Review Question - QID 106159

This patient has an acute systolic heart failure exacerbation with cardiogenic pulmonary edema. Noninvasive ventilation is indicated, but the peak inspiratory pressure (PIP) is adversely compromising blood pressure (and thus tissue perfusion) and should be decreased.

Cardiogenic pulmonary edema can be addressed with intravenous diuresis and noninvasive ventilation. Central positive airway pressure (CPAP) and BiPAP both decrease afterload, decrease wall stress, improve oxygenation, and improve dyspnea - they have been shown to lower in-hospital mortality. In a naive patient, BiPAP is typically started at 10/5 cm H2O. As with intubated ventilation, positive pressure from noninvasive ventilation increases intrathoracic pressure, decreases venous return, and decreases stroke volume and cardiac output. This patient's PIP settings are aggressively high, and should be decreased.

Incorrect Answers:
Answer 1: Resuming metoprolol will further decrease myocardial contractility, worsening this patient's decompensation from congestive heart failure.

Answer 2: Decreasing the furosemide rate runs counter to the aggressive diuresis that the patient needs to remove third-spaced fluid.

Answer 3: Decreasing the dobutamine rate may exacerbate heart failure at this time because it acts as an inotrope that supports contractility.

Answer 5: Decreasing positive end-expiratory pressure from 5 cm H2O to anything lower will not produce any significant clinical benefit.

Bullet Summary:
In patients who are in shock or have compromised cardiac output, initiation of positive pressure mechanical ventilation can result in a profound decrease in preload and worsen systemic perfusion.