Pulmonary Edema

1. Pulmonary Edema “Acute systolic heart failure” is useful for hospital billing, but pulmonary edema is more descriptive.

2. Pulmonary EdemaLearning Goals • Management of symptomatic pulmonary edema • Management of cardiogenic shock • Not in this talk:Chronic outpatient systolic and diastolic failure

3. Case #1 • 72 W with dilated ischemic cardiomyopathy, EF=45 %, presents to the ED after waking up at 2am from shortness of breath. • It is now 6 days after Thanksgiving; “I didn’t eat any salt,” but she admits to eating canned gravy and canned cranberry sauce

4. Case #1, HPI, continued • Notes worsening in ankle swelling and worsened orthopnea • Baseline ET 2 blocks, now 20 feet limited by dyspnea; denies chest pain • Usually she makes copious urine after taking furosemide, but had almost no urine output after yesterday’s dose

5. Case #1, ROS, continued • Denies lightheadedness and syncope • Notes a new decrease in appetite; on further questioning she still feels hungry and wants to eat, but feels full after only 2-3 bites of food

6. 72 W DICM, ate too much salt • PMH: HTN, DM, CAD, CHF • PSH: Cath one year ago showed chronic total occlusion of mid LAD; no other severe lesions on cath; no intervention performed • Medications: Lisinopril 10mg PO daily Carvedilol 12.5mg PO bid Furosemide 40mg PO daily ASA 81, Simvastatin 40, Insulin

7. 72 W DICM, ate too much salt • NKDA • Social: Quit tobacco one year ago, drinks 1-2 8oz glasses of wine per week, denies drug use Lives next door to her daughter and grandchildren, weighs herself and checks her BP at home daily • Family: Father died age 63 of MI

8. 72 W DICM, ate too much salt • 150/90 P82 R28 SpO2=93% 2L T=98.4 • Weight is 62kg; baseline is 57kg • Jugular venous pressure 12cmH2O • Crackles to mid lung fields bilaterally • RRR, II/VI apical holosystolic murmur • Bilateral pitting ankle edema; extremities warm

9. 72 W DICM, ate too much salt • CBC normal, coags normal • Na=129 K=4.9 BUN=18 Cre=1.1 • Albumin=3.6, LFT’s otherwise normal • EKG shows normal sinus rhythm, left atrial enlargement, left ventricular hypertrophy, and poor R-wave progression, all unchanged from routine EKG taken three months ago

10. Chest X-Ray

11. 72 W pulmonary edema ED Course • Receives furosemide 40mg IV once, makes 1.5L urine • Reports complete resolution of her shortness of breath; now feels normal • BP 130/80 P80 R21 SpO2=98% 2L • JVP=10; ankle edema persists

12. 72 W pulmonary edema What to do next? • Emergent cardiac catheterization • Transfer to CCU, consider inotropes • Admit to telemetry, rule out MI • Discharge home with close clinic f/u

13. Intestinal edema • Early satiety is one of the most sensitive and specific symptoms of heart failure exacerbation Jakob SM. Clinical review: splanchnic ischemia. Crit Care. 2002;6:306–312.15. Higgins CB, Vatner SF, Franklin D, et al. Pattern of differential vasoconstriction in response to acute and chronic low-output states in the conscious dog. Cardiovasc Res. 1974;8:92–98.16. Zelis R, Nellis SH, Longhurst J, et al. Abnormalities in the regional circulation accompanying congestive heart failure. Prog Cardiovasc Dis. 1975;18:181–199.

14. Ate salt • Cannot absorb PO meds Central venous pressure increases; mesenteric venous pressure increases Intestinal edema

15. 72 W pulmonary edema What to do next? • Emergent cardiac catheterization • Transfer to CCU, consider inotropes • Admit to telemetry, rule out MI • Discharge home with close clinic f/uAnd increase furosemide dose from 40mg PO daily to 80mg PO bid for five days; instruct pt. to return to clinic immediately if weight fails to return to baseline

16. 72 W pulmonary edema What to do next? • Emergent cardiac catheterization • Transfer to CCU, consider inotropes • Admit to telemetry, rule out MI • Discharge home with close clinic f/u“This is not a heart failure exacerbation, it’s Lasix deficiency syndrome.”

17. Case #2 • 71 W with a one-year history of asthma treatment from a community physician, presents to the ED after waking up at 2am with shortness of breath.

