Respiratory Emergencies: CHF, Pulmonary Edema, COPD, Asthma CPAP & Albuterol Nebulizer

1. Respiratory Emergencies: CHF, Pulmonary Edema, COPD, Asthma CPAP & Albuterol Nebulizer Condell Medical Center EMS System ECRN CE Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this program, the ECRN should be able to: • review the signs and symptoms and field interventions for the patient presenting with CHF, pulmonary edema, COPD, and asthma. • review criteria for the use of CPAP. • review the SOP for Acute Pulmonary Edema, Asthma/COPD with Wheezing, and Conscious Sedation

3. Objectives cont’d • review the Whisperflow patient circuit for CPAP used in the field. • review the set up of the albuterol nebulizer kit and in-line Albuterol set-up. • successfully complete the quiz with a score of 80% or better.

4. Heart Failure • A clinical syndrome where the heart’s mechanical performance is compromised and the cardiac output cannot meet the demands of the body • Considered a cardiac problem with great implications to the respiratory system • Heart failure is generally divided into right heart failure and left heart failure

5. Heart Failure • Etiologies are varied • valve problems, coronary disease, heart disease • dysrhythmias can aggravate heart failure • Variety of contributing factors to developing heart disease • excess fluid or salt intake, fever (sepsis), history of hypertension, pulmonary embolism, excessive alcohol or drug usage

6. Left Side of the Heart • High pressure system • Blood needs to be pumped to the entire body • Left ventricular muscle needs to be significant in size to act as a strong pump • Left sided failure results in backup of blood into the lungs

7. Right Side of the Heart • Low pressure system • Blood needs to be pumped to the lungs right next to the heart • Right ventricle is smaller than the left and does not need to be as developed • Right sided failure results in back pressure of blood in the systemic venous system (the periphery)

8. Left Ventricular Heart Failure • Causes • failure of effective forward pump • back pressure of blood into pulmonary circulation • heart disease • MI • valvular disease • chronic hypertension • dysrhythmias

9. Left Ventricular Failure • Pressure in left atrium rises • increasing pressure is transmitted to the pulmonary veins and capillaries • increasing pressure in the capillaries forces blood plasma into alveoli causing pulmonary edema • increasing fluid in the alveoli decreases the lungs’ oxygenation capacity and increases patient hypoxia

10. As MI is a common cause of left ventricular failure: • Until proven otherwise, assume all patients exhibiting signs and symptoms of pulmonary edema are also experiencing an acute MI

11. Right Ventricular Heart Failure • Causes • failure of the right ventricle to work as an effective forward pump • back pressure of blood into the systemic venous circulation causes venous congestion • most common cause is left ventricular failure • systemic hypertension • pulmonary embolism

12. Congestive Heart Failure • A condition where the heart’s reduced stroke volume causes an overload of fluid in the body’s other tissues • Can present as edema • pulmonary • peripheral • sacral • ascites (peritoneal edema)

13. Compensatory Measures - Starling’s Law • The more the myocardium is stretched, the greater the force of contraction and the greater the cardiac output • The greater the preload (amount of blood returning to the heart), the farther the myocardial muscle stretches, the more forceful the cardiac contraction • After time or with too much resistance the heart has to pump against, the compensation methods fail to work

14. Acute Congestive Heart Failure Often presents as: • Pulmonary edema • Pulmonary hypertension • Myocardial infarction

15. Chronic Congestive Heart Failure Often presents as: • Cardiomegaly - enlargement of the heart • Left ventricular failure • Right ventricular failure

16. Patient Assessment Field & ED • Initial assessment • airway • breathing • circulation • disability • AVPU (alert, responds to verbal, responds to pain, unresponsive) • GCS • expose to finish examining

17. Priority patients identified • Additional assessment • vital signs, pain scale • determine weight • room air pulse ox, if possible, and oxygen PRN • cardiac monitor; 12 lead ECG if applicable • 0.9 NS IV established TKO • determine blood glucose if indicated • unconscious, altered level of consciousness, known diabetic with diabetic related call • reassess initial assessment findings and interventions started

18. Closest Appropriate Hospital • Hospital of patient’s choice within the Fire Department’s transport area • The patient who is alert and oriented has the right to request their hospital of choice • EMS can have the patient sign the release for transport to a farther hospital • If EMS does not feel comfortable transporting farther away, EMS can communicate this to the patient to get the point across in a diplomatic manner (ie: “I’m very concerned about your condition and I would feel more comfortable taking you to the closest hospital”)

19. Refusals • A conscious and alert patient has the right to refuse care and/or transportation • A refusal, though, with a patient in CHF might prove devastating • worsening of signs and symptoms • increased and unnecessary myocardial damage • severe pulmonary edema • death • Avoid refusals in these patients at all costs • EMS to thoroughly document the efforts taken to encourage transportation

