akut egzacerb hron si
TRANSCRIPT
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Acute exacerbation ofcongestive heart failure
HighlightsSummary
Overview
Basics
Definition
Epidemiology
Aetiology
Pathophysiology
Classification
Prevention
Primary
Screening
Secondary
DiagnosisHistory & examination
Tests
Differential
Step-by-step
Criteria
Guidelines
Case historyTreatment
Details
Step-by-step
Emerging
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Guidelines
Evidence
Follow Up
Recommendations
Complications
Prognosis
Resources
References
Images
Online resources
Patient leafletsCredits
Email
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Add to Portfolio
BookmarkAdd notes
History & exam
Key factors presence of risk factors (previous cardiovascular
disease, age >70 years) dyspnoea pulmonary crepitations peripheral oedema cool peripheries chest pain
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third heart sound (S3)
Other diagnostic factors
fatigue and weakness hypotension tachycardia elevated jugular venous pressure displaced apex beat (point of maximal impulse) dullness to percussion and decreased air entry in lung
bases wheezing palpitations cough fever syncope murmur ascites hepatomegaly central cyanosis
History & exam details
Diagnostic tests
1st tests to order ECG CXR Hb TFT troponin B-type natriuretic peptide (BNP)
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Tests to consider echocardiography cardiac catheterisation endomyocardial biopsy
Diagnostic tests details
Treatment details
Acute
haemodynamically stable
oxygen therapy morphine loop diuretics vasodilators supportive care ventilation inadequate response to loop diureticso non-loop diuretics due to cardiac ischaemiao aspirin revascularisation due to valvular diseaseo nitroprusside due to acute right heart failureo treatment of underlying cause due to acute myocarditiso supportive care or immunosuppressant therapy inadequate response to combination diureticso ultrafiltration
hypotensive (systolic BP
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oxygen therapy inotropes supportive care ventilation intra-aortic balloon pump left ventricular assist device (LVAD) due to cardiac ischaemiao aspirin revascularisation due to valve stenosiso percutaneous valvotomy
hypertensive crisis oxygen therapy IV beta-blockers and glyceryl trinitrate nitroprusside supportive care ventilation
Ongoing
acute episode stabilised: LVEF 100 mmHg
ACE inhibitor or angiotensin-II receptor antagonist beta-blocker aldosterone receptor antagonist vasodilators diuretics supportive care
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acute episode stabilised: LVEF
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DefinitionAcute congestive heart failure (CHF) is the rapid onset of symptoms andsigns due to abnormal cardiac function. It may be due to cardiac or extra-cardiac causes and results in reduced cardiac output, tissue hypoperfusion,
increased pulmonary capillary wedge pressure, and tissue congestion.[1]EpidemiologyBoth the incidence and prevalence of heart failure increase with age.[3] Inthe UK there were 60,480 cases of CHF in the 1-year period between 2006and 2007, with just more than 42,000 cases occurring in people over the ageof 75 years. [NHS. Hospital episode statistics] (external link) Studies of heartfailure in the US and Europe found that the annual incidence in people under65 years of age is 1/1000 for men and 0.4/1000 for women. Over 65 years ofage, the annual incidence is 11/1000 for men and 5/1000 for women. Under65 years of age, the prevalence of heart failure is 1/1000 for men and 1/1000for women; over age 65 years the prevalence is 40/1000 for men and30/1000 for women.[3]Heart failure is the most common indication for hospitalisation in the US, andacute decompensated heart failure is the most common cause forhospitalisation among patients over 65 years.[4]The prevalence of heart failure in the US in 2004 was an estimated 5.2 millionpeople. It has significant public health implications and the estimated cost ofheart failure in the US is $33.2 billion for the year 2007. The incidence ofheart failure is around 10/1000 people over 65 years per year.[5] In the US,the mean age of people with heart failure is 74 years, with 52% being womenand mostly white people affected (73% to 78%).[6] [7] The average age ofpeople with heart failure in studies conducted in Europe is also older than 70years, with slight predominance of men.[4]Heart failure is a global epidemic with a prevalence ranging from 11,000 to19,000 per million population among other countries.[8]
AetiologyCauses and precipitating factors in acute CHF are:[1]
Decompensation of pre-existing chronic heart failure
Acute coronary syndrome
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Hypertensive crisis
Acute arrhythmia
Valvular regurgitation
Severe aortic valve stenosis
Acute severe myocarditis
Cardiac tamponade
Aortic dissection
Post-partum cardiomyopathy
Non-cardiovascular precipitating factors
o Lack of compliance with medical treatment
o Volume overload
o Infections
o
Severe brain insult
o After major surgery
o Reduction of renal function
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o Asthma
o Drug abuse
o Phaeochromocytoma
High output syndromes
o Septicaemia
o Thyrotoxic crisis
o Anaemia
o Shunt syndromes.
