Acute Heart Failure Treatment with Pleural Effusion

Initial Evaluation and Monitoring

• The European Society of Cardiology recommends establishing continuous monitoring immediately, including pulse oximetry, blood pressure, respiratory rate, and continuous ECG within the first minutes of patient contact 1, 2
• Measuring transcutaneous SpO₂ is mandatory to guide oxygen therapy, according to the European Heart Journal 1, 4
• Obtaining gasometry, including pH and CO₂ tension, is recommended, especially in patients with acute pulmonary edema or a history of COPD, using venous blood (arterial if cardiogenic shock is present) 1
• A chest radiograph is necessary to evaluate pulmonary congestion and quantify pleural effusion, as suggested by the European Heart Journal 2, 3

Respiratory Support

Oxygen Therapy

• The European Heart Journal recommends administering oxygen if SpO₂ <90%, which is a Class I recommendation 1, 4, 2
• For SpO₂ 90-94%, clinical judgment should be used, considering respiratory work and difficulty, as suggested by the European Heart Journal 4
• The target SpO₂ should be >90%, but hyperoxia should be avoided, as it can cause vasoconstriction and reduce cardiac output in non-hypoxemic patients, according to the European Heart Journal 1, 4
• In patients with COPD, the target SpO₂ should be 88-92% to avoid hypercapnia, as recommended by the European Heart Journal 4

Non-Invasive Ventilation

• CPAP or BiPAP should be considered in patients with respiratory difficulty (respiratory rate >25/min, SpO₂ <90%) and should be initiated as soon as possible to reduce respiratory difficulty and decrease the rate of endotracheal intubation (Class IIa recommendation) 1
• CPAP is simpler and does not require a ventilator or special training, making it preferable in the prehospital setting, according to the European Heart Journal 1
• BiPAP is preferred in patients with significant hypercapnia, especially those with COPD, as suggested by the European Heart Journal 1

Intubation

• Intubation is indicated if respiratory failure occurs with hypoxemia (PaO₂ <60 mmHg), hypercapnia (PaCO₂ >50 mmHg), and acidosis (pH <7.35) that cannot be managed non-invasively, according to the European Heart Journal 1, 5, 6
• Midazolam is preferred for intubation, as it has fewer cardiac side effects than propofol, which can induce hypotension, as recommended by the European Heart Journal 1

Pharmacological Treatment

Loop Diuretics (First-Line)

• The European Society of Cardiology recommends initiating loop diuretics within 60 minutes of presentation, with a dose of 40-80 mg of furosemide IV if the patient is not taking diuretics, or twice the daily oral dose if they are already taking diuretics 2
• The dose should be titrated to achieve a urinary sodium output of ≥50-70 mmol/L within 2 hours and a urine output of ≥100-150 mL/hour within 6 hours, as suggested by the European Heart Journal 2

Vasodilators (Nitrates)

• The European Heart Journal recommends nitrates as first-line therapy in most patients with adequate blood pressure and signs of congestion 7, 5, 6
• Nitroglycerin can be administered by spray (400 mcg, 2 puffs every 5-10 minutes) or orally (isosorbide dinitrate 1-3 mg) while monitoring blood pressure, as suggested by the European Heart Journal 7, 5, 6
• Intravenous nitroglycerin (20 mcg/min, increasing to 200 mcg/min) or isosorbide dinitrate (1-10 mg/h) can be used, with careful monitoring of blood pressure, according to the European Heart Journal 7, 5, 6

Combined Diuretic Therapy

• The European Heart Journal suggests considering acetazolamide 500 mg IV once daily if basal bicarbonate is ≥27 mmol/L, especially useful in the first 3 days 8
• Alternative therapy with hydrochlorothiazide in combination with loop diuretics can be considered, as suggested by the European Heart Journal 8

Morphine

• The European Heart Journal recommends considering morphine in the early stages of treatment if there is severe dyspnea and anxiety (Class IIb recommendation, Level of Evidence B) 7, 5, 6
• The dose should be 3 mg IV boluses, which can be repeated as needed, according to the European Heart Journal 7, 5, 6

Pleural Effusion Management

Non-Invasive Evaluation

• Ultrasonography can be used to measure the angle formed by the diaphragm and the lung (right side) or pericardium (left side) in a seated position using a subscapular approach, as suggested by the European Heart Journal 1

Thoracocentesis

• The European Heart Journal recommends considering thoracocentesis if the pleural effusion is >500 ml (ultrasonographic angle >35 degrees) 2, 3
• Benefits of thoracocentesis include reducing the required dose of IV furosemide and shortening the duration of oxygen therapy, according to the European Heart Journal 2, 3

Treatment Algorithm Based on Blood Pressure

If SBP >110 mmHg:

• IV diuretics (full dose) + IV nitrates should be administered, as recommended by the European Heart Journal 2
• Non-invasive ventilation should be considered if there is respiratory difficulty, according to the European Heart Journal 1, 2

If SBP <110 mmHg:

• IV diuretics (lower initial dose) should be administered, as suggested by the European Heart Journal 2
• Close monitoring for hypotension is necessary, and vasodilators should be avoided or used with extreme caution, according to the European Heart Journal 1, 2

Continuous Monitoring

• Vital parameters, including dyspnea (visual analog scale), respiratory rate, blood pressure, SpO₂, and heart rate and rhythm, should be monitored, as recommended by the European Heart Journal 3
• Urine output should be strictly controlled, and daily weight should be evaluated to assess treatment response, according to the European Heart Journal 2, 3
• Peripheral perfusion, including clinical signs of perfusion and congestion, should be monitored, as suggested by the European Heart Journal 2, 3
• Electrolytes and renal function should be evaluated