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....................................................... SpO2 <90% or PaO2 <60 mmHg to correct hypoxaemia. In chronic obstructive pulmonary disease (COPD), hyper-oxygenation may increase ventilationperfusion mismatch, suppress ventilation and lead to hypercapnia. During oxygen therapy, acid-base balance and SpO2 should be monitored.

Non-invasive positive pressure ventilation, either continuous positive airway pressure and pressure support, improves respiratory failure, increases oxygenation and pH, and decreases the partial pressure of carbon dioxide (pCO2) and work of breathing. Although a large randomized trial had neutral results, meta-analyses suggest it may improve dyspnoea and reduce the need for intubation and mortality, compared with traditional oxygen therapy.1,458,459 Noninvasive positive pressure ventilation should be started as soon as possible in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) to improve gas exchange and reduce the rate of endotracheal intubation.448,459 The fraction of inspired oxygen (FiO2) should be increased up to 100%, if necessary, according to oxygen saturation level. Blood pressure should be monitored regularly during non-invasive positive pressure ventilation. The increase in intrathoracic pressure with non-invasive positive pressure ventilation decreases venous return and right and left ventricular preload. It may also decrease cardiac output and BP and should therefore be used with caution in patients with reduced preload reserve and hypotension. The increase in pulmonary vascular resistance and RV afterload may also be detrimental in RV dysfunction.448

Intubation is recommended for progressive respiratory failure in spite of oxygen administration or non-invasive ventilation (Supplementary Table 20).448

11.3.3 Diuretics Intravenous diuretics are the cornerstone of AHF treatment. They increase renal excretion of salt and water and are indicated for the treatment of fluid overload and congestion in the vast majority of AHF patients.

Determine aetiology Alleviate symptoms Improve congestion and organ perfusion Restore oxygenation Limit organ damage (cardiac, renal, hepatic, gut) Prevent thromboembolism Close monitoring of vital signs and grading severity of symptoms/signs Disposition decisions: ICU/ICCU ward Initial treatment to support circulatory and respiratory functions (vasodilators, vasopressors, inotropes, diuretics, supplemental O2)

Identify aetiology and relevant co-morbidities and start targeted treatment Titrate therapy to control symptoms and to relieve congestion, manage hypoperfusion and optimize blood pressure Initiate and up-titrate diseasemodifying pharmacological therapy Consider device therapy in appropriate patients

Goals Procedures Phases

Determine aetiology Improve signs and symptoms Limit organ damage Prevent thromboembolism

Improve symptoms and quality of life Achieve full congestion relief Prevent early readmission Improve survival Initiate and up-titrate diseasemodifying pharmacological and device therapy Develop a care plan with the identification of caregivers, a schedule for up-titration and monitoring of pharmacological therapy, review of device therapy Enrolment in a disease management programme

Immediate

Pre-discharge and long-term

Intermediate

Phases

Figure 11 Stages of management of patients with acute heart failure. ICCU= intensive coronary care unit; ICU= intensive care unit. Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026