The most common concurrent conditions present in patients with acute CHFare CAD, HTN, DM, atrial fibrillation, and renal insufficiency.[4] [9]
Causes of right heart failure include:[10] Secondary to LV failure
Secondary to pulmonary arterial hypertension
Secondary to right ventricle (RV) myopathic process
RV infarction
Arrythmogenic RV cardiomyopathy
Restrictive cardiomyopathy
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Pericardial disease
Right-sided valvular disease
Congenital heart disease.
PathophysiologyDuring an episode of acute CHF, the majority of patients will have evidenceof volume overload with pulmonary and/or venous congestion.Haemodynamic measurements in these cases usually show increased right-and left-sided ventricular filling pressures with depressed cardiac index and
cardiac output. However, if there is associated infection, the cardiac outputmay be normal or, in some cases, increased.
Activation of the sympathetic nervous system causes tachycardia, increasedmyocardial contractility, increased myocardial oxygen consumption,peripheral vasoconstriction, and activation of renin-angiotensin system withsalt and water retention. There is also activation of vasoconstrictorneurohormones, which leads to sodium and fluid retention, increasedmyocardial wall stress, and decreased renal perfusion.[11]
If the condition is not treated effectively, the myocardium becomes unable tomaintain a cardiac output sufficient to meet the demands of the peripheralcirculation. In order for patients with acute CHF to respond quickly totreatment, the increased myocardial stress must be reversed; for example,correction of acute severe HTN. This is particularly important in acute CHFcaused by ischaemia, as a dysfunctional myocardium can return to normalwhen appropriately treated.
ClassificationClinical presentations[1]
Acute CHF has been classified by the European Society of Cardiology intofollowing clinical groups:
1. Acute decompensated heart failure (ADHF)
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De novo or as decompensation of chronic CHF withsigns and symptoms of ADHF, which are mild and do notfulfil criteria for cardiogenic shock, pulmonary oedema, orhypertensive crisis.
2. Hypertensive acute CHF
Signs and symptoms of heart failure are accompaniedby high blood pressure (BP) and relatively preserved leftventricular (LV) function, with a CXR compatible with acutepulmonary oedema.
3. Pulmonary oedema (verified by CXR)View imageView image
Severe respiratory distress with associated crackles onlung examination, orthopnoea, and reduced oxygensaturation, usually below 90% on room air before treatment.
4. Cardiogenic shock
Defined as evidence of tissue hypoperfusion induced byheart failure after correction of preload.
Usually characterised by reduced BP (systolic BP 30 mmHg)and/or low urine output (60 bpm, with or without evidence of organ congestion.
There is a continuum from low cardiac output syndrometo cardiogenic shock.
5. High output failure
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Characterised by high cardiac output, usually with highheart rate (caused by arrhythmias, thyrotoxicosis, anaemia,Paget's disease, iatrogenic, or other mechanisms), withwarm peripheries, pulmonary congestion, and, sometimes,
with low BP such as in septic shock.
6. Right heart failure
Characterised by low output syndrome with increasedjugular venous pressure, increased liver size, andhypotension.
Clinical classification of acute heart failure (AHF)[2]For simplification these patients can be classified into 3 main groups:
1. Hypertensive AHF (acute de novo heart failure or vascular failure)
Symptoms develop rapidly against a background of
hypertension (HTN) with increased sympathetic tone andneurohormonal activations.
