Flash Pulmonary Edema

[EMS Patient Care Advocate]

LOL Who's mad? I don't know anything about your level of education and I applaud your supposed willingness to learn but being hostile to those who are instructors of the things you are trying to learn doesn't really lend itself to the belief that one is really interested in anything but having himself or herself patted on the back and told that his way of thinking was the best one out there.



No, I questioned your decision making. Ask anyone here....if I was attacking you personally, I'd already be wearing your spine as a necklace. Learn the difference between someone attacking you and someone being critical of your choices. There is a significant difference and being able to separate the two is very helpful if one wishes to last long in any career field.

and we all have our opinions. I exposed myself, and my decisions to have people be critical of me. It was your approach I didnt care for, dont read into it more than that.

 

[fast65]

Pardon me for asking for clarification and trying to make a teaching point out of something that confuses a lot of EMS providers (PEEP vs. CPAP)

Would you go further into this?

 

[usafmedic45]

Would you go further into this?

The five cent explanation.....from a physiological standpoint, PEEP and CPAP are the same thing. The only difference is that in PEEP, the patient is receiving at least some of their breaths from a mechanical source. In CPAP, the patient is breathing entirely on their own. If you want more detail, I can provide it.

 

[usafmedic45]

I exposed myself, and my decisions to have people be critical of me. It was your approach I didnt care for, dont read into it more than that.

If you want people to be critical of you, then you should expect them to be critical of you. Sugarcoating stuff or blowing sunshine and rainbows up someone's *** doesn't fix the problem nearly as succinctly as just getting down to the point.

 

[Handsome Robb]

Would you go further into this?

seconded. I think I understand what your getting at USAF but I'm not sure.


Both are providing positive end expiratory pressure (PEEP) one manually through a BVM + PEEP valve whereas CPAP or BiPAP for that matter are controlled by a regulator and use "self" sealing masks. BiPAP is more complicated than CPAP seeing as the pressure is alternated between an inspiratory pressure and an expiratory pressure that is selected by the provider. Like USAF pointed out BVM+PEEP valve work in closed circuits better than just with a mask due to difficulty maintaining an adequate mask-to-face seal.

The only difference I see is for BiPAP or CPAP requires the pt to be breathing spontaneously, but couldn't the increase in FiO2 along with the pressure pushing the edema back into the vascular space which increases oxygenation and will help correct the hypoxia which in turn will cause an increase in RR.

Let the lynching begin

 

[fast65]

The five cent explanation.....from a physiological standpoint, PEEP and CPAP are the same thing. The only difference is that in PEEP, the patient is receiving at least some of their breaths from a mechanical source. In CPAP, the patient is breathing entirely on their own. If you want more detail, I can provide it.

Alright, that makes sense, but I would still love some more detail if you have time.

 

[usafmedic45]

Like USAF pointed out BVM+PEEP valve work in closed circuits better than just with a mask due to difficulty maintaining an adequate mask-to-face seal.

Actually the bigger issue, especially with higher PEEP settings in the hands of a person skilled with a BVM, is with gastric insufflation.

 

[Handsome Robb]

Alright, that makes sense, but I would still love some more detail if you have time.

I'm gonna keep quoting because I'm agreeing :rofl:

 

[usafmedic45]

Alright, that makes sense, but I would still love some more detail if you have time.

http://www.ccmtutorials.com/rs/mv/page14.htm This is a good introduction and be sure to follow the link at the bottom of the page....any further questions, let me know.

 

[Scott33]

Wouldn't that make things worse?

CHF can be caused by a number of things - we commonly assume it is a systolic problem ("failure of the pump", another classroom mantra) and I am sure 9/10 times it will be. However heart failure can also be due to diastolic dysfunction where ventricular filling pressures and / or volume is inadequate, and the root cause of the patient's symptoms. What would we expect the BP to show in a situation like this? This is where a fluid bolus could increase preload and raise CO.

If you have an obvious case of CHF, but with an abnormally low BP, it may point more to a filling problem more than a pumping problem.

 

[fast65]

I'll take a look at that link, thanks usaf! And thanks Scott for that little bit of info as well.

 

[EMS Patient Care Advocate]

seconded. I think I understand what your getting at USAF but I'm not sure.


