Albuterol for CHF

[BruceD]

from what i understood and remember from class (forgive me if i ramble and go all over the place bc i'm tired).....wheezing is the first sound you hear in CHF (meaning it's the beginning sound from there goes to fluid and etc). bronchoconstriction in asthma is caused by spasming of the muscles in the airways and broncioles. bronchoconstriction in CHF is caused by the excess fluid (where the muscle spasm would be). kinda reverse illustration would be a balloon - hang it off the spigot and put a bit of water in it, till it starts to get a bit bigger (this represents the fluid coming into the lungs and causing broncoconstriction). now remove the balloon - what happens if you squeeze the balloon? (representing what happens if you give albuterol to CHF and it opens the airways/relieves broncoconstriction) - the water comes out - same with CHF, the fluid that was contained in the broncoconstriction is now being pushed out and into the lungs.
Last company protocol I knew was O2, monitor, IV (preferred saline lock but slow KVO okay), NTG SLx3 per BP allowance, NTG paste per MC, Lasix, CPAP, MS (little shaky on where the command line was bc i haven't seen that protocol in a while - long story). albuterol is not recommended in CHF (known) - but may be used VERY CAREFULLY (say in unknown CHF or a pt with hx of asthma and CHF cc wheezing) and be prepared to have issues (from what i remember from class) - also albuterol will have adverse side effects as previously mentioned by others in CHF).
sorry if i confuzzled anyone or am confuzzled myself...

bruce - not too long, i enjoyed the refresher

Hehe, I sit here imagining all the people that fell asleep or died while reading my post..... and those that skipped it due to the sheer size

I may be incorrect, but I don't believe there is much in the way of bronchoconstriction in CHF. Isn't it more of a problem of interstitial fluid preventing O2 from diffusing thru the alveolar walls, with the fluid people coughing up being a result of damage to those walls?
Wheezes in asthma tend to be around bronchioles and wheezes in CHF tend to be near the diaphram?

Let me know.
-B

 

[AJemt]

heh, your guess is as good as mine. i think what our instructor was saying with the diagrams he was drawing - circles and all that i can't figure out how to put on a computer - is there's a difference b/t broncospasm and broncoconstriction and the spasm is more asthma while constriction is more bronchitis, chf, pneumonia, whatever - its two words for the same action but different causes i think. idk. been a couple years since medic school and i don't know where the stuff is to go look it up....though the location of the wheezing is something i hadn't thought of it does kinda make sense bc the fluid starts at the bottom and works its way up.....

 

[BruceD]

heh, your guess is as good as mine. i think what our instructor was saying with the diagrams he was drawing - circles and all that i can't figure out how to put on a computer - is there's a difference b/t broncospasm and broncoconstriction and the spasm is more asthma while constriction is more bronchitis, chf, pneumonia, whatever - its two words for the same action but different causes i think. idk. been a couple years since medic school and i don't know where the stuff is to go look it up....though the location of the wheezing is something i hadn't thought of it does kinda make sense bc the fluid starts at the bottom and works its way up.....

I know that in COPD there's a permanent physiologic bronchoconstriction (I believe due to long term inflammation?), while bronchospasms can be cause of an exacerbation. But I was thinking there was no mechanical obstruction in CHF... I think I need to read

Been a good thread,
Thanks!
-B

 

[AJemt]

i don't know.....i'll have to see if i can find my books again and re-read them....i don't remember. meh.

 

[respiratorygirl]

I'm a Respiratory Therapist and have been taught bronchodilators do not fix crackles in a chf patient. Bronchodilators such as Albuterol(Ventolin), Duonebs(Albuterol/Atrovent) treat wheezes, rhonchi or rales. It's more for your asthma and copd'ers. In patients with CHF you will hear audible wheezes and rales which for CHF pts is the fluid around the heart and in the lungs which will not benefit from bronchodilators. This is best treated with CPAP and diuretics. Hope this helps.

 

[Shishkabob]

Diuretics :glare:

 

[fma08]

2008...? :glare:

 

[Shishkabob]

2008...? :glare:

Wasn't me.

 

[18G]

Interstitial fluid in the lungs from CHF can cause a reflex bronchoconstriction which is where the albuterol comes into play. The albuterol is not aimed at correcting the primary disorder it is merely an adjunctive treatment to prevent further issues with ventilation and diffusion of oxygen.

"Cardiac Asthma" refers to wheezing from the reflex bronchconstriction from fluid in the lungs. Some may argue that with albuterol being a sympathomimetic it may worsen the CHF or be counter productive given its side effects of increased heart rate and myocardial O2 demand, but generally not so much. With CHF there is already a strong sympathetic response as compensatory.

