Aliases
Congestive heart failure, respiratory distress, respiratory failure, acute respiratory distress syndrome, myocardial infarct, pulmonary embolism, COPD, asthma, anaphylaxis
Patient Care Goals
- Decrease respiratory distress and work of breathing
- Maintaining adequate oxygenation and perfusion
- Direct supportive efforts towards decreasing afterload and increasing preload
Patient Presentation
Inclusion Criteria
- Respiratory distress with presence of rales
- Clinical impression consistent with congestive heart failure
Exclusion Criteria
- Clinical impression consistent with infection (e.g. fever)
- Clinical impression consistent with asthma/COPD
Patient Management
Assessment
- History
- Use of diuretics and compliance
- Weight gain
- Leg swelling
- Orthopnea
- Exam
- Breath sounds – crackles/rales
- Lower extremity edema
- JVD
- Cough and/or productive cough with pink/frothy sputum
- Diaphoresis
- Chest discomfort
- Hypotension
- Shock
- Respiratory distress, assess:
- Patient’s ability to speak in full sentences
- Respiratory accessory muscle use
Treatment and Interventions
- Manage airway as necessary
- Administer oxygen as appropriate with a target of achieving 94-98% saturation
- Initiate monitoring and perform 12-lead EKG
- Establish IV access
- Nitroglycerin
- SBP 100 – 149 mmHg: 0.4 mg SL
- SBP 150 – 199 mmHg: 0.8 mg SL
- SBP 200 or greater: 1.2 mg SL
- Repeat every 3 minutes as long as SBP greater than 100 mmHg
- The use of nitrates should be avoided in any patient who has used a phosphodiesterase inhibitor within the past 48 hours
- Administer nitrates with extreme caution, if at all, to patients with inferior-wall STEMI or suspected right ventricular (RV) involvement because these patients require adequate RV preload
- For moderate to severe respiratory distress, CPAP
- Max of 10 cm H2O with commercial device or 20 cm H2O with BVM and PEEP valve
- Discontinue if SBP < 100 mmHg
- Consider advanced airway for severe distress or if not improving with less invasive support
- Etomidate is preferred for sedative-assisted advanced airway placement
- If PEEP valve available, titrate valve to oxygen saturation between 94-98%