Save more lives in CCU with CPAP : Should be used liberally in LVF to prevent the onset of cardiogenic shock !

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Save more lives in CCU with CPAP : Should be used liberally in LVF to prevent the onset of cardiogenic shock !

August 23, 2015 by dr s venkatesan

Coronary care units are the place, where acute myocardial infarction patients are housed. Thrombolysis is still the primary modality of treatment world over .Large infarcts, , impending or established cardiogenic shock are major source for mortality .

Acute left ventricular failure (LVF ) in CCU has to be swiftly managed in whatever phase of MI .Standard regimen of sedation, diuretics, Nitro glycerine, and Dobutamine are administered are often not good enough .( Its true many of these patients are to be taken for emergency PCI ) Still, medical management of LVF has a huge impact on the outcome.

While cath lab procedures are given top priority , I have seen many times, simple concepts in CCU not getting proper attention.Continuous positive airway pressure(CPAPA/Bilevel-NPPV) aided oxygen administration has a critical role to play in this setting.

It reduces the work of breathing
Opens up wasted Vp/Vq zones in lungs
Interstitial gas diffusion is facilitated by keeping the respiratory units
Keeps a check on the LVEDP from going to very high levels in an indirect fashion (Lung helping heart !)

Why not Intubate these patients ?

It’s true Intubation and ventilation may be required ultimately in many of these patients. .It has its own issues of prolonging the stay and infection .

Final message

Even though the clinical trials do not show consistent impact on long term survival , we have time and again found this modality useful .Timely administration of of CPAP definitely halts the progression of mild forms of LVF to full fledged cardiogenic shock and leads to recovery in many .

CPAP/Bilevel-NPPV is important hemodynamic stabilising tool , that should be used liberally whenever possible .

Reference

There has been number of studies exploring the role of CPAP in acute LVF during STEMI.

1. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.Bersten AD, Holt AW, Vedig AE, et al N Engl J Med1991;325:1825–30.

2.Continuous positive airway pressure by facemask in acute cardiogenic pulmonary edema Rasanen J, Heikkila J, Downs J, et al.Am J Cardiol1985;55:296–300

3.Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema.Vital FM¹, Ladeira MT, Atallah AN.Cochrane Database Syst Rev. 2013 May 31;5

4.A multicentre randomised controlled trial of the use of continuous positive airway pressure and non-invasive positive pressure ventilation in the early treatment of patients presenting to the emergency department with severe acute cardiogenic pulmonary oedema: the 3CPO trial. Gray AJ¹, Goodacre S, Newby DE,et all ; 3CPO Study Investigators.Health Technol Assess. 2009 Jul;13(33):1-106