NURSING UPDATE

MANAGEMENT OF ACUTE
PULMONARY OEDEMA
By :
Sugiyono S.Kep. Ns.

Auditorium National Cardiovascular Center

Harapan Kita, Jakarta
12 th November 2017 11/9/2017 1
 Introduction
Patient with presence in
Hospital AHF 40,5% and
CHF 59,5% in case AHF
is Die 23,66% dan 6,4%
and case CHF
(ESC HF 2016 )
In Indonesia prevalence
HF is 0,33 % or 530.068
people , the higher in
West java (0,19%), lowest
in Maluku (0,02%). )
(Riset kesehatan Dasar 2013 )

In ED PJNHK AHF IS number

two after ACS in the year 2016,
case with percentage AHF
15,9%, (Kardiogenic Syok
0,73%,ADHF 93,37%, ALO 5,89%)

( Medical Record RSPJNHK , 2017)

11/9/2017 2
Introduction
Guideline AHF-ESC 2016
 AHF may present as a first occurrence
(de novo) or, more frequently, as a
consequence of acute decompensation of
chronic HF
 The one-year mortality rate for APE is up
to 40%. Et cause cardiogegenic desease
 It is a life-threatening medical condition
requiring urgent evaluation and treatment,
typically leading to urgent hospital
admission
11/9/2017 3
Introduction
 The initial management of patients with
cardiogenic pulmonary edema (CPE)
should address the ABCs of resuscitation,
that is, airway, breathing, and circulation.
 For the best possible patient outcomes, it
is essential that NURSES in all clinical
areas are equipped to accurately
recognise, assess, manage and evaluation
patients with acute cardiogenic
pulmonary oedema.
11/9/2017 4
Definition
 Acute cardiopulmonary oedema is diagnosed from a
patient’s presentation, which generally includes sudden
onset of dyspnoea, particularly when lying down; rales
(rattles or crackles) on auscultation; and oxygen
desaturation.
Powell J et al (2016)
• life-threatening condition and
should be treated
• as a medical emergency.
DANGER
• RED
Triage ZONE
11/9/2017 5
11/9/2017 6
 CLINICAL
MANIFESTATION
AHF (ESC,2008)

Hypertensive
Acute
AHF
Decompensated
Chronic HF
Cardio
Pulmonary
Cardiogenic shock Oedema
Right HF

ACS and
HF

11/9/2017 7
 Congestion (+)
Congestion (-) Pulmonary Congestion
Nocturnal dyspnea
Klasifikasi stevenson Peripheral (bilateral)oedema
Jugular venous dilation
Congested hepatomegaly
Gut congestion, ascites
Hepatojugular reflux

WARM-WET
Hypoperfusion (-)

WARM-DRY

Cold sweated extremitis COLD-DRY COLD-WET

Oliguria
Mental confision
Dizzines Class Lung (Kongesti) Extremity
Narrow pulse pressur (Perfusi)

IA Dry (kering) Warm (hangat)

IIB Wet (basah) Warm (hangat)

III dry(kering) Cold (dingin)

IVC Wet (basah) Cold (dingin)

Downloaded from http://eurheartj.oxfordjournals.org/ by

guest on May 21, 2016 11/9/2017 8
11/9/2017 9
OEDEMA PULMONARY

11/9/2017 10
Signs And Symptoms ALO
Shortness of breath

Orthopnea
Moist cough with pink frothy
sputum
Chest discomfort

Palpitations

Fatigue

Syncope

Cyanosis

Respiratory distress

11/9/2017 11
( Australian Managing Acute Pulmonary Edema, April 2017 ) 12
 Refrence :
2016 ESC Guidelines for the diagnosis and
11/9/2017 13
treatment of acute and chronic heart failure:
11/9/2017 14
Nursing Action of Acute Pulmonary
Oedema
 Assessment
 Primary survey A, B, C maintenance and
stabilisation
 Etiology: Likely cardiac vs non cardiac?

