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FF162718
10-08-2002, 11:15 PM
There is a debate, (imagine that), about how to treat a severely hypoxic/dyspneic patient with a history of both asthma and CHF, when wheezing is present.

This brings us to the all important question, “Is it bronchial constriction, or is it a cardiac wheeze (fluid in the alveolar sacs filling to the bronchials)?” Obviously, other things need to be assessed prior to medicating our patients, pitting pedal edema, JVD, etc. Let’s assume that we have a patient without any obvious signs that scream CHF/pulmonary edema. I had one just the other day, so I know this is possible.

Some suggest, in these cases, treating the wheeze of unknown origin with a bronchodilator, such as Albuterol, to open the bronchials ultimately revealing crackles/rales (equating to CHF/pulmonary edema), then treating the fluid with a diuretic. That has the potential to create a problem. If it is CHF causing the dyspnea, the heart is already taxed by some type of pathology (i.e. prior infarction). Also, through compensatory mechanisms (not blocked by other meds), the human body will increase the heart rate to combat the current hypoxia. Most importantly, it is forbidden by my protocols to give a known CHF patient Albuterol for the above reasons.
So, what do we have? We have an injured heart with an already increased oxygen demand, which will be exacerbated by the Albuterol, potentially leading to further myocardial injury, and the potential lose of certification/license for deviation from protocol. Is this an acceptable risk?

Some others suggest treating the wheeze of questionable origin with a diuretic (i.e. Furosemide), providing certain parameters are in place (i.e. not hypotensive). This too has its negative effects, anywhere from renal failure to hypotension. Not to mention, if it is COPD/asthma, we have done nothing to fix the current means of hypoxia for the five minutes it takes for the diuretic Furosemide to onset. And let's be honest, diuretics are not exactly indicated for wheezing.

The first, most important rule in medicine is "Do no harm", and a personal rule of mine “Don’t lose your job”. So the question is how can we keep from breaking these rules? Are there any other diagnostic tools, or assessment techniques, (barring a Chest X-Ray), available to help with a treatment plan for these patients?
:eek:

ALS142
10-09-2002, 07:49 PM
This is one of the finest questions I have come across in 25 years of emergency medicine. If it's CHF and you give the albuterol, you open up the aveoli and create a vacuum which sucks more fluid into the space. If it's asthma and you give Laxix, or any other diuretic, while you're waiting for the effect, the patient gets worse.

I'm actually going to have to hit the books to find an acceptable answer to this one. Thanx.

hageremtp
10-09-2002, 09:04 PM
Tell you what we do here, we treat wheezes as just that. Give the bronchdilator.....then should the condition of rales or crackles come up you treat that. I spoke with our MD and he said that even though the heart is taxed in CHF, the lack of oxugen that the patient is getting (evident through the wheezes) will TAX the heart greater than giving the bronchdilator. He would rather see treating wheezes, and then deal with what arises then let the patient go untreated....but this is just him and what he wants....the next MD would tell you a complete different story.

On a side note, I took a pt in to the ER with cardiac asthma....did the neb and lasix treatment. The attending MD told me that the 2.5 cc's of NS in the neb is too much fluid for a patient that is already full, he stated that the pt should be given the lasix first then the neb.....

Who's right???? I will never know, but as long as I got my Medical Director behind me, I will stick to the protocols that I have in place......

latigo
10-10-2002, 01:52 AM
First I would want to know how long the transport time will be. If it will be short, why do this in the field? I understand that time is of the essence, but can treatment wait for a few minutes? Secondly, I why not call med control and talk to the ER doctor? Give them your assessment, and let them make the call. That's why they get the big bucks!:D I am not in any way being critical, just asking. Great scenario, FF162718! I always learn a lot from you guys throwing things around!:D

