Congestive Heart Failure,

Pulmonary Edema,
and CPAP

James Pointer, MD, FACEP

Medical Director
Alameda County EMS
 Objectives
 Review cardiac physiology and
pathophysiology of CHF
 Early recognition of CHF
 Management of CHF
 Use of CPAP
 Terminology
 Heart Failure: The inability of the heart to
maintain an output adequate to maintain the
metabolic demands of the body.
 Pulmonary Edema: An abnormal
accumulation of fluid in the lungs.
 CHF with Acute Pulmonary Edema:
Pulmonary Edema due to Heart Failure
(Cardiogenic Pulmonary Edema)
 Etiology
 Arteriosclerotic Cardiovascular
Ischemia
– Acute MI
– Ischemic Cardiomyopathy (Dilated
Cardiomyopathy)
 Hypertension
 Miscellaneous
 Acute Myocardial Infarction
People Live With Atherosclerosis
– But Die of Thrombosis!

Arteriosclerotic plaques gradually narrow the

coronary arteries, but it is a rupture of the plaque
and subsequent platelet aggregation and thrombosis
that occludes the artery.
 Hypertension
 Hypertrophic Cardiomyopathy
Heart Failure - Concepts
 Frank-Starling Length: Tension Ratio
 Ejection Fraction
 Cardiac Output
 Preload
– Primarily a venous and diastolic function
 Afterload
– Primarily arterial and systolic function
Three Pathophysiological
Causes of Failure
 Increased work load (HTN)

 Myocardial Dysfunction (ASCVD)

 Decreased Ventricular Filling

(Valvular, cardiomyopathy, etc.)
Compensatory Mechanisms
 Increased Heart Rate
– Sympathetic = Norepinephrine

 Dilation
– Frank Starling = Contractility

 Neurohormonal
– Redistribution of Blood to the Brain
 CHF Vicious Cycle
Low Output

Increased Preload Increased Afterload Norepinephrine

Increased Salt Vasoconstriction Renal Blood Flow

Renin
Angiotension I
Angiotension II
Aldosterone
 Decompensation
Increased Pulmonary Venous Pressure (PAWP)

Interstitial Edema

Alveolar Edema
Infiltration of Interstitial Space

 Normal
Micro-anatomy

 Micro-anatomy
with fluid
movement.
 Acute
Pulmonary
Edema
a true life-
threatening
emergency
Precipitating Causes
 Non Compliance with Meds and Diet
 Acute MI
 Arrhythmia (e.g. AF)
 Pneumonia
 Increased Sodium Diet (Holiday Failure)
 Anxiety
 Pregnancy
 Symptoms
 Fatigue  GI Symptoms
 Nocturia  Chest Pain
 DOE  Orthopnea
 PND  Profound Dyspnea
 Physical Exam
 Anxious  Rales
 Pale  Rhonchi
 Clammy  Tachycardia
 Tachypnea  S3 Gallop
 Confusion  JVD
 Edema  Pink Frothy Sputum
 Hypertension  Cyanosis
 Diaphoretic  Displaced PMI
 EMS Management
 Sit upright
 High Flow O2
 NTG (If SBP > 100)
 Diuretics (furosemide) – use care
 Morphine (base consult)
 Ventilatory Support
– BVM
– CPAP
– intubation/ventilation
 CPAP - Introduction
 CPAP is a non-invasive procedure that is easily
applied and can be easily discontinued without
untoward patient discomfort.
 CPAP is an established therapeutic modality,
recently introduced into the prehospital
setting.
 In the primary phase CPAP application in
cardiogenic pulmonary edema, thus far,
appears to be beneficial to patient outcome.
 Key Points of CPAP
 CPAP has been successfully demonstrated
as an effective adjunct in the management
of pulmonary edema secondary to
congestive heart failure.
 CPAP may prove to be a viable alternative in
many patients previously requiring
endotracheal intubation by prehospital
personnel.
 CPAP Mechanism
 Increases pressure
within airway.
 Airways at risk for
collapse from excess
fluid are stented
open.
 Gas exchange is
maintained
 Increased work of
breathing is
minimized
 Prehospital Indications
 Congestive Heart Failure
 Pulmonary Edema associated with
volume overload
– renal insufficiency, iatrogenic volume
overload, liver disease , etc.
 Near Drowning
 Prehospital Indications -
Patient Assessment
 Patient, age > 8, in severe respiratory
distress who meets one of the following
criteria:
– Medical history and presenting complaints
consistent with cardiogenic pulmonary
edema
– Near drowning
 Absolute Contraindications
 Age < 8
 Respiratory or Cardiac Arrest
 Agonal Respirations
 Severely depressed LOC
 Systolic Blood Pressure < 90
 Pneumothorax
 Major Trauma, esp. head injury with increased
ICP or significant chest trauma
 Facial Anomalies (e.g. burns, fractures)
 Vomiting
Relative Contraindications

 History of Asthma/COPD
 History of Pulmonary Fibrosis
 Decreased LOC
 Claustrophobia or unable to tolerate
mask (after initial 1-2 minutes)
 Complications
 Hypotension
 Pneumothorax
 Corneal Drying
 Using the Machine
 Turn all three control knobs fully clockwise to
the OFF position
 Turn the ON/OFF valve counter-clockwise to
the ON position
 Turn the Flow Adjustment Valve about 5
complete turns counter-clockwise to the
completely open position to provide full flow.
 Turn the Oxygen Control Valve 5 complete
on/off Flow O2
turns counterclockwise (50-60% 02).
•You may deliver higher oxygen concentrations (up to 100%) by turning the valve
farther counterclockwise.
•In the closed position (completely clockwise) the unit will deliver a minimum
28-29% oxygen to the patient.
 Verify that air is flowing to the mask.
 Leave the oxygen and flow controls as you have just set them, then turn the
ON/OFF valve fully off (clockwise).
 Important Points
 Pulmonary edema patients,
properly selected, quickly improve
with CPAP in a matter of minutes.
– CPAP is to CHF like D50 is to insulin
shock.
 Visual inspection of chest wall
movement demonstrates improved
respiratory excursion.
 Important Points (cont.)
 COPD and Asthmatic
patients do NOT respond
predictably to CPAP.
– They have a higher risk of
complications such as
pneumothorax, and thus
should not be treated in
the field with CPAP
 CPAP vs. Intubation
 CPAP  Intubation
– Non-invasive – Invasive
– Easily – Usually don’t
extubate in field
discontinued
– Potential for
– Easily adjusted infection
– Does not require – Traumatic
sedation
– Comfortable
 CPAP Study
1996 – 1997 1997 – 1998
September – May September – May

Intubated 22 8

CPAP 0 50

Hospital Stay(d) 14.8 8

ICU Admission 100% 48%

 Alameda County Data
 22 Patients
 19 lived / 3 died / 2 patients to ICU
 Respiratory Rate:
– Range: 42 - 16 / Mean Change: 7.25 (n=16)
 SPO2:
– Range: 30 - 100 / Mean Change: 19.5 (n=18)
 RDS:
– Range: 10 - 3 / Mean Change: 4 (n=15)
– Unable to obtain RDS in 2 patients
 2 pts intubated / 1 intubated pt died
Alameda County CPAP Policy
 Summary
 CPAP provides an adjunct between
oxygen by NRB mask and
endotracheal intubation
 Eliminates trauma of intubation
 Reduces length of hospital stay
 Reduces costs of care