Presented as a requirement for Hospice and Palliative Medicine Fellowship at the University of Kansas

1. S
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, 2013
Andi Chatburn, DO

3. The Case
S Ms. G
S Severe COPD, FEV1 = 21%
S Oxycodone 10mg Q3h
S Unclear history of recreational drug use
S On BiPAP vs. High flow 02
S How to discharge?
S Mr. R
S Stage IV NSCLC admitted with acute respiratory distress, goal
of comfort.
S BiPAP

4. Clinical Question
S Is NIV more effective compared with oxygen in reducing
dyspnea at the end of life?
S Does NIV reduce the total dose of opioids used?
S And is this a value?
S Is NIV a feasible option outside the ICU?
S Access?
S Cost?
S Logistically prohibitive?

5. PICO
S Patients: In Patients with dyspnea at the end of life
S Intervention: Non-Invasive Ventillation
S Comparison: Oxygen via Mask
S Outcome:
S Relieving dyspnea
S Better
S Quicker
S Decreasing total opioid requirement

6. Background
S Researchers: Committee of The Society of Critical Care
Medicine
S Why: comfort, cognition, communication
S Really?
S While avoiding negative consequences
S Discomfort from mask
S Prolonging death
S Prior studies on 02 and morphine didn’t include people with
severe respiratory distress.

7. Methods
S Multicenter Randomized, blinded to statisticians only
S Where?
S Respiratory ICU or CCICU of ED
S Italy, Spain, Taiwan
S Who?
S 200 patients
S End Stage Cancer (Solid Tumor)
S Admitted for acute respiratory failure/distress
S Goals = Comfort

8. What is “End Stage?” PPI >4

9. It’s all a matter of perspective
S Primary outcomes dependent on survey
S Must be competent: Kelly Score <4
Kelly Score: Neuro Status in Pulmonary
Dz
Grade 1 Alert, follows 3 complex commands
Grade 2 Alert, follows simple commands
Grade 3 Lethargic but arousable
Grade 4 Stuporous but can follow simple
commands
Grade 5 Comatose, brain stem intact

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

12. Randomization
S Both given a demonstration of NIV
S Hypercapnic: PaCO2 >45
S NIV
S O2
S Non-Hypercapnic: PaCO2 <45
S NIV
S O2

13. NIV Study Arm
S Patients allowed to use NIV on PRN basis
S Encouraged during nighttime
S Stopped NIV when:
S Patient or family requested to stop
S Physician judged death imminent
S Persistent (>6h) improvement during SBT

14. Morphine
S 10mg SQ Q4h, Titrated to Goal:
S Reduce by 1 point on Borg scale
S Ideally Borg <5
S If refractory, increased dose to 50%
S If still breathless after 48h, given 20mg Oral Morphine SR

15. Outcomes
S Primary Endpoints:
S Improvement in dyspnea
S Decrease in total 48h dose of morphine
S Secondary Endpoints:
S Improved hypercarbia
S Improved symptom distress scale
S Overall 3 and 6 month Mortality

16. Findings
S Mean of 23h on NIV during (m) 41h on study
S 11 of 99 patients in NIV group stopped before 48h
S Claustrophobia
S Suffocation
S Anxiety
S Didn’t understand protocol
S Family member’s request

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

18. 48h Morphine Use
Overall PaCO2<45 PaCO2>45
NIV 26.9mg 22.4mg 21.3mg
Oxygen 59.3mg 58.1mg 60.8mg

19. Mortality
S In-hospital mortality similar
S Overall, patients died after a mean of 118h
S In patients with hypercapnea, survival better with NIV

20. Discussion
S Is NIV an option for palliating dyspnea?
S Mortality in hypercapnic patients treated with NIV
S How long?
S Is prolonging death a value?
S Lower morphine doses
S Is lower morphine dose a value?
S Big Picture: 1st world problem?
S Discharge: still can’t go to NH with NIV!

21. Did it Change My Practice?