Pulmonary Edema vs

Pneumonia

Oregon EMT-IntermediateOregon EMT-Intermediate

Acute Pulmonary Edema

Clinical signs: shock, hypotension, congestive heart failure, acute pulmonary edema

Most likely problem?

Volume problem Pump problem Rate problem

First-line ActionsOxygenNitroglycerine SLFurosemide 0.5 to 1mg/kgMorphine IV 2 to10 mg

AdministerFluid

Bradycardia?See algorithm

Tachycardia?See algorithm

Blood pressure

EMT-IntermediateAcute Pulmonary Edema, Hypotension, Shock

Let’s Review:

Cardiac OutputCardiac Output 5000-6000 ml/min.5000-6000 ml/min.

HR or SV = COHR or SV = CO Sympathetic effects:Sympathetic effects:

HR and SVHR and SV Parasympathetic:Parasympathetic:

Slows HRSlows HR Little effect on SVLittle effect on SV

Review:

SV = pressure in ventricle SV = pressure in ventricle Frank Starling effectFrank Starling effect

Peripheral vascular constriction Peripheral vascular constriction increases venous return increases venous return = Increased RV output.= Increased RV output.

Vasodilation of arteries decreases PVR Vasodilation of arteries decreases PVR and diastolic pressureand diastolic pressure = Decreased CO.= Decreased CO.

Vital Signs

Normal B/P is 120/70 mmHgNormal B/P is 120/70 mmHg Increases with ageIncreases with age General:General:

Systolic – 100 + age up to 140Systolic – 100 + age up to 140 At age 50: usually 140 mmHgAt age 50: usually 140 mmHg Increases 1 mmHg/yr after 50.Increases 1 mmHg/yr after 50.

CHF Causes

Normal heart muscle

AMI

Left ventricular enlargement

Abnormal Cardiac Function

Dispatched as:Dispatched as: Man downMan down Chest painChest pain Heart attackHeart attack SOBSOB FaintedFainted DizzyDizzy

Passed outPassed outChokingChokingStroke Stroke DFODFODRTDRT

Initial Assessment:

Brief HistoryBrief History OOnsetnset PProvoking factorsrovoking factors QQualityuality RRadiationadiation SSeverityeverity TTimeime BP changesBP changes

Initial Assessment

MedsMedsCardiac rhythmCardiac rhythmAbnormal breathingAbnormal breathingEdemaEdemaRalesRalesChanges in skin color and Changes in skin color and

moisturemoisture

Right and Left Heart Failure

Right Heart FailureRight Heart Failure CausesCauses

COPD COPD Left heart failureLeft heart failure

ProgressionProgression Right ventricle cannot Right ventricle cannot

eject all of the bloodeject all of the blood Fluid/pressure backs upFluid/pressure backs up

Right atriumRight atrium Venous systemVenous system Pedal edema, JVDPedal edema, JVD

Left Heart FailureLeft Heart Failure CausesCauses

High afterloadHigh afterload ProgressionProgression

Left ventricle cannot Left ventricle cannot eject all of the bloodeject all of the blood

Fluid/pressure backs upFluid/pressure backs up Left atriumLeft atrium Lung tissueLung tissue AlveoliAlveoli Pulmonary edemaPulmonary edema

Acute Left Ventricular Failure

Acute LVF from heart disease:Acute LVF from heart disease: #1 cause of heart failure.#1 cause of heart failure. Assume the worst, hope for bestAssume the worst, hope for best

Pt. with CAD w/ hx of MI(new or old) Pt. with CAD w/ hx of MI(new or old) May develop LVF.May develop LVF.

Frequently LVF is only manifestation of Frequently LVF is only manifestation of AMI.AMI.