 Oxygen therapy ?
 Monitoring drug terapy Use Nitrogliceyrin,
Deuretic, Inotropic support, Morphine ?
 Diuresis
 CXR/Exam: Determination of pump status
 Directed evaluation
Emergency Department
11/9/2017 15
Nursing Colaboration Therapy
Acute Pulmonary oedema
Nitrates
start 5-10
mcg-max
200 mcg
Ventilatory
support Diuretics
<90 % 40-80 mg.iv
NRM/NIPPV ALO
Management

Inotropes
Morphine
5-10
micro/kg/m 1-2.5 mg iv
nt
11/9/2017 16
DRUG DOSE

11/9/2017 17
DRUG DOSE

11/9/2017 18
MAIN GOAL MANAGEMENT
THERAPY
CPE focuses on main goals:
 Reduction of pulmonary venous return
(preload reduction)
 Reduction of systemic vascular resistance
(afterload reduction), and, in some cases,
 Inotropic support.
 Improve oxygenation
 Maintain an adequate blood pressure for
perfusion of vital organs
 Reduce excess extracellular fluid.
 The underlying cause must be addressed.

11/9/2017 19
 DIAGNOSTIC X-RAY
Example X-Ray of Kerley B Lines

Kerley B lines are caused by peri-vascular edema, with a base

on the pleural surface of the lung and extending horizontally a
variable, but usually short, distance toward the center of the
chest.

n 11/9/2017 20
 ECG
 A 12-lead electrocardiogram
(ECG) to find cause MI, the
underlying cause, such as
myocardial infarction,
hypertrophy, enlargement of
one or more heart chambers
or ischaemia that requires
immediate correction
(Murray et , Mebazaa et al 2015).

 A new onset arrhythmia is one

of the most common causes of
acute pulmonary oedema
(Parissis et al 2010),

11/9/2017 21
ECHOCARDIOGRAM
 A bedside
echocardiogram is an
important diagnostic
tool in patients with
acute pulmonary
oedema who are
haemodynamically
unstable and can provide
important
 information about
aetiology. (Mebazaa et al
2015)

11/9/2017 22
ROLE AS NERS EMERGENCY WITH ALO
Powell J et al (2016) Acute cardio pulmonary oedema. Nursing Standard
International

 The following sections outline :

◦ A systematic approach  assessment and
immediate management of APE
◦ Drawing on research evidence and professional
opinion from the literature.
◦ Practice, new guidelines and EBN are regularly
becoming available.
◦ It is important to review the literature  best
possible nursing care to patients with APE
(Navarro Aldana 2001).
11/9/2017 23
11/9/2017 24
ASSESMENT
 Nursing care is focused primarily on
optimising oxygenation (Robles, 2002),
 The ABCDE (Airway, Breathing,
Circulation, Disability, Exposure) approach
to assessment is used in various
healthcare settings and is particularly
useful in time-pressured situations
(Thim et al, 2012).

11/9/2017 25
Nursing Action..
ASSES AIR WAY
 Keep air way  Use of suction, airway
management head up management focuses on
position the problems related to
 Partial obstruction of breathing.
the lower airways  Audible crackles when
with fluid is common. the patient breathes
 Persistent cough.
 The presence of pink
frothy sputum

11/9/2017 26
Nursing Action.. BREATHING
 Assessedperipheral
and central cyanosis,
 RR
 Use WOB work of
breathing
 And oxygen saturations
(SpO2)
(Mebazaa et al 2015).

 Orthopnoea is relieved by
sitting or standing
(Nicholson 2007)

11/9/2017 27
Nursing Action..BREATHING
 Auscultation of lung
 Monitoring useful
muscle respiration
 Arterial blood gas
checked
 Chest X-ray should
be requested to
Monitoring
 Saturation target >95
-100 %

11/9/2017 28
Nursing Action..BREATHING
 Patients who remain hypoxic despite
supplemental oxygen and are showing signs
of respiratory distress (respiratory rate >30
breaths per minute (bpm), SpO2<90%) may
require further ventilatory support
(NICE 2014, Solvari et al 2015).
 Non-invasive positive pressure ventilation
(NIPPV)
◦ CPAP
◦ BIPAP

11/9/2017 29
 The literature indicates successful use of NIPPV
in the management of acute non-cardiogenic
pulmonary oedema (O’Leary and McKinlay 2011,
Shetty et al 2015).
11/9/2017 30
11/9/2017 31
11/9/2017 32
Nursing Action..CIRCULATION
 Patients with APE are often hypertensive;
hypotension  poor heart function nd
cardiogenic shock.
 Cardiac arrhythmia  so manual pulse
checks and cardiac monitoring are
essential.
 Large intravenous (IV) lines should be in
place to administer needed medications

11/9/2017 33
Nursing Action..CIRCULATION
---> Assessments (Mebazaa et al 2015).
 Chest pain and discomfort  APE e. MI.
 Feel the patient’s hypoperfusion skin
peripherally shut down, cool or clammy;
 Capillary refill time <2 t wo seconds
(Ferns et al 2010).