Left ventricular ejection fraction (LVEF) is usuallypreserved and there are clinical and radiological findings ofpulmonary congestion, usually without signs of systemiccongestion; for example, peripheral oedema.
Response to therapy is rapid.
2. Normotensive AHF (acutely decompensated chronic heart failure)
History of progressive worsening of chronic heart failure.
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BP is usually normal and symptoms and signs developgradually with both systemic and pulmonary congestion.
LVEF is usually reduced.
3. Hypotensive AHF
Presents with symptoms and signs of hypotension,organ hypoperfusion, and cardiogenic shock.
Types of heart failure
Systolic
Associated with LV dysfunction and characterised bycardiomegaly, third heart sound, and volume overload withpulmonary congestion. LVEF is decreased.
Diastolic
Typically associated with normal cardiac size,hypertension, pulmonary congestion, and a fourth heartsound. LVEF is preserved.
Primary preventionAggressive control and treatment of risk factors should be considered in order
to prevent acute heart failure: CAD is managed with aspirin, beta-blockers,statins, and ACE inhibitors.
Optimising treatment of HTN, smoking cessation, and lipid control providessubstantial benefit in patients with CAD.
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Optional control of HTN may require more than one antihypertensivemedication.
In asymptomatic patients with reduced LVEF, ACE inhibitors arecardioprotective and reduce further decline in LVEF.[19] Beta-blockers may
also be considered in this group of patients.All patients with diabetes mellitus (DM), in addition to metabolic control, needaggressive control of lipids, BP (target
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Salt intake restricted: 1 teaspoon of salt equals 2.2 g ofsodium. Therefore, patients are advised not to exceed 1teaspoon of salt a day. They should lower salt intake asmuch as possible, ideally to 65 mmols/day of sodium
(corresponding to 1.5 g/day of sodium).
Alcohol intake limited to 2 drinks a day for men and 1drink a day or less for woman.
Importance of continuing medication as prescribed bydoctor should be stressed.
Weight should be checked daily.
If patients notice more than 0.9 kg (>2 pounds) weight gain in 24 hours, 2days in a row, or develop symptoms of shortness of breath, chest pain,palpitations, increased tiredness, dizziness. or lightheadedness, or increasingswelling of the legs or abdomen, they should seek medical attention.
Complications
Complicationhide all
arrhythmias
see our comprehensive coverage of Overview of dysrhythAcute CHF is frequently precipitated by arrhythmias, in pa
cause arrhythmias.[71] [72]
complications of glyceryl trinitrate
Commonly causes headache and hypotension. The headseverity and either resolves or diminishes in intensity with
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hypotension occurs then the infusion rate should be decreinfusion should be discontinued and re-started when patie
complications of treatment: nesiritide
Causes headache and hypotension. If hypotension occursdecreased. If hypotension persists than the infusion shoupatient is haemodynamically stable.
complications of treatment: diureticsOver-diuresis leads to worsening of renal function, hypoteactivation of neurohormones including renin-angiotensin smay potentiate the toxicity of other agents like digoxin, eitdecreasing the glomerular filtration.
In cases of worsening renal impairment due to over-diures
decreased. In case of severe renal impairment the diureticassessed daily, with re-introduction of diuretic at lower do
complications of treatment: inotropes
Dobutamine and milrinone can cause arrhythmias and wo
The occurrence of sustained arrhythmias should lead to dmedications are absolutely needed, concomitant use of amthere are no large-scale data on the use of anti-arrhythmicsymptomatic coronary ischaemia, these infusions should
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PrognosisIn hospital, mortality ranges from 2% to 20% depending on clinical factorsfound on admission.[69] Predictors of adverse outcomes include:hypotension, renal dysfunction, older age, male sex, ischaemic CHF,
previous CHF, respiratory rate on admission >30/minute, anaemia,hyponatraemia, elevated troponin, elevated B-type natriuretic peptide (BNP),and other comorbidities such as cancer.[70]
Case history #1A 70-year-old woman complains of increasing exertional dyspnoea for thelast 2 days and now has dyspnoea at rest. She has a history of hypertensionfor the last 5 years and a 35 pack-year smoking history, but no otherestablished illnesses. Current medications are hydrochlorothiazide daily forthe last 3 years. She has been prescribed lisinopril but failed to fill theprescription. On examination her BP is 190/90 mmHg, heart rate 104 bpm.There is an audible S4 and the jugular venous pressure (JVP) is elevated 2cm above normal. Lung examination reveals fine bibasal crepitations. Thereis no ankle oedema.
