Pulmonary Oedema

Question 1

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous MI with three stents inserted, AF and a previous DVT.

Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

Blood Pressure: 164/97
Heart Rate: 117
Respiratory rate: 28
Saturations: 85% on room air
Temperature: 36.9 degrees

How would you approach this patient?

Answer 1

A
* Ensure patent airway
* If any compromise, call for help early (anyone in A&E with airway skills or ITU/anaesthetic registrar

B
* Pt is SOB with 85% on RA - start oxygen - 100% NRB
* Continuous SpO2 monitoring
* Look, auscultate and percussion - any crepitations / wheezing?

C
- HR, BP, CRT
- 12-lead ECG
- Signs of fluid overload (JVP, peripheral oedema)
- Pt will need close monitoring of fluid balance - catheter
- Establish IV access

D
- Blood glucose, temperature

E
- Examine the rest of the patient, anything else that could be causing SOB?

Question 2

What is the likely diagnosis and what are your differential diagnoses?

Answer 2

Likely: Pulmonary oedema 2nd to decompensated heart failure

Seconds to minutes
* Acute asthma attack
* Anaphylaxis
* Pneumothorax
* Inhaled foreign body

Hours to days
* Pneumonia
* Heart Failure
* Pleural Effusion
* Acute PE

Weeks to months
* Worsening COPD (smoker)
* Chronic asthma
* Heart failure
* Pulmonary fibrosis
* Anaemia
* Pulmonary hypertension
* Obesity

Question 3

What initial investigations will you arrange?

Answer 3

Bedside
- Continuous SpO2 monitoring (could be innacurate if peripherallu shutdown)
- 12-lead ECG
- ABG for PaO2, PaCO2

Bloods
- FBC, U&Es, Bone profile, CRP
- Troponin if indicated (ACS > decompensated HF, pt is diabetic, could be silent)
- If signs of sepsis >sputum MC&S, blood cultures, urine MC&S

Imaging
- CXR for signs of pulmonary oedema, pneumothorax, consolidation
- Echocardiogram (when pt more stable) to assess LVEF

Question 4

What signs on CXR would suggest pulmonary oedema?

Answer 4

• Interstitial shadowing
• Enlarged hila
• Prominent upper lobe vessels
• Pleural effusions
• Kerley B lines
• Cardiomegaly (may or may not be present)

Question 5

Your assessment and initial investigations suggest that this patient has pulmonary oedema secondary to decompensated heart failure. How will you manage this patient?

Answer 5

• Sit upright
• Supplemental O2 if SpO2 < 90%
• Establish IV access
• Insert urine catheter if not in already (monitor UO)
• Monitor ECG - treat any arrhythmias

Diuretics
* Furosemide 40-80 mg IV (larger dose if CKD or already on diuretics)

Vasodilators
* If sBP > 90 mmHg
* IV GTN infusion, titrate

Pt needs to be continually monitored
* If any worsening, contact ITU (pt may benefot from non-invasive ventilation
* If pt has sBP < 90 mmG on presentation, I would contact ITU for inotropic support

Vasodilator therapy for pts with urgent need for afterload reduction (e.g. severe HTN)

Question 6

What could be the cause of this patient’s decompensation?

Answer 6

• Chronic stable heart failure - easy to decompensate due to intercurrent illness (like e.g. pneumonia)
• Acute Coronary Syndrome
• Cardiac Arrhythmias (AF)
• Uncontrolled HTN
• Pt’s failure to adequately fluid restrict / lack of compliance with meds

Question 7

Do you know any classifications of heart failure?

Answer 7

New York Heart Association (NYHA) - functional classification of the extent of heart failure

Question 8

What medications improve morbidity and mortality in patients with heart failure?

Answer 8

• ACEi / ARBs
• Beta blockers
• Mineralocorticoid receptor antagonists
• ARNi (antiotensin receptor Neprilysin inhibitor) - entresto
• SGLT2 inhibitors

Question 9

The patient has AF. Would you start them on anticoagulation?

Answer 9

• Calculate CHADS2-VASC score to estimate the risk of thromboembolic stroke in that patient
• Calculate ORBIT score to estimate the risk of bleeding
• Decide based on that

Question 10

What counselling should the patient receive before starting a DOAC?

Answer 10

• Explain what DOACs do and their importance to prevent stroke
• No monitoring needed
• Rapid onset compared to warfarin (requires a loading period)
• Safety net regarding the signs and symptoms of unusual bleeding and to seek urgent medical attention
• To seek urgen medical attention if any trauma, as higher risk of bleeding
• To inform their doctor/dentist that they are taking DOAC before any planned procedure
• Advise to carry a patient alert card with them at all times

Question 11

You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 11

Situation: This is a 72 year old woman who has decompensated heart failure with significant pulmonary oedema causing saturations of 85% at presentation. Her breathing has been deteriorating over the last two weeks. There is no suggestion of infection based on her presentation.

Background: She has an extensive cardiovascular history including a previous myocardial infarction.

Assessment: Initial medical management has been with oxygen and IV diuretics. Investigations, including her chest x ray, would suggest that this is decompensated heart failure.

Recommendations: If initial management is not helpful in relieving her symptoms, I would recommend initiating a vasodilator, such as a GTN infusion, if her BP remained elevated. If the BP is dropping or persistently low then the patient may need inotropic support and ITU should be involved early. Investigations will be needed to establish the cause of the decompensation.