20. Signs and Symptoms CHF • Progressive or acute shortness of breath • Labored breathing especially during exertion (ie: standing up, walking a few steps) • Awakened from sleep with shortness of breath (paroxysmal nocturnal dyspnea) • increasing episodes usually indicate the disease is worsening • Positioning • tripod - resting arms on thighs, leaning forward • inability to recline in bed without multiple pillows • using more pillows to be comfortable in bed

21. Changes in skin parameters • pale, diaphoretic, cyanotic • mottling present in severe CHF • Increasing edema or weight gain over a short time • early edema in most dependent parts of the body first (ie: feet, presacral area) • Generalized weakness • Mild chest pain or pressure • Elevated blood pressure sometimes • to compensate for decreased cardiac output

22. Typical home medication profile • diuretic - to remove excess fluids • hypertension medications - to treat a typical co-morbid factor • digoxin - to increase the contractile strength of the heart • oxygen • Worst of the worst complications - pulmonary edema

23. Progression of Acute CHF • Left ventricle fails as a forward pump • Pulmonary venous pressure rises • Fluid is forced from the pulmonary capillaries into the interstitial spaces between the capillaries and the alveoli • Fluid will eventually enter & fill the alveoli • Pulmonary gas exchange is decreased leading to hypoxemia ( oxygen in blood) & hypercarbia ( carbon dioxide in blood)

24. Progression of CHF cont’d • Hypercarbia ( carbon dioxide retained in the blood) can cause CNS depression • slowing of the respiratory drive • slowing of the respiratory rate

25. Wheezes heard in any geriatric patient should be considered pulmonary edema until proven otherwise (especially in the absence of any history of COPD or asthma)

26. Progression of Pulmonary Edema • Untreated, leads to respiratory failure • Oxygen exchange inhibited due to excess serum fluid in alveoli hypoxia  death • Presentation • tachypnea • abnormal breath sounds • crackles (rales) at both bases • rhonchi - fluid in larger airways of the lungs • wheezing - lungs’ protective mechanisms • bronchioles constrict to keep additional fluid from entering the airway

27. Acute Pulmonary Edema Region X SOP • Routine medical care • patient assessment • IV-O2-monitor • cautiously monitor IV fluid flow rates • Place patient in position of comfort • often patient will choose to sit upright • dangle the feet off the cart to promote venous pooling • Determine if the patient is stable or unstable • evaluate mental status, skin parameters, and blood pressure

28. Stable Acute Pulmonary Edema Region X SOP • Patient alert • Skin warm & dry • Systolic B/P > 100 mmHg • Nitroglycerin 0.4 mg sl - maximum 3 doses • Consider CPAP • Lasix 40 mg IVP (80 mg if already taking) • If systolic B/P remains >100 mm Hg give Morphine Sulfate 2 mg IVP slowly • If wheezing, obtain order from Medical Control for Albuterol nebulizer

29. Pulmonary Edema Medications Used in Region X SOP • Nitroglycerin • venodilator; reduces cardiac workload and dilates coronary vessels • do not use in the presence of hypotension or if Viagra or Viagra-type drug has been taken in the past 24 hours (may get resistant hypotension) • can repeat the drug (0.4 mg sl) every 5 minutes up to 3 doses total if blood pressure remains > 100 mmHg • onset 1 - 3 minutes sl (mouth needs to be moist for the tablet to dissolve & be absorbed)

30. Lasix® (Furosemide) • diuretic; causes venous dilation which decreases venous return to the heart • avoid in sulfa allergies & in the presence of hypotension • dose 40 mg IVP • 80 mg IVP if the patient is taking the drug at home • vascular effect onset within 5 minutes; diuretic effects within 15 - 20 minutes

31. Morphine sulfate • narcotic analgesic (opioid) • causes CNS depression; causes euphoria • increases venous capacity and decreases venous return to the heart by dilating blood vessels • used to decrease anxiety and to decrease venous return to the heart in pulmonary edema • give 2 mg slow IVP; titrate to response and vital signs and give 2 mg every 2 minutes to a maximum of 10 mg IVP • effects could be increased in the presence of other depressant drugs (ie: alcohol)

32. Albuterol • bronchodilator • reverses bronchospasm associated with COPD • dose is 2.5 mg in 3 ml solution administered in the nebulizer • the patient may be aware of tachycardia and tremors following a dose • Albuterol must be ordered by Medical Control for the acute pulmonary edema patient

33. Using CPAP With Medications • Medications and CPAP are to be administered simultaneously • The use of CPAP buys time for the medications to exert their effect • CPAP and medications used (Nitroglycerin, Lasix, and Morphine) can all cause a drop in blood pressure • CPAP and medications must be discontinued if the blood pressure falls < 100 mmHg

34. Case Scenario #1 • A 68 year-old female calls 911 due to severe respiratory distress which suddenly woke her up from sleep. She is unable to speak in complete sentences and is using accessory muscles to breathe. Lips and nail beds are cyanotic; ankles are swollen. • B/P 186/100; P - 124; R - 34; SaO2 - 88% • Crackles are auscultated in the lower half of the lung fields.

