Chapter 11: HF/Acute Pulmonary Edema

Question 1

How many people suffer from heart failure in the US and why is it rising?

Answer 1

5 million;

Number is rising due to aging population and MI survival

Question 2

When is heart failure and what is its etiology?

Answer 2

Occurs when heart muscle is impaired and no longer pumps sufficient blood to body tissues and organs;
Can result from almost any kind of CVD;
MI and hypertension are most frequent etiology;
Also associated with thyroid disease, renal insufficiency, and pulmonary disease

Question 3

When does heart failure usually occur?

Answer 3

Initially presents during exertion;

As disease progresses, symptoms occur even when at rest

Question 4

How does the dental setting affect heart failure?

Answer 4

Physiological and psychological stress exacerbate symptoms;

Can lead to pulmonary edema

Question 5

What are the clinical manifestations of HF?

Answer 5

Left ventricular HF
Right ventricular HF
Both left and right ventricular HF

Question 6

What is left ventricular HF?

Answer 6

Inability of the left ventricle to pump blood to the body tissues;
Results in a fall in CO;
Usually occurs before right ventricular HF;
Blood coming to left ventricle may back up causing fluid to leak into lungs (pulmonary edema)

Question 7

What are the signs and symptoms of Left HF?

Answer 7

Classic: dyspnea
Tachypnea
Increased depth
Non-productive, dry cough due to lung congestion
Cardiac asthma(congestion of bronchial mucosa–>wheezing)
Pale and cool to touch
Diaphoresis
Increased BP
Pulse rapid and thready (may alt between strong and weak)
Pulsus alternans
Weakness and fatigue

Question 8

When are symptoms of left HF more prominent and why?

Answer 8

At night (paroxysmal nocturnal sleep);
while patient is supine (orthopnea)
head needs to be elevated

Question 9

What ASA are heart failure patients and what may they require?

Answer 9

ASA III or IV;

Often require supplemental oxygen via nasal cannula

Question 10

What are the signs and symptoms of right heart failure?

Answer 10

Usually develops after left HF;
Classic: peripheral edema with pitting
Fatigue and weakness
Pitting edema in lower legs and ankles
Distended jugular vein
Nocturia
Nausea
Vomiting
Anorexia
Headaches
Insomnia
Irritability

Question 11

Right heart failure results in…

Answer 11

Inability of the heart to pump blood from the systemic circulation to the lungs;
Congestion in systemic venous system;
Reduction in renal blood flow–>retention of fluid

Question 12

What happens if the patient has reduction in renal blood flow due to right heart failure?

Answer 12

During the day, patient’s activity increases degree of HF–>less urine production;
At night, patient is less active–>renal and cardiac function may improve (nocturia may result–>increased urination at night

Question 13

Signs and symptoms of later stages of HF

Answer 13

Edema in abdomen
Mental confusion, anxiety, and restlessness–>lack of oxygen to brain
Cardiac cachexia-wasting of tissues
Cyanosis of skin, mucous memb, nail beds, lips

Question 14

Classification of heart failure

Answer 14

Stages A&B: no signs or symptoms, but are at risk due to risk factors or heart abnormalities
Stage C: current or past symptoms
Stage D: refractory heart failure–>eligible for advanced treatment and/or transplantation

Question 15

What are the treatments for heart failure?

Answer 15

Lifestyle changes can lessen symptoms

Drug therapy

Question 16

What are the lifestyle changes that can lessen HF symptoms?

Answer 16

Smoking cessation
Exercise
Weight loss
Limit consumption of caffeine and alcohol
Reduce stress

Question 17

What are the drug therapies for HF?

Answer 17

ACE inhibitors
Diuretics
Vasodilators
Beta blockers
Calcium channel blockers

Question 18

What questions do you ask a patient to check for current HF?

Answer 18

Heart failure
Swelling in feet or ankles
Shortness of breath
Weight gain–>3 pounds over 7 days with edema***red flag- postpone treatment

Question 19

What are the physical characteristics observed in the dental setting indicating heart failure?

Answer 19

Cyanosis
Jugular veins
Vital signs prior to treatment and throughout appointment

Question 20

How is an ASA II patient managed in the dental setting?

Answer 20

(mild dyspnea and fatigue during exertion)
May need supplemental oxygen, 3-5L/min via nasal cannula
Chair more upright position

Question 21

How do you manage an ASA III patient?

