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Lesson

CHF & Pulmonary Edema

12 min Medical Skip to quiz

Objective: Separate wet lungs from a failing heart and from COPD when you can. Sit the patient up, use CPAP when it fits, and give nitroglycerin only if the protocol and the blood pressure allow it. Do not give a fluid bolus for wet lungs.

Why this matters

Wheeze is a finding, not a diagnosis. Heart failure, COPD, pneumonia, and a pulmonary embolism can all make breathing hard. A pulmonary embolism is a clot in the lung. The heart-failure picture is often shortness of breath at night, trouble lying flat, wet crackles, high blood pressure, neck veins that stand out, and a heart history. Get it wrong and you may treat tight airways like heart failure. Or you may fill a failing heart with saline. Do not do either.

Key points
  • Sit them up first. Give oxygen when the sat is low. Use CPAP if they protect the airway. Get a 12-lead. Give nitroglycerin only if your protocol and the blood pressure allow it.
  • You do not have a BNP blood test, a chest x-ray, or an ICU ventilator. BNP is a hospital blood test for heart strain. Do not wait for those before you treat the work of breathing.
  • This is often a failing pump pushing against high pressure. Do not treat it like volume loss. Do not give a trauma-style fluid bolus. Tell the hospital this may be wet lungs and possible acute coronary syndrome, a heart-attack picture.

Field Picture

  • Sudden severe shortness of breath, worse when lying flat. Pink frothy sputum is a late classic sign when you see it.
  • High blood pressure is common when fluid suddenly fills the lungs. That backup is pulmonary edema. Low blood pressure is a sicker picture of pump-failure shock. See shock categories.
  • Get a 12-lead. Ischemia, poor blood flow to the heart muscle, may be the trigger. Do not skip the 12-lead because they are “only short of breath.”

Clinical sequence

  1. Sit them up. Give oxygen when the sat is low, then adjust it. See the oxygen lesson.
  2. Use CPAP, or other noninvasive ventilation, if they are alert, not vomiting, and the blood pressure is not low. See the CPAP lesson.
  3. Give nitroglycerin only if you are authorized, the blood pressure is not low, and there is no right-sided heart attack or a recent erectile-dysfunction drug your protocol treats as a caution. See the nitroglycerin lesson.
  4. Do not give a large fluid bolus. This is not bleeding and it is not dehydration.
  5. Notify early and choose the right hospital. They can worsen after a good first 10 minutes. If the 12-lead shows a STEMI, an ST-elevation heart attack, go to a hospital that can open the artery. Do not choose the closest hospital only because it has an open bed.

Common errors

  • Giving only albuterol because you heard a wheeze.
  • Putting CPAP on a lethargic patient who is vomiting.
  • Giving nitroglycerin when the blood pressure is low and the 12-lead shows an inferior or right-sided heart attack.
Verbalize
  • They cannot lie flat. The lungs are wet. The blood pressure is often high. There is a heart history.
  • Sit them up. Use CPAP if the airway is protected and the blood pressure allows it.
  • Do not give a trauma-style fluid bolus.
  • Get a 12-lead. Poor flow to the heart muscle may be the trigger.

Practice

One-minute check

Two wheezing patients. One is a barrel-chested COPD smoker. The other has wet lungs, high blood pressure, and cannot lie flat. State your first three actions for each. Say why a large fluid bolus is the wrong move in the second patient.

Related: CPAP, Nitroglycerin.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. Awakened gasping, sits bolt upright, wet crackles, BP high, CHF history. Best picture:
2. That wet hypertensive patient is alert and protecting the airway. Best next themes:
3. Partner opens fluids “wide open” for this flash-edema picture. That move is:
4. You hear wheezes on that CHF-looking patient. What does wheeze mean here?
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