Case history #2A 73-year-old woman presents to the emergency department having
collapsed. She is breathless and finding it difficult to talk in full sentences. Onexamination she is centrally cyanosed with cool extremities. Her pulse is 110bpm and systolic BP only just recordable at 80 mmHg. Jugular venouspressure (JVP) is elevated 3 cm above normal and the cardiac apex beat isdisplaced. Respiratory rate is increased and she has widespread cracklesand wheezes on chest examination.
Other presentations
Patients may present with predominant symptoms of the underlying conditionsuch as chest pain with acute MI, syncope with significant valvular stenosis,palpitations with arrhythmias, and viral prodrome with myocarditis.
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Differential diagnosis
Condition
Differentiating
signs/symptoms Differentiating
Pneumonia Fever, cough,
productivesputum.
Focal signs ofconsolidation -increased vocalfremitus andbronchialbreathing.
WCC: ele
Blood cul
CXR: con
Pulmonary embolism Haemoptysis and
sharp, pleuriticchest pain.
Risk factors ofthromboembolism (TE) includepersonal historyof TE, familyhistory, recenttrauma,prolongedimmobilisation,
CT pulmo
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smoker, or OCPuse.
Asthma Wheezing on
physicalexamination.
Reduced
Spirometr
Interstitial lung disease Progressively
increasingdyspnoea.
Oxygendesaturation withexercise.
Fine bibasalcrepitations withno other signs ofheart failure.
CXR: retic
High-resohoneycom
Spirometr
Adult respiratory distress
syndrome
Severe hypoxia,
fine crepitations.
CXR: diffu
Pulmonar
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History & examinationKey diagnostic factorshide allpresence of risk factors (previous cardiovascular
disease, age >70 years) (common)
Key risk factors include age over 70 years, previouscardiovascular disease, diabetes, and poor compliancewith medication for chronic CHF.
dyspnoea (common)
Predominant symptom and is present in the majority ofpatients with acute CHF.[9]
pulmonary crepitations (common)
Key finding on chest examination.[9]peripheral oedema (common)
Present in the majority of patients (around 65% ofcases).[6] [9]
cool peripheries (common)
is a key diagnostic factorchest pain (uncommon)
If underlying cardiac ischaemia.third heart sound (S3) (uncommon)
is a key diagnostic factor
Other diagnostic factorshide allfatigue and weakness (common)
is a diagnostic factorhypotension (common) is a diagnostic factor
tachycardia (common)
Due to activation of the sympathetic nervous system orunderlying arrhythmia.
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elevated jugular venous pressure (common)
is a diagnostic factordisplaced apex beat (point of maximal
impulse) (common)
is a diagnostic factordullness to percussion and decreased air entry in lung
bases(common)
Suggestive of pleural effusion.wheezing (common)
Suggests cardiac asthma.palpitations (uncommon)
If underlying arrhythmia.cough (uncommon)
Due to pulmonary congestion.fever(uncommon)
Suggestive of precipitating underlying infection.syncope (uncommon)
Suggestive of underlying cause, such as significant
aortic stenosis or pulmonary embolism.murmur(uncommon)
Both significant stenotic and regurgitate lesions canlead to heart failure.
ascites (uncommon)
is a diagnostic factorhepatomegaly (uncommon)
is a diagnostic factorcentral cyanosis (uncommon)
is a diagnostic factor
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Risk factorshide all
Strong
age >70 years A typical patient with acute heart failure is older than
70 years.[6]prior episode of congestive heart failure
In patients hospitalised for acute CHF, around 75%have a history of prior heart failure.[6]
coronary artery disease
CAD accounts for around 50% of all patients withacute HF.[6] [7] [12] [13] Chronic myocardialischaemia results in myocardial damage withprogressive decline in left ventricular (LV) systolicfunction. Subendocardial ischaemia also causesincrease in left ventricular end diastolic pressure(LVEDP) leading to pulmonary oedema in the
presence of normal LV systolic function. Acute coronary ischaemia can lead to acute CHF
either due to pump failure or papillary muscledestruction/rupture. In the case of pump failure, the LVfunction is depressed, but in cases of heart failureassociated with papillary muscle rupture, themeasured LV function may appear preserved.
