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Flashcards in Pulmonary Oedema Deck (30):
1

 

 

What is acute heart failure?

 

Occurs with the rapid onset of symptoms and signs of heart failure secondary to abnormal cardiac function, causing elevated cardiac filling pressures. This causes severe dyspnoea and fluid accumulates in the interstitium and alveolar spaces of the lung (pulmonary oedema)

2

 

 

What are symptoms of acute pulmonary oedema??

 

  • Dyspnoea
  • Orthopnoea
  • PND
  • Pink frothy sputum

3

 

 

What are signs of acute pulmonary oedema?

  • Distressed/Pale/sweaty
  • Tachycardia
  • Tachypnoea
  • Pulsus alternans
  • Increased JVP
  • Fine bi-basal crackles
  • Gallop rythm
  • Wheeze - cardiac asthma
  • Sitting up and leaning forward

4

 

 

What is the main feature of acute heart failure?

 

 

Acute pulmonary oedema

5

 

 

What are classes of causes of acute heart failure?

 

 

  • IHD/MI - papillary muscle rupture or VSD
  • Valvular disease - regurgitation in endocarditis or prosthetic valve thrombosis
  • Hypertension - episodes of ‘flash’ pulmonary oedema
  • AKI/CKD - fluid overload and a reduced renal excretion
  • Atrial fibrillation

 

6

 

 

What are the different syndromes of acute heart failure?

 

 

 

  • Acute decompensated HF
  • Hypertensive AHF
  • Acute pulmonary oedema
  • Cardiogenic shock
  • High output heart failure
  • Right heart failure

 

8

 

 

What would other differentials should you consider in someone presenting with symptoms of acute pulmonary oedema?

 

  • Asthma/COPD
  • Pneumonia

 

9

 

 

How would you assess someone with acute pulmonary oedema?

 

  • ECG
  • CXR
  • ECHO
  • Bloods - BNP, U+E's, Troponin, ABG, LFTs, albumin, total protein

10

 

 

What are you looking for on ECG in someone with acute pulmonary oedema?

 

  • ACS
  • LVH
  • AF
  • Valvular heart disease
  • LBBB

11

 

 

What might you see on CXR in someone with acute HF?

 

  • Alveolar oedema - Bat wings
  • Kerley B lines (interstitial oedema)
  • Cardiomegaly
  • Dilated upper lobe vessels
  • Pleural Effusion

12

 

 

What might you see on ABG in acute pulmonary oedema?

 

 

  • Decreased PaO2
  • Decreased PaCO2 (hyperventilation), or increased PaCO2 (severe oedema)

14

 

 

When performing a CXR for investigating acute pulmonary oedema, what would you want to exclude?

 

  • Pneumothorax
  • PE
  • Coonsolidation - pneumonia

15

 

 

Why would you investigate total protein and serum albumin in someone with acute pulmonary oedema?

 

 

 

 

Look for hypoalbuminaemia - reduced oncotic pressure leading to pulmonary oedema

16

 

 

What are signs of pulmonary oedema on CXR?

 

  • Bilateral shadowing
  • Costophrenic effusions
  • Fluid in the lung fissures
  • Kerley B lines
  • Prominent upper lobe vessels

17

 

 

What is the initial treatment for acute pulmonary oedema?

PODIMAN - for all treatments to consider using - use "-MAN" part in specific situations

  • Positioning - sit upright
  • Oxygen
  • IV Diuretics + fluid restriction
  • IV access - send bloods
  • Morphine*
  • Anti-emetic*
  • Nitrates*

*GTN infusion if SBP >110, or 2 puffs GTN spray if SBP >90 in crashing pulmonary oedema

*Only use morphine in distressed patients - should not be routinely offered in acute heart failure/pulmonary oedema (as per NICE guidelines)

18

 

 

After initial management of acute pulmonary oedema, what further management would you consider?

 

  • Treat the cause
  • Assess respiratory failure
  • Asses haemodynamic status

19

 

 

What SBP threshold would you use for determining whether to use GTN spray in acute pulmonary oedema?

 

 

> 90 mmHg

20

 

 

What SBP threshold would you use to help determine whether to use IV nitrates in acute pulmonary oedema?

 

 

>100 mmHg

21

 

 

How would you manage acute heart failure?

Same approach as acute pulmonary oedema - PODIMAN - for all treatments to consider using - use of "-MAN" part in specific situations (see below)

  • Positioning - sit upright
  • Oxygen
  • IV Diuretics + fluid restriction
  • IV access - send bloods
  • Morphine*
  • Anti-emetic*
  • Nitrates*

*GTN infusion if SBP >110, or 2 puffs GTN spray if SBP >90 in crashing pulmonary oedema

*Only use morphine in distressed patients - should not be routinely offered in acute heart failure/pulmonary oedema (as per NICE guidelines)

22

 

 

If SBP was < 90 mmHg, how would you treat the patient?

 

 

As for cardiogenic shock

23

 

 

If, after initial management of acute heart failure, the patients condition continued to worsen, how would you treat them?

 

  • Consider CPAP
  • Treat underlying cause
  • Give further diuretics
  • Consider increasing nitrates if can maintain BP > 100mmHg

24

 

 

What is important to distinguish in acute pulmonary oedema?

 

 

Whether it is cardiogenic or non-cardiogenic

26

 

 

When would you not give nitrates in acute pulmonary oedema/heart failure?

 

 

If BP < 90mmHg

28

 

 

How would you monitor progress of treatment in someone with acute heart failure?

 

  • Observations - BP, HR, RR, Urine output
  • JVP
  • Signs of cyanosis
  • ABG

29

 

 

What would you consider giving someone who had acute heart failure, and had a SBP < 90?

 

  • Dobutamine (inotrope)
  • Phosphodiesterase inhibitors
  • Noradrenaline/dopamine - if < 80mmHg
  • Intra-aortic balloon pump

30

 

 

Once stabilised, what would your long term management of someone with acute heart failure be?

Treat cause where possible

Pharmacological treatments

  • 1st line: ACE-inhibitor + beta-blocker + diuretic
  • 2nd line: add aldosterone antagonist
  • 3rd line: add digoxin

Non-pharmacological treatments

  • Cardiac Resynchronisation Therapy (CRT) device
  • Implantable cardioverter defibrillator (ICD)

31

 

 

When inspecting someone on examination, what might you find if they had Acute LVF?

 

  • PATIENT LOOKS ILL - pale and grey
  • Cold/clammy peripheries
  • Cyanosis
  • Frothy blood stained sputum
  • Orthopnoeic using accessory muscles
  • May have a wheeze - cardiac asthma

32

 

 

Why would you perform U+E's in someone with acute HF?

 

 

Monitor renal function and electrolytes with use of diuretics

33

 

 

What mnemonic can you use for remembering the main causes of LVF?

 

  • Coronary syndrome
  • Hypertensive emergency
  • Arrhythmia
  • Mechanical - acute valve leak, VSD, LV aneurysm
  • Pulmonary embolus

34

 

 

Why would you not routinely offer opiates in someone with acute heart failure?