People with end stage COPD now living longer

The natural progression of Chronic Obstructive Pulmonary Disease will eventually lead to heart failure.  When this happens the disease is considered to be in its end stages.  Good news here is that, while the prognosis is still quite poor, it has now been extended from two years to four hears, according to a study reported on in 2013 by the American Heart Association.  

Sometimes heart failure is caused by the aging process, simply by the it getting weak with age.  However, often it is secondary  to to the heart working too hard to pump blood through diseased lungs.  Patients with cystic fibrosis, bronchiectasis, and chronic obstructive pulmonary disease (COPD) are some of the lung diseases that may lead to heart failure. 

When heart failure is secondary to pulmonary disease, this usually begins by the right heart becoming enlarged (hypertrophic) from years of working too hard.  It then becomes an inefficient pump.  This is called cor pulmonale. 

Cor pulmonale may eventually lead to left heart failure, whereby the heart fails to meat the demands of the body.  Venous return to the heart increases, leading to blood becoming backed up in the legs, ankles, and lungs.  When blood backs up in the lungs this is called pulmonary edema.  It's also referred to as acute heart failure, or congested heart failure. 

There is no cure for heart failure, although the symptoms can be treated.  There are medicines to strengthen the force and contractility of the heart, and medicines to help remove the fluid from the lungs and ankles.  Acute heart failure may also be treated with noninvasive ventilation to reduce venous return and reduce cardiac output and blood pressure.  

Generally speaking, when patients with COPD develop heart failure it is considered end stage COPD.  This is where the patient will need to be monitored closely by a physician, and may require frequent physician and hospital visits in order to treat flare ups.  

At this point, flare ups may be caused by exposure to COPD triggers such as strong smells and cigarette smoke, but they may also be caused by heart failure. This is when treating the disease becomes difficult

Usually, patients with lung diseases develop atrial fibrilation prior to heart failure, so this may be a sign that it's time to consider heart failure.  

Heart Failure: Everything RT's need to know

To understand Congestive Heart Failure (CHF) you must understand the heart. I am sure you know this already, but for those who want a review, this should suffice.

You effectively have two hearts. Your right heart is responsible for pumping blood through your lungs, and your left heart is responsible for pumping blood through your entire body, including your heart and lungs. Your right heart is a relatively small pump that generates a light pressure to pump blood, and the left heart is a strong pump that generates a strong pressure needed to pump blood through the rest of the body.

The right heart is a smaller pump that generates a pressure of about 15. That's all that is needed to pump blood through healthy, compliant lungs. The left heart is a bigger pump that generates a pressure of about 120/80. This is what is needed to push blood through the body. Nothing new here.

You can have a diagnosis of heart failure and have no symptoms on a day to day basis. However, as your heart becomes a weaker pump, you may present with symptoms, such as noted above. The symptoms may present similar to asthma and COPD, and may include dyspnea and wheezing. Usually, but not always, the wheeze is upper airway, and it's frequently audible.

Congestive Heart failure usually refers to a is a condition where the left heart becomes unable to pump blood through the body. It is unable to fully oxygenate tissues and organs that work to keep the body functioning as a system. Without adequate blood flow, tissues and organs will fail to perform their jobs, and the body will die.

When a heart is in failure it is unable to maintain an adequate...

Cardiac Output (CO). This is the volume of blood pumped from the heart per minute. CO is the product of both the stroke volume and heart rate. An easy way of measuring CO is blood pressure. It can also be indirectly measured by feeling for a pulse. So, these are just some simple ways we check CO. It can also be checked with a pulse oximeter. If the pulse ox reading is low, a low CO may be the reason. This is important, because when a person is on too high a PEEP, CO is the first thing to be affected. You lower PEEP you increase CO. Okay, enough about that. Moving on.

Stroke Volume (SV). This is the volume of blood pumped from the heart per beat. This is determined by CO minus heart rate times stroke volume.

Heart Rate (HR). This is simply the number of heartbeats per minute. Easy enough. We check this all the time.

So, by using the formula above, you can see that cardiac output is affected by anything that decreases the heart rate or decreases the strength of the heart, or the ability of the heart to constrict and force blood to the lungs or body will decrease the amount of blood leaving the heart.

Afterload. This is blood leaving the heart.

Preload. This is blood entering the heart.

Without doing extensive testing, an easy way to measure cardiac output is by taking a blood pressure. And the even easier way is by simply taking a pulse. Since a pulse oximeter measures oxygen saturation using a pulse, a decreasing oxygen saturation can also be an indicator of decreased cardiac output. So, there I said it twice now. So, you should never forget it.

