ACUTE EXACERBATION OF CONGESTIVE HEART FAILURE WITH PULMONARY OEDEMA

Recognition

Definition

• Heart Failure
  • “Defined clinically as a syndrome in which patients have symptoms and signs resulting from an abnormality of cardiac structure and/or function” (ESC guidelines for the diagnosis and treatment of acute and chronic heart failure).
• Pulmonary Oedema
  • There is no general consensus on the definition of pulmonary oedema but “it is characterised by the presence of excess fluid within the pulmonary interstitium, and, at its most severe, within the alveoli” (RCEM learning).
  • There are multiple different causes of pulmonary oedema:
    • Congestive heart failure
    • Acute lung injury
    • Fluid overload with kidney injury
    • Iatrogenic fluid overload from excessive Intravenous (IV) fluid administration

Risk Factors (BMJ best practice)

• Age > 70
• Prior episode of Congestive Heart Failure (CHF)
• Coronary artery disease
• Hypertension
• Valvular heart disease
• Pericardial disease
• Myocarditis
• Atrial Fibrillation
• Diabetes mellitus
• Non-compliance with medications

Severity

• New York Heart Association (NYHA) clinical classification of heart failure:
  • Patient symptoms
    • No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, dyspnoea (shortness of breath)
    • Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea
    • Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity cause fatigue, palpitation, dyspnoea
    • Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases
  • Objective Assessment
    1. No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity
    2. Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest
    3. Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less than ordinary activity. Comfortable at rest
    4. Objective evidence of severe cardiovascular disease. Severe limitations. Experience symptoms even while at rest

History

If possible, ascertain if patient has:

• Previous admissions with chest pain or cardiac conditions
• Any operations or treatment for cardiac conditions
• Any allergies

General symptoms

• Shortness of breath (dyspnoea)
• Cyanosis
• Pink frothy sputum
• Chest pain
• Cool peripheries
• Peripheral oedema
• Distressed

General Signs

• Tachypnoea
• Low oxygen saturations
• Use of accessory muscles
• Dullness to percussion at lung bases
• Wheeze (cardiac asthma)
• Inspiratory crackles
• Reduced air entry at lung bases
• Pale
• Hypotension
• Tachycardia
• Raised Jugular Venous Pressure (JVP)
• Triple/gallop rhythm

Initial Assessment and Investigations

• ABCDE assessment
• Sit patient up if able to tolerate
• Assess patient’s airway
• Monitor oxygen saturations and respiratory rate
• If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
• Target saturations:
• 94 - 98% for patients not at risk of hypercapnic respiratory failure
• 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest
• Listening for:
  • Bibasal crepitations
  • Cardiac wheeze
• If signs of congestion consider pharmacological immediate management as below
• Arterial blood gas (ABG)
• Chest X-ray. If the patient is unwell request a portable X-ray
  • Look for:
    • Cardiomegaly
    • Fluffy bilateral shadowing with peripheral sparing (“bat wings”)
    • Kerley B lines
    • Pleural effusions
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Liver Function Tests (LFTS), Thyroid Function Tests (TFTs), Glucose, Troponin and B - Type Natriuretic Peptide (BNP)
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
• Monitor heart rate and blood pressure
• Treat arrhythmias as per Arrhythmias Chapter
• Listen to patient’s heart sounds
• Check for raised Jugular Venous Pressure (JVP)
• 12 lead echocardiogram (ECG)
• Call for senior help
• Check urine output and consider catheterisation
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Check for pedal and sacral oedema
• Consider venous thromboembolism prophylaxis

Response

Management

Immediate management

• Immediate pharmacological management (NICE guidance cG187)
  • Furosemide 20-40 mg IV
    • Consider catheterisation
  • Do not routinely offer opiates – a senior will review if these are required
  • Do not routinely offer nitrates– a senior will review if these are required
  • Consider Continuous Positive Airway Pressure (CPAP)
• Non-pharmacological management
  • Further imaging
    • Echo

Referrals

• Discuss with senior member of the team
• Contact critical care outreach team
• Referral to cardiologists
• Consider referral to Intensive Care Unit (ICU) if:
  • Failure to respond to medical management
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

Future management

• Review by cardiologists regarding future management
  • Pharmacological
    • Beta-blocker
    • Angiotensin-Converting Enzyme inhibitor (ACEi)
    • Mineralocorticoid Receptor Antagonist
      • Spironolactone
  • Cardiac rehabilitation