Congestive Heart Failure & the RT

The increasing overlap of specialties in healthcare industry should be of no surprise to anyone, as aggravated medical diseases fail to exist inside a vacuum. Cardiac and pulmonary systems are prominent examples of this bitter truth, and many singular health issues that once begin with the heart and vessels later manifest their existence with breathing impairments to the patient. For the purpose of this article, we will discuss the multi-tiered collaboration of specialties in the treatment of congestive heart failure; and the specific role of the respiratory therapist.

The term “Congestive Heart Failure” (CHF) is a chronic cardiopulmonary disease that affects the ventricle’s ability to pump adequately; leading to a backup of interstitial fluid into the surrounding lung fields. Acute pulmonary edema and severe dyspnea can present in these cases, leading to the need for immediate respiratory intervention.

In CHF, a decreased amount of oxygenated blood is pumped to the body by the left ventricle per heartbeat, better known as the stroke volume. This reduction of blood volume may lead to a decrease in overall cardiac output; normally pumped into the body through the systemic circuit. To understand heart failure, we must recall our humble beginnings with A & P; and follow the pathway of blood through a healthy heart.

A healthy heart’s right atrium receives its deoxygenated blood from the body by both the superior and inferior vena cava, sending the contents though the right atrium and right ventricle into the pulmonary trunk. The blood is then sent to the lungs by the pulmonary arteries to be oxygenated at the alveolar capillary bed region. After the hemoglobin is fully oxygenated, the blood returns to the left atrium of the heart through the pulmonary veins. This is known as the pulmonary circuit. Next, the blood is sent through the mitral valve in the left ventricle. The left ventricle then contracts, pushing blood through the aortic valve into the aorta; and traveling into the systemic circuit to nourish the tissues and organs of the individual.

Hemodynamics are instructive in identifying and treating heart failure patients. Elevated pressures in the left atrium and pulmonary veins lead to a backup of the “pump system”; increasing the amount of interstitial fluid in the lung and leading to an exacerbation of symptoms. As the name suggests, the fluid or pulmonary edema is also called pulmonary “congestion”; and it crowds the cardiopulmonary tissues causing low cardiac output and a variety of marked symptoms. Symptoms of a person with congestive heart failure may include dyspnea (shortness of breath), tachycardia, arrythmias, radiating chest pain, syncope (fainting), chronic cough, cyanosis from hypoxia, pedal edema, severe fatigue, and wheezing during auscultation. These symptoms can be life threatening often leading to pulmonary emboli and strokes; and thus medical attention should be sought immediately. Imagine the sensation of drowning without ever stepping foot in water.

There are three categories of congestive heart failure, each with unique physiology as to the side of the heart on which they present. The most prevalent is left sided CHF, where the left ventricle of the heart does not effectively pump blood due to lowered hemodynamic pressure. This cause can either be systolic heart failure, which is where the walls of ventricle fail to contract within normal parameters; or diastolic failure, where the myocardial walls of the left ventricle become “stiff” and the myocardium cannot relax between contractions. Right sided CHF is identified when the right ventricle cannot pump efficiently, causing a backup of blood into the systemic veins. This type can be identified by the presence of edema from fluid retention into the lower extremities and abdominal region. The third variation is a collaborative of both left and right sided CHF, which usually occurs when patient with original left sided issues does not receive appropriate treatment. {Mayo Clinic Staff (2017). Heart Failure. Retrieved December 23, 2017, 2017, from: mayoclinic.org/disease-conditions/heart-failure/basics/definition/con-20029801.}

A confirmed diagnosis of CHF is a collaborative process and can be completed by obtaining a series of tests and labs. A twelve lead EKG should be done to determine arrythmias (atrial flutter and atrial fibrillation), followed by an echocardiogram to monitor the blood flow and any irregular areas in the heart vasculature. In many facilities, Respiratory therapists will perform the EKGs on cardiac patients. On a chest x-ray, cardiomegaly (increased heart size) will be present with blunted costophrenic angles with the presence of opacities in the dependent areas of the lungs. Other tests including an MRI, a cardiac stress test, or blood draws to check for elevated levels of BNP. The primary predispositions to developing congestive heart failure are systemic and pulmonary hypertension, coronary artery disease, heart valve malformations, and morbid obesity. Less common causes can include acute pulmonary infections, endocarditis, thyroid disease, and diabetes.

