduction in preload centrally
-May provide anxiolysis
-May reduce BP and respiratory drive
-If used, titrate in small doses (2,5mg IV as needed, max 0,1mg/kg)

25
Q

Afterload Reduction – ACE inhibitors

A

-Combination with nitrates exceeds benefit of either drug used on its own
-Rapid reduction of afterload and preload
-Decreases need for intubation/ NPPV
-SBP > 110mmHg: Captopril 25mg s/l crushed
-SBP 90-110mmHg : Captopril 12,5mg s/l crushed

26
Q

ACE inhibitors

A

-MECHANISM OF ACTION
-Sublingual or IV

*↓ Afterload
*↓ Preload
*↓ Pulmonary Capillary Wedge Pressure
*Down-regulate renin-angiotensin system

27
Q

inotropic support

A

-Should be used when LV contractility is poor and patient is hypotensive or shocked
-Must be initiated after discussion with consultant or senior (involve them early)
-Inotropes should ideally be started in the emergency centre
-Options include adrenaline, dopamine, dobutamine, milrinone(depending on availability)
-Follow institutional guidelines regarding dose and preferred agent

28
Q

non- invasive positive pressure ventilation

A

-Consider CPAP (continuous positive airway pressure) via tight fitting mask if there is respiratory failure or acidosis
-Start with a low PEEP of 5, and slowly increase as needed. Educate patient how to hold mask and breathe, as it is uncomfortable
-If combative or confused, consider intubation
-CPAP decreases work of breathing, improves oxygenation, CO2 exchange

29
Q

intubation

A

-Consider intubation :
-Cardiac arrest
-Imminent respiratory failure
-No improvement on NPPV
-Patient not tolerating NPPV

Most senior person to intubate
RSI

30
Q

disposition

A

-Almost all patients should be admitted
-Patients who are intubated or require NPPV will need high care or tertiary referral
-Patients requiring ongoing monitoring and in-hospital treatment will need referral to Internal medicine
-Consider inpatient vs outpatient work-up

31
Q

discharge criteria

A

-No longer hypoxic on room air
-Vital signs have returned to normal parameters
-Return to baseline effort tolerance
-Cause of failure identified and appropriately managed
-Patient understanding of medication compliance checked
-Medication adjusted as required
-Follow up arranged

32
Q

summary

A

-Stabilise ABC’s
-REDISTRIBUTE FLUID OUT OF LUNGS!
-1ST Line: Nitrates
-2 ND Line: ACE Inhibitors
-3RD Line: Diuretics
-NPPV – use early

Acute Care (15 decks)

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