What is the management for a patient with acute shortness of breath (SOB) and new oxygen requirement on the background of heart failure exacerbation?

From the Guidelines

Management of a patient with acute shortness of breath and new oxygen requirement due to heart failure exacerbation requires prompt intervention with supplemental oxygen, diuretics, and supportive care. Initially, provide oxygen to maintain saturation above 92% (or 88-92% in those with COPD) as recommended by 1. Administer intravenous loop diuretics such as furosemide 40-80mg IV (or 1.5-2.5 times the patient's oral dose if they're already on diuretics), which can be repeated or increased if response is inadequate, as suggested by 1 and 1. Position the patient upright to reduce work of breathing. Consider non-invasive positive pressure ventilation (CPAP or BiPAP) at settings of 5-10 cmH2O if respiratory distress persists despite initial measures, as recommended by 1. Nitrates like nitroglycerin (starting at 10-20 mcg/min IV and titrating up) can provide preload reduction if blood pressure allows (maintain systolic BP >100 mmHg), as suggested by 1 and 1. Monitor fluid status through intake/output, daily weights, and clinical assessment. Obtain an ECG to rule out ischemia and basic labs including electrolytes, renal function, and BNP. Reassess the patient's home heart failure medications and consider initiating or optimizing ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists once stabilized, as recommended by 1 and 1. These interventions work by reducing pulmonary congestion, improving oxygenation, decreasing cardiac preload and afterload, and addressing the underlying volume overload that characterizes heart failure exacerbations. It is also important to note that the use of inotropic agents and vasopressors should be guided by the patient's clinical status and hemodynamic parameters, as suggested by 1 and 1. Overall, the goal of management is to improve symptoms, reduce morbidity and mortality, and enhance quality of life, as emphasized by the need to prioritize interventions based on the most recent and highest quality evidence, such as that provided by 1.

From the Research

Management of Acute Shortness of Breath and New Oxygen Requirement in Heart Failure Exacerbation

• The management of a patient with acute shortness of breath (SOB) and new oxygen requirement on the background of heart failure exacerbation involves addressing the underlying cause of the exacerbation and optimizing oxygen therapy 2.
• Oxygen therapy should be titrated to maintain a target peripheral oxygen saturation (SpO2) range, with the lower and upper limits depending on the presence of risk factors for oxygen-induced hypercapnia 2.
• For patients at risk, oxygen therapy should be started when SpO2 is ≤88% and stopped when it is >92%, while for patients without risk factors, oxygen therapy should be started when SpO2 is ≤92% and stopped when it is >96% 2.
• In terms of pharmacological management, angiotensin receptor-neprilysin inhibitors (ARNIs) such as sacubitril/valsartan have been shown to be effective in reducing morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF) 3, 4, 5.
• The use of ARNIs in clinical practice is supported by several studies, including the PARADIGM-HF trial, which demonstrated the superiority of sacubitril/valsartan over angiotensin-converting enzyme (ACE) inhibitors in improving outcomes in patients with HFrEF 3, 4, 5.
• However, the management of acute SOB and new oxygen requirement in heart failure exacerbation should be individualized and guided by clinical judgment, taking into account the patient's underlying condition, medical history, and response to treatment.

Oxygen Therapy Considerations

• High-flow oxygen should only be used in specific conditions, such as carbon monoxide poisoning, cluster headaches, sickle cell crisis, and pneumothorax 2.
• The benefits and risks of oxygen therapy should be carefully considered, and oxygen should be used judiciously to avoid hyperoxemia and its potential harmful effects 2.

Pharmacological Management

• The use of ARNIs such as sacubitril/valsartan may be considered in patients with HFrEF, as they have been shown to be effective in reducing morbidity and mortality 3, 4, 5.
• However, the initiation and up-titration of ARNIs should be guided by clinical judgment and evidence-based recommendations, taking into account the patient's underlying condition, medical history, and response to treatment 3, 4.