CHF and albuterol

[ambodriver]

I have a question for y'all about giving albuterol to a patient. I know that the indication for albuterol is wheezes. I also heard that CHF is a contraindication for albuterol because the broncodialators in the med will allow more fluids into the lungs, increasing the difficulty breathing (Someone correct me if this explication is wrong). So what do you do for the patient who has a hx of both asthma/ COPD and CHF and has diminished lung sounds? Would you give the albuterol/ duoneb until you can hear better lung sounds, and base your further treatment off of that? What if the cause of the SOB is CHF and you have now made it worse? CPAP?

Sorry if the question above is convoluted, I was wondering because I had a pt recently who had hx of CHF, but no other lung hx, and was diminished on the L side, and my partner gave her a duo neb treatment, even though she was stating at 98% RA, because her RR was about 30 (no other signs of SOB)

When I was initially certified to give neb albuterol, I never learned that CHF was a contraindication for it, and it scares me that I didn't learn all the information about a drug I was certified to give. If y'all have any good resources for this info, that would be great, but I would also like to discuss it here, I always learned best from class discussions

I think giving the neb to better hear lung sounds is bad practice for medicine. You shoud be looking at the whole clinical picture. CHF'er are usually easy to spot....edema...rales....positional SOB. BP can sometimes be high due to the feedback systems fighting each other.

It's poor medicine practive to throw around drugs for the hell of it. It's all about assessments.....assess assess and assess. There are some medics who cold do a lot better if they got better at assessing.

Hope I helped.

I have never seen it, but I know of paramedics that have had to bag a patient that where a foamy substance is coming out of the patient's mouth due to the overload of fluid in the lungs. Our objective is to bag this patient and attempt to push the foamy substance and the fluid out of the lungs and back into the circulatory system, so that the patient will be able to have better oxygen exchange, which then increase their respiratory efforts, hopefully keep them from going into respiratory arrest.

Providing positive pressure ventialions pushes the "fluid" aside so the alveoli can maximize its usefulness.

I am pretty sure the fluid does not return to the cirulatory system with cpap or ppostive pressure vents.

I could be wrong though

Edited December 18, 2010 by ambodriver

[chbare]

Positive pressure is an interesting concept and works in many different ways, some not well understood. Some of the mechanisms include:

1) Increased FRC and surface area available for gas exchange.

2) Increased pressures and alveolar splinting.

3) Potential fluid shifts.

4) Decreased preload and decreased myocardial workload with increased oxygen supply. (This is actually a very important one in an acutely decompensated CHF patient.)

Take care,

chbare.

[CBEMT]

While within my protocols to do so, I prefer to avoid Albuterol for CHF, the same way as I prefer to avoid Lasix. I consider Albuterol in this situation as to be treating a symptom instead of the disease.

While I have had plenty of wheezing CHF patients, I don't recall ever having to resort to Albuterol in order to eliminate the wheeze.

Stick with Nitro, CPAP, and a ride to the hospital.

[Respgirl1]

In my field of practice I see this all the time. Albuterol is neither here nor there when it comes to CHF. If given it will not "drown" a pt. It also will not do anything for a CHF pt. Audible, crackling wheezes are fluid overload and Albuterol is not the drug of choice. CHF pts NEED CPAP & Diuretics! And all CPAP is is PEEP. CPAP is continuous positive airway pressure/PEEP positive end expiratory pressure. When applied it displaces the fluid surrounding the heart and in the lungs enough so the pt can breathe, diuretics(Lasix or Bumex) are then given so the pt. can get rid of the fluid. If not in a hospital setting, place a peep valve at the end of the "ambu" bag and start off with 6-8 of peep, as long as the pts blood pressure can sustain it. If the pressure drops dont use the peep. As the pt breathes in squeeze the bag and this will apply peep. Hope this helps

[tniuqs]

In my field of practice I see this all the time. Albuterol is neither here nor there when it comes to CHF. If given it will not "drown" a pt. It also will not do anything for a CHF pt. Audible, crackling wheezes are fluid overload and Albuterol is not the drug of choice. CHF pts NEED CPAP & Diuretics! And all CPAP is is PEEP. CPAP is continuous positive airway pressure/PEEP positive end expiratory pressure. When applied it displaces the fluid surrounding the heart and in the lungs enough so the pt can breathe, diuretics(Lasix or Bumex) are then given so the pt. can get rid of the fluid. If not in a hospital setting, place a peep valve at the end of the "ambu" bag and start off with 6-8 of peep, as long as the pts blood pressure can sustain it. If the pressure drops dont use the peep. As the pt breathes in squeeze the bag and this will apply peep. Hope this helps

Firstly Welcome:

Some pretty broad statements here.

