ALI FARZAD, M.D. Baylor University Medical Center - Dallas, TX

March 26th & 27th, 2015

Modern management of CARDIOGENIC

PULMONARY EDEMA workshop!

GOAL Review Simple Management Pearls

that help SAVE LIVES!

Discuss Management of Hypertensive Cardiogenic

Pulmonary Edema

OBJECTIVE

220/135, 105, 40, 82%

Hx of HTN, DM, CAD

Woke up dyspneic

Diaphoretic, Distress

Rales to Apex BL

JVD, Looks DRY!

70 YOM with ACUTE DYSPNEA

Severe Respiratory Distress, Agitated

250/160, 120, 45

SpO2 = 78% NRB

“ I can’t breath, I am dying”

ACUTE HYPTERTENSIVE CARDIOGENIC

FLASH PULMONARY

EDEMA

Intubate…?

Furosemide…?

Opiates…?

ACE Inhibitors…?

Nitroglycerine…?

First 5 mins?

What are others doing?Examined use of AHF Tx’s (ESC guidelines)

in different presentations and BP’s (N=620)

• IV Furosemide, 76%

• Nitrates, 42%

• NIPPV, 50%

• Opiates, 29%

Tarvasmäki et al. European Heart Journal: Acute Cardiovascular Care. 2013

Hypertensive AHF

Tarvasmäki et al. Management of AHF & effect of SBP on IV therapies. European Heart Journal: Acute Cardiovascular Care. 2013

Hypertensive AHF

Tarvasmäki et al. Management of AHF & effect of SBP on IV therapies. European Heart Journal: Acute Cardiovascular Care. 2013

IV Furosemide was MOST COMMONLY USED

IV Nitrate use was LOW ~30 %

NIPPV use was LOW ~30 %

Does our patient need LMNOP?

LMNOP

N.O.P !

ACUTE HTN CARDIOGENIC EDEMA

Inability of LV to handle pulmonary venous return

Increased hydrostatic pressure g leakage from pulmonary capillaries and venues into alveolar space

LV DYSFUNCTION

TOO MUCH PRELOAD

TOO MUCH AFTERLOAD

ACUTE HTN CARDIOGENIC EDEMA

ACUTE LV DYSFUNCTION !

CARDIAC OUTPUT

" Catecholamine's

" SVR / BP

AFTERLOAD Mismatch

" O2 Demand

DYASTOLIC Dysfunction !

CONTRACTILITY

" HYDROSTATIC

PRESSURE

PULMONARY EDEMA

HYPOXIA & ISCHEMIA

Resp. Failure Agitation &

Anxiety

" Catecholamine's

THE CYCLE

Management GOALS

BREAK THE CYCLE

CORRECT HYPOXIA

REDISTRIBUTE FLUID OFF LUNGS

DECREASE PRELOAD AND AFTERLOAD

Cotter et al. American Heart Journal 2008 Collins et al. Annals of Emergency Medicine 2008

Treat them all the SAME?~ 50 % of CPE patients

are not fluid overloaded!

Vascular failure rather than total body fluid overload!

Furosemide– IV: Peak effect in 30 mins

– Direct vasodilatory effect

Supposedly reduces preload

in 5-10 minutes?

– Delayed effect (30-120 min)

Pickker et al. Direct Vascular Effects of Furosemide in Humans. Circulation. 1977

Furosemide Harmful?

– IV Furosemide administered to post-AMI CHF patients

– Significant reductions in filling pressures occurred only in patients that had diuresis

Kiely et al. Circulation. 1973

– IV Furosemide caused significant reductions in CO in first 90 mins (~17%)

– CO gradually returned to normal after diuresis

Ikram et al. Clin Sci. 1980

Furosemide Harmful?

– IV Furosemide (1mg/kg) given to AMI patients with LV Failure

– Early adverse HD effects • Increased BP & HR in first 30 mins • Decreased CO & SV in first 90 mins

– Returned to baseline after diuresis

Nelson et al. European Heart Journal. 1983

Furosemide Harmful?

– IV Furosemide given to Class III & IV

– Early activation of RAAS

– Increased in plasma Renin, NE & Vasopressin levels

– Early adverse HD effects • Increased HR & SVR • Decreased SV

– Returned to baseline after diuresis

Fracis et al. Annals of Internal Medicine. 1985

Furosemide Harmful?

– Compared NTG, Furosemide and Morphine in 57 Prehospital APE patients

• NTG alone had best outcomes (NO Adverse Effects)

• Adverse Effects in Furosemide Group – >25% required fluids later

– Significant electrolyte abnormalities

– 23% misdiagnosed, didn't have edema!

– Worse outcomes in patients who got Furosemide & Morphine

Hoffman et al. Chest. 1987

Furosemide Useful?

– Effects of IV Furosemide on PCWP over 1 hr

– Increased PCWP over 15 minutes – Returned to baseline after diuresis

– If patients treated with Nitrates and Captopril first, produced immediate and sustained decrease in PCWP

Kraus et al. Chest. 1990

Furosemide Useful?

Evaluated outcomes in 599 prehospital presumed decompensated CHF patients

–18% of patients were misdiagnosed/tx

–Asthma, COPD, pneumonia, bronchitis

–Patients receiving morphine and/or furosemide (+ NTG) — 21.7% mortality

–Patients receiving NTG alone — 2.2% mortality

Wuerz et al. Annals of Emergency Medicine. 1992

Furosemide Harmful?

Evaluated 144 prehospital presumed decompensated CHF patients given furosemide

– 42% of patients had a final diagnosis that was not CHF, furosemide considered “inappropriate”

– 17% of patients diagnosed with sepsis, dehydration, or pneumonia (without CHF), furosemide considered “potentially harmful”

– Nine patients died, seven of whom received furosemide “inappropriately”

Jaronik et al. Prehosp Emerg Care. 2006

Furosemide Harmful?