Both are providing positive end expiratory pressure (PEEP) one manually through a BVM + PEEP valve whereas CPAP or BiPAP for that matter are controlled by a regulator and use "self" sealing masks. BiPAP is more complicated than CPAP seeing as the pressure is alternated between an inspiratory pressure and an expiratory pressure that is selected by the provider. Like USAF pointed out BVM+PEEP valve work in closed circuits better than just with a mask due to difficulty maintaining an adequate mask-to-face seal.

The only difference I see is for BiPAP or CPAP requires the pt to be breathing spontaneously, but couldn't the increase in FiO2 along with the pressure pushing the edema back into the vascular space which increases oxygenation and will help correct the hypoxia which in turn will cause an increase in RR.

Let the lynching begin

dont forget about the fact it cannot be used with hypotension. I think.

 

[usafmedic45]

dont forget about the fact it cannot be used with hypotension. I think.

As long as you watch the patient and are able to tailor the settings to the patient's condition you should be fine. CPAP has much less of a relative contraindication with hypotension than you would see with BiPAP. Any ventilatory mode is going to have a potential issue with worsening hypotension especially in cases where the ventricular filling "kick" has been lost.

The other thing to keep in mind is that you need to remember that CPAP, BiPAP and any other ventilatory measure is simply an adjunctive treatment. It's not the magic bullet that a lot of EMS providers like to believe it is when it comes to CHF and pulmonary edema. It buys you time to fix the underlying problem.

 

[Handsome Robb]

dont forget about the fact it cannot be used with hypotension. I think.

If the hypotension is secondary to hypovolemia specifically blood loss, not pulmonary edema. I'm guessing due to the possible vagal reflex? However if I'm understanding it correctly, used with volume replacement it is just a relative contraindication, not absolute. Risk vs. Reward.

If it I am wrong, it's happened before, then PEEP would be contraindicated as well.

 

[EMS Patient Care Advocate]

As long as you watch the patient and are able to tailor the settings to the patient's condition you should be fine. CPAP has much less of a relative contraindication with hypotension than you would see with BiPAP. Any ventilatory mode is going to have a potential issue with worsening hypotension especially in cases where the ventricular filling "kick" has been lost.

The other thing to keep in mind is that you need to remember that CPAP, BiPAP and any other ventilatory measure is simply an adjunctive treatment. It's not the magic bullet that a lot of EMS providers like to believe it is when it comes to CHF and pulmonary edema. It buys you time to fix the underlying problem.

Any suggestions for when you have flash edema with severe hypotension? Less than 80 systolic?

 

[sdennislee]

I agree in theory with OP, that sometimes the response provided by usafmedic45 can seem harsh, having said that, I have never failed to learn something from his posts. I tend to appreciate to the point critiques and advice. I can see where if you are the one receiving the critique it could be painful, but assume you will learn and remember and after all isn't that the point.

 

[EMS Patient Care Advocate]

If the hypotension is secondary to hypovolemia specifically blood loss, not pulmonary edema. I'm guessing due to the possible vagal reflex? However if I'm understanding it correctly, used with volume replacement it is just a relative contraindication, not absolute. Risk vs. Reward.

If it I am wrong, it's happened before, then PEEP would be contraindicated as well.

I believe its more to do with intrathoactic pressures and the not so happy venacava, causing the hypotension with CPAP.

 

[usafmedic45]

I'm guessing due to the possible vagal reflex?

Nope. It's due to compression of the right side of the heart as a result of the increased intrathoracic pressure associated with CPAP/PEEP.

However if I'm understanding it correctly, used with volume replacement it is just a relative contraindication, not absolute. Risk vs. Reward.

Pretty much.

If the hypotension is secondary to hypovolemia specifically blood loss, not pulmonary edema.

Anything that reduces ventricular filling will do it. It's even something of a problem when you have higher pressures in folks with atrial fibrillation.

 

[Handsome Robb]

Was there any peripheral edema? JVD? Heart tones? Who called 911 did they see what happened?

 

[EMS Patient Care Advocate]

I agree in theory with OP, that sometimes the response provided by usafmedic45 can seem harsh, having said that, I have never failed to learn something from his posts. I tend to appreciate to the point critiques and advice. I can see where if you are the one receiving the critique it could be painful, but assume you will learn and remember and after all isn't that the point.

Great advice!