MANAGEMENT OF ACUTE PULMONARY EDEMA. Pr. NOUIRA Semir Emergency Department Fattouma Bourguiba University Hospital

Transcription

1 MANAGEMENT OF ACUTE PULMONARY EDEMA Pr. NOUIRA Semir Emergency Department Fattouma Bourguiba University Hospital

2 ACUTE HEART FAILURE 35% 10%

3 Goals of Acute Management Rapidly improve symptoms while preserving and organ fuction. Determine precipitating factors. Restore function to pre-morbid levels and optimize oral chronic therapy. Educate patient and family. Reduce the risk of rehospitalization and death. Control costs.

4 Tissue perfusion Clinical classifications dry and warm wet and warm dry and cold wet and cold Pulmonary congestion

5 Tissue perfusion Clinical classifications dry and warm wet and warm dry and cold wet and cold Pulmonary congestion

6 Rapidly improve symptoms Respiratory assistance Oxygen Class I, C Improves oxygen delivery and tissue perfusion Goal >90% Consider CPAP or NIV Endotracheal intubation as last resort

7 CPAP vs VNI Air + O 2 P + Continuous Positve Airway Pressure CPAP

8 CPAP vs VNI Air + O 2 PEP P + P + AI VNI CPAP

9 Tissue perfusion Clinical classifications dry and warm PA wet and warm PA nle VASODILATORS DIURETICS dry and cold wet and cold Pulmonary congestion

10 Hemodynamic categorization of ED patients with Acute Heart Failure Syndromes

11 Diuresis IV loop diuretics Institute early in the ER Dose should equal or exceed PO dose For ineffective diuresis : Increase dose/frequency Add second diuretic (aldactone, chlorothiazide ) Restore volume depletion (renal function?) If all diuretic strategies are unsuccessful: Ultrafiltration is reasonable (class 2b) Low dose dopamine (class 2b)

12 In administration of loop diuretics in APE which statement is correct? A. Bolus dosing results in less diuresis and less clinical improvement than continuous infusion. B. Continuous infusion results in worsened renal function compared to bolus dosing. C. Higher dose of diuretic results in faster weight loss and a shorter hospital stay than a lower dose of diuretic. D. None of the above

13 In administration of loop diuretics in APE which statement is correct? A. Bolus dosing results in less diuresis and less clinical improvement than continuous infusion. B. Continuous infusion results in worsened renal function compared to bolus dosing. C. Higher dose of diuretic results in faster weight loss and a shorter hospital stay than a lower dose of diuretic. D. None of the above

14 IV Vasodilators: Overview Class IIB recommendation Hypertensive patients Pulmonary congestion not responsive diuretics and standard HF therapy. to initial Beneficial effects: Decrease BP cardiac work. and improve the efficiency of Speed symptom relief Possibly decrease ventilation risk for CCU, mechanical No proven change in mortality Nitroglycerin, Nitropusside, Nesiritide

15 Nitroglycerin Primarily venodilation Decreased pre-load decreased pulmonary congestion May get rebound tachycardia and 20% patients develop resistance rapidly (tachyphylaxis) Preferred in ischemia

16 Tissue perfusion Clinical classifications dry and warm wet and warm dry and cold wet and cold INOTROPES Pulmonary congestion

17 Admission

18 APE Precipitating Factors INFECTION

19 Facteurs déclenchant de l Insuffisance cardiaque aiguë

20 Facteurs déclenchant de l Insuffisance cardiaque aiguë

21 Restore function to pre-morbid levels and optimize oral chronic therapy Prehospital treatment of pulmonary edema significantly decreased hospital mortality from 15% to 6,7% AHF ED CCU Observation Unit

22 Discharge Criteria Near optimal volume status achieved Near optimal oral therapy achieved Transition from IV to oral medications done Exacerbating factors addressed Assess ambulation Assess biomarkers/ Thoracic Fluid Content? Patient and family education done Follow-up clinic visit in 7-10 days

23 Summary Start early treatment Know when and what therapy to use Know when to discharge Follow-up is key

24 THANK YOU