CHF Flashcards
Describe cardiogenic pulmonary edema
An abnormal, diffuse and extravascular accumulation of fluid in the pulmonary tissues and air spaces that arises with changes in hydrostatic forces associated with left sided heart failure
How is heart disease ranked as a cause of death in the US?
1
Accounts for 1 in 7 deaths
What are some of the difference between cardiogenic pulmonary edema and non-cardiogenic pulmonary edema (ARDS)?
Non-cardiogenic pulmonary edema is the result of the immune system attacking the body
Cardiogenic edema is a result of increased hydrostatic forces in the pulmonary capillaries
Non-cardiogenic edema generates exudate
Cardiogenic edema generates transudate
Describe the basic gist of what is happening in the heart that results in pulmonary edema
The left ventricle fails to move blood forward
Pressure in the left ventricle increases
Because pressure in the left ventricle increased, blood from the left atrium cant get in completely so the pressure in the atrium grows
The blood in the pulmonary circulation gets backed up as a result
Pulmonary capillaries act as a relief valve
What is the normal systolic pressure in the pulmonary capillaries?
10-15 mmHg
What is the normal capillary oncotic pressure?
25-30 mmHg
What happens when pulmonary arterial pressure exceeds 30 mmHg?
When PAP exceeds capillary oncotic pressure, the balance tips and fluid is pushed out of the capillaries and is not pulled back in by the oncotic pressure resulting in pulmonary edema
Do red blood cells affect oncotic pressure?
No, since the hemoglobin protein is inside the cell wall of the RBC, they do not affect oncotic pressure
What are some causes of heart failure?
CAD
Arrhythmias
Myocarditis
Acute valve dysfunctions
Cardiomyopathy
Hypertension that isnt controlled
What are the two “flavors” of heart failure?
Heart failure with reduced ejection fraction
Heart failure with preserved ejection fraction
What is heart failure with preserved ejection fraction as called?
Diastolic heart failure
Describe what has happened in HFrEF
The left ventricle has suffered something that has resulted in reduced contractility and can no longer move the normal amount of blood
What does an ejection fraction of >70% indicate?
Hyperdynamic
How can you estimate LVEF?
By using an echocardiogram to estimate heart function
Describe what is happening in HFpEF
The fraction of the left ventricular volume being ejected is preserved
But the total volume of the left ventricle is reduced because the ventricle is failing to fully relax after systole so it cant be completely refilled
What is the normal range for ejection fraction?
50-70%
What does an ejection fraction of 40-49 indicate?
Mild dysfunction
What ejection fraction constitutes a mild dysfunction
40-49%
What does an ejection fraction of 30-39% indicate?
Moderate dysfunction
What ejection fraction constitutes moderate dysfunction?
30-39%
What does an ejection fraction of <30% indicate?
Severe dysfunction
What ejection fraction constitutes a severe dysfunction?
<30%
How can pulmonary edema affect surface tension?
Fluid shifting into the interstitium can lead to a swelling of the interstitium resulting in a decreased radius which results in a greater surface tension
T/F: Pulmonary edema can disrupt surfactant production
True
You suction a patient and see frothy pinkish white secretions. What is causing this and why is the sputum frothy?
Pulmonary edema
Surfactant is causing the sputum to be frothy, red blood cells are causing the sputum to be pink
What could you see in a patient who is going into shock as a result of pulmonary edema?
Low blood pressure
Obtunded
Extremities mottled, cool, clammy
Poor capillary refill
You auscultate a patient with cardiogenic pulmonary edema, what can you expect to hear?
Fine crackles that start at the lung bases and move up and coarsen as edema grows more severe
Wheezes
Rhonchi
Potential heart murmurs
What might you observe when examining a patient who is experiencing pulmonary edema?
Diaphoresis
Nasal flaring
Cough
Intercostal retractions
Supraclavicular retractions
Cynanosis
Enlarged tender liver
Describe paroxysmal nocturnal dyspnea
Shortness of breath at night due to fluid shift from the lower extremities resulting in a pulmonary edema and the need to sleep more upright
Patients usually know about this, ask them if they sleep sat up at night
What hemodynamic indices could indicated cardiogenic pulmonary edema
Increased RAP
Increased PAP
Increased PWCP
Decreased CO
Increased PVR
What does PCWP allow us the approximate?
Pressure in the left atrium
Increased pressure in the circulatory system places strain on the walls of the heart resulting in the release of what?
BNP B-type natriuretic peptide
What does BNp do?
Triggers a release of sodium by the kidneys which will cause fluid to follow the sodium and be removed from the body in
What does BNP greater than 100 pg/dl indicate?
Suggests congestive heart failure
What can testing a patients troponin levels tell us?
Whether or not they have had a myocardial infarction
What can testing BUN and creatinine tell us?
Whether or not the kidneys are adequately perfused
What would we see on a chest radiograph of a patient with cardiogenic pulmonary edema?
Bilateral fluffy opacities
Dilated pulmonary arteries
Left ventricular hypertrophy
Kerley A and B lines
Batswing or butterfly pattern
Pleural effusion
What would you see on the chest radiograph of a patient with moderate left heart failure?
Cardiomegaly
Engorgement of pulmonary artery
Kerley A and B lines
Bats wing or butterfly pattern is an indication of what?
CHF
What would you see on the chest radiograph of a patient with mild left heart failure?
Pulmonary venous congestion with dilated pulmonary arteries
What do Kerley A lines represent?
Deep interstitial edema that radiate out from the hilum into the central portions of the lungs
Where would you see kerley A lines on a CXR?
Most prevalent in the middle and upper lung regions
Do not reach pleura
Describe kerley B lines
Short thin horizontal lines of interstitial edema that extend inward from the pleural surface
Where are Kerley B lines found?
Most commonly seen in lung bases
Can be seen throughout the lung
What would you expect to see on the CXR of a patient with severe left CHF?
Cardiomegaly
Pulmonary artery engorgement
Interstitial pulmonary edema
Fluffy patches of pulmonary edema
Bats wing pattern
Why is supplemental oxygen not necessarily recommended in patients with CHF?
Causes systemic vasoconstriction
Causes pulmonary vasodilation
How does CPAP affect preload?
Decreases preload by reducing venous return by introducing positive pressure in chest
What type of ventilation is typically used to treat people with CHF?
CPAP
How does CPAP affect gas exchange?
Improves gas exchange by reducing the thickness of the alveolar walls
What are the advantages of CPAP for patients with CHF?
Reduced venous return
Decrease alveolar collapse
Reduce vascular congestion
Improve gas exchange
Reduce WOB
What are the common meds used to diurese patients?
Furosemide (lasix)
Bumetanide
Torsemide
What medications are typically used to treat preload?
Nitroglycerin
Morphine sulfate
What medications are typically used to reduce afterload?
Nitroprusside
What medications would be used for chronic management of CHF?
Ace inhibitors
Angiotensin 2 receptor blockers
Diuretics
Antiarrhythmic medication
