Nebbing a CHFvsCOPD/asthma PT

[MS Medic]

On another thread about calling med control, I stated that my local protocols state that I have to call before administering a neb for a wheezing pt if they have a hx of CHF and COPD/asthma. The resulting conversation was threatening to hijack that thread.
I think this is a worthy topic of discussion so I am starting a new thread here and linking it.

 

[MS Medic]

If a pt has a hx of both CHF and COPD/asthma and we find wheezes for lung sounds during an assessment. If we think the pt is having an asthma attack or COPD exasperation, we must call med control to get orders to neb the pt.

The concept is to keep from giving a CHF pt a neb. While I understand the concept, I disagree with requiring med control contact before treating the pt.

Any thoughts?

 

[Veneficus]

My thoughts are if you don't treat an asthma exacerbation you will have a not breathing patient. which will definately be a bigger problem than the CHF aggrivation.

I can see where a conservative medical director would want a provider to call to confirm the patient condition, but I don't agree with it.

If the CHF is stage III or IV and so severe that treating the asthma will push them over the edge, they probably have bigger problems.

More than wheezes, I have a bigger problem with people pushing furosemide for wet lung sounds, without checking a temp or other symptopms of pneumonia since CHFers are prone to developing it.

 

[MS Medic]

I agree on both accounts. In the last service I worked at, we did not have to call for med control on a neb and I have misdiagnosed and nebbed a CHFer twice. One time the person had no other symptoms other than wheezes and low SpO2. The other time, the person gave me a poor Hx with conflicting info and had conflicting findings on assessment. Both times I had a line established before giving the neb and monitored the pt during Rx. When I noticed the change from wheezes to wet, I DCed the neb and pushed NTG, making sure the BP was still good, until I dried them up.

I dislike the prehospital use of lasix period. There is evedence that overuse, even in a CHF pt, leads to prolonged hospitalization. ER docs who aren't Cardiologist misdiagnose the pt 50% of the time and that is with X-rays of the Cx. It has no effect in the field unless you have a long Tx time and if it does kick in you have to worry about the pt urinating all over the stretcher and back of the ambulance.

If you are like me and still don't have CPAP and NTG infusion, then I would prefer to just give NTG as long as the BP will tolerate it.

 

[el Murpharino]

More than wheezes, I have a bigger problem with people pushing furosemide for wet lung sounds, without checking a temp or other symptopms of pneumonia since CHFers are prone to developing it.

Nothing makes the hospital staff happier than a patient with concrete in the lung bases after giving a pneumonia pt. lasix...

 

[mgr22]

It's always interesting -- and sometimes amazing -- to hear about major differences in protocols from one region to another. Our standing orders for CHF include NTG, Lasix and albuterol, conditionally, according to lung sounds.

It's almost always a challenge to manage an acute patient with CHF and COPD. I think Lasix is more harmful than albuterol to a large subset of these patients. Experience, ongoing assessment, and knowledge of pharmacology are more important than rote adherence to protocols.

 

[Epi-do]

Lasix was removed from our protocols last year. We no longer carry it on our trucks at all. This year they increased the dose of ntg that we give CHFers from 0.4 mg to 1.2 mg. We can also give albuterol if we hear wheezes in the lungs. In fact, we have been told in the past by the medical director that if the patient isn't moving any air at all and has a history of both CHF & COPD/asthma, to give them a little albuterol to open them up enough to hear something in the lungs and then treat appropriately from there.

 

[MrBrown]

If our Diploma level Technicians can figure the diff between asthma and CHF I am thinking even the ten week quicky patch factory graduate in a Houston Fire Department ambulance should be able to.

Frusemide is being looked at hard here and I am guessing it'll be going away come 2011 when our next update comes out.

 

[Veneficus]

If our Diploma level Technicians can figure the diff between asthma and CHF I am thinking even the ten week quicky patch factory graduate in a Houston Fire Department ambulance should be able to.

I didn't think you were such an optimist.

 

[FLEMTP]

I say do a good assessment on your patient, assuming time and pt condition permits. If the patient has a history of CHF and COPD, and they now present with wheezing, you have to look at several factors.

Has there been a recent change in the amount of diuretic medications, either an increase or decrease?

-A recent decrease in a diuretic medication may be contributing to a
pulmonary edema type event. If there was a recent increase, you may
be looking at a COPD exacerbation, especially because dehydration can
tend to exacerbate COPD.


Was this a gradual onset or a sudden onset?

-gives you an idea if you are looking at a pulmonary edema vs an
infection vs COPD.

How does the patient sleep at night?

-Patients with CHF exacerbation that is not an acute event tend to
report that they have to sleep sitting up, in a recliner, or with extra
pillows in order to obtain quality sleep at night.

How do their vital signs present?


-A CHF may present with hypertension, despite the use of
prescribed anti-hypertensives on a daily basis, due to the increase
in preload in the cardiovascular system. A good history is
necessary to determine if they have a hypertension history
and if it is adequately controlled


On exam, is there noticeable edema present?