LVF

Common causesCommon causes Systemic HTNSystemic HTN

AfterloadAfterload Coronary artery diseaseCoronary artery disease

Arteriosclerosis/atherosclerosisArteriosclerosis/atherosclerosis IschemiaIschemia

Local/temporary occlusionLocal/temporary occlusion

LVF

Common CausesCommon Causes InfarctionInfarction

Permanent, necrosisPermanent, necrosisSignificant Sized InfarctSignificant Sized Infarct

• Decrease effective wall motionDecrease effective wall motion

• Decreased stroke volumeDecreased stroke volume CardiomyopathyCardiomyopathy

• Alcoholism one of main causesAlcoholism one of main causes

LVF

Other CausesOther Causes Volume overloadVolume overload

Bag of Potato ChipsBag of Potato Chips Severe anemiaSevere anemia

HypoxemiaHypoxemia

LVF and Pulmonary Edema

Incidence of CHF doubles per decade Incidence of CHF doubles per decade of lifeof life

> 3 million in US; > 400,000 new > 3 million in US; > 400,000 new diagnoses/yrdiagnoses/yr

5 yr mortality rate /p dx;5 yr mortality rate /p dx; 60% in men60% in men 43% in women43% in women

Basically this happens

Forward or backward ventricular flow.Forward or backward ventricular flow. Forward – (LVF) – reduced flow into Forward – (LVF) – reduced flow into

aorta and systemic circulationaorta and systemic circulation Backward – elevated systemic Backward – elevated systemic

venous pressurevenous pressure

NY Heart Association’s classification of CHF Class IClass I

Not limited by symptomsNot limited by symptoms Class IIClass II

Fatigue, dyspnea, other sx with ordinary Fatigue, dyspnea, other sx with ordinary physical activityphysical activity

Class IIIClass III Marked limitation with normal activityMarked limitation with normal activity

Class IVClass IV Symptoms at rest or with any activitySymptoms at rest or with any activity

CHF

Acute CHFAcute CHF RapidRapid

Chronic CHFChronic CHF SlowSlow Midnight shoppersMidnight shoppers

Pulmonary edema also results from:

CVACVA Pulmonary embolismPulmonary embolism Infection - SepsisInfection - Sepsis AllergyAllergy Inhalation of fumesInhalation of fumes Narcotic abuse Narcotic abuse

Especially Inhaled (Heroin)Especially Inhaled (Heroin) Altitude sickness.Altitude sickness.

Acute Findings HistoryHistory

Recent change in sleep patternsRecent change in sleep patternsMore frequent trips to the bathroomMore frequent trips to the bathroomNeed to sleep on more pillows at nightNeed to sleep on more pillows at nightRecent move to the recliner at nightsRecent move to the recliner at nightsNew episodes of PNDNew episodes of PND

• Paroxysmal Nocturnal DyspneaParoxysmal Nocturnal Dyspnea• Sudden awakening with acute shortness of Sudden awakening with acute shortness of

breathbreath• Relieved after standing or sitting upright for a Relieved after standing or sitting upright for a

period of time (Midnight Walmart shoppers)period of time (Midnight Walmart shoppers)

Acute Findings

HistoryHistory Is more nitroglycerin needed to stop the Is more nitroglycerin needed to stop the

episodes of chest pain?episodes of chest pain? Have nitroglycerin or oxygen doses Have nitroglycerin or oxygen doses

increased incrementally in the last few increased incrementally in the last few days? days?

Acute Findings – Critical Patient

General impression/initial assessmentGeneral impression/initial assessment Labored respirationsLabored respirations Audible soundsAudible sounds Tripod positionTripod position Frothy sputumFrothy sputum Retraction of chest musclesRetraction of chest muscles

Acute Findings – Critical Patient

General impression/initial assessmentGeneral impression/initial assessment Lung soundsLung sounds

Wheezing, cracklesWheezing, cracklesMiddle-to-upper lung fieldsMiddle-to-upper lung fields

Diaphoresis, change in skin colorDiaphoresis, change in skin color Severe anxiety or restlessnessSevere anxiety or restlessness Tachycardia or bradycardiaTachycardia or bradycardia Severe hypertension may be presentSevere hypertension may be present

TachypneaTachypnea OrthopneaOrthopnea Paroxysmal Nocturnal DyspneaParoxysmal Nocturnal Dyspnea

Elevation of pulmonary venous & cap Elevation of pulmonary venous & cap pressurespressures

Wakening from sleepWakening from sleep

Pulmonary Edema – S/S

Pulmonary Edema – more S/S

Noisy Labored Noisy Labored BreathingBreathing

Fine crackles/RalesFine crackles/Rales WheezesWheezes

Reflex airway spasmReflex airway spasm ““Cardiac asthma”Cardiac asthma”

Coarse Coarse crackles/Rhonchi (larger crackles/Rhonchi (larger airways)airways)

CoughingCoughing Blood Tinged Blood Tinged

SputumSputum Pink FrothyPink Frothy

Normal chest xray

So, What to do?