Albuterol is neither here nor there when it comes to CHF

I would dispute that statement. You may find that around 46% of CHF patients have associated COPD, the study by singer is suggestive that is an increase in mortality with the use of "albuterol" in the CHF with no pre-existing COPD. In the combined COPD / CHF (the 46 % club) the mortality was decreased, other studies footnoted in this link may help.

http://www.medcontrol.com/omd_pub/bronchodilator_and_chf.pdf

Could you explain in your statement that all CPAP is PEEP, can one positively say that a PEEP valve on a BVM (spring loaded valve) is true PEEP ? Squeezing the bag will apply PEEP most interesting, as I thought (as in your statements above) that PEEP was Positive "END" expiratory pressure, not PIP Peak Inspiratory Pressures. (the squeeze part)

When you stated "fluid around the heart" as I always though that was called an effusion ?

Are there any other choices if diuretics or other rx used in your practice perhaps that are potassium sparing ? Furosemide is being looked at with a more critical eye these days in CHF.

Are there no J receptors triggered to respond when pulmonary oedema is present, this leading to an increase in hypoxia and that Bronchospasm in the CHF patient never occurs, as a result.

http://en.wikipedia.org/wiki/Juxtacapillary_(J)_receptors

Taken from an RT book (Dr. Creed)

While heart failure was mentioned in section B5 as an indication for bronchodilator, we decided to add this section due to questions ad nauseum regarding the use of bronchodilaotrs for such a purpose. It is believed that bronchodilators are merely bronchodilators, although we as physicians know that can't possibly be true. Since heart failure causes a wheeze, a bronchodilator is definitely indicated. The known scientifically proven fact is that heart failure can often cause a prolonged expiratory wheeze and shortness of breath similar to asthma.

This wheeze is caused by increased pressure in the lungs due to pulmonary fluid overload, secondary to left heart failure. Since the increased pressure basically causes the fluid to squeeze the lungs, symptoms mimicking asthma occur.

Now while it might appear a bronchodilator will not resolve this problem because this is not real bronchospasm per se, it sure makes us physicians feel like we are doing something, and it also makes the patient and family feel like we are doing something too.

Yet we are doing something. While it is not scientifically proven, it only makes sense that the 0.5 micron particles of the bronchodilator reach the bronchioles and bind to beta receptors there, these magically shrink to 0.1 microns and reach the alveoli.

From there we know that by a magic osmosis process the Ventolin particles cross over into the blood stream and take up a spot on hemoglobin and sits next to the oxygen molecule, and then it is transported to the kidneys, which have a known affinity to Ventolin.

Once there, the Ventolin attaches to the beta adrenergic receptors that we just know have to be there. Thereby to treat the renal muscle spasm. This also works to undead necrotic kidney tissue and improves the kidney's ability to clean blood and excrete secretions. Thus, along with being a bronchodilator, Ventolin is also a distal tubular dilator.

It can only be stated that while RTs will complain that our methods are not scientifically proven, we know that even with all the data, studies, hypo-the-sisses and hoax theories

As one can see there is quite a bit of controversy in the medical field regarding the use of bronchdialators in CHF.

cheers

[ambodriver]

I've seen a doc use it when I use to moonlight in an ER as a tech.

I asked the doc about it, he told me that sometimes treating the wheezing/bronconstriction with albuterol will allow the pt. to breathe a bit easier, therefore lowering O2 demand on the heart and all the associated benefits that brings. The CPAP was hooked up to a neb.

This is all what a doc told me in the ER, so it is not a study etc.

For the bad CHF'ers CPAP/NTG/Lasix seems to work great in the field.

CPAP has taken away a LOT of our tubes, and that is a good thing for the patients.