-Noticeable edema can point to cardiac insufficiency and fluid overload,
which points towards a CHF over a COPD


Does the patient present with cool pale skin, hot dry skin, etc?


-Cool, pale moist skin is more typical of a cardiac related event. A hot
dry skin may indicate fever, which could help rule out a CHF type event,
and possibly point toward infection or pneumonia.



Obviously if the patient is unstable, or having a severe respiratory compromise then you need to being treatment sooner than later, preferably some of the more general treatments, such as high flow oxygen, and CPAP.

Once you establish CPAP and the patient appears to be tolerating it well, consider an in-line albuterol treatment. If you are dealing with a COPD, it would certainly help, and if it is CHF, your risk of increasing the edema is lower due to the higher airway pressures generated by the CPAP.

There also might be occassions where you are dealing with both CHF and COPD exacerbation together, which can further confuse a provider and give uncertain exam results.

Regarding the use of lasix in CHF-

approx 2/3rds of the patients you will encounter that are in Congestive Hearth Failure will actually be mildly dehydrated. (I do recall reading a study that provided a sound basis for this, and I will attempt to locate my sources and cite them here) so giving lasix is not the most appropriate treatment and may actually worsen the condition. I reserve my lasix administration for patients that appear to be very fluid overloaded in the extremities as well as presenting with pulmonary edema, as well as patients who may receive marginal relief with our standard treatment of CHF.

In our system we dont have protocols, we use medical guidelines that encourage us to examine and assess our patient well, and provide an appropriate treatment based on our exam, assessment, and experience. For CHF this may include the use of nitrates, both sublingual and IV, CPAP, aspirin administration, preload reducing narcotics (morphine in our case) and albuterol. A 12 lead is always performed on any patient with breathing difficulties, whether it is thought to be CHF or COPD, because many times a respiratory issue can have an underlying cardiac pathology. (ie: wheezing and edema secondary to a atrial fib with a rapid ventricular rate)

We have the freedom here to decide what is and what is not appropriate, or use an outside the box approach, depending on the patient.

We do not have a medical control per say that we must contact or follow up with, but we do have a very thorough QA/QI process to ensure that appropriate treatments are being performed in the field.

Obviously in hospital diagnostics make it much simpler to make an accurate diagnosis, with chest x-rays, blood work, etc. so I always try and follow up with the ER physician to decide if my treatment and field diagnosis is accurate, and if not, discuss with the Dr how I came to reach the conclusion I did, and how to be better at it in the future.

Hope this helps a little!

 

[18G]

Sometimes pulmonary edema in CHF can cause bronchoconstriction and wheezes so I don't see where it is wrong to administer albuterol in these cases.

I agree both CHF and COPD can have overlapping presentations but there are usually some key assessment criterias that help differentiate although still some patients can be hard to decipher.

COPD:
75% of COPD exacerbations are caused by a URI. Has the patient had URI symptoms lately?

Is the patient febrile? This would point to a potentially infectious cause of the distress owing more towards COPD than CHF.

Increase in inhaler use lately? Any changes with sputum quality or quantity?

CHF:
Increase in PND? Had to increase number of pillows?

Change in diet? Has the patient splurged in a high sodium diet recently? Has the patient been complaint with their preload reducers (diuretics, nitrates, ACE inhibitors)? Did they run out?

Has the patient had increase in edema (pedal, ascites)?

Using capnography can help differentiate COPD/Asthma from CHF. CHF will not have the prolonged upslope (shark-fin) on the waveform like COPD/asthma exacerbations will.

 

[FFMedic75]

You have to treat the COPD/Asthma if there is wheezing or diminished lung sounds. This the more immediate problem to be corrected. It can make the CHF/PE worse by increasing HR, O2 demand, etc. Do a good assessment. If it is obstructive pulmonary in nature about 90% of the time you will find dry, warm skin. If it is Cardiac/Pulmonary Edema in nature skin will be cool and clammy. Probably the best new way of determining the underlying issue is using Waveform Capnography and look for "Saw Tooth" or downward sloping waveforms. Look at the BP, look for JVD. If you find an underlying problem that is an obstructive pulmonary in nature treat it. If the patient also has a history of CHF then know what signs and symptoms to look for and be prepared to treat it should it manifest itself. Remember often times one of the best way to treat CHF/Pulmonary Edema is to decrease anxiety. What better way to do that than to make it easier to breath?

 

[FLEMTP]

You have to treat the COPD/Asthma if there is wheezing or diminished lung sounds. This the more immediate problem to be corrected. It can make the CHF/PE worse by increasing HR, O2 demand, etc. Do a good assessment. If it is obstructive pulmonary in nature about 90% of the time you will find dry, warm skin. If it is Cardiac/Pulmonary Edema in nature skin will be cool and clammy. Probably the best new way of determining the underlying issue is using Waveform Capnography and look for "Saw Tooth" or downward sloping waveforms. Look at the BP, look for JVD. If you find an underlying problem that is an obstructive pulmonary in nature treat it. If the patient also has a history of CHF then know what signs and symptoms to look for and be prepared to treat it should it manifest itself. Remember often times one of the best way to treat CHF/Pulmonary Edema is to decrease anxiety. What better way to do that than to make it easier to breath?

