Acute LVF and pulmonary oedema

Question 1

What is LVF?

Answer 1

Left ventricle is unable to effectively move blood through the left side of the heart and out into the body & systemic circulation

Question 2

What is pulmonary oedema?

Answer 2

Where the lung tissue and alveoli become full of interstitial fluid, which interferes with normal gaseous exchange

Question 3

What symptoms does pulmonary oedema cause?

Answer 3

A - anaemia –> pale & asthma (cardiac)
B –> orthopnoea/SOB - improves on sitting up
C –> cyanosis

Question 4

Triggers of pulmonary oedema

Answer 4

Iatrogenic - aggressive IV fluids in an elderly frail pt
Sepsis
MI
Arrhythmias

Question 5

What are the signs of LVF?

Answer 5

Increased RR
Reduced O2 sats –> type 1 respiratory failure
Sinus tachycardia or AF
Signs of cardiomegaly - displaced apex/signs of valve disease
Third/fourth heart sounds
Raised JVP & peripheral oedema if there is right sided HF
Bibasal crackles –> sounding “wet” on auscultation due to right sided or bilateral pleural effusions
Systolic hypotension in severe cases - cardiogenic shock

Question 6

Causes of LVF?

Answer 6

CHAMP

Coronary syndrome
Hypertensive emergency 
Arrhythmias
Mechanical - acute valve leak, VSD, LV aneurysm
PE

Question 7

Radiographic changes in acute LVF?

Answer 7

Bilateral hilar shadowing - Batwing shadowing
Cardiomegaly
Diversion of the upper lobes
Effusions - bilateral or right sided pleural effusions
Fluid in the interlobar fissures

Question 8

Investigations for LVF

Answer 8

Bloods FBC - anaemia
U&E, creatinine - renal function and electrolytes
Blood glucose - excluding underlying diabetes
BNP - ventricular stretching
Troponin - for evidence of infarction
ABG - for hypoxia & acute respiratory acidosis
ECG - arrhythmia, heart block, ischaemia
Echo within 48 hrs - valvular disease, structural abnormalities, - LV ejection fraction >50% is considered normal

Question 9

Management of LVF

Answer 9

PourSOD
Pour away - STOP IV fluids
Sit upright 
Oxygen - 15l via non-rebreathe mask 
Diuretics - IV furosemide 40mg STAT

Intravenous vasodilators if systolic <90mmHg e.g. GTN or isosorbide mononitrate
Monitor fluid balance
Consider NIV if not improving - CPAP
Consider ITU if NIV doesnt work
Consider ionotropes - increase strength of contractions & improve HF - noradrenalin/ dobutamine if systolic <90mmHg - but needs close monitoring so needs to be in CCU HDU or ITU