Heart Failure - Acute Pulmonary Edema

Heart Failure

Clinical syndrome that results from the inability of the heart to supply sufficient oxygenated blood for the body’s metabolic needs.

• Heart becomes inefficient pump depriving the various tissues and organs of an adequate supply of O₂

  • Left ventricular failure

  • Right ventricular failure

  • Congestive heart failure

Acute Pulmonary Edema

Life threatening emergency involving an acute exacerbation of moderate to advanced heart failure symptoms in response to stress.

• Marked by extreme degrees of respiratory distress

Left Ventricle Failure

Congestion from fluid accumulates in the pulmonary circulation characterized by moist cough and orthopnea (the inability to breath when in the supine position.

Right ventricular failure

Characterized by signs and symptoms of systemic venous and capillary congestion such as edema and weight gain associated with fluid retention.

Congestive heart failure

Sometimes used to refer to a combination of left and right heart failure.

• Right heart outlasts left typically.

• Left ventricle is more vulnerable to heart disease and disorders in its blood supply.

  Symptoms:

  • Mild and arise solely upon exertion

  • More advanced may demonstrate in a resting state.

Heart failure with reduced ejection fraction

Happens when the muscle of the left ventricle is not pumping as well as normal. Is 40% or less.​

Predisposing Factors

• Increased workload of the heart

• Damage to the muscular walls of the heart

• Reduced ejection factor

Hypertension

Responsible for 75% of all congenital heart failure.

Increased workload of the heart

• High blood pressure

• Cardiac valvular deficiencies

• Increase in body’s requirement for oxygen

  • Ex: pregnancy, anemia, hyperthyroidism

Damage to the muscular walls of the heart

• Myocardial infarction

• Coronary artery disease

Reduced ejection factor

Amount of blood pumped out of the ventricle each time the heart muscle contracts

• Normal: 50%-70%

• Reduced: 40% - 49%

• Heart failure with reduced: < 39%

Medical/ Dialogue History

• High BP

• History of MI/Heart attack

• Congenital Heart Disease/Defect

• Damaged/ artificial heart valve

• Heart problems

• Shortness of breath

• Swollen Ankles (pitting edema - typically late in day)

  • Right ventricular heart failure

• Weight gain (3 lbs or more w/in week)

• Exertional dyspnea - when you walk upstairs do you have to stop because of pain, shortness of breath, or fatigue?

  • Early sign of left ventricular heart failure

• Orthopnea - inability to breath lying in a supine position

  • Sign of left ventricular heart failure

Blood Pressure

Elevated with the increase in diastolic more profound than that associated with the systolic —> narrower pulse pressure

Typical - 135/100 sometimes decreased

Pulse

Usually increased

• Tachycardia/ increased sympathetic activity as a means to compensate for reduced cardiac output

Respiration

Usually increased

• Tachypnea is evident early in progression of heart failure as the severity of the dyspnea increases.

Drug history

• Cardiac Glycosides (Digoxin)

• Diuretics (HCTZ)

• ACE Inhibitors (Lisinipril)

• Angiotensin II Receptor Antagonists (Diovan)

• B Blockers (Coreg)

Physical Examination

• Obvious Weight Gain

• Skin

  • Cyanosis especially in mucous membranes and nail beds

• Neck

  • Jugular vein distention with right heart failure

• Ankles

  • Dependent or pitting edema

• Abdomen

  • Ascites

ASA II

Patients can climb one flight of stairs or walk two city blocks without having to pause due to shortness of breath or undue fatigue, but must stop once they complete their task because of distress.

• Mild dyspnea upon exertion

ASA III

Patients can climb one flight of stairs or walk two city blocks but must stop and rest before completing the task because of distress.

• Dyspnea/fatigue with normal activities

• Medical consult needed

• Keep patient upright

• Implement stress reduction protocol

ASA IV

Patients cannot negotiate a flight of stairs or walk two city blocks because of shortness of breath or undue fatigue at rest

• Dyspnea, orthopnea, and undue fatigue at all times

Clinical Manifestations

• Weakness / Undue fatigue

• Dyspnea on exertion

• Cough and expectoration (moist respirations)

• Orthopnea (Inability to breath lying down)

• Paroxysmal nocturnal dyspnea (Awakens from sleep gasping for air)

• Edema (especially in ankles/lower extremities)

• Elevated BP and narrow pulse pressure

• Tachycardia

• Tachypnea

• Weight gain / fluid retention —> Pitting / Dependent edema and ascites

• Cyanosis

• Jugular vein distention

• Left ventricular hypertrophy

Dyspnea

Shortness of breath

Tachycardia

Heart beating to fast

Tachypnea

Rapid and shallow breathing rate

Ascites

Excess fluid accumulates in abdominal cavity

Patient at significant risk for Acute Pulmonary Edema, Angina, or Myocardial Infarction

• Dyspnea on exertion

• Edema

• Tachycardia

• Tachypnea

• Cyanosis

Acute Pulmonary Edema

• Patients with history of heart failure/ congestive heart failure

  • Development of acute shortness of breath typically in response to additional stress factor

• Tachypnea

• Dyspnea at rest/Labored shallow respirations

• Restless

• Increased anxiety/apprehensiveness

• Air Hunger

• Cyanosis

• Blood-tinged or frothy pink sputum

• Peripheral and neck veins are usually engorged

• BP and HR are increased

• Pulse may be full and pounding or weak and thready

• Edema of the extremities

• Profuse diaphoresis (sweating)

• Respiratory acidosis

• Crackles (abnormal respiratory sounds) ranging from bubbling noises to popping sounds to lower pitched sounds in the lungs.

Management of Acute Pulmonary Edema

• R - Recognize signs and symptoms / cease treatment

• E - Evaluate level of consciousness

• P - Position accordingly

  • Conscious - preferably upright

  • Unconscious - supine

• A - Activate CAB’s of CPR

  • Monitor vitals / CPR as indicated

• I - Implement appropriate protocol for acute pulmonary edema

  • Activate EMS

  • Calm Patient - Consider pharmaceutical approach

  • Manage / Alleviate Respiratory Distress

    • Administer O2

  • Consider administration of vasodilator - Systolic BP > 100

  • Bloodless phlebotomy - In extreme circumstances

• R - Refer to emergency medical services for hospitalization