ADHERE registry, N=> 100,000 patients

Compared patients who got more or less than 160 mg IV

Furosemide in 24hrs.

– <160 mg had significantly less decline in renal

function, length of stay, and in-hospital mortality

(OR 0.87, 95% CI 0.78-0.97 p=0.01)

Peacock et al. Insights from ADHERE. Cardiology. 2009.

Furosemide Harmful?

Furosemide Summaryi Preload through diuresis is a delayed effect!

Many patients are NOT fluid overloaded anyway! – No good data on direct venodilating effect

– Activates SNS & RAAS

– h HR, SVR, myocardial 02 demand, ischemia

– i SV, CO & tissue perfusion

– May cause adverse HD effects early-on

– Harmful when diagnosis of HF is wrong!

Furosemide Pearls

Consider only if certain that patient is in acute HF & is volume overloaded

May be HARMFUL…JUST HOLD OFF!

~ HALF of the patients with AHF are NOT total body fluid overloaded!

MORPHINEThought to reduce:

– Preload

– Afterload

– HR & O2 Demand

• IV: 2-5 mg bolus, works quickly

• Causes Nausea

Morphine SummaryTHE EVIDENCE IS POOR!

ADHERE analysis:

–Independent predictor of mortality (OR = 4.84) –Increased risk of intubation, LOS, ICU admission rate

BECAREFUL WITH OPIATES & ANXIOLYTICS Blunts respiratory drive!

Peacock et al. ADHERE analysis. Emergency Medicine Journal 2008

ACE-InhibitorsSome recommend adding ACE inhibitors along with nitrates for greater AFTERLOAD reduction.

Enalaprilat at a dose of 1.25mg IV OR Captopril 25mg sublingually.

Appears to be safe & effective.

Has more effect on afterload than nitrates.

NITROGLYCERIN– Dose dependent dilation of

arterial and venous beds

– Decreases Preload, Afterload,

and O2 demand

• Onset: 1-3 mins

• Duration: 3-5 mins

• Contraindications: PDE-5 inhibitors

Sublingual NTGSL tab = 400 mcg or 0.4 mg

– q5 mins =80 mcg/min. ~ 75% absorbed = 60!

– q3 mins = 100 mcg/min

– Dry Mouth? - Spray or few drops of water

START THE DRIP HIGH AND TITRATE UP QUICKLY

Lots of Nitrates vs. Lots of Furosemide

Cotter et al. The Lancet. 1998

110 patients randomized

Isosorbide 3 mg q5 mins = 600 mcg/min NTG!

vs Furosemide 80mg q 5 mins.

Furosemide Group:

–More people intubated (21 vs. 7, p=0.004)

–More people with MI (19 vs. 9, p=0.047)

HIGH DOSE NITRATES

Sharon et al. Journal of American College of Cardiology. 2000

40 patients who failed conventional treatment

(Lasix, O2, Morphine)

Repeated boluses of IV ISDN 4mg q 4 min vs. BIPAP and standard dose nitrates, pre-hospital

– Intubation: 16 BIPAP vs 4 ISDN

– Death/MI: 17 BIPAP vs 5 ISDN

– Quicker improvement with ISDN at 1hr

HIGH DOSE NTG

Levy et al. Annals of Emergency Medicine. 2007

29 patients who failed conventional treatment

~ 30 mcg/min IV gtt. Then 2mg IV boluses q 3-5 mins for 30 mins.

Mean dose was 6.5 mg!

HIGH DOSE NTG Group:

– Less intubations: 14% vs 27%

– Less complications: 20% vs 29% (1 clinically insignificant episode of hypotension)

– Less BIPAP: 7% vs. 20%

– Less ICU admissions: 38% vs. 80%

– Shorter LOS: 4.1 days vs 6.2 days

BOLUS DOSE NTG

Mallick et al. Society of Critical Care Medicine Congress. 2012

Protocol of Bolus Dose NTG & NIV to Avert Intubation

N=41, Prospective Cohort in Sympathetic Surge Crashing APE

ED Called Anesthesiology for EMERGENT INTUBATION

Started on NIV instead, repeated boluses of NTG

Bolus Dose NTG:

– Mean # of boluses = 4 (800-28k mcg) – None (0%) required intubation! – 2 had transient SBP < 100, resolved with IVF

NTG Pearls

DON’T GIVE WIMPY DOSES

SL NTG q 5 mins = 60-80 mcg/min absorbed

Start IV gtt at least at 100/mcg and titrate up,

FAST!

NIPPV Summary

Vital et al. Cochrane Database of Systematic Reviews. 2008

21 Trials, N=1071

NIPPV significantly reduced:

–Hospital mortality (RR 0.6, 95% CI: 0.45-0.84)

• NNT = 1 in 13 helped (LIVE SAVED)

–Intubation (RR 0.53, 95% CI: 0.34-0.83)

• NNT = 1 in 8 helped (NO TUBE)

NIPPV Summary

Vital et al. Cochrane Database of Systematic Reviews. 2013

32 Trials, N=2916

NIPPV significantly reduced:

– ICU LOS by 1 day

– Adverse Effects

NIPPV Pearls

No outcomes difference between CPAP& BIPAP

Safe, saves lives, prevents intubations!

Reduces WOB, recruits alveoli, works FAST!

Let’s Summarize

The Final Pearls~ HALF of the patients with AHF are NOT

total body fluid overloaded!

Focus on what saves lives: Early NIV and NTG (Don’t

give wimpy doses!)

These patients don’t have time for LMNOP FUROSEMIDE MAY BE HARMFUL…

PEDAL EDEMA DOES NOT KILL!

@alifarzadmd

THANK YOU!