As heart failure progresses, and as the heart becomes too weak to effectively pump blood through the body, blood will back up into the vessels in the lungs, thus increasing the...

Pulmonary vascular resistance. This is the blood pressure in the lungs. As this increases, blood will seep out of the blood vessels and into the lungs, causing...

Pulmonary edema. This is fluid in the lungs. It often appears as pink and frothy. If you see this coming ouf of a person's nose and mouth, it is not a good sign. I have rarely seen this in a person who survived. Thankfully, I have not seen this in many years. So, this probably means heart failure is being treated better today than when I first arrived on the scene back in 1995.

Increased pulmonary vascular resistance actually squeezes airways, causing them to become narrow. This is why heart failure may mimic asthma, as this causes a wheeze. This is called a cardiac wheeze. It's quite often audible, as fluid may be pushed to the upper airway and sit on the vocal cords. Nurses and doctors like to think this is bronchospasm. But, it's not.

Fluid is also squeezed out of blood vessels into the intrapulmonary spaces. Some of these secretions may work their way up to the upper airways and sit by the vocal cords, thereby causing that forced, audible expiratory wheeze so commonly heard among the heart failure community. This is called a cardiac wheeze, and it used to be called cardiac asthma. This wheeze cannot be treated with a breathing treatment, although this too often is attempted.

The life expectancy of most CHF patients

Did you know most people who are diagnosed with congested heart failure (CHF) die within two years of diagnosis. This is true in most cases because CHF is usually secondary to the heart working overtime for a long time.

In some cases it occurs as part of the aging process, as an old heart is going to weaken at some point. In other cases it is diagnosed in younger people with lung problems, such as cystic fibrosis, bronchiectasis, COPD, or other lung diseases. The heart gets tired of working so hard to push blood through the lungs.

In the case of lungs causing CHF, this usually starts by the right heart becoming a weak an inefficient pump after working so hard to push blood through the lungs, called cor pulmonale, and this ultimately results in the left heart working too hard and causes left pump failure, or CHF.

You see this quite a a bit in end stage COPD patients. Usually, however, atrial fibrillation precedes CHF in these patients. So if you have a patient in atrial fibrillation who also has COPD, you can start thinking of measures to prevent CHF, assuming that's the next evolutionary stage of their disease process.

Of course there are systemic diseases too that can cause the heart to poop out too, like high blood pressure, cardiac disease, etc.

How heart failure is treated

Heart failure is what happens when the heart becomes a weaker pump, and thus fluid backs up into the lungs and the rest of the body. Often the ankles become swelled, and breathing becomes difficult.

This can occur as a result of a variety of ailments from a heart attack to lung disease such as severe COPD. The good thing about heart disease is it can be managed, although it may entail some lifestyle changes, and managing some new medicines.

Heart failure may may refer to congested heart failure (CHF), which is when the left heart fails, or it may refer to left heart failure secondary to right heart failure.

Methods of improving heart function include anything that reduces afterload. This is anything that forces the heart to use a more forceful contraction, such as systemic hypertension, or pulmonary hypertension caused by pulmonary disease, or coronary artery disease. Another way to improve heart function are medicines that increase that make the heart a better pump.

Note that any blood used to decrease afterload must be titrated to make sure blood pressure is not decreased too much. Individual response to such medicines vary from person to person.

According to the American Heart Association, Medicines used to treat heart failure are:
1. Ace inhibitors: They are a type of vasodilator, which are medications that cause the blood vessels to expand, lowering blood pressure and reducing the heart's workload (reduce afterload). Medical billing employees in cardiac offices are familiar with these drug names.
Common brand names are: Capoten, Vasotec, Altace, Prinivil, Zestril, Accupril, Monopril, Lotensin, Univasc, Mavik, and Aceon

2. Diruetics: Diuretics are prescribed for almost all patients who have fluid buildup in the body and swelling in the tissues. A diuretic causes the kidneys to remove more sodium and water from the bloodstream than usual and convert it into urine. This actually reduced preload (the amount of fluid that arrives in the heart that it has to pump to the system), and thus helps to relieve the heart's workload, since there's less fluid to pump throughout the body. It also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Diuretics are usually given in high doses when symptoms are more severe, and tapered off as as the patient gets better. Note here that diuretics make you pee (coffee isalso a diuretic, as you may have noticed you pee more after drinking several cups. Theophylline used to treat asthma and COPD is also a diuretic).

