NPPV has a place in palliative care if it eases patients’ respiratory distress and allows them time to make their final farewells

Noninvasive positive pressure ventilation (NPPV) has been defined as “the provision of ventilatory support through the patient’s upper airway using a mask or similar device.”¹ In the hospital setting, NPPV was first applied to patients experiencing acute exacerbations of chronic obstructive pulmonary disease (COPD). Most of the prospective, randomized, controlled trials have been performed with this patient population.

NPPV has been shown to reduce hypercapnia. This is accomplished while decreasing the work of breathing, unloading the respiratory muscles, and increasing alveolar ventilation. In addition to reducing the partial pressure of carbon dioxide (Paco₂) in the blood, NPPV can improve oxygenation and, thus, the partial pressure of oxygen and the oxygen saturation (Spo₂). This allows a reduction in the fractional concentration of inspired oxygen (Fio₂).²

The strongest evidence for the use of NPPV is with patients suffering from exacerbations of COPD; patients who develop acute pulmonary edema; and immunocompromised patients who develop fever, infiltrates, and neutropenia.³ NPPV is now considered a “standard of care” for treating patients with an exacerbation of COPD.⁴

What Is Palliative Care?
The World Health Organization (WHO) has defined palliative care as care that “affirms life and regards dying as a normal process, … neither hastens nor postpones death, … [and] provides relief from pain and other distressing symptoms.”⁵ When attempting to optimize the quality of life for those with life-threatening or debilitating chronic illnesses, health care practitioners “are expected to provide basic elements of palliative care (eg, pain and symptom assessment and management, advance care planning).”⁶ 

NPPV and Palliative Care: What Is Its Role?
NPPV has been shown to decrease the incidence of endotracheal intubation. It has been used successfully in cystic fibrosis patients awaiting lung transplantation and has also been effective in reducing the risk of nosocomial pneumonia.⁷ One of the primary roles of providing NPPV to patients at the end of life is for the relief of dyspnea. NPPV also can permit the avoidance of, or reduction in, the use of narcotics and anxiolytics. Medications of this type are associated with significant side effects, including the suppression of respiration, increased somnolence, and constipation.⁸  

In a recently published position statement, the American College of Chest Physicians (ACCP) states, “Patients with pulmonary and/or cardiac disease may experience significant discomfort as they enter the terminal phase of their illness.”⁹ Among the many symptoms experienced by these individuals, breathlessness and fatigue are frequent complaints that can be significantly relieved with the implementation of NPPV.

Those of us who have worked with patients during their final stage of life can attest to the difficulty many of these patients experience just to get a breath, something that many of us take for granted. If we can play a small role in providing relief to the significant dyspnea experienced by these individuals, even if it is temporary, we will be providing a worthwhile service to them.

In a study of 30 elderly COPD patients, Benhamou and colleagues¹⁰ reported a successful application of NPPV with approximately 60% of patients experiencing acute respiratory failure. In these patients, endotracheal intubation was believed to be either “contraindicated or postponed.” Levy and colleagues¹¹ examined a group of do not  intubate (DNI) patients that were treated with NPPV. Their paper describes a 43% survival to discharge rate. Schettino and colleagues¹² report a discharge to home success rate of approximately 60% in select DNI patients.

Improving Patient Comfort
Liesching³ reported in Chest in 2003 that NPPV clearly improves patient comfort while reversing deterioration, and this provided terminal patients with time for family members to arrive and to finalize their affairs. This scenario forms the basis for our program of providing NPPV to this patient population. The dyspnea that is experienced by many of our patients is quite profound, and the relief that many feel as a result of NPPV is often significant. Although narcotics are frequently used to counteract this breathlessness, the side effects commonly associated with these drugs have led some patients to refuse receiving them.

We consider the issue of “buying time” for the arrival of family members and the finalization of affairs to be significant. In our experience, providing this service at the patient’s request has been instrumental in assisting some patients to experience a more dignified end-of-life experience.

There is no question that the withdrawal of NPPV is by far easier to accomplish than with invasive mechanical ventilation. The interface may be removed at any time, either for short periods of time, or permanently. The patient can and should be given control over its removal.

Ethical Issues
When selecting patients for the use of NPPV from this population who may already have DNI orders, it is important that patients understand that there is an alternative to invasive ventilation. They need to be given a clear understanding of what NPPV is, what it can and cannot do, and how it differs from invasive ventilation. The practitioner needs to stress to the patient that NPPV can be discontinued at any time. Patients should also be informed that in some cases, the cause of their acute deterioration could actually be reversed in a relatively short amount of time, without leading them to believe that the NPPV will cure their disease, which, of course, it will not do. Noninvasive positive pressure ventilation is ventilatory assistance, it is a life support measure, and it should be explained to, and understood by, the patient as such.

It is important from both a clinical and an ethical standpoint that as health care professionals we understand and comply with the wishes of the patient. We do, however, have the tremendous responsibility for candidly presenting all reasonable options that are available to patients and their family members. It is equally important that in the event that NPPV is chosen as a form of therapy, a discontinuation plan also be established for the dying patient so that it does not prolong suffering when there is no hope for recovery. Once again, for this patient population, the goal of NPPV is to promote comfort by relieving dyspnea.

