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Emergency Management

of Acute Lung Edema

Dasdo Antonius Sinaga


Cardiologist
Rumah Sakit Awal Bros - Pekanbaru
Apa itu
GAGAL JANTUNG AKUT

 Terjadinya perburukan tanda dan gejala


gagal jantung akut.
 PERBURUKAN dari gagal jantung kronik
 Mengancam jiwa
 Memerlukan pengobatan SEGERA

2013 ACCF/AHA Guideline for the Management of Heart Failure


PENTING !!!
SESAK NAFAS akut bisa
diakibatkan oleh masalah:
 JANTUNG (Acute coronary syndrome – Acute
heart failure)
 PARU – PARU (PPOK eksaserbasi akut – Asma
bronkiale serangan sedang-berat)
 GINJAL (asidosis metabolik, CKD dengan volume
overload)
PENTING untuk bisa
MEMBEDAKAN:
Kardiak / Pulmo / Renal
Anamnesis:
 Riwayat sebelumnya:

 Pernah serangan jantung atau gagal jantung?

 Riwayat asma

 Hemodialisa

 Compliance terhadap obat-obatan rendah?

 Minum berlebihan

 Dyspneu on effort / Orthopneu / Paroxysmal nocturnal


dyspneu
 Nafas berbunyi “mengi”
 TANDA OVERLOAD CAIRAN  gagal
jantung atau overload pada end stage CKD

 Peningkatan JVP
 Ronki basah halus di basal paru
 (Ronki basah kasar disertai wheezing lebih
banyak ditemui pada pneumonia dengan
bronchospasme, walalupun bisa juga terjadi pada
edema paru yang berat).
 Hepatomegali, ascites dan edema tungkai (tanda
right heart failure / gagal jantung kanan).
POLA NAFAS
KUSMAULL: Nafas cepat dan dalam
 Tanda asidosis pada pasien CKD

Cheyne Stokes: Nafas cepat kemudian melambat


bergantian
 Tanda sesak karena kelainan sentral atau hipoksia
cerebral karena cardiac low output syndrome
Initial and Serial Evaluation of the HF
Patient

Diagnostic Tests

2013 ACCF/AHA Guideline for the Management of Heart Failure


Diagnostic Tests

I IIa IIb III Initial laboratory evaluation of patients presenting with HF


should include complete blood count, urinalysis, serum
electrolytes (including calcium and magnesium), blood
urea nitrogen, serum creatinine, glucose, fasting lipid
profile, liver function tests, and thyroid-stimulating
hormone.

I IIa IIb III Serial monitoring, when indicated, should include serum
electrolytes and renal function.

2013 ACCF/AHA Guideline for the Management of Heart Failure


Diagnostic Tests (cont.)
I IIa IIb III
A 12-lead ECG should be performed initially on all
patients presenting with HF.

I IIa IIb III


Screening for hemochromatosis or HIV is reasonable in
selected patients who present with HF.

I IIa IIb III Diagnostic tests for rheumatologic diseases, amyloidosis,


or pheochromocytoma are reasonable in patients
presenting with HF in whom there is a clinical suspicion of
these diseases.

2013 ACCF/AHA Guideline for the Management of Heart Failure


Recommendations for Noninvasive Imaging

Recommendation COR LOE

Chest x-ray I C

A 2-dimensional echocardiogram with Doppler should be performed for


I C
initial evaluation of HF
Repeat measurement of EF is useful in patients with HF who have had a
significant change in clinical status or received treatment that might affect I C
cardiac function, or for consideration of device therapy
Noninvasive imaging to detect myocardial ischemia and viability is
IIa C
reasonable in HF and CAD
Radionuclide ventriculography or MRI can be useful to assess LVEF and
IIa C
volume
MRI is reasonable when assessing myocardial infiltration or scar
IIa B
APLIKASI di INDONESIA
 Chest X – Ray

 ECHOCARDIOGRAFI: mengukur
kontraktilitas jantung

 Nuclear Scan (di pusat jantung tertentu: RS


Jantung Harapan Kita, RSPAD Gatot
Subroto, RS Hasan Sadikin, RS Sardjito
Yogyakarta)
PEMERIKSAAN PENUNJANG
Rontgen Thorax:
 Cardiomegali dengan kranialisasi / kongesti paru

 PNEUMONIA: konsolidasi lebih segmented


Rontgen Thorax pada pasien
Pneumonia
ELECTROCARDIOGRAPHY

EKG pada
Sesak nafas NON KARDIAK
VS
KARDIAK
In Acute Heart Failure

I IIa IIb III


Measurement of BNP or NT-proBNP is useful
to support clinical judgment for the diagnosis of acutely
decompensated HF, especially in the setting of
uncertainty for the diagnosis.

I IIa IIb III


Measurement of BNP or NT-proBNP and/or cardiac
troponin is useful for establishing prognosis or disease
severity in acutely decompensated HF.

2013 ACCF/AHA Guideline for the Management of Heart Failure


MANAJEMEN FASE AKUT:
• Oksigenasi (nasal atau NRM)
Target Saturasi > 95%

• Tanda overload cairan:


Furosemide: 1-2 mg/kgBB BOLUS IV
(40 – 80 mg, atau 2-4 ampul bolus)

• Pasien gelisah
Opiate/morphine 2 – 4 mg bolus IV
Jangan diberi jika pCO2 tinggi  gagal nafas

• VASODILATOR intravena: NITRATE


Jika SBP > 100-110 mmHg
 Nitrate yang direkomendasikan oleh literatur
sebagai obat intravena adalah:
NITROGLYSERIN atau NITROPRUSSIDE

 Nitroprusside tidak tersedia di Indonesia

 Isosorbid dinitrate direkomendasikan sebagai


obat oral, bukan intravena.
KENAPA NITRAT ??

Venodilatasi
Mengurangi preload
 Mengurangi beban
jantung

Pada dosis tinggi:


arteriodilator
 Menurunkan
resistensi
vaskular/beban
afterload.
Opie LH & Horowitz JD. Nitrates and newer antianginals. In: Drugs for the Heart. 7th ed. Saunders Elsevier. China
Thomas Münzel et al. Circulation. 2011;123:2132-2144
Cold skin, low pulse volume, poor urine
output, confusion, myocardial ischaemia

dobutamine 2.5 μg/kg/min,


2012 ESC Guidelines for the
doubling dose every 15 min
diagnosis and treatment of acute
and chronic heart failure
2012 ESC Guidelines for the
diagnosis and treatment of acute
and chronic heart failure
TARGET pengobatan awal:

Sesak berkurang (respiratory rate membaik


Heart rate berkurang
Diuresis cukup: > 100 cc per jam
Ronki berkurang
KESIMPULAN

• Gagal jantung akut: MENGANCAM JIWA –


sangat bisa tertangani
• Penanganan cepat: jangan tertunda
• Target awal perbaikan hemodinamik, perfusi
organ, oksigenasi, mengurangi simptom.
• Evaluasi respon terapi.
• Libatkan kardiologist untuk evaluasi:
• Acute Coronary Syndrome
• Echocardigrafi
• Chronic heart failure