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Monday, June 18, 2012

"All that wheezes" - CHF and albuterol

Medics aren't happy unless they're arguing about something.

Since most paramedics are 1) intelligent, 2) clever,  and 3) convinced they are more clever than the other medic they're arguing with, they need an appropriate subject to engage in. The ideal topic should provide the opportunity for them to put their knowledge of physiology, gas laws, and hydrodynamics on display, but also allow them to parry with a quick "In my experience..." Ideally, there should be no clear empirical studies on the subject.

The "danger" of giving albuterol to a dyspneic patient who may have CHF is just such a topic.

Fortunately, a complete literature review on the topic easily will fit in one blog post, with plenty of room left over for a relevant case, complete with ECGs!

The Wheezer

"Hey Doc, you gotta see this guy next."

Generally I listen when an experienced nurse tells me that, so I went to see Mr Wheezer right then.

Not our patient.
He did not look good - sweaty, pale, working to breathe, with his second albuterol/ipratropium neb going. "I think it's my allergies," he says. So much for the patient telling me the diagnosis...

So I asked him to tell me about his "allergies." He'd been having some dyspnea on exertion over the past 2 weeks, with a nagging cough. But an hour ago, while at rest, he felt like his chest was being pressed in, right up into his jaw, and he had started sweating buckets. His breathing had worsened, and his wife called 911. He had a history of diabetes, hypertension, and stents in all 3 of the major coronary arteries.

The paramedics had started the series of neb treatments he was receiving, and a quick exam revealed why - he had the loudest, clearest, most unambiguous wheezes I have ever heard. No crackles, no rhonchi, no upper airway crud fouling it up. Textbook wheezes. Even the greenest of EMT-B's, using a Fisher-Price stethescope, could confidently diagnose these wheezes.

"And an S3. He's definitely got an S3."
On the other hand, the first ECG looked like this:

That's pretty bad case of allergies. I looked at his old ECG:

No slam-dunk STEMI here. I grabbed the ultrasound, and took a look at the heart and lungs. No pericardial effusion, no signs of a PE, but when I looked at his lungs, I saw the shimmering artifact that suggests wet lungs. For an example (not my patient):

I took off the neb, and popped in a tab of nitroglycerin. Within 2 minutes he had his color back, he didn't't look so drenched, and he was breathing easier. Like a lightswitch - click! -  he was improving.

I got cardiology involved pronto, before any labs, or even the chest x-ray came back. After they evaluated the patient and the ECG, they shared my concern, and were planning to take him for an urgent cardiac catheterization. Almost as an afterthought, we checked out the labs together.

Troponin - negative.
BNP - negative.


We checked out the chest film - clear.

But the ball was rolling, and he went to the lab. Good thing, too, since he ended up having severe stenosis in his mid and distal LAD, as well as the circumflex, which all got new stents. The RCA, which previously been patent, was now totally and permanently occluded.

Soooo, that proves it was CHF, right?!? Well, he still had dyspnea after the procedure, though nowhere near as bad as before, so he got more tests and consults. I won't go through the details, but after being evaluated by 3 cardiologist, 2 pulmonologists, and one lowly ER doc, he had a diagnosis of "likely CHF."

This encounter made me consider a few questions:

How good are paramedics at diagnosing CHF?

The medic in my case only gave albuterol, no nitro or Lasix, and had not obtained an ECG, and so was clearly not considering CHF. But the diagnosis can be tough for physicians, even with all the clinical gizmos at our disposal.

With that in mind, how does the paramedic diagnosis of CHF stack up against the emergency physician's? Turns out, it's pretty good, within limits.

One study from 1995 looked prospectively at the paramedic's diagnosis compared with the ED physician diagnosis. Considering that the doctor had access to medical records, x-rays, labs, etc, the paramedics did fairly well, showing "good concurrence" with physician diagnosis. Another study looked at how well paramedics determined a cardiac cause of dyspnea. This could include angina or MI, as well as CHF, so it wasn't a perfect comparison, but the agreement between medic and doctor had a kappa of 0.71, or "good, approaching excellent."

