Simulation 02: 60 Year-Old Man with Wheezing, Hypoxemia (Congestive Heart Failure with Pulmonary Edema) Flow Chart Opening Scenario Section 1 Type: IG Section 2 Type: DM Section 3 Type: IG 60 year-old man in respiratory distress in ED on 4 L/min nasal cannula Pt semi-alert/anxious; bilateral wheezing + crackles; SpO2 = 86% with peripheral cyanosis; high HR/RR, low BP; +3 pedal edema; Hx: pt SOB when lying down. Recommend nonrebreathing mask at 12 L/min SpO2 = 90%; some Cheyne-Stokes resp; ECG = LVH; coughing pink, frothy sputum with worsening breath sounds; CXR = bilateral infiltrates + cardiomegaly; 5 sec cap refill; ABG = resp acidosis + hypoxemia Section 4 Type: DM Echo = ejection fraction 44%; Labs: CK, MB and troponin normal; elevated BNP, low Na+. Recommend NPPV, IPAP = 15, EPAP = 5, 100% O2 Section 5 Type: DM Recommend IV furosemide End
Opening Scenario (Links to Section 1) You are the day-shift respiratory therapist assigned to the ED in a 400-bed teaching hospital. You are called to the Emergency Department at 7:30 AM to assist in the management of a 60- year old man who arrived in acute respiratory distress. (Click the Start button below when ready to begin) 2
Information-Gathering Section Simulation Section #: 1 Links from: Opening Scenario Links to Section: 2 Upon arrival at the bedside you observe a semi-alert, somewhat anxious patient who is accompanied by his wife. He is receiving oxygen via a nasal cannula at 4 L/min. The patient is 170 cm. (5 ft. 7 in.) tall and weighs 77 kg (180 lb.). The resident physician asks you to assess the patient and give your recommendations. (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed) Requested Information Response Data Response Score Complete blood count (CBC) + Pending +1 hematocrit Electrolytes Pending +1 Breath sounds Bilateral expiratory wheezing and crackles at +2 the bases Vital signs HR 118/min and thready; RR 30/min; BP +2 90/72; T 37 C Chief complaint Feels chest pressure, palpitations, "can't +2 catch my breath" General appearance Mild peripheral cyanosis; labored breathing; +2 no diaphoresis Peak flow Physician disagrees -2 SpO2 86% +2 Recent history Wife states patient woke up at 5 AM with +2 chest tightness and wheezing. He takes water pills and usually sleeps sitting up. Pedal edema + 3 +1 Perfect Score: 15 Minimum Pass Score: 13 3
Decision-Making Section Simulation Section #: 2 Links from Section #: 1 Links to Section: 3 Which of the following initial actions would you recommend be taken at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Increasing the O2 flow to 6 L/min and administering 2.5 mg albuterol (Proventil) in 3 ml NS via SVN Switching to a 35% air entrainment mask Intubating the patient and initiating mechanical ventilation Switching to a nonrebreathing mask at 12 L/min Administering 0.5 ml 2.25% racemic epinephrine in 3 ml NS via SVN Response to Selection Response Score -1-1 -2 Physician agrees. Therapy performed. +2 3-2 Link to Section Perfect Score: 2 Minimum Pass Score: 1 4
Information-Gathering Section Simulation Section #:3 Links from Section #: 2 Links to Section: 4 30 minutes later the physician requests you reassess the patient. His SpO2 is 90%, his HR 140/min, and RR 35/min with some Cheyne-Stokes respirations. The patient also is coughing and producing pink frothy secretions. What additional information is indicated to complete your reassessment? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed.) Requested Information Response Data Response Score Chest X-ray Bilateral fluffy infiltrates and cardiomegaly +2 12 lead ECG Sinus tachycardia with evidence of left +2 ventricular hypertrophy Chest auscultation Pronounced bilateral inspiratory crackles with +2 severe expiratory wheeze; prominent S3 gallop Echocardiogram Pending +1 Arterial blood gas ph = 7.30; PCO2 = 61 torr; HCO3 = 29 +2 meq/l; PO2 = 58 torr CT of the chest Physician disagrees -2 Cardiac biomarkers (CK, MB, Pending +1 troponin, BNP) Nail bed refill 5 seconds +2 Bronchoscopy Physician disagrees -3 Bedside spirometry (FVC) Physician disagrees -2 Perfect Score: 12 Minimum Pass Score: 9 5
