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Palliative use of NIV in EOL patients with solid tumors

Stefano Nava et al. Lancet Oncology Vol 14 March 2013: 219-27.

Journal Club Sep 12, 2013Andi Chatburn, DO

The Case

Ms. G Severe COPD, FEV1 = 21% Oxycodone 10mg Q3h Unclear history of recreational drug use On BiPAP vs. High flow 02 How to discharge?

Mr. R Stage IV NSCLC admitted with acute respiratory distress, goal of

comfort. BiPAP

Clinical Question

Is NIV more effective compared with oxygen in reducing dyspnea at the end of life?

Does NIV reduce the total dose of opioids used? And is this a value?

Is NIV a feasible option outside the ICU? Access? Cost? Logistically prohibitive?

PICO

Patients: In Patients with dyspnea at the end of life Intervention: Non-Invasive Ventillation Comparison: Oxygen via Mask Outcome:

Relieving dyspnea Better Quicker

Decreasing total opioid requirement

Background

Researchers: Committee of The Society of Critical Care Medicine

Why: comfort, cognition, communication Really? While avoiding negative consequences

Discomfort from mask Prolonging death

Prior studies on 02 and morphine didn’t include people with severe respiratory distress.

Methods

Multicenter Randomized, blinded to statisticians only Where?

Respiratory ICU or CCICU of ED Italy, Spain, Taiwan

Who? 200 patients End Stage Cancer (Solid Tumor) Admitted for acute respiratory failure/distress Goals = Comfort

What is “End Stage?” PPI >4

It’s all a matter of perspective

Primary outcomes dependent on survey Must be competent: Kelly Score <4

Kelly Score: Neuro Status in Pulmonary Dz

Grade 1 Alert, follows 3 complex commandsGrade 2 Alert, follows simple commandsGrade 3 Lethargic but arousableGrade 4 Stuporous but can follow simple

commandsGrade 5 Comatose, brain stem intactGrade 6 Comatose, brain stem dysfunction

Exclusion Criteria

Exclusion: COPD/Cardiac cause of respiratory failure Weak cough Agitation/non-cooperation Facial anatomic abnormalities Failure of >2 organs Use of opioids within past 2 weeks Adverse reactions to opioids History of substance misuse ESRD (due to morphine being study drug)

Randomization

Both given a demonstration of NIV Hypercapnic: PaCO2 >45

NIV O2

Non-Hypercapnic: PaCO2 <45 NIV O2

NIV Study Arm

Patients allowed to use NIV on PRN basis Encouraged during nighttime Stopped NIV when:

Patient or family requested to stop Physician judged death imminent Persistent (>6h) improvement during SBT

Morphine

10mg SQ Q4h, Titrated to Goal: Reduce by 1 point on Borg scale Ideally Borg <5

If refractory, increased dose to 50% If still breathless after 48h, given 20mg Oral

Morphine SR

Outcomes

Primary Endpoints: Improvement in dyspnea Decrease in total 48h dose of morphine

Secondary Endpoints: Improved hypercarbia Improved symptom distress scale Overall 3 and 6 month Mortality

Findings

Mean of 23h on NIV during (m) 41h on study 11 of 99 patients in NIV group stopped before 48h

Claustrophobia Suffocation Anxiety Didn’t understand protocol Family member’s request

*But: not statistically significant diff between dyspnea in NIV and O2 if not hypercarbic

48h Morphine Use

Overall PaCO2<45 PaCO2>45NIV 26.9mg 22.4mg 21.3mg

Oxygen 59.3mg 58.1mg 60.8mg

Mortality

In-hospital mortality similar Overall, patients died after a mean of 118h In patients with hypercapnea, survival better with

NIV

Discussion

Is NIV an option for palliating dyspnea? Mortality in hypercapnic patients treated with NIV

How long? Is prolonging death a value?

Lower morphine doses Is lower morphine dose a value?

Big Picture: 1st world problem? Discharge: still can’t go to NH with NIV!

Did it Change My Practice?