Of course your doctor will need to find a good balance of diuretics, as too much will cause your kidney's too pump out too many electrolytes such as potassium (see below), which isn't good either. Often times, a potassium supplement may me necessary.

Common brand names: Bumex and Lasix. Others include: Hydrodirul, Diuril, Aldactone, Dyrenium, Zaroxolyn, Lozol, Midamo and Dyazide

3. Vasodilators: Vasodilators cause the blood vessel walls to widen or relax, allowing blood to flow more easily. These are used for people who can't tolerate ACE inhibitors. Some, such as Nitro, are used in the emergency room to control angina (chest pain) due to cardiac disease or mycardial ischemia (heart attack).

Common brand names: Isordil, Apresoline, Loniten, Natrecor, nitroglycerin, nitropress (nitroprusside), Nitrogard (Nitroglycerin pills), Nitro-Bid (Nitroglycerin patch), Hydralazine,

4. Inatropic drugs: Increase the force of the heart's contractions, which can be beneficial in heart failure. This relieves heart failure symptoms, especially when the patient isn't responding to ACE inhibitors and diuretics. Most people continue taking the drug even after they feel well, to keep the heart working effectively.

In the hospital setting the nurse will often have to work to find the right dose of the inatropic drug to increase the force of the heart (to increase blood pressure) and the anit-hypertensive agent (like Nitroprusside) to maintain the target blood pressure.
It also slows certain types of irregular heartbeats (arrhythmia), such as atrial fibrillation. This is the rapid, irregular beating of the heart muscle that's present in some people with heart failure. When used by someone who has atrial fibrillation, digoxin prevents the ventricles (the lower, more powerful chambers of the heart) from beating too rapidly.

A patient on Digitalis will need to have his level checked often for dig toxicity, which will result in nausea, insomnia, vomiting, altered color vision, and irregular heart beat such as preventricular contractions (PVC). This shows up on the EKG as large t-waves.

Common brand names: Lanoxin (Digoxin), Dobutamine, amrinome

5. Beta blockers: The failing heart tries to compensate for its weakened pumping action by beating faster, which puts more strain on it. Beta blockers reduce the heart's tendency to beat faster. The drugs block specific receptors ("beta receptors") on the cells that make up the heart, reducing the effects of chemical messengers that increase heart rate. This allows the heart to maintain a slower rate and lowers blood pressure. Beta blockers are used for mild to moderate heart failure and often with other drugs such as diuretics, ACE inhibitors and digoxin.

Note: Beta blockers block the effects of beta adrenergic medicines such as Albuterol and Xopenex. They also can cause bronchodilation. So they should be used with caution in patients with COPD and asthma.

Common generic and brand names: carvedilol (Coreg), metoprolol (Lopressor & Toprol XL), atenolol (Tenormin), bisoprolol (Zebeta), labatelol, propranolol (Inderal), sotalol (Betapace), pindolol, penbutolol, acebutolol (Sectral), timolol (Blocadren), nadolol (Corgard), betaxolol (Kerlone).

6. Blood thinners: People with heart failure are at risk of developing blood clots, usually in the blood vessels of the legs, lungs and heart. The last type can occur in cases of a condition called atrial fibrillation, which happens when the heart's upper chambers (atria) contract rapidly and without coordination. This causes the blood to pool in the atria, where it can form clots. These clots can be carried into the blood vessels that supply the brain. If one gets stuck in a vessel, blood flow to the brain is cut off and a stroke results. Doctors prevent strokes by prescribing blood thinners for patients who have a history of clots in the lungs or legs, atrial fibrillation or stroke.

Common blood thinners: 1) heparin. It can only be taken by injection, and usually in the hospital 2) warfarin (Coumadin) It can be taken long term at home.

6. Angiotensin II Receptor Blockers (ARBs): ACE inhibitors, the cornerstone of heart failure drug therapy, prevent the formation of a chemical called angiotensin II. This chemical causes the small blood vessels to constrict, which raises blood pressure and places more stress on the heart. However, even when a patient is using an ACE inhibitor, some angiotensin II may still be formed. Rather than lowering levels of angiotensin II (as ACE inhibitors do), angiotensin II receptor blockers (ARBs) prevent this chemical from having any effects on the heart and blood vessels. This keeps blood pressure from rising.

Common meds available: Losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro), candesartan (Atacand), telmisartan (Micardis), leprosaria (Teveten), olmesartan.

7. Calcium Channel Blockers: Muscles of the heart and blood vessels need calcium to contract. Calcium channel blockers may be used to treat the high blood pressure often associated with heart failure. These drugs interfere with calcium's role in the contraction of these muscles, which causes the muscles to relax. This lowers blood pressure and can improve the blood circulation in the heart.