+1 on the waveform capnography.. i forgot to mention that...

oh.. for anxiety.. i find that 2mg/kg of succinylcholine works pretty good

 

[18G]

oh.. for anxiety.. i find that 2mg/kg of succinylcholine works pretty good

2mg/kg of succinylcholine would definitely increase my anxiety! being conscious with complete feeling yet not being able to breathe or move... not much of a anxiety reliever...lol... unless of course your gonna sedate me first.. but than its the etomidate or versed that is reducing the anxiety... Versed 0.1mg/kg would do the trick

 

[FLEMTP]

2mg/kg of succinylcholine would definitely increase my anxiety! being conscious with complete feeling yet not being able to breathe or move... not much of a anxiety reliever...lol... unless of course your gonna sedate me first.. but than its the etomidate or versed that is reducing the anxiety... Versed 0.1mg/kg would do the trick

Who said I was talking about the patient's anxiety!!B)

 

[Martyn]

Lasix was removed from our protocols last year. We no longer carry it on our trucks at all. This year they increased the dose of ntg that we give CHFers from 0.4 mg to 1.2 mg. We can also give albuterol if we hear wheezes in the lungs. In fact, we have been told in the past by the medical director that if the patient isn't moving any air at all and has a history of both CHF & COPD/asthma, to give them a little albuterol to open them up enough to hear something in the lungs and then treat appropriately from there.

Makes sense to me, if you cant hear anything how can you treat it.

 

[18G]

We carry Lasix but it is way down the list and never end up getting to it. I'm not convinced that Lasix is needed pre-hospital when you have O2, nitro, and CPAP with standard transport times.

 

[dmiracco]

If you hear wheezing then there is some constriction and narrowing of the lungs so I say open them up.
If you cant hear anything becuase there way to tight then I say open them up.
Pretty simple stuff.
Also lasix is definatley over used in the prehospital setting however it clearly has some benefits when utilized correctly.
Cheers

 

[MSDeltaFlt]

If a pt has a hx of both CHF and COPD/asthma and we find wheezes for lung sounds during an assessment. If we think the pt is having an asthma attack or COPD exasperation, we must call med control to get orders to neb the pt.

The concept is to keep from giving a CHF pt a neb. While I understand the concept, I disagree with requiring med control contact before treating the pt.

Any thoughts?

I would love to know from which part of our great state you hail. I honestly don't call med control to give nebs. If they're wheezing, I give nebs. If they're full, I give NTG. It's usually straight forward, and not rocket science.

I wish I could give NTG and CPAP on my ground service, but alas I'm not that lucky. Dreams do come true... sooner or later.

 

[medic3974]

Cardiac Asthma... Thats what I call a wheezing CHFer. Albuterol not going to help. It will make it worse by increasing the heart rate and putting a patient into a hypoxic fit. Here is the scenario your faced with 40 to 50 yoa m c/o trouble breathing. Paramedic school taught you to look for JVD, onset short or long, pedal edema. Here is the real life. The patient is in a tripod position on your arrival sitting or standing against a wall. He can only speak in 1 word sentences, His Grand mama is on scene saying that he has asthma. The patient wont be able to tell you anything but " iiii caaant breatheee" New onset of CHF will sometimes have little to no pedal edema, good luck on listening to lung sounds when the patient is already very anxious and wont be still. Here is when some of you folks hear wheezing. Its more of a high pitch wheeze but none the less a wheeze. So you have a choice to make asthma or chf. I'm not a paramedic instructor but I am a medic who knows what works. If the patient is hypertensive treat for CHF. Systolic above 150. Start spraying ntg like a mad man 2 sprays q 5 w/o limit unless systolic bp falls below 90. Wont happen most are 200/palp or higher. Dont worry about those silly protocols. Become informed as a Paramedic do the right thing for the patient and worry about getting a signiture latter. You can have my lasix. I dont see any immediate results from it. Dont take my ntg. Ntg saves chf'ers lives. try it. Ok hypoxic fit. this is the patient that wont sit down on the bed because they feel anxious and in reality their drowning and if they sit down it feels like their head is going under water. So this can be a huge safety danger to EMS cause he starts moving around on that bed on the way down some stairs and you could drop the patient or worse hurt yourself. Start an INT inside the house and give 5mg of ms fast push not like adensonie fast but fast. this will stun your patient and they will have a seat on your bed and not move. Swear to god one of you paramiedic's out their say it will not their resp drive out I will hunt you down. It will slow it down but unless their very elderly and weigh 90lbs it a safe drug so dont be afraid of it. Ok thats how I do it reduce pain and suffering do whats best at that moment. You will get that trip report signed latter.