Answer 21

(mild dyspnea and fatigue under normal conditions)
Require medical consultation
Orthopnea s concern
Modification in patient positioning
Supplemental oxygen

Question 22

What are the symptoms and how do you manage an ASA IV patient?

Answer 22

(dyspnea, orthopnea, and fatigue at all times)
Require medical consultation
Elective treatment should be postponed until symptoms are controlled

Question 23

What is Acute Pulmonary Edema?

Answer 23

Most dramatic life-threatening symptom of left HF
Inhibits lung expansion
Decreased ability of lungs to oxygenate blood

Question 24

What are the precipitating events of Acute Pulmonary Edema?

Answer 24

Stress
Infection
Failure to take medications as prescribed
Meal high in sodium

Question 25

What are the signs and symptoms of Acute Pulmonary Edema?

Answer 25

``` Gasping for air Rapid pulse Cool, moist skin Cyanotic lips and nail beds Anxiety Dyspnea with cough that may produce frothy, blood tinged sputum Loud course lung sounds ```

Question 26

What are the basic treatments for Acute Pulmonary Edema?

Answer 26

Focus on reduction of fluids in lungs Sitting patient upright redirects blood to lower extremities and relieves pressure on lungs Drug therapy: diuretics, vasodilators Oxygen Severe cases may need to be intubated and ventilated mechanically in a hpspital

Question 27

What is the treatment protocol of Acute pulmonary edema in the dental setting?

Answer 27

Life threatening Call EMS Terminate all treatment Reduce patient anxiety to reduce cardiac and respiratory workload Position patient comfortably, usually upright to aid breathing ABC's Oxygen at 10L/minute Monitor vital signs every 5 minutes Nitroglycerin 2-3 tablets/sprays every 5-10 minutes (do not use if systolic BP < 100mmHg If consciousness is lost, place in supine and start CPR

Question 28

What do can you do if dyspnea continues in a patient experiencing acute pulmonary edema?

Answer 28

Perform bloodless phlebotomy: Place 3 tourniquets or BP cuffs on 3 limbs (6 inches below groin/4 inches below shoulder) tight enough to reduce blood flow, but loose enough to maintain arterial pulse Remove one tourniquet at a time every 5-10 minutes and reapply to free extremity

Question 29

What does bloodless phlebotomy do?

Answer 29

Removes blood from circulation permitting heart to pump remaining blood more effectively Results in reduction in pulmonary congestion and improves breathing

Question 30

``` 1. Left ventricular HF results in A. respiratory distress B. peripheral edema C. distended jugular while lying or sitting D. Nocturia ```

Answer 30

A. respiratory distress

Question 31

2. All of the following symptoms are observed in late stage heart failure except one. Which symptom is the exception? A. cyanosis of the lips and/or nail beds B. cardiac cachexia C. mental confusion and anxiety D. stabbing chest pain lasting less than 30 seconds

Answer 31

D. stabbing chest pain lasting less than 30 seconds

Question 32

3. Right ventricular heart failure usually develops before left ventricular heart failure. The major clinical symptom of RV heart failure is pulmonary edema. A. The first statement is true, the second statement is false. B. The first statement if false, the second statement is true. C. Both statements are true. D. Both statements are false.

Answer 32

D. Both statements are false.

Question 33

4. When providing elective dental treatment, supplemental oxygen and modification of patient positioning should be considered for all of the following except one. Which one is the exception? A. ASA II heart failure patients B. ASA III heart failure patients C. ASA IV heart failure patients

Answer 33

C. ASA IV heart failure patients

Question 34

5. A bloodless phlebotomy A. should only be performed in a hospital setting on patients suffering from heart failure. B. could be performed in the dental setting to help reduce peripheral edema in heart failure patients. C. could be performed in a dental setting to help manage lung congestion in patients suffering from acute pulmonary edema. D. Is never a treatment option for patients experiencing Acute pulmonary edema.

Answer 34

C. could be performed in a dental setting to help manage lung congestion in patients suffering from acute pulmonary edema.

Question 35

The administration of nitroglycerin is indicated in the management of acute pulmonary edema and heart failure. The administration of nitroglycerin is contraindicated in patients with a systolic pressure less than 100mmHg. A. The first statement is true, the second statement is false. B. The first statement if false, the second statement is true. C. Both statements are true. D. Both statements are false.

Answer 35

B. The first statement if false, the second statement is true.