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AIP: Shortness of breath > HF with pulmonary oedema > Flashcards

HF with pulmonary oedema Flashcards

1
Q

What is pulmonary oedema?

A

excess fluid in the lungs - not a diagnosis but a symptom of an underlying cause

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2
Q

What are the 3 groups of causes of pulmonary oedema?

A
  1. Increased pulmonary capillary pressure (hydrostatic)
    • what occurs secondary to de-novo heart failure due to reduced cardiac ouptut
  2. Increased pulmonary capillary permeability
  3. Decreased intravascular oncotic pressure
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3
Q

What are 6 clinical features of acute pulmonary oedema?

A
  1. Acute breathlessness
  2. Cough
  3. Frothy blood-stained (pink) sputum
  4. Restless and anxiety
  5. Signs of fluid overload
  6. Collapse/ cardiac arrest/ shock
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4
Q

What are 5 signs of fluid overload on examination in acute pulmonary oedema?

A
  1. Bilateral reduced air entry
  2. Inspiratory crepitations
  3. Raised JVP
  4. S3 gallop
  5. Peripheral oedema
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5
Q

What are 4 possible associated features with pulmonary oedema which may reflect the cause?

A
  1. Chest pain or palpitations - ischaemic heart disease/MI, arrhythmia
  2. Preceding history of dyspnoea on exertion - poor left ventricular function
  3. Oliguria, haematuria - acute renal failure
  4. Seizures, signs of intracranial bleed
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6
Q

What is the main differential diagnosis for acute pulmonary oedema?

A

acute infective exacerbation of COPD

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7
Q

What are 4 types of causes of increased pulmonary capillary pressure which can lead to acute pulmonary oedema?

A
  1. Left atrial pressure
  2. Left ventricular end-diastolic pressure (LVEDP)
  3. Pulmonary venous pressure
    • Left to right shunt (e.g. VSD)
    • veno-occlusive disease
  4. Neurogenic
    • intracranial haemorrhage
    • cerebral oedema
    • post-ictal
    • high-altitude pulmonary oedema
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8
Q

What are 3 causes of increased left atrial pressure which can lead to acute pulmonary oedema?

A
  1. Mitral valve disease
  2. Arrhythmia (e.g. AF) with pre-existing mitral valve disease
  3. Left atrial myxoma
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9
Q

What are 9 causes of increased left ventricular end-diastolic pressure (LVEDP) which can lead to acute pulmonary oedema?

A
  1. Ischaemia
  2. Arrhythmia
  3. Aortic valve disease
  4. Cardiomyopathy
  5. Uncontrolled hypertension
  6. Pericardial constriction
  7. Fluid overload
  8. High-output states (anaemia, thyrotoxicosis, Paget’s, AV fistula, beriberi)
  9. Reno-vascular disease
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10
Q

What are 2 causes of pulmonary venous pressure whcih can lead to acute pulmonary oedema?

A
  1. Left to right shunt (e.g. VSD)
  2. Veno-occlusive disease
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11
Q

What are 4 causes of neurogenic acute pulmonary oedema?

A
  1. Intracranial haemorrhage
  2. Cerebral oedema
  3. Post-ictal
  4. High-altitude pulmonary oedema
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12
Q

What is a cause of increased pulmonary capillary permeability that can lead to acute pulmonary oedema?

A

acute lung injury - acute respiratory distress syndrome (ARDS)

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13
Q

What causes decreased intravascular oncotic pressure?

A

hypoalbuminaemia

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14
Q

What are 3 types of causes of hypoalbuminaemia that can lead to acute pulmonary oedema?

A
  1. Increased losses e.g. nephrotic syndrome, liver failure
  2. Reduced production e.g. sepsis
  3. Dilution e.g. crystalloid transfusion
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15
Q

What are the 3 big causes of acute pulmonary oedema to be aware of?