hypertension A history of HTN is present in 72% of patients in the
US and 60% of patients from Europe.[6] [12] [13] HTN predisposes to the development of heart failure
by increasing the after-load on the ventricles, which
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induces LVH, which in turn leads to LV dysfunction, anincreased risk of MI, and significant arrhythmias.
In patients with non-compliant ventricles, an abrupt orsignificant increase in BP increases the LVEDP,
precipitating acute CHF.valvular heart disease
About 23% of patients in the US and 34% in Europehave valvular disease as an associatedcondition.[6] [13]Both significant stenotic andregurgitate lesions can lead to heart failure.
Although rheumatic valvular disease is now rarely
found in western countries, calcific valvular heartdisease, in particular aortic stenosis, is commonlyencountered.
In patients with significant valvular disease, the heartfailure will not improve until the underlying valvulardisease has been corrected.
pericardial disease
A large pericardial effusion can present with symptomsor signs of acute CHF.
Pericardial constriction, such as tuberculosispericarditis or the effects of radiotherapy, can alsopresent with acute CHF.
myocarditis
There are many causes of myocarditis, of which a viral
aetiology appears to be the most common. There isusually a prodrome of a non-specific illnesscharacterised by fatigue, mild dyspnoea, and myalgias.
atrial fibrillation
Present in 31% of cases.[6]
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diabetes mellitus
Related directly to ischaemia and renal failure.non-compliance with medications
Precipitating factor in patients with chronic CHF.
Weak
excessive salt intake
Present in 22% of cases.[14]excessive catecholamine stimulation
Can be caused by phaeochromocytoma orsubarachnoid haemorrhage.[15]
abnormal thyroid function
Both hypothyroidism and thyrotoxicosis can beassociated with heart failure.[16] [17]
excessive alcohol intake
Excessive drinking is associated with heart failure (>3drinks/day).[18]
Diagnostic tests1st tests to orderhide all
Test
ECG
The ECG analysis in acute CHF shows atrial fibrillation in 26% of the cases.[6]ECG abnormality is found in almost all cases of heart failualternate diagnosis should be considered.[31] View imag
CXR
Pulmonary congestion on CXR is present in up to 76% of
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image
Hb
Suggests anaemia as a precipitating cause.
TFT
Hypo- or hyperthyroidism can cause acute CHF.
troponin
Elevated in acute cardiac ischaemia.
Also elevated in over 50% of cases of acute CHF without
B-type natriuretic peptide (BNP)
If above 500 nanograms/L (>500 picograms/mL), dyspnoe
If below 100 nanograms/L (
-
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Left ventricular ejection fraction (LVEF) 40% is transient systolic dysfunction or diagnosticPreserved LVEF (45%) is observed in 34% of patients wGuidelines from the European Association of Echocardiognormal. An LVEF of 45% to 54% is mildly abnormal, LVEFLVEF of
-
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chronic CHF such as dietary indiscretion with excessive salt intake, non-compliance with medications, and excessive alcohol or drug intake.
Symptoms
Heart failure presents with dyspnoea, decreased exercise tolerance, swellingof the legs, fatigue, and generalised weakness. Sometimes the patient maypresent with predominant symptoms of the underlying condition, such aschest pain, syncope, palpitations, or viral prodrome.
SignsCommon signs include central cyanosis, tachycardia, elevated jugular venouspressure (JVP), displaced apex beat, S3, crepitations or pleural effusion,
hepatomegaly, ascites, and oedema. The presence of these signs dependsupon the duration, acuity, and the underlying cause of heart failure. Patientswith end-stage heart failure may exhibit most of these clinical signs, whereasthose in the early phase of the illness may have minimal signs.