18. Case #2, HPI, continued • Often awakens in the middle of the night; gets up and takes albuterol, usually feels good enough to go back to sleep • Baseline ET 1 block, now has dyspnea at rest; denies chest pain • Sometimes feels lightheadedness and palpitation after taking albuterol

19. 71 W “asthma” • PMH: HTN, DM, CHOL, asthma (PFT’s never done) • PSH: None • Medications: Amlodipine 10mg PO daily Aliskiren 300mg PO daily HCTZ 25mg PO daily Albuterol PRN; using 6-8 puffs a day now Advair 500/50 2 puffs PO bid ASA 81, Pravastatin 10, Insulin

20. 71 W “asthma” • NKDA • Social: Smokes 1/2 ppd x50 years, no EtOH, denies drug use • Family: Father died age 63 of MI

21. 71 W “asthma” • 102/64 P118 R32 SpO2=91% 4L T=99.4 • Diaphoretic • Jugular venous pressure 12cmH2O • Expiratory wheeze from lung bases to mid lung fields bilaterally • Rapid rate, regular rhythm, III/VI apical holosystolic murmur • Bilateral pitting ankle edema; extremities warm

22. 71 W “asthma” • Labs drawn; results pending • EKG shows sinus tachycardia, left atrial enlargement, left ventricular hypertrophy with ST-T changes that could be due to hypertrophy or ischemia, and poor R-wave progression No prior EKG for comparison

23. Chest X-Ray

24. 71 W pulmonary edema ED Course • “Doctor. Please help me. (Gasp.) I feel terrible.” • What do you do?

25. 71 W pulmonary edema Intubation? IABP? Morphine? Nitroglycerin? Simvastatin? BiPAP? Diltiazem? Digoxin? Levophed? Dopamine? Dobutamine? Nesiritide? Nexium? Hydralazine? Lisinopril? Captopril? Albuterol? Xopenex? Furosemide? Tirofiban? ASA? Plavix? Metoprolol? Heparin?

26. 71 W pulmonary edema Intubation? IABP? Morphine? Nitroglycerin? Simvastatin? BiPAP? Diltiazem? Digoxin? Levophed? Dopamine? Dobutamine? Nesiritide? Nexium? Hydralazine? Lisinopril? Captopril? Albuterol? Xopenex? Furosemide? Tirofiban? ASA? Plavix? Metoprolol? Heparin?

27. Here, have a mnemonic • Lasix IV (high dose if pt. prev. on it) • Morphine (at least 4mg IV to start) • Nitroglycerin (SL, paste, or drip) • Oxygen (100% NRBM, then PAP) • Positive pressure ventilation (noninvasive bilevel positive airway pressure “BiPAP™” or intubation)

28. Someone comes rushing in. • “The labs came back! The troponin is elevated. We have our diagnosis: This is a NSTEMI! Rush the patient to the cath lab!”

29. Laboratory Values • CBC normal, coags normal • Na=126 K=5.1 BUN=28 Cre=1.3 • Albumin=3.4, mildly elevated transaminases, LFT’s otherwise normal • Troponin I=0.13, CK=164

30. Physical examination now • 98/62 P96 R26 SpO2=99% on Bilevel PAP set at IPAP=10, EPAP=5, FiO2=60% • Diaphoretic • Bilateral pitting ankle edema; extremities warm

31. Yikes! We have troponin! • You shout: “Are you having any chest discomfort at all?” She shakes her head no. “How is your breathing?” She indicates through the mask that she is starting to feel better. • Repeat EKG shows normal sinus rhythm, otherwise unchanged (LVH, LAE, ST-T wave changes of hypertrophy or ischemia)

32. 72 W pulmonary edema What to do next? • Emergent cardiac catheterization • Transfer to CCU, consider inotropes • Admit to telemetry, continue LMNOP • Call the cardiology fellow to ask “Should we give heparin?”

33. Pt. goes to the CCU: Best case • Pt. continues to feel better with repeat furosemide dosing. Blood pressure improves. Stops BiPAP. Echo shows EF=35%, mod MR. Weight drops 4kg in two days; edema resolves. Cardiac catheterization two days later shows chronic total occlusion of mid LAD. No other significant lesions noted.

34. Best case scenario, continued • Pt. sent home on ACE, beta blocker, diuretic, statin, aspirin, insulin. Quits smoking. Fires her old internist and chooses a physician at Jacobi’s internal medicine continuity clinic. Echo 3 months later shows EF=45%, mild MR. Doesn’t go to the ED again until shortly after Thanksgiving of the following year.

