Albuterol in CHF?

[mshow00]

Pretend you have the protocols for this or they are silent:

To continue a discussion from class to night: Would/should you give albuterol to a Pt with CHF crisis?

Speaking from a pathophysioloy stand point then it would be warranted. Yes it has some Beta effects on the heart, but more importantly (esp in this pt) it does more to "open the air way". The class seemed to be split almost 50/50, and our instructor said that field opinion was spilt the same. Around here (especially the older generation Drs) SNF docs often order albuterol for CHF pts. Now I am also aware of the flash PE, but is the benefit more than that risk? I mean you could always tube the pt and force the fluid out of the lungs in that case. So I am interested in hearing from more on this subject.

[JPINFV]

Are we talking CHF with a reactive airway issue or CHF with pulmonary edema?

[mshow00]

PE sorry I thought I specified that.

[JPINFV]

Pulmonary edema is caused by an increase in pulmonary venous pressure due to the left ventricles decreased ability to pump. As such, the problem is with the lungs and not the conducting airways. As such, treatments should focus on either increasing diffusion (increased FiO2) or reversing the problem (nitro, lasix, CPAP, etc). Seeing as there are absolutely zero muscle cells in the alveoli, what exactly are people hoping to accomplish with Albuterol and CHF/PE patients?

[bigj1130]

Pulmonary Edema as stated is not a problem with constricted bronchioles. Pulmonary edema has everything to do with a pump problem. Most likely left sided failure causing right sided failure causing pulmonary edema. However some Failure patients have reactive airway disease also, IMHO this is where Qualitative ETCO2 comes in handy. The ETCO2 waveform will help determine air trapping due to reactive airway. these patients will also be hypercarbic as well. My experience says that's ok for a beta agonist tx then. Also look for the other subtle signs that is is Reactive airway rather than failure. Most not all Reactive Airway pts. will have that very expanded exhalation period because they are trying to blow off that co2 they are trapping. Failure patients I have seen are tachycardiac, tachypneic, and hypertensive almost always. In the case of pulmonary edema in a failure patients Positive Pressure Ventilations with a bag mask are going to do more than the beta agonist will to "open them up." Nitrates are also beneficial and in our system are going frontline with CPAP or BVM over lasix and morphine with lasix going way down the algorithm and morphine gone altogether. So in a nutshell My opinion is beta agonist are bad in pulmonary edema patients

[mshow00]

I apologize here, I think I should have been a little (lot) more descriptive here: I know that albuterol does not do anything to remove the excess fluid that hinders oxygen diffusion. What I am getting at is you have your Pt in high fowlers and have followed most or all of your CHF-PE protocols. Your pt still has decent respitory distress and you don't have a CPAP (as in my company). Would you give albuterol to help open up (even slightly) the "clear" part of the lungs?

I argued that I would give the abuterol and my reasoning is if you have 50% of "clear" lung space and then give the albuterol and gain 4%. The 54% is obviously better, but does it out way the risks?

[tamaith]

if the patient has a prescribed inhaler. than why not give the albuterol. if it may help them breathe a little better, i don't believe that there any contraindications

[JPINFV]

Absent any indication that the broncoles are constricted, then I see no reason to give Albuterol in the first place. The broncoles should already be dilated just because the patient is stressed (sympathetic nervous system activation) as well the body should naturally be shifting blood towards the aveoli that are being oxygenated. I don't believe that CHF/PE is a contraindication (Ventmedic?) insomuch as resp. distress due to PE isn't an indication for Albuterol.

As an aside, if anyone makes a claim that Albuterol has an affect on aveoli size (the "my instructor told me that it's bad because it increases the wrong container size" argument), I will be giving a quick histology lesson

[streethealer535]

Most likely left sided failure causing right sided failure causing pulmonary edema.

Mabey Im a little comfused but since when does RIGHT sided failure cause PE???? Its left sided failure causing PE then the elevated PA presure caused Elevated RV presure and then right sided failure!! Also we can get into the discusion of systolic or diastolic CHF, but I belive the question is a little easier to answer. Seems to me that most of our patients do not have simple one track disease processes. I might be wrong but it seems to me if there is PE then the Airway will become irritated and can be inflamed. So sometimes it takes albuterol to even hear rales instead of wheezes. Yes we can harm patients in CHF by giving them Albuterol, but in combination with everything else (C-pap, dieretics, baging, O2, Nitro if HTN) I think it is a good option as long as you continue to think about what you are doing to the patients.

Just my thoughts... :wink:

Street~

[JPINFV]

Mabey Im a little comfused but since when does RIGHT sided failure cause PE????

Grr at not catching that. While it is slightly counter intuitive, increased arterial pressure (in the sense of pulmonary HTN) has nothing to do with edema. Edema is caused by increased lymph pressure, increased venous pressure, or loss of plasma proteins. As such, CHF causes edema in the area that leads up to it. Hence left side failure causes PE while right side failure causes distal edema.