Patients with acute CHF can be classified clinically into 4 haemodynamicprofiles.[24] These profiles, which are based on haemodynamic principles ofpresence or absence of elevated filling pressure (wet or dry) and perfusionthat is adequate or critically limited (warm or cold), include:
Warm and dry
Warm and wet
Cold and dry
Cold and wet.
Patients with pulmonary oedema present with severe respiratory distress withreduced oxygen saturation (usually 60 bpm and/or low urine output (
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without evidence of organ congestion, are considered to be in cardiogenicshock.
Immediate investigations
An ECG and CXR should be performed immediately in all patients withsuspected acute CHF. ECG findings are commonly related to the underlyingpathologies and include presence of Q waves, ST-T changes, left ventricularhypertrophy (LVH), left bundle branch block, and atrial fibrillation.View image
CXR may show cardiac enlargement (cardiothoracic ratio >50%); however,there is poor correlation between the cardiothoracic ratio (CTR) and presenceof heart failure, as the heart size may be normal in patients with diastolicdysfunction, acute valvular regurgitation as part of infective endocarditis, oracute MI. An enlarged CTR may also be seen in the absence of heart failure
(e.g., pericardial effusion and LVH).
Evaluation of the lung fields will show signs of pulmonary congestion, initiallyin the upper zones, then in the horizontal fissures followed by pulmonaryoedema and pleural effusion.View imageView image The x-ray findings haveto be taken in the context of clinical picture, as pulmonary infiltrates andcongestion, in some cases, may be due to non-cardiac cause such as ARDSor alveolar haemorrhage.
CXRs rarely may show pericardial calcification, prosthetic valves, or valvularcalcification. In these situations, it is helpful in identifying the possibleunderlying aetiology for heart failure.
The following blood tests should be requested when patients present withsuspected acute CHF:[22]
Hb: may identify anaemia as a contributing factor.
TFTs: both hypothyroidism and hyperthyroidism cancause heart failure.
Cardiac enzymes: >50% of patients with cardiogenicpulmonary oedema (but without evidence for MI) haveelevated troponin T levels.[25] Elevated troponin T levels in
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patients with acute CHF may reflect subendocardialischaemia due to elevated left ventricular end diastolicpressure. In patients with acute cardiogenic pulmonaryoedema, a troponin T level of 0.1 g/L (0.1 ng/mL) is a
powerful independent predictor and is associated with poorlong-term survival.[25]
BNP: measurement of serum BNP level in patients withsymptoms of heart failure is now routinely carried out in mostcentres. The addition of BNP or N-terminal pro-brainnatriuretic peptide (NT-proBNP) levels to clinical assessmentsignificantly enhances the accuracy of diagnosis and
effectiveness of acute management.[26] [27] BNP is alsohelpful in differentiating a cardiac from a pulmonary cause ofdyspnoea.[28]An elevated BNP level is a predictor of in-hospital mortality in patients with acute decompensatedheart failure.[29]However, an elevated BNP level shouldonly be taken in the context of clinical picture as it may beincreased in a variety of other condition, such as atrial
fibrillation, pulmonary embolism, or sepsis.[30]
Subsequent investigationsEchocardiogram is an integral part of the evaluation in a patient with acuteCHF and should be performed as soon as possible to presentation. It isrequired to assess chamber size, ventricular function (systolic and diastolic),ventricular wall thickness, valvular function, and the pericardium.ViewimageView image
Cardiac catheterisation is needed in cases where significant CAD is thoughtto be the contributing factor, and is also indicated in cases where the causeof acute CHF can not be determined from other tests.
Endomyocardial biopsy is not recommended for routine evaluation of acuteCHF, but is indicated in patients whose clinical findings suggest acutemyocarditis.
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Click to view diagnostic guideline references. Diagnosticcriteria
Framingham criteria for CHF[33]The Framingham criteria are the most widely accepted clinical criteria fordiagnosing heart failure. For establishing a definite diagnosis of CHF, 2 majorcriteria or 1 major and 2 minor criteria must be present.