Common meds available: Amlodipine (Norvasc), Verapamil

8. Potassium: Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles. It's important to have just the right amount of potassium in the body, especially for the heart. The kidneys control the amount of potassium in the bloodstream and eliminate any excess through the urine.

Since most diuretics remove potassium from the body, heart failure patients who use them are at risk of losing too much potassium. Some patients need to take potassium supplements or pills to compensate for the amount they're losing. Sometimes all they need to do is eat foods high in potassium, such as bananas. However, ACE inhibitors can cause the body to retain potassium, so this needs to be taken into account too.

The doctor will do blood tests to check on potassium level and kidney function. Kidney function can change over time in people with heart failure, which can result in potassium level changes. Patients should check with their doctors to determine their potassium needs.

8. Sedatives: These are used sometimes to reduce anxiety and agitation, and reduce autonomic (neurological) stimulation on the heart (prevent rapid heart rate and increased force and contractility of the heart due to outside stimulants, such as stress and anxiety).

Examples of this include morphine and Versed.

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Word of the day: Cognizant: To be aware, fully informed, or conscious
It's good to be cognizant of the latest wisdom.

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Albuterol is a bronchodilator and nothing more

Some of the posts on this site, including my list of 'olins on the bottom of the page, are my humble attempts to make a humorous account of why doctors order Albuterol on patients having absolutely no signs of bronchospasm.

RT Cave Rule #5: There is only one purpose for bronchodilators, and that is to treat shortness-of-breath due to bronchospasm

In no way do I think I am smarter than a doctor, for they have knowledge in far more areas than I will ever imagine to have. It is their job, after all, to fix patients. And, when they order therapies I disagree with, I will still do them without complaining.

I have to say, however, that this is difficult not to complain when I know a treatment is not indicated, especially considering I have been using Albuterol since it was invented in the 1980s, and before that I used Alupent, and never once used either one for anything other than SOB due to asthma. In this way, I have over 30 years of bronchodilator experience.

Likewise, I have given many breathing treatments to patient in the hospital the past 12 years as a registered respiratory therapist, and have seen first hand for whom they have a beneficial effect and for whom they have no effect.

Plus I believe my opinion is in concordance with nearly every other RT on the planet.

If you are an RT or suffer from diseases like Asthma or COPD, you know how wonderful a drug Albuterol is. I can tell you from personal experience it's a life saver. In fact, without the drug I'd probably would have died many years ago.

And that brings up my next point. Bronchodilators of the past, such as Alupent and Bronchosol, did have some bad side effects. Alupent was proven to be a great bronchodilator, but had the side effect of making the heart thump. I remember abusing it when I was a kid and fearing that I might now wake up in the morning.

Alupent was a good drug in it's time, and was used for many years, but in 1987 a new refined bronchodilator was invented that was proven to have very little effect on the cardiac muscle, and thus rarely causes the heart to thump or increase. I'm not saying it never does, but very rarely, and usually only when it's given in huge quantities all at one time.

I can tell you from my personal experience as a "Rescue Inhaler Abuser" that I have gone through an entire inhaler in a day and still not had my heart thump like it used to when I used Alupent. Now, I wouldn't recommend using that much Albuterol outside the hospital setting, but my point is that Albuterol is that safe.

When patients come into the hospital, and you are having bronchospasm, we quite often give you an aerosol of Albuterol. If that aerosol doesn't do the job, we have been known to give as many as 10 in a row back to back to back. Again, I wouldn't recommend doing this at home, but I bet many of you chronic asthma and COPD patients have at one point or another. Hey, back me up here.

Now, understanding how quickly and magically Albuterol can get an asthmatic or COPD patient breathing easy, and considering how safe it is, many doctors choose to try it for other respiratory illnesses, even illnesses that are not bronchospasm in nature

I find that some doctors order Albuterol because a patient is short-of-breath because of pneumonia (fluid in alveoli), atelectasis (collapsed alveoli), pleural effusion (fluid in lung) and pneumothorax (collapsed lung) . All of these diseases are in the alveolar sacks, and the aerosol particle of Albuterol are too large to deposit in the alveoli, and thus have no effect there.

If, however, a patient has a bronchospasm component to their disease with any of the diseases listed in the last paragraph, then I'd recommend Albuterol. But if there is not bronchospasm, then it has no benefit to the patient.

Other diseases that Albuterol does not benefit that it is often prescribed for are: Croup, upper airway congestion or excess secretions, CHF, pulmonary edema, post-operative, obesity, cancer and many more.

