Acute Cardiogenic Pulmonary Edema | SWORBHP Ask MAC

Category Archives: Acute Cardiogenic Pulmonary Edema

December 20, 2013 SWORBHP Category: Acute Cardiogenic Pulmonary Edema, CPAP, Oxygen Therapy | Date: 20-Dec-2013

Question: If respirations are at or above 28, historically paramedics are taught to assist via BVM. What is the rationale with pulmonary edema to apply NRB with tachypnea instead of assisting with a BVM until CPAP and or nitro is prepared?

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November 22, 2013 SWORBHP Category: Acute Cardiogenic Pulmonary Edema, Bronchoconstriction, CPAP | Date: 22-Nov-2013

Question: CPAP for CHF and COPD is to maintain a constant pressure in the airways (splinting with COPD) and to help push the fluid out of the alveoli and into the circulation with CHF. Would paramedics who do not have CPAP available be wrong, if the patient is conscious and tolerates, assist each inhalation with a BVM to increase tidal volume and create more positive pressure during inhalation, although not maintained with exhalation, in an attempt to force the fluid out with CHF. Debate is that we assist the ventilation at one breath every 5 seconds or 12/minute unless hyperventilating due to head trauma and respiratory problems with coning of the pupil(s). Thanks for the assistance.

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July 11, 2013 SWORBHP Category: Acute Cardiogenic Pulmonary Edema | Date: 11-Jul-2013

Question: If we are treating a patient with acute cardiogenic pulmonary edema that is a nitro virgin that's blood pressure is above 140 systolic and then their blood pressure drops below 140 systolic but not by one third then can we consider them now as not being a nitro virgin and therefore continue treating them with 0.4 nitro? Thank you for taking the time to answer all of these questions.

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Acute Cardiogenic Pulmonary Edema

April 17, 2013 SWORBHP Category: Acute Cardiogenic Pulmonary Edema | Date: 17-Apr-2013

Question: A CHF patient who has a BP of over 140mmHg systolic who is getting 0.8mg of NTG for SOB, patient's BP drops below 140mmHg so NTG dosage is changed to 0.4mg, patient's systolic BP rebounds above 140mmHg. Does patient go back to getting 0.8mg of NTG or is it like the "once you are out, you are out" mentality that they stay at 0.4mg NTG?

General answers to this question from other paramedics I have asked usually say that the patient will continue to get 0.4mg of NTG regardless of systoloic BP, if it has dropped below 140mmHg at any time during the call. Thank you in advance for your time and help.

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Acute Cardiogenic Pulmonary Edema

March 6, 2013 SWORBHP Category: Acute Cardiogenic Pulmonary Edema | Date: 6-Mar-2013

Question: I have a question regarding nitro use with lung cancer patients. I recently had a patient who was obviously in the end stages of lung CA. Patient was complaining of mild SOB due excessive amounts of fluid buildup in his lungs. He stated that he needed to go to the hospital to have the fluid drained. Patent had 5-6 word dyspnea, O2 sats at 92 %, radial pulse 90, NSR, respiratory rate 22 regular, audible crackles when patient took a deep breath, and B/P 124/86. Patient stated that within the last couple of days he had noticed swelling to his ankles and abdomen which were abnormal for him. Patient had a previous history of nitro use due to angina. Would this patient benefit at all with nitro use? He wasn't in severe respiratory distress nor did he require assisted ventilations.

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Acute Cardiogenic Pulmonary Edema

December 3, 2012 SWORBHP Category: Acute Cardiogenic Pulmonary Edema, Bronchoconstriction | Date: 3-Dec-2012

Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed.

Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation.

I thank you for your comments and insights.

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Answer:

Thanks for your questions: interesting discussion and thoughts surrounding the possible expanded use of CPAP.

As CPAP is a relatively new technology (especially in the prehospital field), the evidence supporting its use is limited mostly to the patients with severe pulmonary edema as well as impending ventilatory failure for COPD (as listed in your indications under the current medical directive).