Treatment options for CHF involve a dual role for physicians. Primary actions after identification involve tackling the initial symptoms with treatment to improve vital signs. The second role is one of maintenance to provide stability and prevent any future exacerbations. In the case of a valve malformation (congenital or otherwise), surgery to replace or repair the problem might immediately be warranted. An angioplasty or a coronary artery bypass graft (CABG) surgery may also be utilized to relive blocked coronary arteries. Oxygen therapy is given to treat hypoxemia and cyanosis, while bronchodilators will assist to help relieve bronchospasms and improved work of breathing. A beta blocker like Metoprolol can be used to manage hypertension and tachycardia, and loop diuretics (Lasix) like Furosemide can be administered to relieve the pulmonary edema by means of the kidneys. ACE inhibitors assist with blood vessel dilation to improve blood flow, or Nitroglycerin can be administered to relieve the chest pain from heart failure. Another drug called Digoxin can be administered to strengthen the force of the heart’s contractions (a positive inotropic drug), which increases the stroke volume. This in turn, increases the cardiac output; which is equal to the heartrate multiplied by stroke volume. Maintenance medication for hypertension (including diuretics) and arrythmias should be required daily. Weight loss for obese patients, healthy exercise habits, smoking cessation, and management of diabetes are vital to decreasing future hospitalizations.

Respiratory care has a crucial role is providing the CHF patient with oxygen therapy, CPAP and BIPAP therapy, mechanical ventilation support, patient monitoring, and vigilant patient assessment. Indicators of hypoxemia and peripheral cyanosis should not be overlooked, from cool temperature of the skin to purple extremities. Auscultation of the lung fields is crucial for CHF patients, as the changes in breath sounds could indicate a future exacerbation of symptoms before the dyspnea has even begun for the pateint. Adventitious (abnormal) breath sounds including crackles could indicate an increase in pulmonary edema, and patient inspection for pedal or peripheral edema is important for documentation. Pink frothy sputum can indicate flash pulmonary edema; and the ability to suction the airway must be available at all times. In addition, listen to the mechanics of the patient’s cough for red flags, especially if they already have digital clubbing due to chronic hypoxemia. Arterial Blood Gas analysis is vital for any noticeable changes in the patient’s level of consciousness, even if their disorientation might be documented as stemming from another clinically documented issue; like dementia or Alzheimer’s disease. Although congestive heart failure is chronic and degenerative condition which cannot be reversed, steps should be taken to improve the patient’s prognosis and the extent of their life. While untreated CHF is ultimately fatal, survival rates of treated CHF from five to ten years ranges from 14% to 50%. (Des Jardins, T.,& Burton, G.G., 2016). The healthcare specialties must collaborate on this patient population to ensure the best level of treatment is provided without exception. With our combined efforts, we can work to improve these percentages.

References

The entirety of this presentation falls under the Fair Use Doctrine for the purpose of education, and may only be used for the express purpose of education within the guidelines referencing (Section 107 of the Copyright Act, 1976), with MLA citation format.

1.    Des Jardins, T.,& Burton, G.G. Clinical Manifestations and Assessment of Respiratory Disease.7th ed. St. Louis, Missouri: Elsevier., 2016. paperback

2.    Heuer, A. J. . Wilkins’ Clinical Assessment of Respiratory Care. 7th ed. Maryland Heights, Missouri: Elsevier Mosby., 2014. paperback.

3.    Mayo Clinic Staff (2017). Heart Failure. Retrieved December 23, 2017, 2017, from: mayoclinic.org/disease-conditions/heart-failure/basics/definition/con-20029801.