# 230 Using Non-Invasive Ventilation at the End of Life

FAST FACTS AND CONCEPTS #230 PDF

Authors: Mei-Ean Yeow MD, Rohtesh S Mehta MD MPH, Douglas B White MD, MAS, and Eytan Szmuilowicz MD

Background Non-invasive positive pressure ventilation (NPPV, often called 'BiPAP') is commonly used in patients with respiratory failure from COPD, CHF, and other disorders. NPPV decreases the work of breathing and allows respiratory muscle rest during inspiration. This Fast Fact discusses medical decision making around its use at the end of life. Fast Fact #231 discusses practical aspects of applying NPPV in dying patients, as well as how to discontinue it safely.

Goals of NPPV at the end of life NPPV is used in 3 general circumstances in patients close to death, all of which are likely to be encountered by palliative specialists (1):

  1. In patients who desire full, life-prolonging interventions, regardless of prognosis. If the patient's respiratory status deteriorates, intubation and ventilation are initiated.
  2. In patients who want life-prolonging and restorative therapy but with limitations (e.g., patients who have a 'Do Not Intubate' order but otherwise want all attempts at life prolongation). Ideally, NPPV is used only if the etiology for the respiratory failure is thought to be reversible and is stopped if it is not producing the desired response or the patient is not tolerating NPPV. In practice, this may not be the case.
  3. In dying patients with respiratory failure or dyspnea for palliative purposes. This category includes dying patients who have decided to forego life-prolonging therapies and wish to focus on comfort measures. NPPV can be used with the intention to reduce the work of breathing, to ease dyspnea, and to help maintain wakefulness by reducing the amount of opioids a patient needs to be comfortable. NPPV can also be used to prolong life for a short period to meet a patient's goals while otherwise providing a comfortable death (e.g., to allow time for family to visit). Unlike #2, the goal is not to bridge a patient through a reversible illness, but to forestall death to meet a specific goal.

Research Findings

  • In several trials NPPV has been shown to reduce mortality and decrease intubation rates and hospital length of stay in patients with COPD, as well as reduce intubation rates in patients with respiratory failure from heart failure and in immunocompromised patients (2-4). For the second category of patients, there are no high-quality trials. Some observational studies suggest that NPPV can reverse acute respiratory failure and decrease hospital mortality in patients with COPD or CHF who have 'Do Not Intubate' orders (5,6). Apart from ALS (see Fast Fact #73) there are no data to support its use in other patient populations.
  • There is little research about the use of NPPV to alleviate dyspnea in dying patients, whether it is opioid-sparing, or how tolerable it is to dying patients. In a survey, a majority of pulmonologists endorsed a belief that NPPV relieves dyspnea in dying patients in addition to anxiolytics and analgesics (7). That clinical impression has never been investigated. In a controlled study of hospitalized end-stage cancer patients with severe respiratory failure, NPPV was shown to improve dyspnea much faster than passive oxygen therapy (8). However, 57% of patients were discharged alive in this study, underlying the reality that NPPV's role in imminently dying patients has not been rigorously investigated.

Drawbacks of NPPV NPPV is noisy, can be uncomfortable and frightening, can interfere with family intimacy, and can confuse care goals if not discussed carefully. It can be challenging or impossible to initiate outside of acute care environments (e.g. at home, nursing home, or hospice facility) - (see Fast Fact #231).

Medical Decision Making and Counseling

Patients in categories #1 & 2, as with all patients nearing the end of life, need ongoing discussions about their realistic prognosis, goals, and options (see Fast Facts #164,165, 222-7).

  • For dying patients with distressing dyspnea and comfort-only goals of care, opioids are first line agents (see Fast Fact #27). For patients who need sedating doses of opioids to be comfortable, and who articulate a strong preference to be as awake as possible, it is reasonable to offer NPPV if the patient is in an environment which can accommodate it and the risks are acceptable to the patient, including the possibility that the dying process will be prolonged. Reassure patients that you can alleviate their symptoms even if NPPV is unhelpful or intolerable.
  • For dying patients who wish to forestall death briefly for a specific goal, it is reasonable to start a trial of NPPV. Before initiating NPPV, it is important to discuss withdrawal of NPPV after the above goal has been achieved, and to caution the patient/family that NPPV might not be able to forestall death long enough as hoped.

References

  1. Curtis JR, Cook DJ, Sinuff T, et al; Society of Critical Care Medicine Palliative Noninvasive Positive VentilationTask Force. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med. 2007; 35(3):932-9.
  2. Peter JV, Moran JL. Noninvasive ventilation in exacerbations of chronic obstructive pulmonary disease: implications of different meta-analytic strategies. Ann Intern Med. 2004; 141(5):W78-9.
  3. Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med. 2004; 32(12):2516-23.
  4. Rusterholtz T, Kempf J, Berton C, et al. Noninvasive pressure support ventilation (NIPSV) with face mask in patients with acute cardiogenic pulmonary edema (ACPE). Intensive Care Med. 1999; 25(1):21-8.
  5. Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select "do-not-intubate" patients. Crit Care Med. 2005; 33(9):1976-82.
  6. Levy M, Tanios MA, Nelson D, et al. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med. 2004; 32(10):2002-7.
  7. Sinuff T, Cook DJ, Keenan SP, et al. Noninvasive ventilation for acute respiratory failure near the end of life. Crit Care Med. 2008; 36(3):789-94.
  8. Nava S, et al. Multicenter, randomized study of the use of non-invasive ventilation (NIV) vs oxygen therapy (O2) in reducing respiratory distress in end-stage cancer patients (Abstract). Am J Respir Crit Care Med. 2008; 177:A767.

Author Affiliations: Northwestern Memorial Hospital, Chicago, IL (MEY, ES); University of Pittsburgh Medical Center, Pittsburgh, PA (RSM, DBW).

Fast Facts and Concepts are edited by Drew A. Rosielle MD, PalliativeCareCenter, Medical College of Wisconsin. For more information write to: drosielle@gmail.com. More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc. Readers can comment on this publication at the Fast Facts and Concepts Discussion Blog (http://epercfastfacts.blogspot.com).

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Yeow M, Mehta RS, White DB, Szmuilowicz E. Using Non-Invasive Ventilation at the End of Life. Fast Facts and Concepts. May 2010; 230. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_230.htm.

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