Major criteria are:
Paroxysmal nocturnal dyspnoea or orthopnoea
Neck-vein distention
Rales
Cardiomegaly
Acute pulmonary oedema
S3 gallop
Increased venous pressure >16 cm of water
Circulation time 25 seconds or longer
Hepatojugular reflux.
Minor criteria are:
Ankle oedema
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Night cough
Dyspnoea on exertion
Hepatomegaly
Pleural effusion
Vital capacity reduced one third from maximum
Tachycardia (120 bpm).
Major or minor criteria are:
Weight loss of 4.5 kg or more in 5 days in response totreatment.
New York Heart Association (NYHA) clinical classification
of heart failure[34] Class I: asymptomatic
Class II: mild symptoms with moderate exertion
Class III: symptoms with minimal activity
Class IV: symptoms at rest.
Treatment Options
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-34 -
7/27/2019 Akut Egzacerb Hron Si
32/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-68&optionId=expsec-637860&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-68&optionId=expsec-637860&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1 -
7/27/2019 Akut Egzacerb Hron Si
33/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-69&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-70&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-71&optionId=expsec-637863&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-39http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-56http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-57 -
7/27/2019 Akut Egzacerb Hron Si
34/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-58http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-59http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-72&optionId=expsec-637866&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-73&optionId=expsec-637866&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
35/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1 -
7/27/2019 Akut Egzacerb Hron Si
36/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-37&optionId=expsec-637890&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
37/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-38&optionId=expsec-637890&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-39&optionId=expsec-637890&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
38/78
-
7/27/2019 Akut Egzacerb Hron Si
39/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-41&optionId=expsec-637884&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-49 -
7/27/2019 Akut Egzacerb Hron Si
40/78
-
7/27/2019 Akut Egzacerb Hron Si
41/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
-
7/27/2019 Akut Egzacerb Hron Si
42/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
-
7/27/2019 Akut Egzacerb Hron Si
43/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-43http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-60http://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence/score/5.html -
7/27/2019 Akut Egzacerb Hron Si
44/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence/score/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-60http://bestpractice.bmj.com/best-practice/monograph/62/treatment/evidence/score/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-44http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-45http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-46http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-47 -
7/27/2019 Akut Egzacerb Hron Si
45/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-74&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-74&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-75&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1 -
7/27/2019 Akut Egzacerb Hron Si
46/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-76&optionId=expsec-637896&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-77&optionId=expsec-637896&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
47/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53 -
7/27/2019 Akut Egzacerb Hron Si
48/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-53 -
7/27/2019 Akut Egzacerb Hron Si
49/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-42&optionId=expsec-637926&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
50/78
-
7/27/2019 Akut Egzacerb Hron Si
51/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-15&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-14&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-15&optionId=expsec-15&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
52/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-16&optionId=expsec-15&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-55http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-1&optionId=expsec-16&dd=MARTINDALE -
7/27/2019 Akut Egzacerb Hron Si
53/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
-
7/27/2019 Akut Egzacerb Hron Si
54/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/62/resources/references.html#ref-1 -
7/27/2019 Akut Egzacerb Hron Si
55/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
-
7/27/2019 Akut Egzacerb Hron Si
56/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
-
7/27/2019 Akut Egzacerb Hron Si
57/78
-
7/27/2019 Akut Egzacerb Hron Si
58/78
Patient group
Treatment line Treatmenthide all
haemodynamically stable
1st oxygen therapy
Oxygen saturationshould ideally bemaintained between95% and 98% tomaximise tissue
oxygenation.
adjunct
[?]morphine
Morphine results in mildvasodilatation and slowsthe heart rate. It isparticularly useful if the
patient is restless andsignificantlydyspnoeic.[1]
Primary Options
morphine sulphate : 2.5to 10 mg intravenouslyevery 2-6 hours whenrequired
plus
[?]loop diuretics
Indicated in patients witha systolic BP >85mmHg.[1]
http://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-61&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-61&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-62&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-63&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-64&optionId=expsec-637920&dd=MARTINDALEhttp://bestpractice.bmj.com/best-practice/druglink.html?component-id=179025-65&optionI