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ALI FARZAD, M.D. Baylor University Medical Center - Dallas, TX
March 26th & 27th, 2015
Modern management of CARDIOGENIC
PULMONARY EDEMA workshop!
GOAL Review Simple Management Pearls
that help SAVE LIVES!
Discuss Management of Hypertensive Cardiogenic
Pulmonary Edema
OBJECTIVE
220/135, 105, 40, 82%
Hx of HTN, DM, CAD
Woke up dyspneic
Diaphoretic, Distress
Rales to Apex BL
JVD, Looks DRY!
70 YOM with ACUTE DYSPNEA
Severe Respiratory Distress, Agitated
250/160, 120, 45
SpO2 = 78% NRB
“ I can’t breath, I am dying”
ACUTE HYPTERTENSIVE CARDIOGENIC
FLASH PULMONARY
EDEMA
Intubate…?
Furosemide…?
Opiates…?
ACE Inhibitors…?
Nitroglycerine…?
First 5 mins?
What are others doing?Examined use of AHF Tx’s (ESC guidelines)
in different presentations and BP’s (N=620)
• IV Furosemide, 76%
• Nitrates, 42%
• NIPPV, 50%
• Opiates, 29%
Tarvasmäki et al. European Heart Journal: Acute Cardiovascular Care. 2013
Hypertensive AHF
Tarvasmäki et al. Management of AHF & effect of SBP on IV therapies. European Heart Journal: Acute Cardiovascular Care. 2013
Hypertensive AHF
Tarvasmäki et al. Management of AHF & effect of SBP on IV therapies. European Heart Journal: Acute Cardiovascular Care. 2013
IV Furosemide was MOST COMMONLY USED
IV Nitrate use was LOW ~30 %
NIPPV use was LOW ~30 %
Does our patient need LMNOP?
LMNOP
N.O.P !
ACUTE HTN CARDIOGENIC EDEMA
Inability of LV to handle pulmonary venous return
Increased hydrostatic pressure g leakage from pulmonary capillaries and venues into alveolar space
LV DYSFUNCTION
TOO MUCH PRELOAD
TOO MUCH AFTERLOAD
ACUTE HTN CARDIOGENIC EDEMA
ACUTE LV DYSFUNCTION !
CARDIAC OUTPUT
" Catecholamine's
" SVR / BP
AFTERLOAD Mismatch
" O2 Demand
DYASTOLIC Dysfunction !
CONTRACTILITY
" HYDROSTATIC
PRESSURE
PULMONARY EDEMA
HYPOXIA & ISCHEMIA
Resp. Failure Agitation &
Anxiety
" Catecholamine's
THE CYCLE
Management GOALS
BREAK THE CYCLE
CORRECT HYPOXIA
REDISTRIBUTE FLUID OFF LUNGS
DECREASE PRELOAD AND AFTERLOAD
Cotter et al. American Heart Journal 2008 Collins et al. Annals of Emergency Medicine 2008
Treat them all the SAME?~ 50 % of CPE patients
are not fluid overloaded!
Vascular failure rather than total body fluid overload!
Furosemide– IV: Peak effect in 30 mins
– Direct vasodilatory effect
Supposedly reduces preload
in 5-10 minutes?
– Delayed effect (30-120 min)
Pickker et al. Direct Vascular Effects of Furosemide in Humans. Circulation. 1977
Furosemide Harmful?
– IV Furosemide administered to post-AMI CHF patients
– Significant reductions in filling pressures occurred only in patients that had diuresis
Kiely et al. Circulation. 1973
– IV Furosemide caused significant reductions in CO in first 90 mins (~17%)
– CO gradually returned to normal after diuresis
Ikram et al. Clin Sci. 1980
Furosemide Harmful?
– IV Furosemide (1mg/kg) given to AMI patients with LV Failure
– Early adverse HD effects • Increased BP & HR in first 30 mins • Decreased CO & SV in first 90 mins
– Returned to baseline after diuresis
Nelson et al. European Heart Journal. 1983
Furosemide Harmful?
– IV Furosemide given to Class III & IV
– Early activation of RAAS
– Increased in plasma Renin, NE & Vasopressin levels
– Early adverse HD effects • Increased HR & SVR • Decreased SV
– Returned to baseline after diuresis
Fracis et al. Annals of Internal Medicine. 1985
Furosemide Harmful?
– Compared NTG, Furosemide and Morphine in 57 Prehospital APE patients
• NTG alone had best outcomes (NO Adverse Effects)
• Adverse Effects in Furosemide Group – >25% required fluids later
– Significant electrolyte abnormalities
– 23% misdiagnosed, didn't have edema!
– Worse outcomes in patients who got Furosemide & Morphine
Hoffman et al. Chest. 1987
Furosemide Useful?
– Effects of IV Furosemide on PCWP over 1 hr
– Increased PCWP over 15 minutes – Returned to baseline after diuresis
– If patients treated with Nitrates and Captopril first, produced immediate and sustained decrease in PCWP
Kraus et al. Chest. 1990
Furosemide Useful?
Evaluated outcomes in 599 prehospital presumed decompensated CHF patients
–18% of patients were misdiagnosed/tx
–Asthma, COPD, pneumonia, bronchitis
–Patients receiving morphine and/or furosemide (+ NTG) — 21.7% mortality
–Patients receiving NTG alone — 2.2% mortality
Wuerz et al. Annals of Emergency Medicine. 1992
Furosemide Harmful?
Evaluated 144 prehospital presumed decompensated CHF patients given furosemide
– 42% of patients had a final diagnosis that was not CHF, furosemide considered “inappropriate”
– 17% of patients diagnosed with sepsis, dehydration, or pneumonia (without CHF), furosemide considered “potentially harmful”
– Nine patients died, seven of whom received furosemide “inappropriately”
Jaronik et al. Prehosp Emerg Care. 2006
Furosemide Harmful?
