Acute left ventricular failure and oedema

Question 1

What are the triggers of Acute LVF and oedema?

Answer 1

SAMI

S- sepsis
A- arrhythmia
M- Myocardial infarction
I - iatrogenic –> aggressive IV fluids in elderly with impaired left ventricular function.

Question 2

How do patients with acute left ventricular failure present?

Answer 2

• Rapid onset of breathlessness, which gets worse when lying flat.
• Type 1 respiratory failure (hypoxia and normocapnia)

Symptoms

• SOB
• Cough (Frothy white/pink)

On examination

• Tachycardia
• Tachynoea (high resp rate)
• Reduced SpO2
• Third Heart sound
• Bilateral basal crackles
• Hypotension (cardiogenic shock)

Symptoms associated with underlying cause

• Sepsis (fever)
• Arrythmia (palpitations)
• Myocardial infarction (chest pain)

If they also have signs associated with RVF
- Raised JVP
- Peripheral oedema
(ankles, legs, sacrum)

Question 3

Ix when suspecting acute left ventricular failure with pulmonary oedema?

Answer 3

• History
• Cardioresp examination
• Bloods (routine blood tests for infection (S), troponin (when suspecting MI), BNP (raised), kidney function
• Echo –> assess heart function (ejection fraction)
• Chest X ray (cardiomegaly (cardiothoracic ratio > 0.5), venous diversion (backflow due to LVF), pleural effusion, fluid in intralobar fissures and septal lines (Kerley lines)
• ECG –> to look for Ischaemia (M) and arrhythmia (A)
• Arterial Blood gas (type 1 resp failure: hypoxia and normocapnia.

Note that if a patient is presenting with Acute LVF –> TREAT THEM –< dont need to wait for echo or BNP.

Question 4

How do you manage acute left ventricular failure with pulmonary oedema?

What additional managements plans can you consider if a patient has severe acute left ventricular failure with pulmonary oedema or if the patient becomes hypotensive (i.e. cariogenic shock)?

Answer 4

Pour SOD

Pour away (stop) their IV fluids

Sit them upright

Oxygen (if SpO2 < 95%) –> but be careful of COPD patients whose hypoxic drive may become depressed with supplemental oxygen.

Diuretics (furesomide 40mg stat) to remove excess fluid from the body.

Monitor fluid balance by measuring:
 > Fluid intake 
 > Urine output 
> U&Es 
> Bloods 
> Daily body weight 

Additional management plans to consider if the patient develops severe acute left ventricular failure with pulmonary oedema or if they develop hypotension (cardiogenic shock)

> IV opiates –> this is because opiates such as morphine act to vasodilate, therefore reduce systemic BP and therefore reduce symptoms associated with pulmonary oedema. However, note that IV opiates are not routinely used.

> Non-invasive ventilation (CPAP) –> if it doesn’t work, then consider invasive ventilation and intubation.

> Ionotropes such as noradrenaline which help to increase the ejection fraction of the heart by increasing its contractility. At this point, consider referring the patient to the local coronary care unit/ HDU/ ICU.