Today, I ran an elderly pt with moderate SOB, SaO2 at 92%. My pt had a huge list of medical issues that included every respiratory problem known to man. Lung sounds slightly diminished but no rales or wheezing. No edema visible on extremities. I give the pt a neb treatment and then upon reassessment, I hear the lung sounds get worse with rales. As it turns out, the pt was on lasix even though I didn't see it in her house and it was working according to the doc at the hospital. Plus, there was slight JVD that I didn't notice. The doctor told me when I gave albuterol, it opened up the pts bronchioles and increased the pulmonary edema. As it turns out, there was pitting edema. Even though there was nothing visible on the pts ankles, the doctor showed me there was in fact pitting edema visible on the mid shinbone. Anyway, I thought this was a neat call and wanted to get some opinions about it as well as share it with you all.
Please forgive my ignorance, A+P and pharmacology are not my strong points. I am trying to learn as much as possible being a new medic. Please someone explain why exactly this happened to the Pt.:unsure:
The medication administered was able to open the bronchioles up enough to auscultate lung sounds of the fluid crossing over the alevoli (rales) such as in CHF. As well it sounds like you might had caught this patient in the "dumping mode" from right heart failure to left. There is a small amount of cessation and improvement at this time.
CHF or congestive heart failure is primarily caused by "pump damage" (heart). The primary cause of that is usually associated with an AMI, poor stroke or ejection fraction (pumping out blood from the left ventricle) to the rest of the body. Poor circulation causes a "pooling" or "back up" (simplistic terms) effect... thus causing more pulmonary congestion.
The problem is however Albuterol can actually make CHF worse. That is why the importance of good assessment techniques, as well as identification of adventitious lung sounds such as rales versus wheezes. The use of EtC02 monitoring as well will give you a better picture of the differential of pulmonary congestion versus pulmonary obstruction. There is a major difference and the treatment is definitely not the same.
With EtC02 one will note "shark like fin" wave form noting pulmonary obstruction (such as in Asthma, COPD etc) and in CHF there will not be such presentation unless they have a combination of both.
Beta drugs such as respiratory nebulizer med.'s can potentially cause an increase in infarct size as well as increasing pulmonary congestion. The use of Nitrates is more indicative of CHF allowing an increase of venous pooling (pre-load effect- before it pumped to the heart) and use of CPAP as a positive pressure device to help "decrease the fluid accumulation at the alveoli level, (blowing the fluid back into the blood system)..will increase their oxygenation and saturation levels and the use of diuretics (med's that make you pee) to shift and shed the excess fluid and reduce the work load as well. The edema you noted is called pre-tibial. (Remember the first place to accomodate edema is not the ankles... where do you think it might be ? )
There will be an over whelming amount of people that will be diagnosed with CHF in the next 5 years... and the majority of our patients we treat will have it.
Rid summed it up pretty well. I'll add, the reason I thought this was an interesting case, was because the pt denied CHF and did have a hx of COPD. If my initial assessment skills had been better, I wouldn't have increased her pulmonary edema with the albuterol. So let this be a lesson to other providers because our first commitment is to always do no harm.
P.S. thanks for the EtCO2 tip, I'm definitely using that from now on.
Wow! thanks for the info, I feel so far behind the curve. Are these things I should know in and out, or are these things I will learn over time?:blush:
Oh CHF I understand pretty well, its the interactions, actions and reactions of the smaller things that I am having a little trouble of. Thanks for the pointers and kind teaching.
