left ventricle cannot pump out the amount of blood entering the ventricle, or when the ventricle is damaged and cannot effectively pump enough blood to meet the body’s needs. It may also occur due to a build-up of excess fluid in the body due to renal failure or other dysfunction due to disease. Fluid begins to build up in the lungs causing pulmonary oedema. “Pulmonary oedema is a widespread exudation or transudation of fluid into the alveolar walls and spaces from the pulmonary capillaries”. (Greaves, Porter, Smith 2011)
“Congestive heart failure is a complex disease and can be subdivided into cardiogenic shock, pulmonary oedema, hypertensive crisis and exacerbated Heart Failure”, (Cotter et al, 2002). The two most critical disorders associated with CHF are acute pulmonary oedema and cardiogenic shock. This manifests itself clinically in both as a result of decreased peripheral perfusion and congestion of the pulmonary system (Cotter et al, 2002). In the cardiogenic setting there is an increase in vascular hydrostatic pressure and in the non-cardiogenic setting manifests itself in the form of oedema as a result of increased permeability of the pulmonary capillaries. In either case there is an increase in extravascular fluid in the lungs as a result of poor cardiac function.
In CHF the effort of breathing increases due to airway obstruction by fluid, this reduces the amount of air able to reach the lungs. The alveoli begin lose the ability to exchange gases effectively resulting in severe dyspnoea in many patients. As the condition progresses this congestion eventually causes the right ventricle to begin to fail. When this occurs, the blood supply containing oxygen and nutrients to the systemic cells is disrupted, and the by-products in the form of CO2 are no longer removed effectively causing a build-up of toxins and ultimately causing cell death.
Diseases of the heart and circulatory system were the second most common cause of death in the United Kingdom in 2014, with a total of around 155,000 deaths. In 2014, Cardio vascular disease caused 27% of all deaths and cancers caused 29% (British Heart Foundation 2015).
Patient symptoms with CHF can vary from mild, moderate to severe, but in the acute setting can include laboured breathing; light-headedness; generalized weakness; cold, pale, or even bluish skin tone; accumulation of fluid in extremities and/or lungs; distended neck veins; abnormal heart rate and rhythm; and chest pain. “Additional symptoms like orthopnea (the sensation of breathlessness while lying flat) and paroxysmal nocturnal dyspnea may develop” (EMS World 2009). Many of these symptoms develop gradually over time as a result of chronic heart failure.
A differential diagnosis should always be considered in the pre hospital setting based on patient medical history and findings during assessment. Consideration should be given to non-cardiac origins when assessing acute pulmonary oedema such as chest infection, trauma, COPD, septic shock or toxic origins. Acute pulmonary oedema can often be confused with exacerbations of COPD and other pulmonary conditions. In a study conducted in the USA “The rate of misdiagnosis of congestive heart failure in the prehospital setting was documented in a study to be as high as 23%”, (Hoffman JR, 1987, p.586). Successful outcomes for CHF patients rely on a rapid accurate clinical assessment and treatment by the paramedic and other health care professionals.
Clinical Assessment and treatment
In the pre-hospital setting a complete past and present medical history and physical examination are essential in initial evaluation of patients suspected from having CHF. Current medications and compliance with medications, any recent illnesses or hospital admissions may give the paramedic clues to making an accurate diagnosis. An ECG should be carried as soon as possible after patient contact. Sinus tachycardia is one common ECG abnormality in CHF. Other common ECG abnormalities include sinus bradycardia, atrial fibrillation and other ventricular arrhythmias. The signs and symptoms CHF are the key for early detection and successful treatment.
CHF Treatment in hospital consists of a chest x-ray and is normally done immediately and is diagnostic tool showing marked interstitial oedema. Measurement of serum BNP/NT levels (elevated in pulmonary oedema but normal in COPD exacerbation) is helpful if any doubt exists about the diagnosis. Other diagnostic tools and interventions include an ECG, pulse oximetry, and blood tests (cardiac markers, electrolytes, creatinine and for severely unwell patients, ABGs) are done. Echocardiography is sometimes used to assess the cause of the pulmonary oedema (eg: Myocardial Infarction, valvular malfunction and hypertensive heart disease) and may influence the choice of treatment. “Hypoxemia in acute pulmonary oedema patients can be severe and CO 2 retention is a late, ominous sign of secondary hypoventilation” (Malcolm J, Arnold O, 2013).
With CHF patients, treatment involves finding a balance between the right medications and devices that help the heart beat properly (Mayo Clinic 2010). Prescribed medications that are often used to treat CHF include: ACE inhibitors (ACE inhibitors are a type of vasodilator), ARBs (have many of the same benefits as ACE inhibitors, but for people who can't tolerate ACE inhibitors), Digoxin (increases the strength of your heart muscle contractions and also tends to slow heartbeat), beta blockers (class of drugs that slows your heart rate and reduces blood pressure), diuretics (decrease fluid in your lungs), and aldosterone (these are potassium-sparing diuretics antagonists). If medications are not effective in treating the condition, additional treatment options such as coronary bypass surgery or heart pumps (Ventricular assist devices) may be used (Mayo Clinic, 2010).
Chest X-ray (CXR) is also an essential component of diagnostic assessment in CHF. It is useful for detection of cardiomegaly (is a medical condition in which the heart is enlarged), Cardiomegaly is one of the abnormalities associated with CHF. CXR will also detect pulmonary congestion and fluid accumulation in the lungs. It can also confirm the presence of any pulmonary disease or infection that will lead to dyspnoea.