35. Case Scenario #1 • History: angina and hypertension; smokes 1 pack per day for the past 30 years • Meds: Cardizem, nitroglycerin PRN; 1 baby aspirin daily; furosemide, Atrovent inhaler as needed • Rhythm:

36. Case Scenario #1 • What is your impression? • What intervention(s) are appropriate following Region X SOP’s? • What is the rationale for these interventions? • What is this patient’s rhythm and do you need to administer any medications for the rhythm?

37. Case Scenario #1 • Impression: congestive heart failure with pulmonary edema • paroxysmal nocturnal dyspnea (sudden shortness of breath at night) • bilateral crackles in the lungs • peripheral edema • cardiac history - hypertension and angina • Rhythm - sinus tachycardia • do not treat this rhythm with medication • determine and treat the underlying cause

38. Case Scenario #1 • Interventions • Sit the patient upright, have their feet dangle off the sides of the cart • promotes venous pooling of blood and decreases the volume of return to the heart • Oxygen via non-rebreather face mask • Prepare to assist breathing via BVM • have BVM reached out and ready for use • IV-O2-monitor • Meds: NTG, Lasix, Morphine, consider CPAP

39. Unstable Acute Pulmonary Edema Region x SOP • Altered mental status • Systolic B/P < 100 mmHg • EMS to contact Medical Control • medications given in the stable patient are now contraindicated due to a lowered blood pressure • CPAP on orders of Medical Control (MD order) • Consider Cardiogenic Shock protocol • Treat dysrhythmia as they are presented • EMS to contact Medical Control for Albuterol if wheezing; possibly in-line with intubation

40. CPAP Continuous Positive Airway Pressure A means of providing high flow, low pressure oxygenation to the patient in pulmonary edema

41. CPAP • CPAP, if applied early enough, is an effective way to treat pulmonary edema and a means to prevent the need to intubate the patient • CPAP increases the airway pressures allowing for better gas diffusion & for reexpansion of collapsed alveoli • CPAP allows the refilling of collapsed, airless alveoli • CPAP allows/buys time for administered medications to be able to work

42. CPAP expands the surface area of the collapsed alveoli allowing more surface area to be in contact with capillaries for gas exchange Before CPAP With CPAP

43. CPAP is applied during the entire respiratory cycle (inhalation & exhalation) via a tight fitting mask applied over the nose and mouth • The patient is assisted into an upright position • The lowest possible pressure should be used • the higher the pressure, the risk of barotrauma (pneumothorax, pneumomediastinum) rises • increased pressures in the chest decrease ventricular filling worsening cardiac output (less coming into the heart, less going out of the heart)

44. Goal of Therapy With CPAP • Increase the amount of inspired oxygen • Decrease the work load of breathing In turn to: • Decrease the need for intubation • Decrease the hospital stay • Decrease the mortality rate

45. Region X SOP Indications & Criteria for CPAP Use • Patient identified with signs & symptoms of pulmonary edema or, in consultation with Medical Control, exacerbation of COPD with wheezing • Patient must be alert & cooperative • Systolic B/P >100 mmHg • No presence of nausea or vomiting; absence of facial or chest trauma

46. Patient Monitoring During CPAP Use • Patient tolerance; mental status • Respiratory pattern • rate, depth, subjective feeling of improvement • B/P, pulse rate & quality, SaO2, EKG pattern • Indications the patient is improving (can be noted in as little as 5 minutes after beginning) • reduced effort & work of breathing • increased ease in speaking • slowing of respiratory and pulse rates • increased SaO2

47. Discontinuation of CPAP • Hemodynamic instability • B/P drops below 100 mmHg • The positive pressures exerted during the use of CPAP can negatively affect the return of blood flow to the heart • Inability of the patient to tolerate the tight fitting mask • Emergent need to intubate the patient

48. CPAP Patient Circuits • Complete package used in the field (and similar to in-hospital use) includes • mask tubing • head strap • Whisperflow CPAP valve • corrugated tubing • air entrapment filter

49. Patient Circuit

50. Case Scenario #2 • EMS has initiated CPAP and simultaneous medication administration (NTG, Lasix and Morphine) to a 76 year-old patient who EMS has assessed to be in acute pulmonary edema • The patient begins to lose consciousness and the blood pressure has fallen to 86/60. • What is the appropriate response for EMS to take?