[firefighter523]

Albuterol has a roll in CHF, is should be considered after reduction of pre and afterload, however agonizing B2 receptors peripherally plays a roll in lowering afterload itself by vasodilating. It does increase 02 demand, so you must increase supply though the use of high flow 02. If given, it should be given empiretically in conjuncion with the preload reducer (nitro). It is not uncommon for clinicians to treat both for COPD and CHF at the same time. Most people are hypertensive, pillow orthopnic, and suffer from PND, are on some type of diuretic, and a B blocker of some sort. Look for a throacic scar, and ascertain wether or not they have suffered from MI, valvular dysfunction, or have a long standing hx of HTN. Look for LVH, and any type of block on the 12 lead.

With all of that being said, this is not my way of treating CHF. I prefer going with nitro right away, and if they are on Lasix and are NOT febrile, then giving them their prescribed dose, maybe doubling it. Coupled with CPAP, is the standard of care for CHF. If you need help confirming dx, you could use capnography to aid in the ddx. Wheeze from lung pathology causes a shark fin appearance, vs cardiac wheeze from extravasation of plasma in the avioli will not usually show as shark fin on capnography, it will remain upright.

Edited February 14, 2011 by firefighter523

[usalsfyre]

In my field of practice I see this all the time. Albuterol is neither here nor there when it comes to CHF. If given it will not "drown" a pt. It also will not do anything for a CHF pt. Audible, crackling wheezes are fluid overload and Albuterol is not the drug of choice.

Unless there's concurrent COPD exacterbation (very common) or the APE itself has induced bronchospasm which can and does happen.

CHF pts NEED CPAP

Sometimes, sometimes just getting afterload down will do.

& Diuretics!

Very occasionally. A good portion of CHF patients actually end up DEHYDRATED. It's not usually a fluid overload problem so much as a distributional and hydrostatic pressure issue.

And all CPAP is is PEEP. CPAP is continuous positive airway pressure/PEEP positive end expiratory pressure.

Invasive vs non-invasive PPV

When applied it displaces the fluid surrounding the heart and in the lungs enough so the pt can breathe, diuretics(Lasix or Bumex) are then given so the pt. can get rid of the fluid.

Nitrates and ACE inhibitors actually do a FAR better job of changing the pressure gradients and treating the true cause behind a CHF exacterbation . If found to be fluid overloaded via diagnostics, than yes the patient needs to be diuresed. Other times they may actually need fluid.

If not in a hospital setting, place a peep valve at the end of the "ambu" bag and start off with 6-8 of peep, as long as the pts blood pressure can sustain it. If the pressure drops dont use the peep. As the pt breathes in squeeze the bag and this will apply peep. Hope this helps

We just discussed this on another board and came to the conclusion with the help of a couple of very smart RRTs that this does not provide CPAP as there is no "continuous" part to it. What your actually doing is increasing the WOB.

Remember, APE and decompensated heart failure are usually afterload issues, NOT fluid overload. High dose nitrates are the treatment of choice. However, if there is wheezing (not rales mistaken for wheezing) than that's indicative of bronchospasm and albuterol should be used to relieve the bronchospasm.

Edited February 14, 2011 by usalsfyre

[tniuqs]

We just discussed this on another board and came to the conclusion with the help of a couple of very smart RRTs that this does not provide CPAP as there is no "continuous" part to it. What your actually doing is increasing the WOB.

You may find in this website that this has been discussed in detail by another smart RRT.

I would and do promoted the use of Bi Level Support over CPAP, just mention in passing oxygenation is dependant on MAP (Mean Airway Pressure)

Lets also not forget the Atrovent with the COPD component.

cheers

[usalsfyre]

You may find in this website that this has been discussed in detail by another smart RRT.

I would and do promoted the use of Bi Level Support over CPAP, just mention in passing oxygenation is dependant on MAP (Mean Airway Pressure)

Bi Level is more comfortable for the patient, but last I checked had not been proven to be clinically superior to CPAP. Combine this with the fact that machines that can do Bi Level tend to be greatly more expensive than simple CPAP setups it's a hard sell to most EMS managers.

I DO agree it's probably a better option.