7.3. EDEMA OF THE LUNGS

Related titles

Chronic (congestive) heart failure, respiratory distress, respiratory failure, acute respiratory distress, myocardial infarction, pulmonary embolism, COPD, asthma, anaphylaxis.

Purpose of assistance

1. Decreasing manifestations of respiratory failure and difficult breathing.
2. Maintenance of adequate oxygenation and perfusion.
3. Directing efforts to reduce afterload and increase preload.

Description of the patient

Inclusion criteria

1. Respiratory failure with existing wheezing.
2. The clinical picture indicates the presence of congestive heart failure.

Exclusion criteria

1. The clinical picture indicates the presence of infection (for example – fever).
2. The clinical picture indicates the presence of asthma/COPD.

Management of the patient

Status assessment

1. Anamnesis:

a) use of diuretics and adherence to their schedule;
b) weight gain;
c) leg swelling;
d) orthopnea.< /p>

2. Examination:

a) respiratory noises – crackling/wheezing;
b) swelling of the lower extremities;
c) straining of the jugular veins;
d) cough and /or productive cough with pink/foamy sputum;
e) sweating;
e) chest discomfort;
e) hypotension;
e) shock;
g) respiratory failure, evaluate:

• • • • ability of the patient to speak in complete sentences;
      • participation of auxiliary respiratory muscles.

Treatment and intervention

1. Control the airway.
2. Carry out oxygen therapy, the goal is saturation at the level of 94-98%.
3. Initiate primary condition monitoring and record ECG.
4. Ensure I/O access.
5. Glyceryl trinitrate 0.4 mg sublingually, can be repeated every 3-5 minutes until the systolic pressure is above 100 mmHg. (if there are no contraindications in setting the time interval, use the indicator of 3 minutes).
6. PPDD/DPPTD – consider an intubation tube if there is severe respiratory failure or if there is no improvement after using less invasive methods.
7. For suspected altitude-related pulmonary edema, treat according to the Mountain Sickness guideline.

Patient safety

There are no recommendations.

Useful information for training

Key points

1. Differential diagnosis:

a) myocardial infarction;
b) chronic (congestive) heart failure;
c) anaphylaxis;
d) asthma;
e) aspiration;
e) COPD;
e) pleural effusion;
e) pneumonia;
g) pulmonary embolism;
h) pericardial tamponade;
br />y) intoxication.

2. Non-invasive ventilation with positive pressure:

a) contraindications:

• • • • hypoventilation;
      • altered state of consciousness;
      • violation of airway patency;
      • risk of aspiration;
      • pneumothorax;
      • facial injury/burns;
      • systolic pressure below 90 mmHg;
      • recent operation of the oropharynx, trachea, bronchi;

b) benefit:

• • • • increased oxygenation and perfusion due to less effort to breathe;
      • prevention of alveolar atelectasis;
      • improving the ability of the lungs to expand;
      • reduction of BH and relaxation of respiratory effort, heart rate and systolic pressure;
      • improving the delivery of bronchodilators;
      • reduction of preload and afterload, improvement of cardiac output;

c) complications:

• • • • most often it is fear and anxiety;
      • theoretically, there is a risk of hypotension and pneumothorax, since noninvasive positive pressure ventilation increases intrathoracic pressure, which in turn decreases venous return and cardiac output;
      • sinusitis;
      • abrasion (scratches) of the skin;
      • conjunctivitis – risk minimization by using a mask of the correct size;
      • possibility of barotrauma – pneumothorax or pneumomediastinum (rare).

3. Allow the patient to take a comfortable position – decompensation may progress if the patient is forced to lie down.

4. Chronic (congestive) heart failure is a typical cause of pulmonary edema – other causes include:

a) medications;
b) exposure to altitude;
c) kidney failure;
d) damage to the lungs by gas or serious infection;
g) severe injury.

5. The use of nitrates should be avoided if the patient has used phosphodiesterase inhibitors within the last 48 hours. Examples: sildenafil, vardenafil, tadalafil, which are taken for erectile dysfunction and pulmonary hypertension. Also avoid IV eprostenol or treprostenil, which are used for pulmonary hypertension. Administer nitrous drugs with particular caution, if at all, to patients with inferior myocardial infarction or suspected right ventricular ST-elevation myocardial infarction, as such patients require adequate right ventricular preload.

6. Glyceryl trinitrate reduces left ventricular filling by venous dilatation. At increased doses, the drug sometimes reduces systemic afterload and increases stroke volume and cardiac output. Although some specialists recommend the use of ACE inhibitors in acute decompensated heart failure, we do not recommend this approach. There is very limited information on the safety and clinical efficacy of using new ACE inhibitors or angiotensin receptor blocker therapy early in the treatment of acute decompensated heart failure (i.e., in the first 12-24 hours).

7. The use of furosemide is not recommended at the pre-hospital stage. Pulmonary edema is a more common problem with volume distribution than with overload, so furosemide does not provide improvement in most patients. Incorrect diagnosis of congestive heart failure with subsequent strengthening of diuresis can lead to complications and death.

8. Nitrates produce objective and subjective improvements and may reduce the success of intubation attempts, the possibility of myocardial infarction (MI), and mortality. A large dose of nitrates can simultaneously reduce preload and potentially increase cardiac output. Because most patients have elevated arterial and venous pressure, frequent use of nitrates may be necessary to control BP and afterload. High-dose nitrate therapy, such as glyceryl trinitrate 0.8-2 mg sublingually every 3-5 minutes, is used in acute distress such as hypoxia, impaired consciousness, diaphoresis, or inability to speak in complete sentences. Application scheme – 2 tablets of glyceryl trinitrate sublingually (0.8 mg) at systolic pressure above 160 mmHg. or 3 tablets (1.2 mg) with systolic pressure above 200 mmHg. every 5 minutes. The problem with using high doses is that some patients are very sensitive even to normal doses and may have severe hypotension as a result. Accordingly, it is very important to monitor blood pressure during therapy with high doses of nitrates.

Key elements of documentation

1. Vital indicators.
2. Oxygen saturation.
3. Time of interventions.
4. Response to intervention.

Criteria for the effectiveness of aid provision

1. Time to start non-invasive positive pressure ventilation.
2. Number of patients with PPTD/DPPTD requiring intubation.
3. Time of onset of clinical improvement.
4. Assessment/auscultation of respiratory sounds in the lungs before and after each intervention.