ADHERE registry, N=> 100,000 patients
Compared patients who got more or less than 160 mg IV
Furosemide in 24hrs.
– <160 mg had significantly less decline in renal
function, length of stay, and in-hospital mortality
(OR 0.87, 95% CI 0.78-0.97 p=0.01)
Peacock et al. Insights from ADHERE. Cardiology. 2009.
Furosemide Harmful?
Furosemide Summaryi Preload through diuresis is a delayed effect!
Many patients are NOT fluid overloaded anyway! – No good data on direct venodilating effect
– Activates SNS & RAAS
– h HR, SVR, myocardial 02 demand, ischemia
– i SV, CO & tissue perfusion
– May cause adverse HD effects early-on
– Harmful when diagnosis of HF is wrong!
Furosemide Pearls
Consider only if certain that patient is in acute HF & is volume overloaded
May be HARMFUL…JUST HOLD OFF!
~ HALF of the patients with AHF are NOT total body fluid overloaded!
MORPHINEThought to reduce:
– Preload
– Afterload
– HR & O2 Demand
• IV: 2-5 mg bolus, works quickly
• Causes Nausea
Morphine SummaryTHE EVIDENCE IS POOR!
ADHERE analysis:
–Independent predictor of mortality (OR = 4.84) –Increased risk of intubation, LOS, ICU admission rate
BECAREFUL WITH OPIATES & ANXIOLYTICS Blunts respiratory drive!
Peacock et al. ADHERE analysis. Emergency Medicine Journal 2008
ACE-InhibitorsSome recommend adding ACE inhibitors along with nitrates for greater AFTERLOAD reduction.
Enalaprilat at a dose of 1.25mg IV OR Captopril 25mg sublingually.
Appears to be safe & effective.
Has more effect on afterload than nitrates.
NITROGLYCERIN– Dose dependent dilation of
arterial and venous beds
– Decreases Preload, Afterload,
and O2 demand
• Onset: 1-3 mins
• Duration: 3-5 mins
• Contraindications: PDE-5 inhibitors
Sublingual NTGSL tab = 400 mcg or 0.4 mg
– q5 mins =80 mcg/min. ~ 75% absorbed = 60!
– q3 mins = 100 mcg/min
– Dry Mouth? - Spray or few drops of water
START THE DRIP HIGH AND TITRATE UP QUICKLY
Lots of Nitrates vs. Lots of Furosemide
Cotter et al. The Lancet. 1998
110 patients randomized
Isosorbide 3 mg q5 mins = 600 mcg/min NTG!
vs Furosemide 80mg q 5 mins.
Furosemide Group:
–More people intubated (21 vs. 7, p=0.004)
–More people with MI (19 vs. 9, p=0.047)
HIGH DOSE NITRATES
Sharon et al. Journal of American College of Cardiology. 2000
40 patients who failed conventional treatment
(Lasix, O2, Morphine)
Repeated boluses of IV ISDN 4mg q 4 min vs. BIPAP and standard dose nitrates, pre-hospital
– Intubation: 16 BIPAP vs 4 ISDN
– Death/MI: 17 BIPAP vs 5 ISDN
– Quicker improvement with ISDN at 1hr
HIGH DOSE NTG
Levy et al. Annals of Emergency Medicine. 2007
29 patients who failed conventional treatment
~ 30 mcg/min IV gtt. Then 2mg IV boluses q 3-5 mins for 30 mins.
Mean dose was 6.5 mg!
HIGH DOSE NTG Group:
– Less intubations: 14% vs 27%
– Less complications: 20% vs 29% (1 clinically insignificant episode of hypotension)
– Less BIPAP: 7% vs. 20%
– Less ICU admissions: 38% vs. 80%
– Shorter LOS: 4.1 days vs 6.2 days
BOLUS DOSE NTG
Mallick et al. Society of Critical Care Medicine Congress. 2012
Protocol of Bolus Dose NTG & NIV to Avert Intubation
N=41, Prospective Cohort in Sympathetic Surge Crashing APE
ED Called Anesthesiology for EMERGENT INTUBATION
Started on NIV instead, repeated boluses of NTG
Bolus Dose NTG:
– Mean # of boluses = 4 (800-28k mcg) – None (0%) required intubation! – 2 had transient SBP < 100, resolved with IVF
NTG Pearls
DON’T GIVE WIMPY DOSES
SL NTG q 5 mins = 60-80 mcg/min absorbed
Start IV gtt at least at 100/mcg and titrate up,
FAST!
NIPPV Summary
Vital et al. Cochrane Database of Systematic Reviews. 2008
21 Trials, N=1071
NIPPV significantly reduced:
–Hospital mortality (RR 0.6, 95% CI: 0.45-0.84)
• NNT = 1 in 13 helped (LIVE SAVED)
–Intubation (RR 0.53, 95% CI: 0.34-0.83)
• NNT = 1 in 8 helped (NO TUBE)
NIPPV Summary
Vital et al. Cochrane Database of Systematic Reviews. 2013
32 Trials, N=2916
NIPPV significantly reduced:
– ICU LOS by 1 day
– Adverse Effects
NIPPV Pearls
No outcomes difference between CPAP& BIPAP
Safe, saves lives, prevents intubations!
Reduces WOB, recruits alveoli, works FAST!
Let’s Summarize
The Final Pearls~ HALF of the patients with AHF are NOT
total body fluid overloaded!
Focus on what saves lives: Early NIV and NTG (Don’t
give wimpy doses!)
These patients don’t have time for LMNOP FUROSEMIDE MAY BE HARMFUL…
PEDAL EDEMA DOES NOT KILL!
@alifarzadmd
THANK YOU!