firemedic89a
10-10-2002, 06:10 AM
One problem with giving a bronchodialator in CHF is that albuterol which is typically given in the field has about 1/2 beta properties, so the heart that is in distress becomes even more so. I've run into this scenario quite a few times......many elderly in my run area with the CHF/COPD/Cardiac Hx and I'll go for the high flow 02/NTG/Lasix/MS if the B/P allows, hypotensive CHF/ right sided CHF is very rare in my area. If it is indeed a COPD type problem, at least the high flow 02 will help, we all understand the hypoxic drive issues, I've yet to drop a COPD'er with high flow 02 in 10 minutes or less while the lasix goes to work. This is where a decent set of "ears" comes into play, your decision to treat is based partially with your lung sounds you hear. Just my 2 cents, good answers in the earlier posts as well.

firemedic89a
10-10-2002, 06:11 AM
Sorry about not mentioning asthma, I don't see it with CHF in my neck of the woods...........

Ohiovolffemtp
10-10-2002, 09:33 AM
I just checked our protocol and a finding of wheezes gets a hand held nebulizer treatment of albuterol & atrovent no matter what the cause.

If asthma is present, we can call and request and order for solumedrol or subQ epi in severe cases.

If CHF is present, the patient also may get up to three nitro sprays/tablets and potentially a 1" nitro paste strip if their BP stays above 100 systolic. They may also get IV Lasix at an amount equal to their current dose if they already have it proscribed, have a hx of CHF, and report that their symptoms are similar to others related to their CHF. Otherwise, we have to call for orders before giving Lasix.

Another thing that we've used with success is CPAP, especially for the CHF'rs.

smurfe
10-10-2002, 10:29 AM
I agree, very good post. I have had many, many patients like this. Numerous times I have had patients that presented themselves with just wheezes and very diminished lung sounds. I treated them with Albulerol, and in the old days, Aminophyillin. When re-assesing treatment, I would now not hear wheezes and now hear rales, so I would switch to CHF protocol. I have never been questioned for this. I have on the contrary had many patients where I asses Rales and wheezes. These patients were treated with the CHF protocol and no bronchodialators given unless ordered to. I did once work in a system where every chf patient got a neb if they were wheezing or not and you would get an order for up to 200 mg of lasix, but you wouldn't give NTG or MS. Strange huh? I on the contray have witnessed many a partner that couldn't distiguish rales and rhonchi and treated a COPD patient under a CHF protocol. This is bad considering MS is a contrindication for COPD. I have gotten in the habit of both medics assesing lung sounds before a drug is administered to make sure both agree on a mode of treatment. If there is a disagreement the senior medic rules.:D ME:D I used to be a big on not sitting on scene with short transport times, but now adays with ER's so overloaded and everyone on divert status, I can see a benefit of doing the treatment as many times I have to hold the wall in the ER waiting for a bed even with a seriuos patient. That is just what it has all came to. At least the patient is getting some relief wating for "difinitive" care

Smurfe:D

ALSfirefighter
10-10-2002, 09:15 PM
For me it also plays off of the complete assessment and interview. Are there any other findings/situations that lead me to bend one way or the other. This is more of a rarity, we tend to see one or the other. One way to always determine whether or not a patient is wheezing from pulmonary edema or any from of COPD is history. If a person doesn't have a history of asthma/COPD its more then likely "cardiac asthma."

smurfe
10-10-2002, 09:31 PM
If a person doesn't have a history of asthma/COPD its more then likely "cardiac asthma."
True, I also consider the same myself, the sad thing is that where I work, 80%+ seem to state they have an asthma HX so that always seems to shoot that down the drain. Cruddy air quality here with miles of chemical plants lining the river here. But an excellent point made. So many medics start treating before they have the whole picture.

Smurfe :D

TraumaDog
10-15-2002, 08:20 PM
One thing these patents have in common is severe dyspnea. Which I can asked questions such as resp rate, tidal volume, mental status, skin color or spo2 reading. I guess I am traveling down the airway road. If they are in severe distress you can hardly be ragged on for intubating you patent, assisting ventilations and protecting their airway. PEEP with pulmonary edema works great.

