Noninvasive ventilation for breathlessness in palliative care

Rochwerg, 2017Scala, 2018 Nava, 2013

Noninvasive ventilation (NIV), also known as noninvasive positive pressure ventilation, is ventilatory support given by a mask. It may be used in an acute setting or long term. Noninvasive ventilation may consist of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP); in BPAP, a higher pressure is given during inspiration (inspiratory positive airway pressure [IPAP]) and a lower pressure is given during expiration (expiratory positive airway pressure [EPAP]).

Noninvasive ventilation is widely used in the acute hospital setting for acute hypoxic and hypercapnic respiratory failure. The need for noninvasive ventilation in this setting predicts a high risk of hospital readmission and life-threatening events in the following year.

For patients with acute cardiogenic pulmonary oedema, consider CPAP.

For patients with hypercapnic respiratory failure in whom an arterial blood gas (ABG) measurement shows a pH less than 7.35 and partial pressure of carbon dioxide (PaCO2) greater than 45 mmHg, consider BPAP. BPAP has been studied specifically for management of acute breathlessness in palliative care with mixed results; some studies support its use in hypercapnic respiratory failure and advanced cancerNava, 2013Scala, 2018.

Before starting noninvasive ventilation, discuss advance care planning with the patient and make a plan for withdrawal. Some questions to consider to help determine the ceiling of care before starting noninvasive ventilation include:

  • Will treatment be escalated to invasive intubation and cardiopulmonary resuscitation if noninvasive ventilation is inadequate? If so, close monitoring with oxygen saturation measured by pulse oximetry (SpO2) and arterial blood gases (ABGs) is required to detect deterioration and to determine when escalation is required.
  • Will noninvasive ventilation be the ceiling of care offered, but with the goal that it is used as salvage therapy for breathlessness, and the intent is to survive hospitalisation? If so, monitoring with SpO2 and ABGs is required, but if the patient’s symptoms do not improve, stopping noninvasive ventilation may require a change of focus to care of the patient in the last days of life.
  • Is the goal of care breathlessness control for comfort while dying, rather than survival? If noninvasive ventilation is being used for patient comfort, it should be continued short term (for hours to days), provided it improves breathlessness and comfort without causing other problems, such as limiting communication and oral intake.

Noninvasive ventilation may be considered for long-term use in the community setting in patients with palliative care needs who have chronic hypercapnic respiratory failure from any cause, obstructive sleep apnoea, obesity hypoventilation syndrome, or neuromuscular disease (eg motor neurone disease)—seek specialist advice (eg from a respiratory or neurology specialist).

For further information on noninvasive ventilation, see Noninvasive ventilation in the Respiratory guidelines.