see also:

• cardiology
• acute pulmonary oedema (APO)
• asthma

• the undifferentiated acutely short of breath elderly patient with a wheeze is a common problem in the ED
• whilst many patients will be able to be rapidly placed into a diagnostic category based on PH, other clinical features which allows targeted acute Rx, in many, the cause of the acute SOB is often not initially clear and a “shotgun” approach to Rx may be required.

• move to a resuscitation room
• high flow oxygen (unless known to be a CO,sub>2</sub> retaining COPD patient in which case aim for oxygen saturation > 92%)
  • avoid hyperoxia as patients with cardiac failure may do worse due to resultant increased vascular resistance and decreased cardiac output
    • BestBets.org - oxygen in cardiac failure
• sit patient up, consider allowing legs to dangle over the side of the bed to reduce venous return
• iv access, take bloods FBE, U&E, cardiac enzymes, glucose (plus BNP if available)
• continuous cardiac and oxygen saturation monitoring +/- ABGs
• 12 lead ECG and CXR when possible
• restrict fluid and sodium
• cautious use of inhaled beta 2 selective agonists
• nitrate Rx if not hypotensive and no C/I
• diuretic Rx
• ACE inhibitors, such as 25mg sublingual (SL) captopril or 1mg intravenous enalapril, may rapidly reverse hemodynamic instability and symptoms in APO, possibly avoiding an otherwise imminent intubation.
• consider nifedipine or nondihydropyridine calcium channel blockers acutely ONLY if known to have diastolic cardiac failure
  • chronic use of calcium channel blockers in CCF increase mortality and increase prevalence of recurrent CHF.
• consider CPAP
  • although BiPAP may improve ventilation and vital signs more rapidly then CPAP in CCF, a higher incidence of MI associated with BiPAP has been reported.
• until the diagnosis is clear, avoid:
  • iv salbutamol or adrenaline
    • whilst the bronchodilating effects of beta agonists are highly desirable in the asthmatic/COPD patient, their potential to induce tachycardia will risk making cardiac failure much worse.
  • theophylline - this may increase cardiac work and risk of arrhythmias, both of which will exacerbate cardiac failure
  • iv/o steroids - these cause fluid retention, hypokalaemia, and possibly hypertension, all of which will exacerbate cardiac failure
    • consider inhaled steroids instead if asthma is more likely
  • beta blockers
    • although judicious use of beta blockers may be of some benefit in Mx of cardiac failure, in particular, to prevent tachycardia, and the use of carvedilol in long term Mx of cardiac failure may be indicated, their use in the acute setting of cardiac failure is not clear, and certainly would not be advisable if the patient really had asthma.