Crackles

[brdavis17]

In a pt who does not have CHF, is it possible for lungs to slowly fill with fluid if they have IV fluids running and have bibasilar crackles? Or is pulmonary edema more sudden? With bibasilar crackles that don't clear with a cough, is it possible that walking around will help clear the lungs?

I ask because I have had a few pts with new-onset crackles lately and am sometimes hesitant to call MD to slow/stop fluids because my charge nurse has told me that you need to consider what they have fluids for (like if it's for the kidneys and they need the fluids)...though with ABCs perhaps the lungs would come first. She also said that it's important to re-assess to see if crackles have increased or there are any VS changes. But what I learned in school is ANY change, report to MD? I know nursing isn't always that black and white, but maybe it is for now because I am a new nurse (5 mos. in). And then another time an RT told me that crackles are not to be worried about unless pt shows other signs like SOB, O2 sat decreases, respiratory distress. I have been stressed about this lately and just need some seasoned nurses' thoughts.

[bgxyrnf, MSN, RN]

In a pt who does not have CHF, is it possible for lungs to slowly fill with fluid if they have IV fluids running and have bibasilar crackles? Yes, certainly... particularly if the patient suffers from CKD... and depending on just how much fluids you're talking about. The patient could also be developing pneumonia.Or is pulmonary edema more sudden? It can be... as in flash pulmonary edema which, if not immediately and aggressively treated, will likely be fatal. Pulmonary edema due to fluid overload can be insidious, though. With bibasilar crackles that don't clear with a cough, is it possible that walking around will help clear the lungs? Sure, if there exists mild pulmonary vascular congestion, getting up and moving can help because gravity can help pool some of the blood in the legs. Moving also tends to increase cardiac output which can help clear the fluid out of the lungs. It all depends on what's really going on with that specific patient.

I ask because I have had a few pts with new-onset crackles lately and am sometimes hesitant to call MD to slow/stop fluids because my charge nurse has told me that you need to consider what they have fluids for (like if it's for the kidneys and they need the fluids)...though with ABCs perhaps the lungs would come first. She also said that it's important to re-assess to see if crackles have increased or there are any VS changes. But what I learned in school is ANY change, report to MD? I know nursing isn't always that black and white, but maybe it is for now because I am a new nurse (5 mos. in). And then another time an RT told me that crackles are not to be worried about unless pt shows other signs like SOB, O2 sat decreases, respiratory distress. I have been stressed about this lately and just need some seasoned nurses' thoughts. If I heard new onset rales, I would generally let the doc know about it although if it was the middle of the night and there were no residents around (meaning I had to call and wake somebody) and the patient was A&O and having no SOB and VS were WNL, I might... might... consider holding off for a couple hours or even holding fluids for awhile... depending on what the fluids were about...

Generally speaking, you are right... report significant changes... but the real world can make that a less-than-sure choice.

[Buckeye.nurse]

Don't forget to check your patient's intake/output trends when you are concerned that fluid overload is causing crackles. Is your patient several liters positive over the last day or so? Do they have signs of peripheral edema? Are their pulses bounding? All of these could help to add to a fluid overload picture.

As a previous poster mentioned, developing pneumonia could be another cause of crackles. If that is your suspicion also monitor temp, HR, RR, oxygen sat, cough (productive? sputum color?), etc.

Also as previous poster said, significant changes in status should be reported to the MD. Take your patient's overall stability into account when deciding how urgently to notify though.

[PeekabooICU77]

1. Don't listen to that RT - those can be later signs leading towards respiratory failure. We are taught to assess for a reason, not just look at numbers on a screen.

Pulmonary edema can have different rates of onset and worsening. People DIE from flash pulmonary edema.

2. Appreciate and consider your charge nurses' advice, but lungs > kidneys. Turn the IV fluids off and call the doc, especially if their BP is ok. I'd rather be "scolded" and turning back on fluids than pumping a ton of fluid in that could be adding to pulmonary edema. If you don't want to turn it all the way off, turn it down to 10ml/hr so you keep the line patent if that matters. It's way easier to give fluids than it is to take them away.

In my experience, it doesn't always take several liters to confirm third spacing that is pulmonary edema. They can have an even or even negative fluid balance, but they are not moving it due to circulatory issues. Not always as easy as seeing if they are fluid positive, and hardly ever several liters positive. In my experience, anyway.

Unless there's a confirmed respiratory issue like pneumonia where there are secretions to mobilize, idk if I would be encouraging a patient with crackles to walk around - the fluid needs to be worked out with a diuretic usually, and I've often given albuterol to try to help open the narrow airways. They need to be chilling out, not expending energy.

3. As you gain experience as a nurse, deciding when to keep an eye on things yourself for a little bit versus notifying the doc for every change will eventually get easier. However it's a safe rule to always notify for any change, always. Some jerk providers might seem annoyed, but at the end of the day you are the eyes and ears, and sometimes more directly than other times - our actions (even just telling someone something!) make the difference between life and death.

Trust your gut but also follow protocol. There is probably something in your policies somewhere that outlines to notify of changes. Experience is invaluable, but I don't always follow the advice of more senior nurses. Whatever.

[vampiregirl, BSN, RN]

Good question!

Another potential cause of bibasilar crackles is atelectasis, just food for thought.

As previously brought up, assessment and critical thinking are skills that are important to develop. They are also gained over time and with experience. For example, a single set of vitals is helpful but looking at several sets of vitals for even subtle trends gives you much more information that just the numerical values themselves.

Gathering all this info together and having it organized when you notify a provider can also make a difference. A well organized, complete report including pertinent data and a complete assessment findings will make it easier for the provider and build credibility for you as well. This is turn will benefit the patient.