Right-side heart failure.

[firefighter523]

It's fine to be aggresive on the airway on the CHF'r, but here in the US, the standard of care is now CPAP, not intubation. If you intubate a CHF pt, they become dependant on the help they are getting, and some never come off the vent. CPAP is the way to go. Tube as a LAST resort....

[zumjus]

Thank you!!

[Ridryder 911]

actually most protocols follow ECC guidelines and suggestions for tx of CHF (left side). I agree, CPAP is a wonderful tool when you have a patient that is not severely distressed. It only buys you time for the diuretics & nitrates to work, re-absorbing the fluid back into the alveoli.

However; there are many patients that still need to intubated and with the use of PEEP as well. Exacerbation of CHF, and when the patient is "worn out" one should protect the airway, and continue with pharmacological agents.

Be safe.

R/R 911

[kevkei]

It's fine to be aggresive on the airway on the CHF'r, but here in the US, the standard of care is now CPAP, not intubation. If you intubate a CHF pt, they become dependant on the help they are getting, and some never come off the vent. CPAP is the way to go. Tube as a LAST resort....

Aren't you confusing this with a COPD'er? With CHF, there is no dependancy on the vent, it's with hypoxia and hypecapneia in COPD where weaning becomes a problem.

[firefighter523]

I don't think I am confusing it. Correct me If I am wrong, but due to the chronic dyspnea and extreme work of the pt, once they are on the vent, the body says " Cool, I don't have to work anymore, someone is doing the work for me, I think I'll just hang back and kick-it" "Wait, wait, don't take that out, that means I have to work to breath again, I don't like that"!!

Am I wrong, isn't that why CPAP came about?

[Dustdevil]

You are correct. Ventilator dependency is a concern with almost all ventilated patients, including CHFers. Obviously, it is much more of a concern in COPD, but yes, we have to be careful will all patients who go to a vent.

[kevkei]

I don't think I am confusing it. Correct me If I am wrong, but due to the chronic dyspnea and extreme work of the pt, once they are on the vent, the body says " Cool, I don't have to work anymore, someone is doing the work for me, I think I'll just hang back and kick-it" "Wait, wait, don't take that out, that means I have to work to breath again, I don't like that"!!

Am I wrong, isn't that why CPAP came about?

Ahh, therein lies the connundrom. Typically pt's with CHF in isolation don't suffer chronic dyspnea, this would suggest more of an obstructive component of COPD with the CHF. If a patient gets to the point of requiring intubation, it's not a concern, because they need it in order to live. Weaning from a vent can be a problem, but there are many ways to overcome it. Things like permissive hypercapnea, pressure support (meaning they have to breathe to trigger the vent), etc.

[Ace844]

Ahh, therein lies the connundrom. Typically pt's with CHF in isolation don't suffer chronic dyspnea, this would suggest more of an obstructive component of COPD with the CHF. If a patient gets to the point of requiring intubation, it's not a concern, because they need it in order to live. Weaning from a vent can be a problem, but there are many ways to overcome it. Things like permissive hypercapnea, pressure support (meaning they have to breathe to trigger the vent), etc.

"Kev,"

Your above statement is misleading in that there is a fair number of pt's out there whom have cardiomyopathy, MR, or low EF's to such a point that they are chronically hypoxic and do suffer baseline dyspnea as a result. Next, I submit for your consideration that it should be noted that there are a few reasons a CHF pt may become vented and the entire clinical picture-case is what makes some concerns in each case more relevant than others.

There is a previous thread which was discussed here about this some time ago; here's the link: Chest pain and breathing difficulty. In that thread alot of the treatment and vent management strategies are outlined and thoroughly explained. here is an excerpt which addresses your statements..

If I were to “feel” that this patient may have a “shot” at successfully responding to the following therapies, I would use NIPPV/BiPAP instead of RSI, Unless while assessing this patient “I got that gut feeling” which would give me the preference toward being more aggressive, and using RSI. To address the NIPPV/ BiPAP: I would use 100%FiO2, 15/5 to start and titrate my settings up or down to patient response to treatment. If no Response after a reasonable time or if the patient decompensates I would progress to RSI. I would do this with the rationale that BiPAP has less mortality/morbidity/treatment complications, with the same treatment benefits. EXCEPT: having the benefit of freeing approx.: 25% of the patients cadiac output and decreasing basilar metabolic/energy expenditures by relieving them of the work of breathing, in that case RSI/Ventilator therepy is SUPERIOR to BiPAP. Which in this patient may be beneficial.

