UMEM Educational Pearls

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.

 

But what’s the data?

A recently-published meta-analysis¹ found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year.

• Higher survival was seen in patients with COPD and pulmonary edema as the cause of their respiratory failure, as opposed to pneumonia or malignancy.
• 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.
• In comfort-measures only (CMO) patients, patients receiving NIPPV had a mildly lower dyspnea score with less opiates required/administered.

 

Independent studies have demonstrated:

• Better survival with NIPPV for DNI COPD and CHF patients^2,3,4 who are awake and have a good cough.⁴
• No decrease in health-related quality of life or post-ICU psychological burden (symptoms of PTSD, anxiety, or depression) in DNI survivors receiving NIPPV.³
• 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).⁵

 

Bottom Line:

1. NIPPV can benefit DNI patients -- most identifiably those with COPD or cardiogenic pulmonary edema as the etiology for their respiratory distress.
2. 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.

References

1. 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. Crit Care Med. 2018;46(8):1209-16.
2. 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.
3. Azoulay E, Kouatchet A, Jaber S, et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med. 2013;39(2):292-301.
4. 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.
5. 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.