It's also very possible that the CHF patient may also have COPD so albuterol is appropriate for several reasons.

 

[Shishkabob]

'Tis why you do Albuterol / Atrovent in-line with CPAP. Best of all worlds.

Doesn't improve in 5 minutes? Say hello to Mr Tube.

 

[JPINFV]

Say hello to Mr Tube.

Is it bad that I read it in this voice?

 

[FFMedic75]

Most of the evidence supports that CPAP and NTG works the best with Lasix. The histamine release caused by Morphine may be more harmful than any benefits gained. If the patient is agitated a small amount of Benzos may be better, some studies are saying Fentanyl may work as well. I have had the occasional patient where upon initial auscultation I heard Diminished lungs sounds or wheezing, then once you clear that up you hear the crackles. In these cases Albuterol is indicated just watch the HR and BP. Keep in mind the quickest way to increase the HR and intern the O2 demand of the heart, is for the patient to be unable to breathe. Capnography is a very useful tool in these patients but look for other indicators of the underlying problem as well, such as pedal edema, JVD and perhaps the most important the skin. The majority of respiratory patients where the heart is the underlying problem have cold clammy skin. It is also important to reassess these patient's often you only want to give enough Albuterol to allow for good air movement not the large amounts we often give to a younger patient with an Asthma Attack.

 

[jrm818]

Can you clarify the bit about Lasix a bit? Are you saying that CPAP and nitro only work well when Lasix is added to the list? (I'd disagree with that) Or just that Lasix has added benefits? (I think I'd have to disagree with that in many circumstances as well) Or something else entirely?

 

[FFMedic75]

sorry, let me clarify, I mean the NTG and CPAP work best. Lasix is an important part of the treatment and overall management of the patient, however it does not have the immediate effects on the patient's condition that the NTG and CPAP have. Oxygenating the patient and decreasing preload should be the initial treatment goals followed by getting rid of the fluid.

 

[jrm818]

gotcha, thanks for the clarification. I agree with that a lot more, although I'll respectfully quibble a bit. There is some evidence that many patients with cardiogenic pulmonary edema are actually fluid depleted or normovolemic, and the problem is one of fluid distribution rather than volume. There is also some evidence that Lasix may cause delayed renal toxicity in some patients.

I don't think there is any evidence that adding Lasix to treatment with vasodialators and NIPPV has any benefit. There is actually a bit of venous dilation that occurs acutely after Lasix administration and apparently that can cause some improvement with lasix monotherapy, but nitrates give you that effect without the renal effects, and when nitrates are already given, I haven't seen any evidence of an additive benefit from lasix. Of course this is all from someone who has never given any of these medications in real life, so I may be missing something.

I certianly agree that decreasing preload is the primary goal.

 

[DFW333]

Sorry for bumping this post, but there's a lot of good information here and I wanted to pick your guy's brains on this one.

One of our trucks yesterday had a run like this. Nursing home patient found supine in bed on 2 LPM O2 via NC w/ audible rales from the hallway. Respirations 44 and very labored, HR 140-150s, BP 112/0, SPO2 78% Auscultation of BS found VERY LOUD rales in all four fields even up as high as the clavicles. The EMT-B described it as blowing bubbles thru a straw being put through a dolby surround system.

A BLS truck was sent as the nearest ALS truck was over an hour away. Pt has no history of cardiac or respiratory problems. Nurse stated patient's abdomen was very distended that morning and the foley bag was empty. So he changed the foley catheter out and the new bag immediately filled with urine twice in 5 minutes. The new foley bag is empty now, but the line is filled with blood. The patient is very diaphoretic, very hot to the touch, and is altered. The only history he has is ALS and hypertension. The patient was put on O2 15 LPM NRB and placed in high fowlers position. SPO2 climbed to 83%

The EMT administered albuterol and reported immediate clearing of the breath sounds in the upper lungs and improvement of SPO2 to 94%.

Im getting very mixed reactions from reading this thread so I thought I'd throw this out there and ask if anyone would have done something different? Our service does not carry CPAP BTW.

 

[truetiger]

What color was the urine?
Looks like this guy could be septic, which has been known to present with rales.
He's tachy, hot to the touch, and the blood pressure could be low depending on what his baseline is.

 

[DFW333]

What color was the urine?
Looks like this guy could be septic, which has been known to present with rales.
He's tachy, hot to the touch, and the blood pressure could be low depending on what his baseline is.

I dont think that information was provided, Im assuming it was yellow.

 

[Hockey]

Septic I'm thinking, with some sort of respritory illness as well possibly? Its that time of the year so...

 

[Shishkabob]

Could be ARDS caused by septicemia.