11/9/2017 34
Nursing Action..CIRCULATION
colaboration for Terapy CPE
 NICE (2014) does not recommend the
routine use of inotropes or vasopressors
for patients in acute heart failure because
of the lack of convincing evidence.

 Both diuretics and vasodilators have been

first-line treatments for people with acute
pulmonary oedema (Parissis et al 2010),

11/9/2017 35
Monitoring Nitrat and IABP
 Nitrates are contraindicated for patients with known
aortic stenosis (McMurray et al 2012), and should be
avoided in patients who are hypotensive (Cowie et al
2014).
 A nitrate preparation is often used to induce
vasodilation and reduce cardiac workload. Nitrates can
be administere, sublingually, but a slow intravenous
infusion can be easily titrated to blood pressure and the
response of the patient.
 In severe, reversible cases of acute pulmonary oedema
or as a bridge to heart transplantation, the use of a left
ventricular assist device or an intra-aortic balloon pump
may be considered (NICE 2014).
11/9/2017 36
Nursing Action.. Disability
 People APE to be acutely distressed.
Opiates have historically  feel more
settled.

 Morphine produce mild vasodilation

and therefore a reduction in afterload,
reducing the workload of the heart.
(NICE (2014)

11/9/2017 37
Nursing Action.. Disability
 Hypoxia is a recognised symptom of acute
pulmonary oedema and may manifest as
headache, restlessness or confusion.

 LOC AVPU (Alert, Alert to Voice, Alert to Pain,

Unresponsive) assessment and changes and
potential deterioration should be monitored.

 The patient’s blood glucose concentration should

be checked with a blood glucose monitor since
undiagnosed diabetes is common in people with
heart failure (McMurray et al 2012)

11/9/2017 38
Nursing Action.. Exposure
 The patient’s  exposing the body to
check for signs of peripheral oedema, Skin
temperature  CHF
 Accurate history is taken while physically
assessing the patient :
◦ Orthopne
◦ Chest discomfort MCI

11/9/2017 39
 Discharge and Evaluation
 The patient experience
◦ Developing a good understanding of the patient
experience enhances empathetic and
compassionate care.
 Long-term management and care
◦ Once the patient has been stabilised, their
prognosis depends on the management of the
underlying cause of acute pulmonary oedema
◦ Patients should bedischarge planning
from hospital
11/9/2017 40
 For Nursing
For the best possible patient outcomes, it is
essential that NURSES in all clinical
areas are equipped to accurately
recognise, assess, manageand Evaluation
patients, with acute cardiogenic
pulmonary oedema.

11/9/2017 41
Refrences :
 Jounal list Australian, April 2017. Managing acute pulmonary
oedema, Megan Purvey,Advanced trainee1 and George Allen, Staff
specialist1 and Retrieval specialist2, Emergency Medicine, Queen Elizabeth II
Jubilee Hospital, Brisbane
 European Heart Journal Advance Access published May 20, 2016, 2016 ESC
Guidelines for the diagnosis and treatment of acute and chronic
heart failure,
 Powell J et al (2016) Acute pulmonary oedema. Nursing Standard. 30,
23, 51-59. Date of submission: July 31 2015; date of acceptance: November
20 2015.
 Jurnal in Nort America (2010) Modern Management of CardiogeniC
Pulmonary Edema. Emergency clinic
 Jurnal Jaime Skinner and Aid´ın McKinney Acute (2011c) Cardiogenic
pulmonary oedema: reflecting on the management of an
intensive care unit patient. The Authors. Nursing in Critical Care 2011
British Association of Critical Care Nurses

11/9/2017 42
Thank You

11/9/2017 43