Decision-Making Section Simulation Section #:4 Links from Section #: 3 Links to Section: 5 The echocardiogram indicates an ejection fraction of 44%. Lab results: CK, MB and troponin normal; elevated BNP, low serum sodium. Based on your reassessment of the patient, which treatment would you now recommend? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Maintaining patient on nonrebreather at 12 L/min, repeating ABG Administering albuterol via SVN on 100% O2 Initiating noninvasive ventilation with IPAP = 15 cm H2O, EPAP = 5 cm H2O, 100% O2 Initiating mask CPAP at 10 cm H2O, 100% O2 Administering an IPPB with 100% O2 Response to Selection Response Score -2-2 Physician agrees +2 5-1 +0 Link to Section Perfect Score: 2 Minimum Pass Score: 1 6
Decision-Making Section Simulation Section #: 5 Links from Section #: 4 Links to Section: End Noninvasive ventilation (IPAP/EPAP = 15/5 cm H2O; FIO2 = 1.0) initiated. What additional therapy would you recommend at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Response Link to Action/Recommendation Response to Selection Score Section Administering IV furosemide Physician agrees. Treatment initiated +2 End Administering IV epinephrine Administering IV lidocaine Administering IV adenosine Administering IV verapamil -3-2 -2-2 Perfect Score: 2 Minimum Pass Score: 2 7
RTBoardReview Simulation 02 60-Year Old Man in Respiratory Distress Condition/Diagnosis: Congestive Heart Failure with Pulmonary Edema Simulation Scoring Individual Response Scoring (Used for All RTBoardReview Simulations) Score Meaning +2 Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem -2 Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 02 Section IG Max IG Min DM Max DM Min 1 15 13 2 2 1 3 12 9 4 2 1 5 2 2 TOTALS 27 22 6 4 MPL% 81% 66% Cut Score = IG Min + DM Min = 22 + 4 = 26 MPL% = Minimum Pass Level as a percent = (Min/Max) x 100 IG and DM MPL% vary by problem; typically ranges are 77-81% for IG and 60-70% for DM If the IG or DM raw score is negative (e.g., -2) then the reported % score = 0 The Cut Score for a problem is the sum of IG Min + DM min To pass a problem, the sum of one s IG + DM raw scores must be the Cut Score 8
Take-Home Points RTBoardReview Simulation 02 60 Year-Old Man with Wheezing, Hypoxemia Condition/Diagnosis: Congestive Heart Failure with Pulmonary Edema The most common cause of heart failure is impaired contractility of the left ventricle (LV), due to CAD, MI, dilated cardiomyopathy, valvular heart disease, or hypertension. Right ventricular (RV) failure also can occur, most commonly due to LV failure, RV infarction, pulmonary hypertension, or tricuspid regurgitation. Signs/symptoms of advanced disease include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Fatigue, chest pain/pressure and palpitations also may occur. With RV failure, jugular venous distention, peripheral edema, hepatomegaly, and ascites are common. Auscultation may reveal a gallop rhythm (with S3 and often S4 sounds) and in valvular disease, heart murmurs. Patients' functional impairment is categorized by the level of dyspnea they experience, as outlined in the New York Heart Association Heart Failure Symptom Classification System: Class I II III IV Level of Impairment No symptom limitation with ordinary physical activity Ordinary physical activity somewhat limited by dyspnea (e.g., long-distance walking, climbing two flights of stairs) Exercise limited by dyspnea with moderate workload (e.g., short-distance walking, climbing one flight of stairs) Dyspnea at rest or with very little exertion With good management, even patients with Class III or IV heart failure can remain relatively stable most of the time. However, patients can decompensate and develop acute dysfunction, most typically resulting in pulmonary edema or hypotension/shock. The following pointers address the basics in the management of stable heart failure and acute decompensation. Assessment/Information Gathering To identify stable CHF: o Assess for the signs and symptoms previously noted. o Recommend electrolytes (fluid balance, Na+ levels), BUN and creatinine (renal function), and B-type natriuretic peptide or BNP (useful in diagnosing CHF) o Recommend chest X-ray; look for cardiomegaly, pulmonary vascular congestion, Kerley B lines, pleural effusion. o Recommend 12-lead ECG to assess for LV or RV hypertrophy or ischemia/cad. o If ECG indicates ischemia/cad, recommend stress test, cardiac catheterization or coronary CT angiography (CTA) to confirm or exclude CAD as the cause o Recommend an echocardiogram to assess for systolic and diastolic function, hypertrophy, chamber size, and valve abnormalities (discussed subsequently). 9