Decide – Sick/NotSick?Decide – Sick/NotSick? VitalsVitals LookLook

Skin – wet/dry, color, tempSkin – wet/dry, color, temp JVDJVD Peripheral edemaPeripheral edema Subtle signsSubtle signs

Look

ListenListen Breath soundsBreath sounds Pulse x 6Pulse x 6 SkinSkin

Treatment of RVF & LVF CHF a circumstance not CHF a circumstance not

a Dxa Dx Treatment objectivesTreatment objectives

Decrease myocardial:Decrease myocardial:WorkloadWorkloadOxygen demandOxygen demand

Reduce fluid retentionReduce fluid retention

Treatment Decrease WorkloadDecrease Workload

No Physical activityNo Physical activity Sitting uprightSitting upright OxygenOxygen

Pt may tolerate BVMPt may tolerate BVM CPAP – studies are promisingCPAP – studies are promising

Decreases preload and afterload in CHFDecreases preload and afterload in CHF Improves lung complianceImproves lung compliance

BiPAPBiPAPCPAP but also delivers higher pressure CPAP but also delivers higher pressure

during inspirationduring inspiration

Treatment

OMIOMI Oxygen, Monitor, IVOxygen, Monitor, IV

MONA - MONA - if appropriateif appropriate Morphine, Oxygen, Nitro, ASA (Not in that Morphine, Oxygen, Nitro, ASA (Not in that

order)order) Don’t let patient walk!Don’t let patient walk! Position of comfortPosition of comfort ReassureReassure Positive Pressure Ventilations if necessaryPositive Pressure Ventilations if necessary

Treatment

Vasodilatory Therapy (Nitrates)Vasodilatory Therapy (Nitrates)AMI reperfusionAMI reperfusionContainer expansion reduces preloadContainer expansion reduces preload

Morphine Morphine Reduce Fluid RetentionReduce Fluid Retention

DiureticsDiureticsLasixLasixBumexBumex

Differential Diagnosis PneumoniaPneumonia Herpes ZosterHerpes Zoster Pleurisy Pleurisy COPDCOPD Rib fractureRib fracture AsthmaAsthma AnginaAngina MIMI PneumothoraxPneumothorax Pancreatitis Pancreatitis HepatitisHepatitis Salicylate ODSalicylate OD

BronchitisBronchitis HyperventilationHyperventilation Lung carcinomaLung carcinoma SepsisSepsis TBTB Muscle painMuscle pain CostochondritisCostochondritis PericarditisPericarditis CHFCHF Percardial tamponadePercardial tamponade

PneumoniaThe statistics Community acquired pneumoniaCommunity acquired pneumonia 4.5 million cases annually in US4.5 million cases annually in US

Winter months/Colder climatesWinter months/Colder climates More men than womenMore men than women 20% require hospitalization20% require hospitalization

66thth leading cause of death leading cause of death Most common infectious cause of deathMost common infectious cause of death

ViralViral Upper and lower respiratory infectionsUpper and lower respiratory infections

Untreated, mortality > 30 %Untreated, mortality > 30 % 37.7% in elder > 80 y/o37.7% in elder > 80 y/o

Sudden onset of S/S & rapid progression Sudden onset of S/S & rapid progression suggest bacterial pneumoniasuggest bacterial pneumonia

S/S

Productive coughProductive cough Sputum may beSputum may be

GreenGreenRust-coloredRust-coloredCurrent jellyCurrent jellyFoul smellingFoul smelling

Rigor or shaking chillsRigor or shaking chills

HeadacheHeadache MalaiseMalaise N/V/DN/V/D Exertional dypsneaExertional dypsnea Pleuritic chest pain, Pleuritic chest pain,

friction rubfriction rub Abdominal painAbdominal pain

S/S, cont.