A
  1. Myocardial ishaemia
  2. Arrhythmia
  3. Valvular disease (mitral or aortic)
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16
Q

What are 7 urgent investigations for all patients with acute pulmonary oedema?

A
  1. ECG
  2. CXR
  3. ABG
  4. Echocardiography
  5. Troponins - if concerned re new cardiac event
  6. Serum BNP
  7. U+Es
17
Q

What are 4 possible findings on ECG in acute pulmonary oedema?

A
  1. Sinus tachycardia - most common
  2. Cardiac arrhythmia e.g. AF, SVT, VT
  3. Evidence of acute ST change (STEMI, NSTEMI, unstable angina)
  4. Evidence of underlying heart disease - left ventricular hypertrophy
18
Q

What are 8 possible findings on CXR of acute pulmonary oedema?

A
  1. Interstitial shadowing
  2. Enlarged hila (batwing sign)
  3. Prominent upper lobe vessels
  4. Pleural effusion
  5. Kerley B lines
  6. Cardiomegaly
19
Q

Why is it important to measure U+Es in a patient presenting with acute pulmonary oedema?

A

likely going to give furosemide, regular K+ measurements should be taken

also renal failure can cause pulmonary oedema

20
Q

What are 4 things you are looking for on an echo in pulmonary oedema?

A
  1. LV function
  2. Valve abnormalities
  3. Ventricular septal defect (VSD)
  4. Pericardial effusion
21
Q

What is the approach to initial assessment and management of a patient with acute pulmonary oedema?

A

ABCDE

22
Q

What is the acronym to remember the management of acute cardiogenic pulmonary oedema?

A
  • PODMANN
    • P= position, sit patient up
    • O=oxygen
    • D= diuretics - furosemide+fluid restriction
    • M=morphine, causes resp depression
    • A=antiemetic e.g. metoclopramde
    • N=nitrates
    • N=NIV e.g. CPAP
23
Q

What dose of furosemide may be given and how in acute pulmonary oedema?

A

20-40mg slow IV injection

24
Q

By how much should patients be fluid restricted in acute pulmonary oedema?

A

1.5L a day

25
Q

What dose of morphine may be given in acute pulmonary oedema?

A

2.5-5mg IV diamorphine

26
Q

Why should an antiemetic often be given in the management of acute pulmonary oedema and how should it be given?

A

giving morphine - metoclopramide 10mg IV

27
Q

In what situation should nitrates be given for acute pulmonary oedema and how?

A

if systolic BP <90

sublingual GTN spray (2 puffs) or IV GTN infusion 1-10mg/h

28
Q

When is NIV indicated and how should it be given?

A

if other measures not working stabilise patient; NIV in form of CPAP, likely to need transfer to ITU (d/w anaesthetist on call/ITU team early)

29
Q

What key factor causes the management of acute pulmonary oedema to vary?

A

if patient systolic BP <100 or >100 i.e. in shock or now

30
Q

What management may be indicated for patients with systolic BP<100 in addition to the additional stabilisation? 2 aspects

A
  1. optimal monitoring and access e.g. in ITU - urinary catheter, arterial line, central line
  2. inotropes: dobutamine if SBP 80-100, adrenaline if <80
31
Q

What management may be indicated for patients with systolic BP>100 in addition to the additional stabilisation? 3 aspects

A
  1. further doses of furosemide may be given (40-80mg IV)
  2. continue GTN infusion
  3. ACEinhibitors if BP adequate and no contraindications
32
Q

In which patients is the management of acute cardiogenic pulmonary oedema especially difficult?

A

if have both heart failure and renal impairment; AKI largely pre-renal due to underperfusion

can’t replace fluids

33
Q

What is usually the solution to the issue of patients with acute heart failure and AKI?

A

usually by off-loading fluid with diuresis (furosemide) the stroke volume improves, there is greater output from the heart, and so perfusion to the kidneys improve (Starling curve - if left ventricle end-diastolic volume too high, stroke volume falls)

AIP: Shortness of breath (12 decks)

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