Title: Noninvasive Ventilation in Do-Not-Intubate Patients<br/>Author: Kami Hu<br/><a href='http://umem.org/profiles/faculty/742/'>[Click to email author]</a><hr/><p dir="ltr" style="line-height:1.38;margin-top:0pt;margin-bottom:0pt;">
<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-b0d35f65-a8d7-c162-aff7-b5f6b6631f74"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">When a do-not-intubate (DNI) hospice patient arrives in the ED with respiratory distress, consideration of non-invasive positive pressure ventilation (NIPPV) could invoke either a “What other option do I have?” or “Why torture the patient and prolong the dying process?” sentiment. </span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span>But what’s the data?</span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="background-color: transparent; color: rgb(0, 0, 0); white-space: pre-wrap;">A recently-published meta-analysis</span><sup style="background-color: transparent; color: rgb(0, 0, 0); font-family: Arial; white-space: pre-wrap;">1</sup><span style="background-color: transparent; color: rgb(0, 0, 0); white-space: pre-wrap;"> found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year. </span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-b0d35f65-a8d7-c162-aff7-b5f6b6631f74"><span style="background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Higher survival was seen in patients with COPD and pulmonary edema as the cause of their respiratory failure, as opposed to pneumonia or malignancy. </span></span></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-b0d35f65-a8d7-c162-aff7-b5f6b6631f74"><span style="background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">In surviving patients, there was no decrease in quality of life at 3 months; quality of life was not assessed in the time before death in nonsurvivors.</span></span></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-b0d35f65-a8d7-c162-aff7-b5f6b6631f74"><span style="background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">In comfort-measures only (CMO) patients, patients receiving NIPPV had a mildly lower dyspnea score with less opiates required/administered.</span></span></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-b0d35f65-a8d7-c162-aff7-b5f6b6631f74"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Independent studies have demonstrated:</span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;">Better survival with NIPPV for DNI COPD and CHF patients<sup style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0); font-family: Arial;">2,3,4</sup><span style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0);"> who are awake and have a good cough.</span><sup style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0); font-family: Arial;">4</sup></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0);">No decrease in health-related quality of life or post-ICU psychological burden (symptoms of PTSD, anxiety, or depression) in DNI survivors receiving NIPPV.</span><sup style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0); font-family: Arial;">3</sup></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0);">63% survival to hospital discharge & 49% survival to 90 days in DNI patients receiving NIVV, with no decrease in health-related quality of life in survivors. Survival was lower for CMO patients (14% and 0% at discharge and 90 days, respectively).</span><sup style="background-color: transparent; white-space: pre-wrap; color: rgb(0, 0, 0); font-family: Arial;">5</sup></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-b0d35f65-a8d7-c162-aff7-b5f6b6631f74"><u><span style="color: rgb(0, 0, 0); background-color: transparent; font-weight: 700; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Bottom Line:</span></u><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;"> </span></span></span></span></p>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span>NIPPV can benefit DNI patients -- most identifiably those with COPD or cardiogenic pulmonary edema as the etiology for their respiratory distress.</span></span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span style="background-color: transparent; color: rgb(0, 0, 0); white-space: pre-wrap;">Mild benefits to dyspnea have been seen in CMO patients, without survival benefit. A trial of NIPPV therapy may be reasonable (especially in COPD or CHF) after frank discussion with the patient and his/her loved ones, with quick cessation if comfort is not achieved and/or more discomfort is caused.</span></span></span></li>
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<fieldset><legend>References</legend>
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<span style="font-family: arial, helvetica, sans-serif;"><span id="docs-internal-guid-6b0c3808-a8d9-1ebd-96b0-9a92219f40b9"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Wilson ME, Majzoub AM, Dobler CC, et al. Noninvasive ventilation in patients with Do-Not-Intubate and Comfort-Measures-Only orders: a systematic review and meta-analysis. </span><span style="color: rgb(0, 0, 0); background-color: transparent; font-style: italic; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Crit Care Med</span><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">. 2018;46(8):1209-16.</span></span></span></li>
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<span style="font-family: arial, helvetica, sans-serif;"><span id="docs-internal-guid-6b0c3808-a8d9-1ebd-96b0-9a92219f40b9"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select “do-not-intubate” patients. </span><span style="color: rgb(0, 0, 0); background-color: transparent; font-style: italic; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Crit Care Med</span><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">. 2005;33(9):1976-82.</span></span></span></li>
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<span style="font-family: arial, helvetica, sans-serif;"><span id="docs-internal-guid-6b0c3808-a8d9-1ebd-96b0-9a92219f40b9"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Azoulay E, Kouatchet A, Jaber S, et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. </span><span style="color: rgb(0, 0, 0); background-color: transparent; font-style: italic; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Intensive Care Med.</span><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;"> 2013;39(2):292-301.</span></span></span></li>
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<span style="font-family: arial, helvetica, sans-serif;"><span id="docs-internal-guid-6b0c3808-a8d9-1ebd-96b0-9a92219f40b9"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Levy M, Tanios MA, Nelson D, et al. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. </span><span style="color: rgb(0, 0, 0); background-color: transparent; font-style: italic; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Crit Care Med</span><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">. 2004;32(10):2002-7.</span></span></span></li>
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<span style="font-family: arial, helvetica, sans-serif;"><span id="docs-internal-guid-6b0c3808-a8d9-1ebd-96b0-9a92219f40b9"><span style="color: rgb(0, 0, 0); background-color: transparent; font-variant-numeric: normal; font-variant-east-asian: normal; vertical-align: baseline; white-space: pre-wrap;">Vilaça M, Aragão I, Cardoso T, et al. The role of noninvasive ventilation in patients with “Do Not Intubate” order in the emergency setting. PLoS One. 2016;11(2):e0149649. </span></span></span></li>
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