Let's tackle croup. The harsh inspiratory noise kids make with this illness is because their throats become swollen. The key word here is throat. There are other medications that might help here, but not a bronchodilator. Hence, Albuterol is a bronchodilator, not a throat dilator.

Chronic Heart Failure (CHF) causes fluid to build up in the lungs called pulmonary edema. This does not occur in the bronchioles, but outside them. When this fluid overload causes the pressure inside the lungs to build up, this can cause the fluid to in effect squeeze the bronchioles and causing a wheeze. This is called a cardiac wheeze. Yes, it does cause the bronchioles to tighten, but, since the cause is outside the bronchioles and not inside, Albuterol will not work to solve this problem. This patient will need diuretics like Lasix.

Nonetheless, a cardiac wheeze is very often confused as a bronchospastic wheeze, and treated like bronchospasm.

Many times in the hospital setting I give a breathing treatment the same time a nurse is giving Lasix. The patient is severely SOB. My treatment has no effect on the patient's WOB. But, an hour later when the Lasix has worked, the patient is no longer SOB. Since the patient actually participated in taking the treatment, he or she often thinks the treatment is what eventually solved the SOB.

So, what happens the next time we get a CHF patient? The doctor orders Albuterol back to back to back to back until the Lasix works. Can you see how I can easily make comedy out of this.

Cancer will not be absorbed and broken up by a bronchodilator, nor will it absorb a pleural effusion, nor re inflate a collapsed lung (that's what a chest tube is for). Even if it did get down into the alveoli, it will not remove fluid in the alveolar sacks caused by pneumonia.

Now hopefully by you reading this you understand RT humor. Since doctors use Albuterol for all these diseases, we RTs (me in particular) have a choice between grumbling and griping about it, or making humor of it. We at Shoreline Hospital choose to make humor, and thus our list of 'olins came to be.

One of the reasons I made this post was because I've received more than one emails or comments from patients who wondered if I was being serious or funny when I wrote "Xoponex now a humidifier." I will confess: I was being facetious.

While Dr. Krane is a brilliant doctor, and while I enjoy working with her, and while I have no problem trying one Albuterol treatment with patients with croup just to see if it works, it is not a humidifier. In fact: Albuterol given via nebulizer treatment is a mist.

Just so you know, any post on this site where I'm using RT humor will be labeled on the bottom as "RT humor" or "funny."

Again, I am in no way proposing that RTs know more about the human body than doctors, but we are the experts in the hospital on the respiratory system -- that's all we do. We study respiratory, we learn respiratory, we learn the other systems as they pertain to respiratory, we keep people alive with our respiratory machines, we sleep respiratory, we breath respiratory. We give breathing treatments all day long, and we see how they work first hand. Doctors can only order them. And, when they do, we have to give them. We have no choice.

Now, if you are a medical staff at a hospital other than an RT, or if you are a patient viewing RT sites like RT Cave, it is important that you know that there really is only one true purpose for Albuterol, and that is to treat shortness-of-breath due to bronchospasm.

To determine if someone is having bronhospasm, it requires an assessment of lungsounds and/or a quick review of the patients history, which usually can be provided by the patient. Most of the time, true bronchospasm is very obvious.

In the insert inside the Albuterol inhaler or aerosol solution you will find an insert. Go ahead and pull it out if you have access to one. On that packet it says: Indication: "(Albuterol) is indicated for the treatment and prevention of bronchospasm in adults and children under 12 years of age and older with reversible obstructive airway disease." (emphasis added)

It is a a fact, proven by much research, that Albuterol is a medications that becomes a particle size of 5 microns and fits perfectly into the size 0.5 micron bronchioles of the lungs to relieve bronchospasm. Five microns is too big to go into the alveoli level (which is 0.1 to 0.2 microns wide) and too large to deposit in the throat (although some of them will deposit there).

It is not a cure for any disease. It will only resolve the symptom of bronchospasm. This is my humble personal and professional opinion. And as long as doctors continue to abuse this most wonderful drug, we will continue our effort at bronchodilator reform. And while we may never get it, we will continue our feeble effort at RT humor here at the RT Cave.

I encourage you to challenge me.

Here is a great column that might explain it better than me.

This article describes what bronchospasm is.

Here's a basic definition of bronchospasm.What are bronchodilators?

Here's how to check if a bronchodilator is indicated.

The indications for Albuterol are listed right here. If you're really bored you can read the whole thing.

Boring study on the particle size of bronchodilator. I just don't want you to think I'm making this stuff up.