FeverFever TachypneaTachypnea TachycardiaTachycardia CyanosisCyanosis Wheezes, coarse & Wheezes, coarse &

fine cracklesfine crackles Anorexia & weight Anorexia & weight

lossloss

Dullness to percussionDullness to percussion Altered mentationAltered mentation

typical pneumonia

generally resides in the nasopharynx

carried asymptomatically

in approximately 50% of healthy individuals

nosocomial pneumonia

aspiration or inhalation; ~ 45% of healthy people aspirate during sleep; even higher in severely ill patients; often bilateral

Pneumocystis carinii pneumonia

Bacterial pneumonia

Bacterial pneumonia

Viral pneumonia

Host Factors

DKADKA AlcoholismAlcoholism Sickle CellSickle Cell HIVHIV

So – how do we tell the difference????? CHF/Pulmonary EdemaCHF/Pulmonary Edema

Wheezes, fine & course Wheezes, fine & course cracklescrackles

Cardiac historyCardiac history Productive coughProductive cough ↑ ↑ dyspnea suddenlydyspnea suddenly JVDJVD CyanosisCyanosis Finger clubbingFinger clubbing Prolonged expiratory phaseProlonged expiratory phase Tachypnea, tachycardiaTachypnea, tachycardia Accessory muscle useAccessory muscle use Paroxysmal nocturnal Paroxysmal nocturnal

dyspneadyspnea

PneumoniaPneumonia Wheezes, Course & fine Wheezes, Course & fine

cracklescrackles Febrile, chillsFebrile, chills Productive coughProductive cough Hx URI, OM, Hx URI, OM,

ConjunctivitisConjunctivitis Tachypnea, tachycardia Tachypnea, tachycardia Cyanosis Cyanosis H/AH/A MalaiseMalaise Abdominal distentionAbdominal distention N/V/DN/V/D

PneumoniaPneumonia Pulm. EdemaPulm. Edema COPD/AsthmaCOPD/Asthma

HistoryHistory N/AN/A HTN, Heart HTN, Heart problemsproblems

Lung problemsLung problems

DyspneaDyspnea Orthopnea Orthopnea potentialpotential

OrthopneaOrthopnea Chronic dyspneaChronic dyspnea

Recent HxRecent Hx Fever, malaise, Fever, malaise, etc.etc.

Acute Wt. gainAcute Wt. gain

Edema in legsEdema in legs

Gradual Wt. lossGradual Wt. loss

CoughCough Productive, Productive, thick, greenthick, green

Foamy sputumFoamy sputum Productive Productive (bronchitis)(bronchitis)

OnsetOnset GradualGradual RapidRapid GradualGradual

BPBP NormalNormal HighHigh NormalNormal

MedsMeds Antibiotics, cold Antibiotics, cold medicinesmedicines

Digoxin, Digoxin, antiHTN, antiHTN, diureticsdiuretics

BronchodilatorsBronchodilators

SteroidsSteroids

TreatmentTreatment Oxygen, Med-Oxygen, Med-neb, IV fluidsneb, IV fluids

High flow O2High flow O2

NTG, Lasix, MSNTG, Lasix, MS

Oxygen, Med-neb Oxygen, Med-neb RxRx

Treatment summary

Pulmonary EdemaPulmonary Edema OMIOMI MONA if approp.MONA if approp. Position of comfortPosition of comfort Nitroglycerin 0.4 mg Nitroglycerin 0.4 mg

SL per protocolSL per protocol Morphine 2-10 mg Morphine 2-10 mg

Lasix per protocol Lasix per protocol (commonly 40 mg)(commonly 40 mg)

CPAP if availableCPAP if available

PneumoniaPneumonia OMIOMI

Limit IV fluids if Limit IV fluids if hx of cardiac hx of cardiac diseasedisease

CPAP if availableCPAP if available

Medications for Pulmonary edema NitroglycerineNitroglycerine MorphineMorphine LasixLasix

Nitroglycerin

Drug Class: Nitrate vasodilatorDrug Class: Nitrate vasodilatorRelieves myocardial workloadRelieves myocardial workload Dilates the arterial and venous systemsDilates the arterial and venous systems

