modern management of cardiogenic pulmonary edema … · ali farzad, m.d. baylor university medical...
TRANSCRIPT
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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!
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GOAL Review Simple Management Pearls
that help SAVE LIVES!
Discuss Management of Hypertensive Cardiogenic
Pulmonary Edema
OBJECTIVE
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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
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Severe Respiratory Distress, Agitated
250/160, 120, 45
SpO2 = 78% NRB
“ I can’t breath, I am dying”
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ACUTE HYPTERTENSIVE CARDIOGENIC
FLASH PULMONARY
EDEMA
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Intubate…?
Furosemide…?
Opiates…?
ACE Inhibitors…?
Nitroglycerine…?
First 5 mins?
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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
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Hypertensive AHF
Tarvasmäki et al. Management of AHF & effect of SBP on IV therapies. European Heart Journal: Acute Cardiovascular Care. 2013
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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 %
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Does our patient need LMNOP?
LMNOP
N.O.P !
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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
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LV DYSFUNCTION
TOO MUCH PRELOAD
TOO MUCH AFTERLOAD
ACUTE HTN CARDIOGENIC EDEMA
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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
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Management GOALS
BREAK THE CYCLE
CORRECT HYPOXIA
REDISTRIBUTE FLUID OFF LUNGS
DECREASE PRELOAD AND AFTERLOAD
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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!
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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
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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
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– 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?
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– 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?
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– 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?
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– 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?
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– 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?
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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?
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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?
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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?
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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!
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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!
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MORPHINEThought to reduce:
– Preload
– Afterload
– HR & O2 Demand
• IV: 2-5 mg bolus, works quickly
• Causes Nausea
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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
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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.
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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
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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
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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)
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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
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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
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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
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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!
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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)
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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
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NIPPV Pearls
No outcomes difference between CPAP& BIPAP
Safe, saves lives, prevents intubations!
Reduces WOB, recruits alveoli, works FAST!
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Let’s Summarize
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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!
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@alifarzadmd
THANK YOU!