Acute LVF and pulmonary oedema

Question 1

Triggers of acute LVF

Answer 1

Iatrogenic e.g. aggressive IV fluids in elderly patient with impaired LV function

Sepsis

MI

Arrhythmias

Question 2

Pathophysiology of acute LVF

Answer 2

Left ventricle is unable to adequately move blood out into the body

Causes a backlog of blood in the left atrium, pulmonary veins and lungs

Fluid leaks out into surrounding tissues causing pulmonary oedema in the lungs

Question 3

Presentation of acute LVF

Answer 3

Rapid onset breathlessness

• Exacerbating by lying flat, better on sitting up
• Type 1 respiratory failure

Cough with frothy white/pink sputum

Signs and symptoms of underlying cause:

• Chest pain (ACS)
• Fever (sepsis)
• Palpitations (arrhythmias)

Question 4

On examination findings of acute LVF include

Answer 4

Increased RR
Reduced O2 sats
Tachycardia

3rd heart sound

Bilateral basal crackers

Hypotension in severe cases (cardiogenic shock)

If also have right sided heart failure could see:

• Raised JVP
• Peripheral oedema

Question 5

Questions to ask in suspected Acute LVF…

Answer 5

Has this patient received IV fluids recently?

Are they septic? Do they have signs of infection or a fever?

Do they have chest pain? (MI)

Do they have palpitations? (Arrhythmias)

Do they have ankle oedema or raised JVP? (evidence of RHF)

Question 6

Investigations in suspected acute LVF

Answer 6

ECG
ABG
CXR
Bloods - FBC, CRP, U&Es, BNP and consider troponin

Echo

If clinically the presentation suggests Acute LVF then treat before having the results confirmed by BNP or echo

Question 7

What is BNP?

Answer 7

Hormone released when cardiac muscle is stretched

High result indicates the heart is overloaded

Other causes of raised BNP:

• Tachycardia
• Sepsis
• PE
• Renal impairment
• COPD

BNP is sensitive but not specific - useful for ruling out heart failure

Question 8

CXR findings in acute LV failure

Answer 8

Cardiomegaly

Upper lobe diversion (In LVF there is such a back-pressure that the upper lobe veins also fill with blood and become engorged)

Bilateral pleural effusions

Fluids in the interlobar fissures
Fluid in the septal lines

ABCDE:
A - alveolar oedema (bat wing opacities)
B - Kerley B lines
C - cardiomegaly
D - dilated upper lobe vessels
E - pleural effusion

Question 9

Management of acute LVF

Answer 9

Stop IV fluids
Sit up
Oxygen

Diuretics - 40mg IV furosemide stat

Monitor fluid balance

Consider IV nitrates, IV morphine or diamorphine to reduce preload

Consider NIV e.g. CPAP if saturations not improving

Inotropes e.g. noradrenalin can also be considered but would need close titration and monitoring (need to be sent to CCU, HDU or ITU)
- These work by strengthening contraction and improving heart failure