Reduces preload to the already overworked Reduces preload to the already overworked ventriclesventricles

Reduces blood pressure to reduce afterloadReduces blood pressure to reduce afterload Allows pressure and fluid to move into the venous Allows pressure and fluid to move into the venous

systemsystem Sublingual doses start at 0.4mgSublingual doses start at 0.4mg

Morphine Sulfate

Drug Class: Narcotic AnalgesicDrug Class: Narcotic Analgesic

Relieves myocardial workload as wellRelieves myocardial workload as well Dilates the venous and arterial systemsDilates the venous and arterial systems

Reduces preload and afterloadReduces preload and afterload May cause hypotensionMay cause hypotension

Morphine Sulfate: Other Actions

Mechanism of actionMechanism of action Binds to opiate receptors throughout the Binds to opiate receptors throughout the

CNSCNS Slows respiratory rate at the medullaSlows respiratory rate at the medulla Stimulates the nausea center in the brainStimulates the nausea center in the brain

Morphine Sulfate

AdministrationAdministration 2-4mg over 1-2 minutes, every 5 2-4mg over 1-2 minutes, every 5

minutes (usual max dose 10 mg)minutes (usual max dose 10 mg)

Furosemide

Class: Loop DiureticClass: Loop Diuretic Moves sodium out of the blood vessels Moves sodium out of the blood vessels

early in the kidneyearly in the kidney Water follows sodium into the kidney Water follows sodium into the kidney

tubulestubules The site pulls out potassium as wellThe site pulls out potassium as well

Provides some vasodilation within 5 min.Provides some vasodilation within 5 min. Diuresis within 20-30 min.Diuresis within 20-30 min.

Furosemide

Reduces preload Reduces preload vasodilationvasodilation Pulls the extra fluid out of the circulationPulls the extra fluid out of the circulation Keeps fluid moving out of the kidneyKeeps fluid moving out of the kidney

Medication effects Medication effects Effects seen within 5-15 minutes of Effects seen within 5-15 minutes of

administrationadministration Peaks in 30 minutes after administrationPeaks in 30 minutes after administration

Furosemide Administration

20-40mg IVP over 1-2 minutes20-40mg IVP over 1-2 minutes Double the dose if the patient is currently Double the dose if the patient is currently

taking a diuretictaking a diuretic Relief of symptoms should begin within 5 Relief of symptoms should begin within 5

minutesminutesIf no relief, consider BVMIf no relief, consider BVM

SHOPS drugs – CHF patients

Street drugsStreet drugs Herbal drugsHerbal drugs OTC drugsOTC drugs Prescription drugsPrescription drugs Sexual enhancementSexual enhancement

Street drugs may contribute to CHF CocaineCocaine MethMeth Inhaled solventsInhaled solvents PCPPCP

Herbal remedies

Possibly helpsPossibly helps High-riteHigh-rite Aqua-riteAqua-rite L-arginineL-arginine Magnesium Magnesium Berberine Berberine

Possibly hurtsPossibly hurts St. Johns WortSt. Johns Wort EphedraEphedra Ginko BilobaGinko Biloba Kava KavaKava Kava Licorice Licorice Ginseng Ginseng Aconite Aconite Alisma plantago Alisma plantago Bearberry BuchuBearberry Buchu Couch grass Couch grass Dandelion Dandelion Horsetail rush Horsetail rush Juniper Juniper

Over-the-counter drugs (OTC)

Cold MedicationsCold Medications

Common Prescription medication for CHF/Pulmonary Edema (Calcium channel (Calcium channel

blocker)blocker) AmiodaroneAmiodarone NorvascNorvasc

Ace InhibitorsAce Inhibitors VasotecVasotec CapotenCapoten LotensinLotensin AccuprilAccupril AltaceAltace

Angiotension II Angiotension II receptor blockersreceptor blockers CozaarCozaar AvaproAvapro

Beta BlockersBeta Blockers CoregCoreg

Sexual enhancement drugs

ViagraViagra 24 hours24 hours

CialisCialis 36 hours36 hours

LevitraLevitra unknown unknown