In this part of the country albuterol is common in pulmonary edema protocol, however Xopenex may be another treatment option as it is broncho dialator with less beta efects. however I am not familiar enough with it indiactions and contras to say for sure. :cool:

PuffyNPFD
10-18-2002, 12:23 PM
I work in 2 different states under 2 VERY different sets of protocols.In Rhode Island the first drug you give for either CHF or COPD/asthma is Albuterol. I disagree with this because of the aforementioned reasons stated by the others. I am also an EMT-P in a state that glorifies the EMT-Cardiac, (1100 hrs. training and clinical vs. 140 classroom teaching "cookbook" EMS) so I know why it shouldn't be given right away. I get into debates with my Lt. (an EMT-C) because on the runs I tech I don't give it right away, if at all. In Connecticut, where I work part time it is absolutely contraindicated for Tx of CHF, because of the obvious negative effects that it can cause.

Medic946
10-18-2002, 02:36 PM
About fifteen years ago when my servie first instituted albuterol we were concerned with giving it to CHF patients who were exhibiting the infamous cardiac asthma. ie new onset or beginning CHF that souded more like a wheeze than rales. Our medical director assured us that albuterol on a CHF'er would do more good than harm and in the years since I can't think of a single case that contradicted his position. In many times when patients have both COPD and CHF history the albuterol would resolve the wheeze and the rales could then be heard loud and clear. They were then treated with lasix, NTG sl and paste, and MS if vitals allowed. Seemed to help everyone I ran into.

swrr88
10-21-2002, 07:12 PM
I have been wondering the same thing myself for awhile but I have to say I don't know the best answer.

I can tell you that here we do treat CHFers with Albuterol. I thought it was a bad idea until the medical director explained his reasoning. He cited multiple studies that showed residents in the ER and hospitals failed to properly determine CHF from COPD,Asthma without x-rays or other advanced test. He manages the residents in his ER and says if he can't expect them to be correct a majority of the time with nothing more than their ears how can he expect us to be?

According to him Albuterol will not cause any undo harm to a CHFer and will in fact help as many have compounding problems of CHF,COPD, and Asthma. We actually don't give Lasix unless its a severe,severe case and then by order only. We do the nebulizer and nitro as long as they are not hypotensive plus MS. Why? The doc says while nitro will definitely help a CHFer and MS will help, too...the lasix could be very harmful to a pt that isn't in CHF but instead is COPD or Asthma.

I thought it was strange at first, but now I think he is on to something. We aggressively treat with what we have to use and have had good success, but we don't have a high number of the wrong treatments being given. I know of calls I have run or partners have run that ended up with xrays showing no signs of CHF. The pt was better anyway because of how we treated. You can still get the lasix when there is pink froth showing but pts aren't being dumped in lasix without solid information.

stu

emstrainer
10-22-2002, 09:19 PM
CPAP seems to be a great tool for CHF and COPD. Is there any research suggesting it's use in Asthma patients ? It also seems that the literature suggests Nitrates are the most important drug for CHF. Our protocols calls for .4mg SL Nitro, Albuterol/Atrovent Combo, Lasix 80mg ....

Jason Kinley LT/EMT-P

RoryEl
10-22-2002, 10:43 PM
I gotta go with ALS on this one. This is an assessment driven differential Dx (yeah, I know we don't Dx, Right!) This is where a good hx and set of ears pays big dividends. The question is are you hearing vescicular and bronchiovescicular breath sounds where you should? Any adventicious breath sounds? If so, what? How about S3 gallop?

