Here are the causes,clinical picture, investigations (diagnosis) and treatment (management) of Acute Left Heart Failure or Cardiogenic Pulmonary edema .
Causes of Cardiogenic Pulmonary Edema
1. Acute left ventricular failure. e.g extensive MI, myocarditis.
2. MS with aggrevating factors e.g AF.
3. Acute mitral incompetence (backward failure), acute AI.
Pulmonary capillary pressure above 20 mmHg leads to interstitial edema.
Alveolar edema occurs when the capillary pressure exceeds the total oncotic pressure (approximately 25 mmHg).
Clinical picture of Cardiogenic Pulmonary Edema
- Manifestations of the cause .
- Marked dyspnea, orthopnea and haemoptysis (frothy pink sputum) .
- Sense of impending death with marked irritability .
- Bubbling crepitations and rhonchi allover the chest .
- Chest x ray: Showing butterfly opacity (Bat wing appearance) .
- Echo: Showing decline of ejection fraction of the left ventricle or any valve lesion.
Treatment of acute cardiogenlc pulmonary edema
- Hospitalization & rest in bed in sitting position, 02 therapy with high concentration (60%,100%).
- Treatment of precipitating factors & the cause.
- Morphia 2-5 mg IV: decreases Venous pressure & sedation, naloxone must be available, metoclopramide 10 mg IV to prevent emesis.
- Furosemide is a potent venodilator and decreases pulmonary congestion before its diuretic action. An initial dose 20-40 mgIV given over several minutes and can be increased, to a maximum 200 mg in subsequent doses.
- Venous vasodilators e.g. nitroglycerin 5-10 ug/m (rapid, effective).
- Na nitroprusside (20-30 ug/m in hypertensive patients, keep the systolic blood pressure > 100 mmHg.
- Powerful positive inotropic: dopamine or dobutamine .
- IV digitalization if needed e.g with rapid AF.
- Aminophylline, 5mg/kg IV infusion over 10 minutes.
- Tracheobronchial aspiration.
- Ultrafiltration, rotating tourniquets, Intra aortic balloon as before.
Recent role of BB in treatment of heart failure
- Activation of the sympathetic system may initially maintain cardiac output through an increase in myocardial contractility, heart rate and peripheral VC . However prolonged sympathetic stimulation leads to cardiac myocyte apoptosis (cell death), hypertrophy and focal myocardial necrosis.
- BB may help to counteract the deleterious effects of enhanced sympathetic stimulation and may prevent arrythmia and sudden death. We can start with small dose, bisoprolol (concor) 1.25 - 2.5 mg/d with gradual increase of the dose according to need with monitoring of patients.
- Abrupt administration of large doses of BB can intensify HF, specially acute HF .
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