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Nick Taylor: So this is a severe presentation of HFPEF (vascular failure)…
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Dilan Epasinghe: Thank you sir…
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Nick Taylor: So this is a severe presentation of HFPEF (vascular failure)…
Dilan Epasinghe: Thank you sir…
Nick Taylor: Thanks for the question Dilan, Great to hear from you. RVF n…
11 Comments
1- COPD exacerbation
2- bronchial asthma exacerbation
3- bronchiactasis exacerbation
COPD with corpulmonale and AF
Echocardiography
2- ABG
Right ventricular hypertrophy and strain
Low flow o2
Heparin
Bibap if needed
Amiodarone
Betablocker
Antibiotic
Stop smoking
Correct AF
Diuretics
this is a nice method of learning!
Hypertensive Emergency with pulmonary oedema
Atrial Fibrallation
Manage with IV GTN
It is Acute Pulmonary Oedema , Prop up, start with CPAP change to BiPAP if indicated in blood gas, IV GTN infusion , ECG , may need enoxaparin also.
So this is a severe presentation of HFPEF (vascular failure). The patient is hypertensive tachycardic and hypoxic.
First question re DDX . You can see the increased work of breathing, rapid respiratory rate but normal I:E ratio. Asthma would have a long expiration time, and PE doesn’t usually have work of breathing because there’s no airflow problem, so it’s pneumonia, ARDS, LVF or restrictive lung disease
With the extra information of the hypertension, it really only leaves LVF and restrictive lung disease. Severe pneumonia or ARDS is likely to be hypotensive . The Vascular failure variant of LVF is now much more likely given the hypertension.
Bedside tests are a VBG, ECG and USS.
The echo shows a thickened LV with relatively preserved ejection fraction and no significant RVH (helping to exclude severe restrictive lung disease , as you’d expect RVH). The lung USS shows widespread bilateral B line profile , consistent with severe acute pulmonary oedema (severe pulmonary fibrosis can give B lines, but they tend to be more “static” in B mode USS.)
Treatment is CPAP non invasive ventilation with high FiO2 initially, start with PEEP 10 at increase up to 20 if needed. This reduces work of breathing, improves oxygenation, reduces preload (positive intrathoracic pressure) and reduces afterload (postive pressure across myocardial wall). GTN immediately as a sublingual tablet or patch and then as an infusion. No frusemide or morphine .
To improve this care
Sit the patient up (helps with fluid redistribution , reduces preload, improves lung mechanics)
Increase PEEP
Increase GTN infusion and/or add better arteriolar dilation eg hydrallazine or SNP
REMEMBER THE MAIN STEPS TO MANAGING acute LVF: RIPPOV
Revascularise (if STEMI)
Inotropes (if hypotensive)
Position (Prop up patient)
Pressure (CPAP)
Oxygen
Vasodilate