RemptyP
10-26-2002, 07:41 AM
So what do you do in the pt with Hx of COPD , CHF and HTN who has a quiet chest? No enough air is moving to discern just what breath sounds are hiding in there? Perhaps the patient is suffering a combination of exacerbation of COPD and an epsiode of CHF! I have used Albuterol in these patients for many years without deleterious effects to the patients. They need to be oxygenated. If, by giving the Albuterol more space is available in the bases for fluid then more space is available in the middle and upper lobes for air exchange and oxygenation, giving more time for you to get nitrates, furosemide and MS on board and working. This may prevent the need for intubation, which, while solving our short term airway problem may cause more long term problems for the now ventilator dependent patient.

hageremtp
10-26-2002, 11:28 PM
Remptyp- I agree with you....use the neb to get em open and then treat what you find from there. I guess if I were to put down that the pt had wheezes on my trip ticket and I didnt treat em with a neb I would have to defend myself in front of the MD at run review. He made the protocols, and ours says: Treat wheezes with a neb. After that opens the lungs then treat what you hear. If the pt continues to wheeze do it again.

Had a good asthma pt the other night. Gave 3 neb treatments and Epi sub Q prior to the Hosp. He was in the tripod positon and there was little air moving. SO I decided to try the neb, first one work somewhat...at least it opened him up enough to allow me to hear the wheezes that I could first hear!

hageremtp
08-22-2003, 05:55 PM
BUMP!

ABMedic
08-22-2003, 11:52 PM
It is a interesting debate - however think about the pathophysiology of "cardiac asthma" - the fluid shift occurs in two phases - initial interstitial pulmonary edema followed by alveolar flooding.

The interstitial pulmonary edema induces the bronchospasm - look at a CXR next time and ask the ER doc to point out peribronchial cuffing to demonstate this phenomena.

Now the shift in fluid causes both a mechanical restriction (wheeze) and also induces bronchospasm (wheeze) possibly due to activation of receptors in the nonadrenergic noncholinergic or NANC pathway in the pulmonary interstitial space.

The clinical utility of Ventolin in the treatment of pulmonary edema is to minimize the degree of bronchospasm, whereas the other pharmacological agents are utilized to reduce ventricular preload and afterload which reverses the fluid shift. Concerns surrounding increased myocardial oxygen demand due to bronchodilators is over-rated, in fact, in most cases a reduction in heart rate is seen.

ABMedic

BCALS11
08-23-2003, 04:05 AM
Dudes,

ABMedic hits it..... bronchospasm is only the symptom of the issue here. Pulmonary edema is history and clinical presentation dependant whether it is cardiogenic in nature or otherwise.

Is the CHF/cardiogenic pulmonary edema patient going to have wheezes associated with their crackles, probably. Is that the thing we should be treating first, not typically. If you have a reasonable history, reasonable clinical findings, and a certain amount of clinical judgement, preload reduction is the name of the game. O2, rest, possibly IPPV (intubation only as a last option), nitrates in large volumes (upwards of 10 mg plus), morphine, and then loop diuretics. If that treatment opens the door to refractory bronchospasm (particularly in the COPD affected patient), then treat with beta 2 agonists as an afterthought.

In my mind, the bronchospasm seen in CHF/cardiogenic pulmonary edema patients is only an associated symptom that is usually relieved with the treatment aimed at the underlying pathology. The old addage of treating the wheezes to bring out the crackles is outdated and only delays treatment of the underlying issue.

Aggressive preload reduction, decreased sympathetic tone (and therefore venous return to the right heart via throacic pump effect), and early diuresis are the name of the game in cardiogenic pulmonary edeam patients that we see pre-hospital. Ventolin seems to me to be a useful adjunct in these patients but only as a late intervention to deal with a concomitant refractory bronchospasm issue.

My 2 cents anyways, good discussion folks.

msharpe1047
08-23-2003, 07:56 AM
Hager,
Yhanks for bringing this other thread up. There is a lot of interesting information in these posts. These post have been very helpful. Where I am just getting ready to attend paramedic class these post give me more understanding about what is going on with pts. Thanks all for the interesting discussions and bring up varied points of view.:D

ABMedic
08-24-2003, 12:20 AM
BCALS11

I think I need to clarify the post - pulmonary edema induced bronchospasm is a symptom ... but with a pathophysiology mechanism that can be concurrently treated with inhaled beta agonist (ventolin etc). Initiating inhaled beta agonists early while concurrently reducing preload and afterload addresses not only the symptoms, but also the pathophysiology of acute heart failure with pulmonary edema.