To assess for decompensation/pulmonary edema: o Assess for signs of acute decompensation, e.g., sudden onset of restlessness, confusion, diaphoresis, dyspnea, work of breathing, tachypnea, tachycardia. o Assess peripheral perfusion; look for cool, pale, cyanotic or mottled skin, slow capillary refill. o Assess cough/sputum production; look for frothy and/or blood-tinged sputum. o Assess breath sounds (bilateral crackles + wheezing -> acute decompensation). o Assess for chest pain (presence suggests acute myocardial ischemia/infarction). o Monitor SpO2 and obtain an ABG (hypoxemia with respiratory alkalosis typical). o Recommend a STAT chest X-ray (typically reveals bilateral fluffy infiltrates). o Recommend CBC, serum electrolytes, BUN and creatinine, BNP (see above), and cardiac biomarkers (troponin, CK, CK-MB) to assess for MI. o Recommend an echocardiogram (helps determine possible mechanical causes such as cardiac tamponade or valve problems). o In the hemodynamically unstable patient recommend pulmonary artery (Swan- Ganz) catheterization to assess heart function and guide therapy. Treatment/Decision-Making To manage stable CHF: o Recommend disease management education, with an emphasis on sodium and fluid restriction, smoking cessation, daily monitoring of BP, weight control and moderate aerobic exercise. o Recommend the following medications for all CHF patients: an angiotensin-converting enzyme (ACE) inhibitor (e.g., captopril) or angiotensin receptor blocker (e.g., valsartan) a beta-blocker (e.g., carvedilol) o Depending on the severity of symptoms additional medications may include digoxin (especially with A-fib), a diuretic (preferably a loop diuretic like furosemide or torsemide) and an aldosterone antagonist such as spironolactone. To manage decompensation/pulmonary edema: o Initiate O2 therapy with the highest FIO2 possible (nonrebreather at 12-15 L/min or high-flow cannula at 30-40 L/min) to obtain SpO2 > 90%. o Recommend CPAP or BiPAP with 100% O2 (improves gas exchange, decreases venous return and ventricular preload) o Recommend morphine or a benzodiazepine such as lorazepam to reduce anxiety (morphine also may decrease preload via venous dilation). o o o o o Recommend the appropriate ACLS protocol for any associated arrhythmia or MI. Recommend the following medications (assumes the patient is not hypotensive): a vasodilator such as nitroglycerin, sodium nitroprusside, nesiritide (to decrease preload and afterload) a rapid acting loop diuretic such as furosemide or torsemide If patient is hypotensive recommend an inotropic agent such as dobutamine to maintain mean arterial pressure > 70-75 mm Hg. Recommend intubation and invasive ventilation if patient develops severe respiratory acidosis on CPAP/BiPAP. In the patient with persistent hypotension and pulmonary edema due to an acute MI, recommend intra-aortic balloon pumping (if available) until angioplasty or cardiac surgery can be performed. 10
Follow-up Resources Standard Text Resources: Des Jardins, T, & Burton, GG. (2011). Pulmonary Edema (Chapter 19). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby- Elsevier. Marshak, AB, & Hicks, GH. (2007). Heart Failure (Chapter 8). In Wilkins, R.L., Dexter, J.R., & Gold, P.M. (Eds). Respiratory Disease: A Case Study Approach to Patient Care. 3rd Edition. Philadelphia: F.A. Davis Useful Web Links: Figueroa, MS, & Peters, JI. (2006). Congestive heart failure: Diagnosis, pathophysiology, therapy, and implications for respiratory care. Respir Care, 51, 403-12. http://rc.rcjournal.com/content/51/4/403.full.pdf Dumitru, I, & Baker, M. (2010). Heart failure. E-Medicine/Medscape http://emedicine.medscape.com/article/163062-overview American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (2013). ACCF/AHA guideline for the management of heart failure. Circulation, 128, e240-e327. http://circ.ahajournals.org/content/128/16/e240.full.pdf 11