What is the best approach to manage shortness of breath in patients with heart failure?

Management of Shortness of Breath in Heart Failure Patients

Start non-invasive positive pressure ventilation (CPAP or BiPAP) immediately in patients presenting with respiratory distress, as this reduces intubation rates and mortality while improving outcomes. 1, 2

Immediate Respiratory Assessment and Positioning

• Position the patient upright immediately to reduce venous return and improve respiratory mechanics 1
• Monitor oxygen saturation continuously with pulse oximetry (SpO2) and assess respiratory rate, work of breathing, and presence of orthopnea 1, 2
• Obtain arterial or venous blood gas measurements to evaluate pH, PaCO2, and PaO2, particularly when respiratory distress is present or hypercapnia is suspected 1, 2

Oxygen Therapy Strategy

• Administer supplemental oxygen only if SpO2 <90%, targeting SpO2 of 94-98% 1, 2
• Avoid routine oxygen administration in non-hypoxemic patients, as hyperoxia causes vasoconstriction, reduces cardiac output, and may worsen outcomes 1, 2
• Increase fraction of inspired oxygen (FiO2) up to 100% if necessary according to SpO2, unless contraindicated 1

Non-Invasive Ventilation (First-Line Respiratory Support)

Initiate NIV immediately when patients present with:

• Respiratory rate >25 breaths/minute 1, 2
• SpO2 <90% despite supplemental oxygen 1, 2
• Use of accessory respiratory muscles or severe dyspnea with respiratory distress 1, 2

CPAP vs BiPAP Selection

• Start with CPAP at 5-10 cmH2O as it is simpler, requires minimal training, and is feasible in pre-hospital settings 1, 2
• Switch to BiPAP (PS-PEEP) if:
  • Patient continues to show respiratory distress after hospital arrival 1
  • Acidosis and hypercapnia are present 1, 2
  • Patient has previous history of COPD or shows signs of fatigue 1
• BiPAP settings: Start with EPAP 5-8 cmH2O and IPAP 12-15 cmH2O, titrating up to 20-25 cmH2O as tolerated 2

Pharmacologic Management

Diuretic Therapy (Cornerstone of Acute Treatment)

Administer intravenous diuretics early to reduce preload and pulmonary congestion 1:

• For new-onset heart failure or patients not on maintenance diuretics: Furosemide 40 mg IV 1
• For established heart failure on chronic oral diuretics: IV bolus at least equivalent to oral dose 1
• Administer as intermittent boluses or continuous infusion, adjusting dose and duration according to symptoms, urine output, renal function, and electrolytes 1
• Monitor symptoms, urine output, renal function, and electrolytes regularly during IV diuretic use 1

Vasodilator Therapy

Consider IV vasodilators for symptomatic relief in patients with systolic BP >110 mmHg (and without symptomatic hypotension) 1:

• In hypertensive acute heart failure, use IV vasodilators as initial therapy to improve symptoms and reduce congestion 1
• Do not use vasodilators if systolic BP <110 mmHg 1
• Monitor symptoms and blood pressure frequently during IV vasodilator administration 1
• Nitrates (isosorbide dinitrate, nitroglycerin) or nitroprusside can be used, particularly in those with high arterial blood pressure 1

Rate Control in Atrial Fibrillation

• Beta-blockers are the preferred first-line treatment to control ventricular rate in patients with heart failure and atrial fibrillation 1
• Consider IV cardiac glycoside for rapid control of ventricular rate in heart failure patients with atrial fibrillation 1

Medications to Avoid or Use Cautiously

Do not routinely use opioids (including morphine), as they are associated with higher rates of mechanical ventilation, ICU admission, and death in the ADHERE registry 1:

• Morphine has never been shown to improve outcomes and may be associated with harm 1
• Avoid routine use of sympathomimetics or vasopressors unless patient has cardiogenic shock with persistent signs of hypoperfusion despite adequate filling status 1
• There is no role for vasopressors if systolic BP >110 mmHg 1
• Do not give dobutamine when pulmonary edema is associated with normal or high systolic blood pressure 1

Management of Chronic Heart Failure Medications During Acute Episode

Adjust guideline-directed medical therapy based on blood pressure and clinical status 1:

When Systolic BP 85-100 mmHg:

• Review/reduce ACE inhibitors or ARBs 1
• Review/reduce beta-blockers 1
• Continue mineralocorticoid receptor antagonists (MRAs) 1

When Systolic BP <85 mmHg:

• Stop ACE inhibitors/ARBs 1
• Stop beta-blockers 1
• Stop MRAs 1

When Heart Rate <50 bpm:

• Stop beta-blockers and other rate-slowing drugs 1

Invasive Mechanical Ventilation Criteria

Proceed to endotracheal intubation if patient has: 1, 2

• Respiratory arrest or impending arrest 1, 2
• Severe hypoxemia unresponsive to NIV 1, 2
• Hypercapnic respiratory failure despite NIV 1, 2
• Hemodynamic collapse 1, 2
• Inability to protect airway 1, 2

Use pressure-controlled ventilation with PEEP starting at 5-10 cmH2O, titrated to optimize oxygenation while monitoring hemodynamics 2

Triage and Location of Care

Admit to ICU/CCU if patient has: 2

• Need for intubation or already intubated 2
• Requirement for NIV 2
• Respiratory rate >25 breaths/minute with SpO2 <90% 2
• Systolic BP <90 mmHg 2
• Signs of hypoperfusion or cardiogenic shock 2

Long-Term Optimization After Stabilization

Once acute symptoms resolve, rapidly initiate or optimize guideline-directed medical therapy to prevent recurrent episodes 1, 3:

• Start SGLT2 inhibitors and MRAs first as they have the least effect on blood pressure but rapid beneficial effects 1
• Subsequently consider low-dose beta-blocker (if heart rate >70 bpm) or low-dose sacubitril/valsartan (50 mg or 25 mg twice daily), then gradually up-titrate 1
• If sacubitril/valsartan not tolerated, use low-dose ACE inhibitor (or ARB if ACE inhibitor contraindicated) 1
• Selective β₁ receptor blockers may be preferred due to lesser blood pressure-lowering effect than non-selective beta-blockers 1
• If beta-blockers not tolerated hemodynamically, ivabradine may be a viable alternative, either alone or with low-dose beta-blockers 1
• Up-titrate one drug at a time using small increments every 1-2 weeks until highest tolerated or target dose achieved 1

Common Pitfalls to Avoid

• Never delay NIV while waiting for blood gas results in patients with obvious respiratory distress 2
• Do not give oxygen to non-hypoxemic patients, as it worsens hemodynamics through vasoconstriction 1, 2
• Monitor for NIV-induced hypotension, especially in patients with borderline blood pressure 2
• Recognize NIV failure early (after 60-90 minutes) and proceed to intubation rather than prolonging inadequate support 1, 2
• Avoid over-diuresis, which can result in lower blood pressure and hypoperfusion 1
• Do not routinely discontinue guideline-directed medical therapy during acute episodes unless severe hypotension or other contraindications exist, as discontinuation is associated with worse outcomes 1