Discussion
In looking back at the ACCP position statement⁹ regarding palliative and end-of-life care for patients with cardiopulmonary disease mentioned earlier in this paper, the authors did not appear to focus on the issue of dyspnea and the significant role that it can play in these patients during their final days, weeks, or months. In fact, Nava and colleagues¹³ very nicely pointed this out in a letter to the editor. They explained, “Pain is a classic symptom for example of patients with end-stage cancer.” They went on to say, “We are, however, pulmonologists dealing not only with cancer patients but also with the patients with end-stage COPD, in whom the ‘pain in the respiratory system’ (ie, dyspnea) is the predominant symptom.” The authors stated that the position paper mentioned “the therapeutic options for dyspnea” include oxygen, various pharmacological interventions, and “not-better-specified nonpharmacological intervention.” It seemed striking, in light of several studies published within the past several years, that the potential benefits of using NPPV were not discussed. In a follow-up letter by Selecky and colleagues, the authors state that they agree with the fact that NPPV plays a role in decreasing dyspnea in certain patients, although it is not tolerated by all patients. They went on to say that it was their “omission not to include NPPV” as a nonpharmaceutical intervention that might be considered by the clinician.

The development of evidence-based guidelines for treating dyspnea in end-stage cardiac and pulmonary diseases is being planned by the ACCP. The College hopes to incorporate information gained through trials that will help with the decision-making process for the treatment of dyspnea. There is a randomized international trial currently in progress in 10 palliative care units that is intended to assess the effect of oxygen therapy alone or in combination with noninvasive ventilation.

Case Study
A 70-year-old man presented in our intensive care unit with terminal metastatic lung cancer. He was alert, oriented, and self-proclaimed himself as a do not resuscitate (DNR)/DNI patient. Since he was experiencing severe air hunger, the issue of a trial of NPPV was presented to him as a possible option to relieve his dyspnea. He requested to try the treatment, and the respiratory therapist proceeded to start him on NPPV using a Vision portable pressure ventilator with a total facemask as the interface.

Once settings were adjusted, the patient experienced immediate and significant relief. He began to verbalize to the therapist that he knew that he was dying, but that he wanted to be able to say good-bye to his family before he died. He stated that he would like to keep the mask on until family members arrived from out of town.

Following 2 complete days of using the NPPV, all but one of the patient’s sisters had arrived. The patient explained to the therapist that the one sister who had yet to arrive had just gone through a similar experience with her own husband, and he did not want her to have to experience that again. He then requested to have the mask removed and went on to say to the respiratory therapist: “Thank you for allowing me to die the way I chose.” He passed away 45 minutes later.

Was the application of NPPV in this particular patient appropriate? Was the use of the NPPV successful in this case? The answer to both of these questions appears to be yes. This is certainly just one of many anecdotal reports, but some of the more recent publications that have been cited on this issue seem to substantiate this claim.

Summary
In summary, NPPV can be compassionately applied to many patients at the end-of-life with significant success. While many patients actually have been shown to recover sufficiently to go home, those that do not can still be afforded the precious time to put their affairs in order and say good-bye to family and friends. Communication with the patient and family is pivotal to the successful and appropriate application of NPPV. When used properly, NPPV can add hours, days, weeks, or even longer to a patient’s life, and can help to provide them with more comfort and control during the final phase of their life.

Paul F. Nuccio, RRT, FAARC, is the director of respiratory care at Boston’s Brigham and Women’s Hospital. A portion of this paper was presented at the 51st International Respiratory Congress of the American Association for Respiratory Care, held December 3–6, 2005, in San Antonio.

References
1. British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax. 2002;57:192-211.

2. International Consensus Conference in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Am J Respir Crit Care Med. 2001;163:283-91.

3. Liesching T, Kwok H, Hill NS. Acute application of noninvasive positive pressure ventilation. Chest. 2003;124:699-713.

4. Hill NS. Noninvasive ventilation for chronic obstructive pulmonary disease. Respir Care. 2004;49:72-87.

5. Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. New York: Oxford University Press; 1998:3.

6. The National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care. Center to Advance Palliative Care, 2006. Available at: www.nationalconsensusproject.org. Accessed April 25, 2006.

7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R, and the CDC and the Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.

8. Benditt JO. Noninvasive ventilation at the end of life. Respir Care. 2000;45: 1376-81.

9. Selecky PA, Eliasson CA, Hall RI, et al. Palliative and End-of-Life Care for Patients With Cardiopulmonary Diseases: American College of Chest Physicians Position Statement. Chest. 2005;128:3599-610.

10. Benhamou D, Girault C, Faure C, Portier F, Muir JF. Nasal mask ventilation in acute respiratory failure. Experience in elderly patients. Chest. 1992;102:912-17.

11. 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: 2002-2007.

12. Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select “do-not-intubate” patients. Crit Care Med. 2005;33:1976-82.

13. Nava S, Cuomo A, Maugeri FS. Noninvasive ventilation and dyspnea in palliative medicine. Chest. 2006;129:1391-2.