A more recent, although retrospective, study looked only at the diagnosis of CHF. Interestingly, they studied all the patients whom the paramedic had given furosemide to, using this as a surrogate for a diagnosis. They then looked at the final diagnosis of the the emergency physician. Generally the medics did well, and the doctors agreed in 60 out of 94 cases.

The disagreements are thought-provoking though. Between pneumonia and COPD, a lot of furosemide was given to people to who didn't need it. Furthermore, there is evidence that suggests that treating pneumonia with diuretics is harmful.

Looking towards the future, however, if we can combine capnography and portable BNP analysis in the prehospital realm, EMS could end up being the gold standard for the ED to live up to!

How often does CHF present with wheezing?

Often enough!

In one study of older patients, it was found that about one third of  patients had wheezing with their acute episode. Perhaps not surprisingly, these patients usually were smokers, had a prior diagnosis of COPD, and were using bronchodilators at home. Unfortunately, they did worse with their CHF events, going to the ICU at a higher rate, for instance.

There aren't too many other studies that study the rate of wheezing, but we can also look at the rate of albuterol/beta-agonist administration as a rough equivalent. In one study 20% of patients got albuterol (in addition to other drugs), while in another study only 2% of CHF patients got albuterol (as the sole therapy). 

I think this evidence suggests that there can often be a component of wheezing with acute episodes of CHF, but that "pure" wheezing, without other indications of of CHF, is pretty rare.

Is there a danger in giving albuterol to a patient with CHF?

My patient ended up getting stented for cardiac ischemia. It seems reasonable to wonder if the 2 neb treatments, in addition to being ineffective, might have  exacerbated the ischemia, causing harm. However, looking at the clinical evidence is difficult, as much of it doesn't apply to emergency medicine, let alone paramedicine.

For example, there are a number of studies that analyze the harm associated with use of bronchodilators in patients who have diagnoses of both COPD and CHF. These studies, however, follow patients over months to years, and aren't very relevant.

One ICU study looked at the degree of tachycardia or number of tachyarrhythmias after albuterol neb treatment. They actually did not find much negative effect on the vital signs.

Well, what about studies in the ED or prehospital that look at truly relevant outcomes? Surprisingly, there only appear to be 2 relatively useful clinical studies available to guide us.

The first was a case-control study done in 1992, by Wuerz. They looked at about 500 dyspneic patients who had received prehospital treatments. They found that it was pretty bad to treat asthma or COPD, for example, with Lasix. However, when they looked at the 9 CHF patients who were mistakenly treated with beta-agonists, they found, reassuringly, that "none died."

The second study (Singer 2008) was bigger, using registry data on about 11,000 CHF patients treated in the ED. The nice thing about using such a data source is that you can get a lot of patients, and find associations. The bad news is that you often can't explain what you do find.

Such is the case with this study. About 20% of the patients received beta-agonists, either by EMS or in the ED, but had no pre-existing history of COPD or asthma. They used some statistical rejiggering to try and make fair comparisons, since CHF patients with a history of COPD are not exactly like CHF patients who don't have COPD. I won't bore you with the details, but that's what they mean by "adjusted with propensity analysis" on the following table.

Now, there wasn't any apparent difference in mortality, discharged alive form the ED, or ICU admission - that's what all those big red Xs mean. There was, however, an increased rate of intubation in those CHF patients who were treated with bronchodilators, but who had no history of COPD.Same for BiPAP and inpatient mechanical ventilation.

So what does this all mean? Now, this study wasn't randomized, and it really only shows an association, not cause and effect. The authors state (emphasis is mine):
Inhaled bronchodilator use in these heart failure patients without chronic obstructive pulmonary disease appeared to be associated with worse outcome. Because of the observational nature of these data, we cannot determine whether these patients’ outcomes were worse because they were more severely ill or because of a directly harmful effect of the inhaled bronchodilator.
However, this association persisted after adjustment for propensity score and standard risk factors for mortality. This finding suggests that inhaled bronchodilators may have contributed to the poorer outcomes observed in heart failure patients without chronic obstructive pulmonary disease who were treated with bronchodilators.
Or may not have contributed - we just don't know. The authors allow that treatment with bronchodilators may just a marker for bad CHF, but not a cause of bad CHF. I'm sympathetic to that point of view.

