Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease
Abstract
:1. Introduction
2. Methods
3. Life-Limiting Respiratory Diseases with Palliative Care Needs
4. Non-Invasive Respiratory Support (NRS) in Palliative Care: Which Options
4.1. Supplemental Oxygen
4.2. Non-Invasive Positive Pressure Ventilation (NPPV)
4.3. High-Flow Nasal Therapy (HFNT)
5. Indications for Respiratory Support in Chronic Respiratory Diseases in the Palliative Care Setting
5.1. Conventional Oxygen Therapy (COT)
5.2. Non-Invasive Positive Pressure Ventilation (NPPV)
- Category 1. Life support without preset limitIn patients without preset limitations on advanced life-sustaining treatment, NPPV is a life support with the primary goals of assisting ventilation and oxygenation, relieving dyspnea and discomfort, and reducing the risk of intubation and mortality. NPPV use is aimed to restore health and intubation is indicated if NPPV fails.
- Category 2: Life support with preset limit—do not intubate (DNI order)In patients who decline endotracheal intubation and invasive mechanical ventilation, NPPV has the same goals of care as category 1, except for indication to intubation. In case of failure in improving gas exchange or unacceptable discomfort, that outweighed the potential benefits, NPPV should be discontinued, in favor of comfort measures only and other palliative symptom strategies.
- Category 3: Comfort measures only (CMO order)In patients with terminal malignancy or end-stage chronic disease refusing any form of life-prolonging therapy, NPPV is just a palliative measure, with the goal of maximizing comfort and relieving dyspnea. NPPV withdrawal is indicated in case of inability to provide further comfort and according to the patient’s desire. In line with that, there is no indication to deliver palliative NPPV in patients with severe sensorium alteration, as they do not experience distress.
5.3. High-Flow Nasal Therapy (HFNT)
6. Pharmacological Strategies for the Treatment of Symptoms That Require Non-Invasive Respiratory Support in the Palliative Care Setting
6.1. Opioids
6.2. Benzodiazepines
6.3. Dexmedetomidine
6.4. Corticosteroids
6.5. Other Drugs
7. Monitoring during Non-Invasive Respiratory Support in Palliative Care Setting
- Even experienced ICU physicians may have difficulty reliably detecting asynchrony [83].
- Asynchronies can occur at any time, making continuous tracking impossible.
- Certain types of asynchronies, such as reverse triggering, are not easily detectable by inspecting pressure, flow, or volume waveforms alone.
- Heart rate and blood pressure (through ECG telemetry and invasive or non-invasive methods, with a maximum interval of 15 min).
- Respiratory dynamics, especially respiratory rate and use of accessory muscles.
- Ventilator waveforms (pressure and flow).
- Expired tidal volume in hypoxemic patients (when feasible).
- Gas exchange via arterial blood gas analysis.
- Level of consciousness using observational scales such as the RASS (Richmond Agitation-Sedation Scale) or the OAA/S (Observer’s Assessment of Alertness/Sedation Scale).
- Indices of NRS method failure, such as the ROX index and HACOR score [90].
7.1. Applications
7.2. Tools and Technologies
8. Quality of Life during Non-Invasive Respiratory Support in Palliative Care Setting
8.1. Symptom Relief and Comfort
- Breathlessness and Dyspnea:
- NRS can significantly alleviate symptoms of breathlessness, a common and distressing symptom in palliative care patients.
- Reduction in dyspnea can improve overall comfort and reduce anxiety associated with respiratory distress.
- Sleep Quality:
- Improved oxygenation and ventilation can enhance sleep quality by reducing nighttime awakenings and sleep fragmentation caused by apnea or hypopnea episodes [91].
8.2. Psychological Impact
- Anxiety and Depression:
- Effective symptom control can reduce anxiety and depressive symptoms associated with severe breathlessness and the fear of suffocation.
- However, the presence of the mask and the noise from the machine can sometimes cause anxiety or claustrophobia in certain patients.
- Sense of Control:
- Patients often feel a greater sense of control over their breathing, which can enhance their overall sense of well-being and independence.
8.3. Social and Functional Aspects
- Communication and Interaction:
- NRS devices can interfere with verbal communication, making it difficult for patients to interact with family and caregivers.
- This can be mitigated by scheduled breaks from the device or using communication aids.
- Mobility and Daily Activities:
- While NRS can improve energy levels and physical endurance by reducing the work of breathing, the equipment’s bulkiness and need for a power source can limit mobility.
- Portable and more user-friendly NIRS devices are available and can help maintain a higher level of independence.
8.4. Comfort and Tolerance
- Device Tolerance:
- The fit and comfort of the mask, skin irritation, and dryness of the mouth or nasal passages are common issues that can affect QoL.
- Proper mask fitting, humidification and regular skin care can alleviate these problems.
- Compliance and Adaptation:
- Patient education and support are crucial for improving compliance with NIRS.
- A multidisciplinary approach involving respiratory therapists, palliative care specialists, and nurses can provide the necessary support and adjustments.
