CPAP vs intubation for CHF

[usalsfyre]

Would anyone have considered NTI as opposed to ETI in this case? For whatever reason, the provider elected away from CPAP, but wanted a secured airway. For a patient who is breathing spontaneously, doesn't this seems more prudent than MAI/RSI?

The nares are really a poor place to put an endotracheal tube down if you can avoid it, it will have to be converted to the oral route later on anyway. If the patient was a poor candidate for a semi-elective intubation, sure. Otherwise I'd go the RSI route.

Performed properly, RSI ( with a full slate of drugs, not the "facilitated" crap) is actually a safe and effective procedure. The problem is so few programs have the training time and oversight to do it properly.

 

[DrParasite]

RSI was not done; just a sedative and pain killer (no paralytic), at least that's what I recall.

Resp rate was around 50 (i think, it has been a couple days since the call). IDK if that changes anything.

I do think he was beyond coaching, esp with the language barrier.

 

[Melclin]

Theres always a .25-.5mg/kg hit of ketamine, too.

Ahh beat me too it.

DSI anyone?


I'm behind sitting the guy up post tube. Better alveolar recruitment.

Can we get some closure on this OPA issue? Whats the go with that?

 

[Akulahawk]

I might have tried a brief CPAP trial with some coaching. That said, anxiety, agitation and claustrophobia are suspicious for respiratory failure and enough to buy a tube. Without being there I'm not gonna second guess the guy.

I forgot about the language barrier, I suppose that is a bit more suspect for respiratory failure. However, I still think a trial of CPAP was warranted before pulling the trigger on intubation. I will admit though, that I probably shouldn't have said this patient was mismanaged, I let the initial description of the medics jade my opinion a bit.

Trial of CPAP sounds perfectly reasonable... however, if the patient is at the point of ripping stuff off... I think I'd seriously consider going straight to ETI too. I'd have to be there to see situation myself though. Given the local constraints out here, I'd have to go to a conscious ETI attempt though, and nobody would be all that happy about having to do that. That being said, if the patient tolerates the procedure fairly well, they'd really be bad off as they'd not even fight because they're too concerned with breathing.

About the only thing I can see with using the OPA on that conscious patient is determining how much he'd tolerate something being put in his mouth... but that might just freak the patient out more and put him further behind.

Lasix, I'd not have given it until later. It just takes too long for that stuff to take effect. NTG/nitroprusside, well that I agree with.

 

[shfd739]

I wouldve done a trial of cpap and skipped the lasix.

I had a patient 2 weeks ago with severe copd exacerbation. Unable to speak and was pulling off the NRB. I was able to place the cpap and after 10mins he was talking and carrying on a conversation with us.

 

[Eli]

This is my first visit to EMTLIFE. And this is the first thread I've really read.
My little back-story... spent years working in an urban area on nights. Treated >100 CHF patients every year. My goal when I started there was to be as good as some of the folks I worked around. I never dreamed I figure stuff out that they hadn't. But I did.

In every service I have worked for or been around, respiratory failure is the ONE area where we can make a difference in short AND long term mortality. It is also the one area EVERY service fails in! Mortality of these patient's is around 6%. More in urban areas, less in affluent populations. My experience with these folks was in the days before CPAP. My plan was simple but effective. My mortality to ICU was < 1 %. None of the patients that I was able to follow up on after admission passed away. But my ability to follow up after the ED was too inconsistent to be a reliable measure. My plan then was calm the patient, AIRWAY, calm the patient, BREATHING, calm the patient, CIRCUALTION, calm the patient.... I always got the nitro on board early. I like a sublingual dose followed by 1-2 inches of paste. I gave the nitro and lasix a chance to work before I EVER considered moving the patient. A CHF patient will always get worse to some degree in the process of moving to the ambulance. Often significantly worse! Screw all the academic criteria they teach us about when to start bagging. You bag them when there's a detiorated LOC or you think they're looking too tired to breath.

Since I left the hood I work in a rural area. I don't see that many patients. And the CHF patient's I see are not nearly as "brittle". Race and economics play a huge factor in these patients. Black people just get the short end of the stick in all areas of cardiovascular issues.

I simply haven't had enough experience with CPAP to have an opinion on it. If it comes down to scoop and run with sirens screaming in the background then yea, CPAP does yield better results. But the results I see with CPAP are about the same as what I got in the 90's without. The main difference I see is that most of my patients were in much better shape by the time I got to the ED than many I've seen hours after arrival at the ED with CPAP. I suspect that has to have some effect on mortality but that's just an educated guess on my part.

With this patient, it would be very hard to coach and comfort him if the language barrier was too severe. There are generally three areas that will adversely affect our ability to successfully manage these patients with just meds. Inability to calm the patient (too anxious, language barrier...), inability to calm the crowd (family, fire, your partner), or inability to give the meds (unsuccessful IV). I found I could manage any one of those areas. But if I encountered two areas of problems that was too much and it was time to switch to a load and go process. Fortunately for me, that was rare. But even without the ability to verbally communicate well it is very conceivable that the EMS team's calm and caring attitude could have been enough to give your patient the patient confidence and reduce his anxiety. Calming him and using nitro would likely have negated the need for CPAP. But at the point you guys got to, I likely would have opted for the CPAP before an ET tube. I don't do RSI; we're just too slow here to have the intubation skills that are needed to go with RSI. Short of RSI, nasal intubation is far more likely to create catastrophic cardiovascular collapse than CPAP is. As to the question of position of the patient after intubation, neither is inappropriate or more likely to be beneficial to the patient.

Okay, I will get off my soapbox now (and this is my soapbox ). Oh one more thing. If these patient’s are hypotensive that changes the game plan. Cardiogenic shock is better managed in the ED than in the patient’s home. Those are load and go patients. Dopamine is good but the ED has additional tools if it doesn’t work. We don’t. Either way, cardiogenic shock with pulmonary edema has a >90% mortality.