Airway and Ventilation Management
The most important initial management goal in patients with ADHF, regardless of etiology, is to ensure adequate oxygenation and ventilation. This may require supplemental oxygen, NIPPV, or, in severe cases, emergent endotracheal intubation with mechanical ventilation. Patients presenting with a room-air oxygen saturation < 90% should receive supplemental oxygen. Patients who are persistently hypoxemic on supplemental oxygen or who continue to exhibit significantly increased work of breathing require more aggressive intervention via positive-pressure ventilation, either invasive or noninvasive.
If the patient is an appropriate candidate, a trial of NIPPV via CPAP or bilevel positive airway pressure (BiPAP) should be attempted prior to intubation. These patients should be alert enough to participate in the care and delivery of NIPPV and cooperate with the intervention. NIPPV is patient-triggered, and the patient must be able to establish synchrony with the device. This can only be accomplished in an awake patient. In patients who are obtunded or apneic, the clinician should proceed directly to endotracheal intubation. NIPPV helps recruit functional alveoli by both preventing alveolar collapse and by expelling intra-alveolar fluid, thereby reducing the required work of breathing. For more information on the use of NIPPV, including absolute and relative contraindications, see the February 2017 issue of Emergency Medicine Practice, “Noninvasive Ventilation for Patients in Acute Respiratory Distress: An Update,” at www.ebmedicine.net/NIV.
To continue reading, please log in or purchase access.