Heart failure and chronic lung disease in frailty — Rapid

Synopsis

Distinguish cardiac, pulmonary and mixed decompensation, treat congestion, bronchospasm, infection and respiratory failure without destabilising other organs, and align long-term disease therapy, rehabilitation and escalation with frailty and personal goals.

Do not label all breathlessness as COPD or all oedema as heart failure; identify physiology, baseline and the precipitating cause.
First-line acute assessment is ABCDE, controlled oxygen, ECG, chest examination, blood gas when indicated, chest radiograph and targeted cardiac, infection and renal tests.
In people at risk of hypercapnic respiratory failure, target oxygen saturation is usually 88% to 92% pending blood gases and individual prescription.
Acute heart failure with congestion requires IV loop diuretic and close urine, weight, renal, electrolyte, pressure and symptom monitoring.
A creatinine rise during effective decongestion does not automatically mean fluids are needed; examine perfusion and residual congestion.
COPD exacerbation treatment uses increased short-acting bronchodilators, prednisolone 30 mg orally daily for five days when indicated, and antibiotics only under sputum and severity criteria.
Non-invasive ventilation is the preferred escalation for persistent hypercapnic ventilatory failure during COPD exacerbation despite optimal medical therapy, when appropriate.
After stabilisation, optimise guideline-directed heart-failure treatment and inhaled therapy, but check renal function, pressure, inhaler technique, cognition and practical administration.
Offer pulmonary or cardiac rehabilitation adapted to frailty, with progressive strength, nutrition, anxiety and breathlessness support.
Create one deterioration plan covering daily symptoms or weight, diuretic actions, inhaler rescue, oxygen target, antibiotics or steroids, and when to seek urgent care.

Key red flags

New severe hypoxia, exhaustion, reduced consciousness or worsening acidosis indicates impending respiratory failure.

Pink frothy sputum, diffuse crackles, hypertension or shock with acute breathlessness suggests pulmonary oedema and requires emergency treatment.

Chest pain, ischaemic ECG change, sustained arrhythmia or syncope requires an acute coronary and rhythm pathway.

Unilateral pleuritic pain, haemoptysis or unexplained tachycardia raises pulmonary embolism despite coexisting COPD or heart failure.

Fever, focal chest signs, new infiltrate or sepsis physiology requires infection assessment and source-appropriate antimicrobials.

Abrupt decline after a sedative, opioid, beta-blocker omission, diuretic change or inhaler failure requires immediate medication reconciliation.

Hypercapnic failure

Drowsiness, headache, tremor or acidosis with raised carbon dioxide requires controlled oxygen and ventilatory assessment.

Acute pulmonary oedema

Severe distress, diffuse crackles, frothy sputum and hypertension or shock requires emergency cardiac treatment.

Investigation priorities

ECG and continuous rhythm assessmentFirst step

Identify ischaemia and arrhythmic precipitants.

Management branches

First-line breathlessness routeSupport gas exchange and distinguish mechanisms

Frailty is accompanied by acute dyspnoea, hypoxia or oedema.

Use ABCDE, controlled oxygen, ECG, chest and congestion examination, blood gas and targeted laboratory and imaging tests.
Treat pulmonary oedema, obstructive exacerbation, infection, ischaemia, arrhythmia or thromboembolism according to the dominant physiology.
Reassess response, renal function and gas exchange early and escalate respiratory or circulatory failure without diagnostic anchoring.

Key medicines

Prednisolone for COPD exacerbationGive 30 mg orally once daily for five days for an acute COPD exacerbation when systemic corticosteroid treatment is indicated under NICE guidance.Review glucose, delirium, infection, fluid retention and gastrointestinal or psychiatric risk; extend beyond five days only for a separate specialist indication.

Intravenous loop diuretic for acute heart failureGive intravenous loop diuretic by bolus or infusion; if the person already takes a loop diuretic, use an initial dose higher than the admission oral dose and titrate to clinical response under the acute-heart-failure protocol.Monitor urine, weight, pressure, creatinine, sodium and potassium closely; persistent congestion may justify continued decongestion despite a modest creatinine rise, whereas hypotension requires reassessment.

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