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A 72-year-old female has been transported to your facility by EMS in acute respiratory distress.
She has nasal flaring as well as intracostal and subdiaphragmatic retractions. Auscultation of her chest reveals scattered wheezing and distinct inspiratory crackles. A member of the staff states: “CHF again…she’s a frequent flyer”.
Because of the wheezing and respiratory distress, a team member recommends administering an aerosolized bronchodilator.
What do you think? Are there other therapeutic options?
Wheezing observed accompanied by clear signs of congestive heart failure (acute pulmonary edema) is typically caused by increased interstitial pressure (hydrostatic pressure) forcing water to be displaced through the alveolar-capillary membrane in to micro-airways and terminal alveolus. The likely etiology of the wheezing is the mechanical narrowing of gas conducting structures, not typically bronchospasm. A more direct approach might be application of continuous positive airway pressure via facemask and steps to emergently reduce high cardiac filling pressure.
Continuous positive airway pressure (CPAP) is initiated using a standard silicone elastomer facemask (FI02 = .40) starting a 5 cmH20 and titrating upwards by 2.5cmH20 until a slowing of the respiratory frequency occurs. At 16 cmH20, the respiratory rate dropped to 28, the skin color improved as well as a dramatic decrease in work of breathing observed. A repeat ABG showed: pH = 7.33, paC02 = 38 mmHg, pa02 = 164 mmHg, sa02 = 92%.
“Wheezing” may have multiple clinical etiologies. Therapeutic interventions are often ineffective or counter-productive when the underlying mechanisms are not understood or ignored. Careful selection and application of CPAP while instituting direct therapies such as vasodilator, inotropic or other modalities capable of reversing underlying pathologic mechanisms provides not only hemodynamic benefits, but improves work of breathing and overall oxygenation status in many unstable acute CHF patients. Use of CPAP requires practitioners to recognize and understand patient suitability for this approach, and the need to dynamically titrate therapeutic airway pressure in response to changes in the patient’s response to therapy. As with all therapies, CPAP can cause negative responses and complications, which practitioners must be fully aware of to safely employ this intervention.