Withdrawal of noninvasive ventilation

Cheng, 2018Faull, 2016National Institute for Health and Care Excellence (NICE), 2016

Noninvasive ventilation (NIV) is ventilatory support given by a mask. It may consist of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP).

In patients who use noninvasive ventilation, a plan for its use at the end of life should be discussed in advance, because communication and cognition may be limited near the end of life.

For some patients who use BPAP intermittently or nocturnally (eg for motor neurone disease or obesity hypoventilation syndrome), stopping ventilation may be as simple as choosing not to use the device again. This situation may not complicate the dying process. Similarly, the use of CPAP for obstructive sleep apnoea can just be stopped.

Other patients may become dependent on BPAP (most commonly those with motor neurone disease), which is characterised by use of BPAP for long periods during the day, and only being able to tolerate removal for eating, drinking or oral hygiene. Some patients are unable to tolerate even minutes without BPAP. Some patients choose to use BPAP until they die, especially if this provides comfort and symptom relief. However, others may request BPAP to be stopped. For patients using BPAP for long periods during the day, or who appear to not tolerate removal for short periods, seek specialist advice from a respiratory, neurology or palliative care specialist with experience in noninvasive ventilation. Procedural sedation before stopping BPAP is likely to be required to proactively manage symptoms of agitation, distress and breathlessness. For ventilation-specific advice, refer to local protocols or consensus state guidelines if available.

Patients who choose to continue noninvasive ventilation in the last days of life and have respiratory distress or agitation can be managed adequately with treatment routinely used in the last days of life—see Agitation and restlessness in the last days of life.