Saw a patient today with documented COPD and a label of CHF. The patient presented with volume contraction and CO2 narcosis. ABGs:
On > 4 liters of oxygen
| ABG | |
|---|---|
| pH | 7.13 |
| pCO2 | 130 |
| pO2 | 128 |
This patient had 2 management issues. First, she had received too much diuresis. The problem here is that she does not have left ventricular systolic dysfunction – her Echo is normal. Someone had given her both furosemide and hctz and clearly overdiuresed her.
Second, she had no understanding of oxygen management.
I believe she only has COPD. She needs occasional (not daily) furosemide. She also needs to use nasal oxygen more sparingly.
We will expunge the diagnosis of CHF from her record and discontinue at least 4 medications.
{ 5 comments… read them below or add one }
DB, The finding of normal systolic function on an ECHO rules out systolic but not diastolic dysfunction. She certainly could have CHF despite her preserved ejection fraction and it would be from diastolic dysfunction. The echocardiogram does not reliably diagnose left ventricular diastolic dysfuncton. Put another way, a “normal” echo doesn’t rule it out. She could also have cor pulmonale, i.e., right sided CHF due to lung disease, and if so would also benefit from diuresis.
What is the basis for your finding of “overdiuresis”?
thanks
David,
Thanks for the comment. It is clear that they were treating systolic dysfunction – ace inhibitor and carvedilol. Regardless they were over diuresing. Those were my big points.
Patients with severe COPD, even with bad hearts, usually do not need aggressive diuresis. First off, most of the sodium retention is in the form of peripheral edema and is not a direct threat. Second there is the risk of overdiuresis, hypokalemia, metabolic alkalosis, all of which will aggravate the situation. Third of all, it is truly impressive how patients who come in with severe chronic hypoxemia from COPD will diurese spontaneously with appropriate oxygen therapy. I have seen patients lose 10-15 pounds in two days simply with one dose of lasix and restoring the PO2 to the 60-70 range. Rarely do these people need more than 40 mg of lasix on a daily basis.
Also, until the patient is clinically and blood gas stable it is advisable to use a Venturi Mask to titrate the oxygen therapy. Oxygen is a drug- giving it by nasal cannula to an unstable COPD patient risks giving erratic doses -either too much or too little. Most patients with severe CO2 retention and hypoxemia stabilize after 24-48 hours on a Venturi Mask and can be converted to a nasal cannula but until they are relatively stable they should receive supplemental oxygen by Venturi Mask, assuming they are not going to receive positive pressure ventilation
Is it possible to get right-sided heart failure from pulmonary hypertension secondary to COPD?
At what point would you consider something like sildenafil for pulmonary hypertension?
What would be the medical rationale in giving the patient with CHF (left ventricular dysfunction), COPD, and acute renal failure, who has severe peripheral edema and pulmonary congestion, a hypotonic solution (1/2 NS @ 100 mL/hr)?