Managing Oxygen Levels in Heart Failure Patients: Key Considerations

Oxygenation issues caused by heart failure?

Dear Doctor,
My father has severe damage to his aortic and mitral valves due to endocarditis (he had received antibiotic treatment at that time).
One year later, his heart has enlarged (he has ankylosing spondylitis and insists on not having surgery).
Despite taking diuretics daily, he still experiences edema in his legs, which has led to skin breakdown and weeping.
Moving his body (for example, standing up) is very difficult, requiring the assistance of one to two people.
He also has pleural effusion and exhibits shallow, rapid breathing (often breathing through his mouth).
He was admitted to the internal medicine ward on April 9, and on April 12, his blood oxygen level on room air was 74%, prompting the use of a nasal cannula.
Eight hours later, his blood oxygen level increased to 96%.
On April 12, arterial blood gas results showed PCO2 (mmHg) 56.2, PO2 (mmHg) 98.7, SO2 (%) 96.8, and he began using BiPAP.
On April 13, venous blood gas results showed PCO2: 50.8, PO2: 117.8, SO2: 98.2.
On April 15, PCO2 was 58.4, PO2: 59.4, SO2: 91.2.
On April 18, venous blood gas results showed PCO2: 56.2, PO2: 41.7, SO2: 78.6.
On April 22, PCO2: 54.8, PO2: 22.0, SO2: 38.9.
At the end of May, a pulse oximeter measured his blood oxygen at 79% (while using a nasal cannula).
I have a few questions for you:
1.
After April 26, he has not used a nasal cannula, oxygen mask, or BiPAP for over 40 days, nor has his blood oxygen been monitored.
He constantly breathes through his mouth, speaks with a slightly weak voice, has mild shortness of breath, and often appears drowsy with his eyes closed.
He responds briefly when spoken to but quickly closes his eyes as if asleep.
Should we promptly provide him with an oxygen mask or nasal cannula to prevent low blood oxygen levels, high PCO2 leading to shock, cerebral hypoxia, brain damage, or even life-threatening situations? At what blood oxygen saturation level should we provide him with an oxygen mask or nasal cannula?
2.
Since venous blood measurements are less accurate, should we perform arterial blood gas analysis to monitor PCO2? If PCO2 is too high, should we continue using BiPAP to expel CO2? Should we only admit my father to the hospital in case of an emergency for timely resuscitation? (Other symptoms: An abdominal ultrasound on May 31 showed severe ascites, lower extremity edema, poor appetite, and despite diuretic use, he continues to develop blisters on his legs.
He can only manage to walk a few steps with crutches and visits the outpatient clinic 2-3 times a week for diuretics and wound care.)
I look forward to your valuable insights.
Thank you!

Miss Lin, 30~39 year old female. Ask Date: 2020/06/18

Dr. Wu Xueming reply Cardiology

Based on your description, your father is suffering from severe valvular heart disease complicated by heart failure, with low blood oxygen levels and elevated carbon dioxide levels.
It is recommended that he be hospitalized for treatment.
If medication management is ineffective, surgical repair or valve replacement should be considered.

Reply Date: 2020/06/18

More Info

Managing oxygen levels in patients with heart failure is a critical aspect of care, especially when they exhibit symptoms such as shortness of breath, hypoxia, and other complications related to their condition. In the case of your father, who has significant heart valve damage due to endocarditis and is experiencing multiple symptoms, including low oxygen saturation and difficulty breathing, there are several key considerations to keep in mind.

1. Monitoring Oxygen Levels
Given your father's history and current symptoms, it is essential to monitor his oxygen saturation levels closely. Normal oxygen saturation levels typically range from 95% to 100%. If his oxygen saturation falls below 90%, it is generally recommended to provide supplemental oxygen, either through a nasal cannula or a face mask, to prevent complications such as hypoxia, which can lead to organ dysfunction, including brain injury.

In your father's case, with reported oxygen saturation levels as low as 74% and subsequent readings indicating significant fluctuations, it would be prudent to re-initiate oxygen therapy. The fact that he is exhibiting signs of respiratory distress, such as mouth breathing and fatigue, further underscores the need for immediate intervention to stabilize his oxygen levels.

2. Use of Non-Invasive Ventilation
The use of BiPAP (Bilevel Positive Airway Pressure) can be beneficial for patients with heart failure who are experiencing respiratory distress. BiPAP helps to improve ventilation and reduce carbon dioxide levels (PCO2) in the blood. Given that your father's PCO2 levels have been elevated, indicating hypoventilation, the use of BiPAP may be warranted to assist in CO2 removal and improve overall respiratory function.

3. Arterial Blood Gas (ABG) Monitoring
While venous blood gas measurements can provide some information, arterial blood gas (ABG) analysis is the gold standard for assessing oxygenation and ventilation status. An ABG can give precise readings of arterial oxygen (PaO2) and carbon dioxide (PaCO2) levels, which are crucial for determining the need for supplemental oxygen and the effectiveness of any interventions. If your father is experiencing persistent respiratory issues, it would be advisable to obtain an ABG to guide further management.

4. Hospitalization Considerations
Given the complexity of your father's condition, including his heart failure, pleural effusion, and the need for diuretics, hospitalization may be necessary for closer monitoring and management. In a hospital setting, healthcare providers can provide more intensive care, including intravenous diuretics, oxygen therapy, and potentially more invasive interventions if needed. This would also allow for immediate response to any acute changes in his condition.

5. Long-term Management
In the long term, managing heart failure involves a comprehensive approach that includes medication adherence, lifestyle modifications, and regular follow-up with healthcare providers. Medications such as diuretics, ACE inhibitors, and beta-blockers are commonly used to manage heart failure symptoms and improve quality of life. Additionally, addressing any underlying issues, such as valve repair or replacement, may be necessary depending on the severity of the heart condition.

Conclusion
In summary, your father's current symptoms and history warrant immediate attention to his oxygen levels and respiratory status. Reinitiating oxygen therapy, considering the use of BiPAP, obtaining arterial blood gas measurements, and potentially admitting him to the hospital for closer monitoring and management are all critical steps. It is essential to work closely with his healthcare team to ensure that he receives the appropriate care to manage his heart failure effectively and improve his quality of life.

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