While near drowning may make sense from a physiology point of view (and other forms of non cardiac pulmonary edema), at this time there is a lack of evidence to support the use of CPAP for these conditions.

In your example of thermal injury, we agree that the potential tissue destruction that could have resulted from the inhalational exposure would be one factor to consider as a contraindication for CPAP, however, rarely does direct thermal injury happen at the alveolar level without concurrent significant upper airway injury (which would be a contraindication as listed in your medical directive).

In terms of your second question, we would suggest that the optimal management strategy would be to make a decision as to the likely etiology of the severe shortness of breath your patient is experiencing. Is it acute pulmonary edema or is it bronchoconstriction such as in severe COPD?

If it is felt that acute pulmonary edema is the likely cause, then CPAP would be indicated along with Nitroglycerin (NTG) as per the Acute Pulmonary Edema Medical Directive. Remember however that it has been our teaching at SWORBHP that if a patient with pulmonary edema is improving with CPAP, there is no need to keep removing the mask to administer NTG especially given the physical difficulty of administering a spray of NTG sublingually when high flow oxygen is also being applied.

If the suspected cause of the respiratory distress is bronchoconstriction, then we would suggest that CPAP could be applied as per the Bronchoconstriction Medical Directive, and the use of bronchodilators such as Salbutamol may be administered in-line via MDI where possible to ease the bronchoconstriction.

The SWORBHP medical directors would however not support treating suspected pulmonary edema with CPAP and then using a bronchodilator simply due to the fact the patient has wheezes as your question seems to suggest. Bronchodilators simply have no role in the therapy of acute pulmonary edema.

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October 11, 2012 SWORBHP Category: Acute Cardiogenic Pulmonary Edema | Date: 11-Oct-2012

Question: I am a current PCP taking ACP. I was recently informed, during an ACP class, that on an unconscious CHF patient, nitro can still be administered if vitals are within normal range and the other conditions are met. When I checked the protocols, under conditions, it states that LOA: N/A (whereas for cardiac ischemia, the LOA must be unaltered). However, it seems to me that if the patient is unconscious, the patient is too unstable to receive nitro. I have never experienced a call like this, and it would seem that in most cases an unconscious patient would have vitals outside the perimeters of nitro administration. Can you please verify this? Thanks

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Acute Cardiogenic Pulmonary Edema

October 11, 2012 SWORBHP Category: Acute Cardiogenic Pulmonary Edema, CPAP | Date: 11-Oct-2012

Question: I have a question about a call. Male patient severe SOB. Crackles throughout with a GCS of 4, suspected acute pulmonary edema. Obviously patient of out nitro protocol. Patient's spo2 31 and 42% with mottling noted. Patient's initial pulse 42 with a respiration rate of 33. CPAP is contraindicated at this time so ventilations assisted via BVM. Enroute patient's GCS improves to 15 and spo2 increases to 99% with ventilation assist. At this point could CPAP be applied or is it like the nitro protocol, once your out your out?

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July 3, 2012 SWORBHP Category: Acute Cardiogenic Pulmonary Edema, Cardiac Ischemia | Date: 03-Jul-2012

Question: Do all Phosphodiesterase Inhibitors generic names end in "fil"? Are all drugs that end "fil" Phosphodiesterase Inhibitors? Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

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June 12, 2012 SWORBHP Category: Acute Cardiogenic Pulmonary Edema | Date: 12-Jun-2012

Question: I know there have been a lot of questions regarding the new cardiogenic pulmonary edema protocol. I am a student and just had a call regarding this. After the call there has been discussion about the directive and I have heard three different views and they are...

1. The first treatment column <140 you can ONLY give NTG if a IV is established (no hx.) 2. The second column stating that =>140 with no hx or Iv you can give 0.4mg is to be completely disregarded as it contraindicate the directives conditions 3. The third column stating that =>140 give 0.8mg ONLY if an IV is established (no hx.)

So the question I am asking is can you please clarify the treatment chart of the acute pulmonary edema directive?

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Acute Cardiogenic Pulmonary Edema

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