What medications should be given to a patient presenting with wheezing and heart failure?

Management of Wheezing in Heart Failure Patients

For patients presenting with wheezing and heart failure, prioritize oxygen therapy (targeting SpO2 88-95%), intravenous loop diuretics (furosemide 20-40 mg IV initially), and non-invasive ventilation with PEEP if respiratory distress persists, while avoiding routine bronchodilators unless concurrent COPD is documented. 1

Immediate Respiratory Support

Oxygen Administration

• Administer supplemental oxygen immediately to achieve arterial oxygen saturation ≥95% (≥90% if concurrent COPD is present) 1
• Use controlled oxygen delivery, starting at 28% via Venturi mask or 2 L/min via nasal cannula if COPD history exists to avoid hypercapnia 2
• Target SpO2 of 88-92% in patients with known obstructive airways disease to prevent CO2 retention 2
• Avoid hyperoxia in normoxemic patients, as routine oxygen therapy in non-hypoxemic heart failure patients does not reduce mortality and may prolong hospital length of stay 3

Non-Invasive Ventilation (NIV)

• Consider NIV with PEEP (5-7.5 cmH2O initially, titrated up to 10 cmH2O) as early as possible in patients with acute cardiogenic pulmonary edema and respiratory distress 1
• NIV reduces the need for intubation and improves clinical parameters including respiratory distress 1
• NIV with PEEP improves left ventricular function by reducing LV afterload 1
• Continue for approximately 30 minutes per hour until dyspnea and oxygen saturation improve without continuous support 1
• Use with caution in cardiogenic shock and right ventricular failure 1

Pharmacological Management

Diuretic Therapy (First-Line)

• Administer IV loop diuretics immediately in the presence of symptoms secondary to congestion and volume overload 1
• Initial dose: furosemide 20-40 mg IV bolus (or 0.5-1 mg bumetanide; 10-20 mg torasemide) 1
• If patient is already on chronic oral diuretics, use at least the equivalent of their oral dose 1, 2
• Monitor urine output frequently; consider bladder catheter placement to assess treatment response 1
• Patients with hypotension (SBP <90 mmHg), severe hyponatremia, or acidosis are unlikely to respond to diuretic treatment 1

Vasodilator Therapy

• Consider IV vasodilators (nitroglycerin or isosorbide dinitrate) in patients with normal to high blood pressure (SBP >110 mmHg) 1
• Vasodilators are contraindicated when SBP <110 mmHg 1
• Early administration of vasodilators has been associated with lower mortality 1
• IV vasodilators may reduce the need for high-dose diuretic therapy 1

Morphine (Use with Extreme Caution)

• Routine use of morphine is NOT recommended in acute heart failure patients 1, 4
• While morphine may relieve dyspnea and reduce preload/afterload in small studies, it was associated with higher rates of mechanical ventilation, ICU admission, and death in the ADHERE registry 1, 4
• If considered, use only in highly selected patients with severe dyspnea, restlessness, or anxiety: 2.5-5 mg IV bolus, repeated as needed 1, 4
• Monitor respiration closely and use with caution in patients with hypotension, bradycardia, advanced AV block, or CO2 retention 1, 4

Bronchodilators

• Bronchodilators are NOT routinely indicated for cardiac wheezing unless concurrent COPD or obstructive airways disease is documented 2
• If COPD coexists, administer ipratropium bromide 500 mcg via nebulizer every 6-8 hours 2
• Short-acting beta-2 agonists may be used if bronchospasm is present, but recognize that cardiac wheezing typically responds to diuresis and afterload reduction, not bronchodilators 5, 6

Critical Monitoring Parameters

Immediate Assessment

• Arterial blood gases with pH, PaCO2, and lactate to guide oxygen therapy and assess for hypercapnic respiratory failure 2
• Chest X-ray to differentiate pulmonary edema from pneumonia or COPD exacerbation 2
• ECG, cardiac biomarkers (troponin), complete blood count, renal function, and electrolytes 2

Ongoing Monitoring

• Pulse oximetry continuously 1
• Recheck blood gases within 60 minutes of oxygen changes or if clinical deterioration occurs 2
• Blood chemistry (urea, creatinine, K+) every 4-6 hours during aggressive diuresis 2
• Daily weights and strict intake/output monitoring 2

Important Caveats

Avoid These Common Pitfalls

• Do not assume all wheezing is asthma or COPD—cardiac wheezing from pulmonary edema is a critical differential diagnosis 5, 6
• When cardiothoracic ratio on chest X-ray is >50%, perform 12-lead ECG and echocardiography to evaluate for heart failure 5
• Take special care in patients with serious obstructive airways disease to avoid hypercapnia when administering oxygen 1
• High doses of diuretics may lead to hypovolemia and hyponatremia, increasing the likelihood of hypotension when ACE inhibitors or ARBs are initiated 1

Contraindications to NIV

• Patients who cannot cooperate (unconscious, severe cognitive impairment, or severe anxiety) 1
• Immediate need for endotracheal intubation due to progressive life-threatening hypoxia 1
• Use caution in patients with severe obstructive airways disease 1

When to Escalate Care

• pH <7.26 predicts poor outcome and may require intubation 2
• Worsening respiratory distress despite NIV—prepare for intubation 2
• Intubation and mechanical ventilation should be restricted to patients in whom oxygen delivery is inadequate by oxygen mask or NIV, and those with increasing respiratory failure or exhaustion 1