Using noninvasive ventilation (NIV) in palliative care

Michael Allison, MD
26th Nov 2020

In certain situations, you may encounter a patient with respiratory failure who has a Do Not Intubate (DNI) order. Or, perhaps, you may encounter someone with a terminal disease, such as cancer, who develops severe dyspnea after deciding on treatment with palliation only. Where does noninvasive ventilation (NIV) fit in with the treatment of these subsets of patients, for whom intubation is not an option?

 

Can NIV be used for patients with a DNI order?

There is little in the way of quality evidence or guideline recommendations to provide a comprehensive understanding regarding the use of NIV only in patients presenting with respiratory failure and DNI orders. 

There have been reports of patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) being treated successfully with NIV in approximately 50% of cases, in the setting of DNI orders. 

Thumbs up and cartoon men with COPD and heart failure. Cartoon.

Figure 1. Noninvasive ventilation (NIV) has been used successfully to treat chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) in 50% of patients with a Do Not Intubate (DNI) order.

In patients presenting with respiratory failure and a wish not to be intubated, a trial of NIV should be conducted before attempting to transition to comfort measures.

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Can I use NIV to provide breathing comfort to those at the end of life?

At the end of life, breathlessness frequently worsens even if patients present with non-respiratory illnesses. This can be a source of distress for the patient and family members. 

Medications such as opioids are often utilized at the end of life to treat breathlessness, but can be associated with side effects such as itching, nausea, and sedation. The use of NIV at the end of life can treat breathlessness and dyspnea without the side effects of excessive sedation. Though generally seen as an intervention with a high rate of intolerance, the use of NIV for palliation of dyspnea has an adherence rate of about 60%. It can also decrease the feeling of breathlessness and decrease the required dose of morphine.

Women in hospital bed on ventilator, thumbs up. Cartoon.

Figure 2. Noninvasive ventilation (NIV) has a 60% adherence rate for the palliation of dyspnea.

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Recommended reading

  • Baillard, C, Fosse, JP, Sebbane, M, et al. 2006. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 174: 171–177. PMID: 16627862
  • Esteban, A, Frutos-Vivar, F, Ferguson, ND, et al. 2004. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 350: 2452–2460. PMID: 15190137
  • Ferrer, M, Sellarés, J, Valencia, M, et al. 2009. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 374: 1082–1088. PMID: 19682735
  • Wilson, ME, Majzoub, AM, Dobler, CC, et al. 2018. Noninvasive ventilation in patients with Do-Not-Intubate and Comfort-Measures-Only orders: a systematic review and meta-analysis. Crit Care Med. 46: 1209–1216. PMID: 29498939