35. The worst outcome • Pulmonary edema is not treated promptly. Patient has RR=44, SpO2=89%, then starts to become lethargic. • Intubated for hypoxic respiratory failure. • (After all, intubation is the ultimate form of positive pressure ventilation.)

36. Why this is bad • This is not bad because of the patient’s long-term prognosis--it’s bad because we physicians failed the patient. • This patient can still recover and turn out just as well as in the best-case scenario long-term (so long as she doesn’t develop ventilator complications). She just had to suffer needlessly to get there.

37. Pt. goes to the CCU: Intermediate outcome, case #2 • Despite LMNOP, the patient continues to complain of shortness of breath in the CCU. Extremities become cooler. BP drops to 92/52, HR=112. Echo shows EF=30%, mod MR. Pt. cannot lie flat for cardiac catheterization; she continues to deny chest pain.

38. What’s the term for this? There’s a name for this cluster of findings: • Hypotension • Elevated JVP • Pulmonary edema • Cool extremities

39. What to do now? Intubation? IABP? Morphine Nitroglycerin Simvastatin BiPAP Diltiazem? Digoxin? Levophed? Dopamine? Dobutamine? Nesiritide? Nexium Hydralazine? Lisinopril? Captopril? Albuterol? Xopenex? Furosemide Tirofiban? ASA Plavix? Metoprolol? Heparin?

40. Cardiogenic shock:Principles of Therapy • Palliate symptomatic pulmonary edema • Confirm diagnosis • Reduce afterload • Remove edema fluid • Increase inotropy This discussion does not apply to the septic (“distributive shock”) patient who also has heart failure

41. Cardiogenic shock:Principles of Therapy First, exclude surgical emergency: • To cardiac cath lab stat if etiology is acute coronary syndrome • If acute structural heart disease is etiology (e.g. endocarditis, ventricular septal wall rupture), consider IABP and OR stat • Get EKG and auscultate; check emergent echo if concerns persist

42. Cardiogenic shock:Principles of Therapy • Palliate symptomatic pulmonary edema • Confirm diagnosis • Reduce afterload • Remove edema fluid • Increase inotropy

43. Cardiogenic shock:Principles of Therapy • Palliate symptomatic pulmonary edema • Confirm diagnosis • Reduce afterload • Remove edema fluid • Increase inotropy

44. Afterload reduction options • Hydralazine • ACE/ARB • Dobutamine/Milrinone • Nesiritide • Diuresis/Ultrafiltration • Phlebotomy

45. Hydralazine (with nitrates) • Hydralazine 10mg PO tid is a reasonable starting dose • Titrate upward every day as BP tolerates; goal systolic BP is usually 95-100 • Maximum dose is 300mg daily • Drug-induced lupus is dose-dependent • Hydralazine + nitrates saves lives compared to placebo; please don’t ask about BiDil

46. ACE/ARB • Compared to hydralazine and nitrates, ACE or ARB therapy extends life still more • This effect is not dose-dependent (low-dose ACE/ARB as life-extending as high dose) • In severely low output states, can cause renal hypoperfusion and injury (evidence poor) • No evidence that adding ACE to ARB or vice versa has any benefit

47. Dobutamine/Milrinone • These are inotropes, not pressors • They are both arterial vasodilators • A good combination, physiologically, for relief of cardiogenic shock

48. Dobutamine/Milrinone adverse reactions • Can cause tachyarrhythmia (AF, Afl, VT, VF) • Decrease dose in case of relentless tachycardia or frequent nonsustained ventricular tachycardia If inotrope deemed necessary and unable to control tachyarrhythmia with reduced dose: • Consider amiodarone • Consider digoxin (keep K>4, Mg>2)

49. Dobutamine v. Milrinone • Renal insufficiency: Milrinone accumulates, causing worsened ability to monitor; still okay for short-term (1-2) day use in renal dysfunction Winner: Dobutamine • Beta blockers wanted: Dobutamine cannot be used with a beta blocker (dobutamine is a beta agonist); however a patient can be on milrinone with a beta blocker Winner: Milrinone • Dopamine or Norepinephrine is in the room:Increases afterload--usually a bad idea in heart failure, but may seem necessary in septic shock Loser: Dopamine and Norepinephrine

50. Dobutamine/Milrinone adverse reactions • In patients with acute coronary syndrome, can worsen infarct (increased oxygen demand) • Never shown to reduce mortality; several studies show increase in mortality