Thoughts?

ABMedic

twocuts
08-24-2003, 09:24 PM
Those are my thoughts as well ABmedic. I usually do not give a neb unless I hear diffuse wheezing. If I have a few wheezes, severe dyspnia, rales, tachycardia and Hypertension, I am going to monitor the wheezes and go for the root of the problem. After re-assessing if they are still wheezing or are wheezing more, I will give them a neb. My experience is that if I have someone I am unsure of the etiology and it is CHF, I know pretty damn fast after giving that first neb. Cause, I am usually bagging them.

3 reasons for a wheeze. Fluid, spasm and edema. Treat the cause.

FF162718
08-26-2003, 07:58 PM
To all who have replied to my initial post, thank you. It has been almost 10 months since the initial post, and I am still receiving replies.

It is a controversial subject that has left me searching for answers. I work in a system that directly stipulates that no beta agonists shall be used in the case of a patient in CHF with pulmonary edema. That has left most of us guessing when we have a patient with a history of both COPD/Asthma & CHF, and has no obvious signs that point to one or the other as the culprit.

My initial question was directed more to the diagnostic capabilities of our Paramedics (or lack there of), not to the treatment of one or the other. There are such options such as CPAP, which can be used to treat either (and we use CPAP aggressively, in my service, to treat CHF only). Maybe a course of treatment that addresses both COPD & CHF is the way to go, but then there are still questions as to what level of PEEP to use.

Those of us who consider B2 agonists as harmful to those suffering from "unconfirmed CHF", (due to the increased myocardial oxygen demand), suggest to start treatment with nitrates, and loop diuretics to decrease preload. That is a great idea, and is used vigorously nationwide, I'm sure! But that poses a serious problem if the patient is suffering from a COPD/Asthma related respiratory disorder.

On the other hand........ If we are aggressive with the B2 agonists with a patient exhibiting a "cardiac wheeze" secondary to CHF, we may very well be "bagging" the patient (as twocuts put it) or worse yet, intubating the patient secondary to our treatment methods.

So to sum up my seemingly endless pursuit of answers........ Are there any better ways to build an "accurate field impression" in a patient who exhibits extreme dyspnea with a sub-acute onset, decreased bilateral breath sounds with a noted diffuse wheeze, +2 - +4 pitting edema, and who has a history of both COPD & CHF?

To quote twocuts again,"3 reasons for a wheeze. Fluid, spasm and edema. Treat the cause."

I ask simply this, how do we accurately know what the "cause" is? Barring chest films, I have read nothing that would lead me to an accurate diagnosis of my patient. Any other thoughts? :eek:

twocuts
08-26-2003, 08:49 PM
Well, the things I look for are Hypertension, tachycardia and tachypnea triad. That is the typical high pressure system that leads to Pulmonary edema in the CHF patient. Basically, if I see that the nitro goes on. It should make a difference. Also, years ago I learned a trick. I look for egophany. Some call it E to A changes. If you listen with a stethescope and ask a person to say the letter E. (It needs to be a long E.) If it sounds like A in your stethescope, it is probably fluid, not a consolodation from COPD/Pneumonia. A temperature usually helps with the Dx as well.

ABMedic
08-27-2003, 12:36 AM
What about S3, S4 heart sounds in these patients, certainly having an atrial and ventricular gallop helps clarify things.

Thoughts

ABMedic

alleganm39
09-21-2003, 10:42 AM
The doctors in my medical system seem to believe field treatment with 2.5 mg albuterol and 0.5 of atrovent, IV and cardiac monitor. The want to prove CHF by x-ray. If you truly hear rales/crackles then by all means use lasix.

twocuts
09-21-2003, 12:01 PM
I think that has to be the most assinign thing I have ever heard on these boards.