I agree, if you are able to PEEP & they seem to respond, that would be great. However; there is a window period that PEEP actually will work the best. The shift between right side & left side heart failure.

Recognizing CHF, & be aggressive in pre-load & afterload meds', as well as nitrates & diuretics. NIPPV can definitely reduce the work-load, as I have seen effective use of it. I usely determine on the patients response & distress. If the patient is wearing out out & distress increasing, I proceed with RSI. I do know the complications of vent; but at this time, this is the least of my & the patients worries. I usually place the patient on PEEP on the vent & slowly decrease as the diuretics take affect.

I agree with your PEEP and airway pressures info. In addition I would also like to add the following comments to your submittied facts. 1.) NIPPV vs ETI, I respectfully submit for the boards consideration that as far as PEEP and other things which you can do to control Tidal Voulmes; affect Peak/Plateau pressures and other things in that vain, a vent. (Note: I mean a modern one, not a circa 1970's vent which may still be out there in some places) is superior in this respect when compared to a NIPPV/CPAP/BIPAP machine. Also ETI has the previously aforementioned benefits in that it, "having the benefit of freeing approx.: 25% of the patients cadiac output and decreasing basilar metabolic/energy expenditures by relieving them of the work of breathing." I do agree with "usafmedic45's", statement that "As for work of breathing, you would be amazed at the decrease in WOB with NIPPV- ." But I would also add that there is no clinical indication for long term NIPPV use. The most I have seen is 3 days( I have been told that this about the longest a patient should be on BIpap/CPAP). After this NIPPV has its own inherent downfalls and its therepeutic value drops significantly after this and most institutions "progress" to ETI. As you mentioned it decreases, but doesn't relieve the work of breathing as with paralytics/ETI. Also if in this scenario this patient continues to be "in distress, extremis" and has "MODS-Multiple Organs System Dysfunction/Failure" then the optimal management option is ETI, as we all previously mentioned. 2.) As part of the down side of Vent management, and where NIPPV becomes so attractive clinically is that when used appropriately with the correct settings it lacks the inherent complications of Paralytics, long/short term vent use, i.e.: vent acquired pneumonia, pharm. complications, airway trauma/tube dislodgement, etc.....3.) Some data on ARDS is that is mostly iatrogenic, but some of the more recent studies have suggested that perhaps some of our patients are predisposed to develop it either as a result of unclear underlying etiology/PHMX. But, also it should be noted that ARDS HAS NOT BEEN ADEQUATELY studied in the setting of NIPPV alone, as ARDS usually becomes most aparent diagnosed long after the clinical efficacy of it has passed and entubation had to be performed. So thus it is very hard to prove wether or not NIPPV was a factor or not. NOTE: Most studies have used patients who were exclusively intubated and most likely haven't undergone NIPPV prior to ETI 4.) Below are some useful links/studies to learn more about this...http://ajrccm.atsjournals.org/cgi/content/full/162/2/374?maxtoshow=&HITS=100&hits=100&RESULTFORMAT=&titleabstract=PA+cath+volume&searchid=1116691080008_2496&stored_search=&FIRSTINDEX=0&journalcode=ajrccm

http://ajrccm.atsjournals.org/cgi/content/...rnalcode=ajrccm

http://ajrccm.atsjournals.org/cgi/content/...rnalcode=ajrccm

Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure http://ajrccm.atsjournals.org/cgi/content/...rnalcode=ajrccm

Congestive Heart Failure http://ajrccm.atsjournals.org/cgi/content/...rnalcode=ajrccm

Noninvasive Ventilation in Cardiogenic Pulmonary Edema http://ajrccm.atsjournals.org/cgi/content/full/168/12/1432

Granted this applies to a 'Clinical grounds' entubation in CHF as oppossed to other reasons which have been previously discussed here.

Hope this helps,

ACE844