8.5. Ethical Considerations
- Goals of Care:
- Discussions around the goals of care and the patient’s wishes are essential. NRS should align with the patient’s overall care plan and end-of-life preferences.
- In some cases, the use of NIRS may be more about symptom management than prolonging life, emphasizing comfort and QoL.
- Decision-Making:
- Informed decision-making involves discussing the potential benefits and burdens of NIRS with patients and their families.
- Advanced directives and palliative care consultations can guide these decisions, ensuring that they align with the patient’s values and goals.
9. Future Prospectives
10. Limitations
11. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Device | Indication | Setting | Monitoring |
---|---|---|---|
Conventional Oxygen Therapy |
|
|
|
High-Flow Nasal Therapy |
|
|
|
Non-invasive Positive Pressure Ventilation (NPPV) |
|
|
|
Measure | Action | Pros | Cons |
---|---|---|---|
Conventional Oxygen Therapy (COT) | Relieve dyspnea even in absence of hypoxemia |
|
|
Non-invasive Positive Pressure Ventilation (NPPV) | Mitigation of static and dynamic hyperinflation, resistive load on the ventilatory muscles, thus reducing dyspnea and improving gas exchange |
|
|
High-Flow Nasal Therapy (HFNT) | Lung alveolar recruitment, CO2 washout (reduction of anatomic dead space), enhanced secretion clearance and expectoration |
|
|
Drug Class | Compounds | Effect | Advantages | Disadvantages |
---|---|---|---|---|
Opioids | Morphine Fentalyn Remifentalin | Sedative and analgesic | Excellent control on pain Mitigation of psychological discomfort | Risk of hemodynamic alterations Need to individualize treatment schedule to avoid severe side effects |
Benzodiazepines | Midazolam | Sedative and anxiolytic | Good efficacy in controlling anxiety and panic associated with breathlessness | Need to individualize treatment schedule to avoid severe side effects Significant impact on the circulation and respiration of patients (risk of hypotension and respiratory depression) |
α2-agonists | Dexmedetomidine | Sedative and hypnotic | Reduces stress and provides good analgesia Additional protective effect on pulmonary vessels | Possible infusion-related side effects related (mainly bradycardia and hypotension) Exclusive hospital use |
Corticosteroids | Dexamethasone Prednisone | Anti-inflammatory | Highly effective in improving airflow and reducing respiratory distress | Weak evidence supporting the use of systemic steroids as symptomatic drugs in palliation of dyspnea Risk of systemic metabolic side effects such as hyperglycemia |
Parameter | Monitoring Frequency | Monitoring Method | Normal Range/Findings |
---|---|---|---|
Respiratory Rate | Every 1–4 h | Visual observation, pulse oximetry | 12–20 breaths per minute |
Oxygen Saturation (SpO2) | Continuous | Pulse oximetry | ≥95% on room air |
Blood Pressure | Every 4–8 h | Automated blood pressure monitor, manual measurement | Systolic: 90–120 mmHg Diastolic: 60–80 mmHg |
Heart Rate | Every 1–4 h | Automated monitor, manual palpation | 60–100 beats per minute |
Consciousness Level | Every 1–4 h | Glasgow Coma Scale (GCS), observation | GCS 15 (fully alert), appropriate for baseline mental status |
Respiratory Pattern | Continuous | Visual observation | Regular, unlabored breathing without signs of distress |
Respiratory Effort | Continuous | Visual observation | Even chest rise and fall, no use of accessory muscles |
Skin Color and Temperature | Every 1–4 h | Observation | Pink and warm, consistent with baseline |
Secretions | Every 1–4 h | Observation | Minimal or manageable, absence of excessive or copious |
Pain Level | Every 4–8 h | Self-report, observation, pain scale assessment | Controlled and manageable, appropriate for baseline |
Anxiety Level | Every 4–8 h | Self-report, observation, anxiety scale assessment | Controlled and manageable, appropriate for baseline |
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Share and Cite
Spinazzola, G.; Ferrone, G.; Michi, T.; Torrini, F.; Postorino, S.; Sbaraglia, F.; Gulmini, L.; Antonelli, M.; Conti, G.; Spadaro, S. Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease. J. Clin. Med. 2024, 13, 5165. https://doi.org/10.3390/jcm13175165
Spinazzola G, Ferrone G, Michi T, Torrini F, Postorino S, Sbaraglia F, Gulmini L, Antonelli M, Conti G, Spadaro S. Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease. Journal of Clinical Medicine. 2024; 13(17):5165. https://doi.org/10.3390/jcm13175165
Chicago/Turabian StyleSpinazzola, Giorgia, Giuliano Ferrone, Teresa Michi, Flavia Torrini, Stefania Postorino, Fabio Sbaraglia, Loretta Gulmini, Massimo Antonelli, Giorgio Conti, and Savino Spadaro. 2024. "Focus on the Role of Non-Invasive Respiratory Support (NRS) during Palliative Care in Patients with Life-Limiting Respiratory Disease" Journal of Clinical Medicine 13, no. 17: 5165. https://doi.org/10.3390/jcm13175165