Echocardiography (ECHO) would be considered if one or both ECG and BNP get an abnormal result. ECHO is widely available and safe and provides essential information on aetiology of HF. Some other tests such as FBC, RP, LFT, ABG, U&E and random glucose test should be carried out to exclude others possible conditions.
Emotional and phychological impact on patients and their families
“Congestive heart failure (CHF) is the end stage of many diseases of the heart and a major cause of morbidity and frequent hospital admissions and mortality”, Chiara et al (2016, p.228). A large number of patients with CHF are diagnosed and treated as outpatients. CHF patients have to cope with a chronic and life-threatening disease that is debilitating and psychologically distressing. Emotional, psychological and spiritual needs should also be considered and managed alongside the clinical treatments.
Healthcare workers should educate patients to better understand their medical condition so that they know when it is necessary to attend hospital and also why it is important to adhere to the treatment plan, be it medications or changes to the patients lifestyle, Giannetti (2001 p305-306). It is important that during discussions with the patient implementation of a care plans are discussed with the patient, family members and established so that patients and their families are not disappointed.
CHF affects not just the patient's ability to carry out daily activities; it also affects their family lives. Patients diagnosed with advanced CHF may require support with daily tasks (i.e. shopping, preparing food, bathing, getting dressed, housekeeping). Families often provide support by helping with these tasks, and the patients family should be educated about the disease process, and when it is necessary to request the health care provider or convey the patient to hospital. This can be very stressful for the family do to the responsibility of managing care. The patient may not be able to perform tasks without assistance and this can lead to frustration and anger which can further exacerbate their condition. This can be detrimental to their social life and can cause anxiety and depression.
Health workers treating dying patients with congestive heart failure face a number of issues. Episodes of acute heart failure can increase in severity and frequency until an episode proves fatal. “Conversations between clinicians and patients with heart failure focus largely on disease management; end of life care is rarely discussed” (Barklay et al, 2011). Many patients do not fully understand their condition or ask questions of the clinician about end of life care (EOLC). “The uncertain prognosis of heart failure, with its risk of sudden death, calls for the development of a unique approach to discussions concerning the end of life” (Barklay et al, 2011).
In the pre-hospital setting, the diagnosis and management of acute decompensated CHF can be challenging. Diuretics like Furosemide 40mg IV are no longer indicated for acute pulmonary oedema as a result of CHF in the pre-hospital setting.
CPAP
Continuous Positive Airway Pressure (CPAP) is a form of non-invasive positive pressure ventilation (NIPPV) that is commonly used in the treatment of pulmonary oedema associated with congestive heart failure. CPAP improves the ability of the alveoli to diffuse oxygen to the red blood cells, by using pressure to drive gas into the alveoli and open alveoli that are filled with fluid, collapsed or unused. It also increases the resistance of gas flow during exhalation providing resistance to the exiting airflow of gas from the lungs.
CPAP can relieve the level of dyspnoea experienced by a patient by improving cardiac output and increasing pulmonary compliance (Vital et al., 2008). Ventilatory status is improved and airway oedema is removed improving oxygenation and CO2 removal. CPAP can also help to reduce the incidence of intubation and invasive ventilation needed in CHF patients (Hubble et al., 2006)
Possibilities for advanced pre-hospital intervention
The ability of Paramedics to provide CPAP therapy for patients who require assisted ventilations, particularly in the presence of a strong history of CHF/pulmonary oedema is a key area for consideration. Prehospital based CPAP therapy is cheap, effective and can be safely deployed by all BLS, ILS & ALS providers. It in turn allows for a reduction in in-patient stays, reduced morbidity and mortality, and lower intubation rates in these patients (Vital et al., 2013).
Accurate assessment of CHF in the pre-hospital setting
The JRCALC Guidelines list specific criteria that should be assessed under respiratory status to accurately diagnose pulmonary oedema in the pre-hospital setting. These include:
The treatment of cardiogenic pulmonary oedema (caused by LVF) contains a number of items and exact protocols vary depending on country, EMS system, guidelines (Shapiro, 2005; Caroline, 2007)
Sit the patient up, with legs dangling over edge of bed/seat – this encourages venous pooling, causing a decrease in venous return to the heart, and so reduces pulmonary oedema.
Nitrates – GTN is indicated for pulmonary oedema. This can be repeated as dictated by local guidelines.
Diuretics like Furosemide 40mg IV are no longer indicated for acute pulmonary oedema as a result of CHF in the pre-hospital setting.is another recommended adjunct. This is a looposmotic diuretic which when administered causes re-absorption of fluid through the Loop of Henle in the small intestine. There are however a percentage of patients who develop increased morbidity associated with dehydration, and electrolyte deficiencies as a result of furosemide administration. There is also evidence to suggest that torsemide or bumetanide use is favoured over furosemide in heart failure patients due to a decrease in mortality and morbidity in studies (Wargo & Banta, 2009).
Morphine should also be considered in the presence of CCF with associated cardiac chest pain. Not only will the analgesic properties of morphine be useful but its’ vasodilation properties may also help in easing the patient’s dyspnoea.
CPAP Therapy has proven to be extremely effective in the management of pulmonary oedema in a prehospital setting.
CPAP Therapy is an approved intervention for UK Paramedics under the JRCALC Guidelines. A study by Hoffman & Reynolds in 1987 suggested that GTN was the most effective EMS