What are the appropriate steps for a patient presenting with acute shortness of breath, history of similar symptoms requiring Bi-level Positive Airway Pressure (BIPAP) therapy, complete left bundle branch block, and hypertension?

From the Guidelines

The patient presenting with shortness of breath, a history of requiring BIPAP support, left bundle branch block (LBBB), and hypertension should be immediately evaluated for heart failure exacerbation or respiratory distress and managed with oxygen supplementation if oxygen saturation is below 90% as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The patient's symptoms and history suggest possible cardiac decompensation, and the presence of LBBB indicates an electrical conduction abnormality in the heart, which combined with hypertension increases the risk of heart failure.

• Initial management should include:
  • Oxygen supplementation if oxygen saturation is below 90% to correct hypoxaemia as recommended by the 2016 ESC guidelines 1
  • Vital sign monitoring including blood pressure, heart rate, respiratory rate, and temperature
  • Laboratory tests including BNP (brain natriuretic peptide), troponin, complete blood count, and basic metabolic panel
  • An ECG should be performed to evaluate the LBBB and rule out acute myocardial infarction
  • A chest X-ray is important to assess for pulmonary edema or infection
• If heart failure is suspected, diuretics like furosemide 40mg IV may be administered as recommended by the 2005 European Society of Cardiology guidelines on the diagnosis and treatment of acute heart failure 1
• For hypertension management, continue the patient's home medications and consider adding short-acting agents if blood pressure is severely elevated
• Non-invasive positive pressure ventilation (CPAP or BiPAP) should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) and started as soon as possible to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation as recommended by the 2016 ESC guidelines 1 The patient's presentation suggests possible cardiac decompensation, and depending on severity, the patient may require hospital admission for closer monitoring and management of underlying cardiac and respiratory issues.
• The patient's LBBB should be evaluated with a history, physical examination, ECG, echocardiogram, and stress test as recommended by the 2015 American Heart Association and American College of Cardiology guidelines on eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities 1

From the Research

Patient Presentation

The patient presents with shortness of breath, a history of similar symptoms, and was previously treated with BIPAP in the ER. The patient also has a complete left bundle branch block and hypertension.

Medical History

• Complete left bundle branch block: a condition where the left bundle branch of the heart's electrical conduction system is blocked, which can lead to abnormal heart rhythms and increased risk of cardiovascular events 2, 3, 4.
• Hypertension: high blood pressure, which can increase the risk of cardiovascular disease and events 2, 4.
• History of similar symptoms: the patient has experienced shortness of breath before, which may be related to their underlying medical conditions 5, 6.

Potential Causes of Shortness of Breath

• Cardiovascular events: such as myocardial infarction or heart failure, which can be associated with left bundle branch block and hypertension 2, 3, 4.
• Respiratory problems: such as chronic obstructive pulmonary disease (COPD) or pneumonia, which can cause shortness of breath 5, 6.
• Other conditions: such as anemia, thyroid disorders, or anxiety, which can also cause shortness of breath 5, 6.

Evaluation and Management

• Electrocardiogram (ECG): to evaluate the patient's heart rhythm and detect any potential abnormalities 3.
• Chest X-ray: to evaluate the patient's lungs and detect any potential abnormalities 5, 6.
• Blood tests: to evaluate the patient's blood chemistry and detect any potential abnormalities 5, 6.
• Medical history and physical examination: to evaluate the patient's overall health and detect any potential underlying conditions 5, 6.