The Bottom Line

 If you're pretty sure the patient has CHF, they need nitro and CPAP. Lasix is old school, and might hurt people when you're wrong about the diagnosis, and there is no evidence that albuterol will help with edema.

On the other hand, if you get fooled by wheezes, don't feel too bad. It might not have helped, but it probably didn't do much of anything at all.


  1. LOVE this. When I was still pretty new at this I had a pt die on me. 41yo F with SOB. recent HX of upper respiratory infection (she was still finishing her Zpak) Ran out of her albuterol inhaler a couple weeks ago. Tachy HTN and wheezing. I went with albuterol. A few min later (10 or 15) I was intubating her because she was all the way to resp arrest. (we didnt have CPAP at the time) At that point I had already switched to nitro and BVM. She didnt make it. I wasn't sure I wanted to do this job. Ive talked to other medics who have mentioned having a pt experience flash pulmonary edema when using albuterol and not nitro initially.

    Now days if there is ANY doubt I give nitro first/in conjunction with albuterol. Its just not worth the risk...

    1. We've ALL had that patient. It's a tough way to gain respect for the wheezing CHF patient...

      I like your approach - NTG is such a safe drug, almost diagnostic, and potentially life-saving.

  2. Nice post. I wrote on the same topic back in March. I even used a similar title.

    This is something that ALL paramedics should be able to figure out. As you note, we don't have CXR, Ultrasound, or many of the other diagnostic tools that doctors do. Nor until recently did we have Capnography. That makes the job easier, but is not essential.

    The clinical tips I was taught for differentiating are as follows.

    Onset. CHF is often, nay usually, of sudden onset.

    Expirations are not prolonged in CHF.

    Hypertension is not definitive, but weighs towards CHF.

    History. Rarely do elderly patients get sudden onset of Asthma at 3:00AM. If the patient has other risk factors, such as hypertension or diabetes and is not a smoker, it's CHF until proven otherwise.

    Diaphoresis. While COPD/Asthma patients can get diaphoretic, CHF patients get REALLY diaphoretic.

    I'll close by pointing out that it's not just paramedics who screw this up. I spent a good amount of time last year yelling at doctors NOT to treat my mother's CHF with Albuterol. Even though she had never smoked a cigarette in her life, early in her CHF episodes she wheezed and PGY 1s and 2s would insist on throwing a neb on her.

    Not to mention how many MD ACLS students I've stumped with my CHF scenario.

    1. One thing I'm not is original!

      I think the most valuable sentence (for me) from your post ( was "My gut feeling was that this was very early Congestive Heart Failure..." With experience, you develop a sense of when isolated elements of the history, exam, and context should fit together. Earlier in our careers, we are led astray by isolated data points (e.g. wheezing, ankle edema), but later we rely on a gestalt, global impression.

      So hard to teach this, to medics, RNs, or MD/DOs. I think you have to personally screw it up once to really get it.

    2. Remember, Experience is something you get five seconds after you needed it.

      That's why doctors go through residency and paramedics should have a much longer field training period than they do.

  3. Interesting article - some pts are tricky. Being a newish EMT and dealing with a status2 CHF Pt, with type2 diabetes and PmHx previous MIs, who could be heard wheezing from the doorway - I gave albuterol (which made him feel better) lifting spo2 from 88% up to 98%. I offered him GTN which he refused as it "causes him to arrest". I tried 10cm PEEP to coerce fluid out of his airways - he couldn't tolerate the 'suffocating' feeling - I took that away and re-nebbed him. ECG showed initial AF, then slight inferior ST elevation enroute. After 60mins transport time to ED, the docs captured sinus tach with short runs of VTach... I'm pleased I refrained from GTN. Still unclear what I was really dealing with. Ideas?

  4. Sounds like a patient with a bad heart!

    Hard to be sure of the diagnosis, of course, but the odds favor CHF in your case. You listed all the reasons I believe so.
    Even if he had a strong asthma/COPD history, I think CHF would still be top of the list.

    Thanks for reading!