Background The COVID-19 pandemic required clinical teams to rapidly adapt to emerging healthcare challenges.1 Non-invasive ventilation (NIV) has a key role in managing respiratory failure secondary to COVID-19,2 but mortality remains high.3 There was a lack of national guidance on managing deteriorating patients where NIV was the ceiling of treatment.4 The Royal Wolverhampton NHS Trust’s Palliative Care and Respiratory teams developed local guidelines to provide high-quality symptom control and end-of-life care for these patients. An audit was conducted to assess the effects of implementing this protocol during the pandemic’s second wave.
Methods A retrospective case note review was conducted on all patients who received NIV on the acute Respiratory ward during 01/08/2020–31/03/2021. Data was collected on initiation and duration of NIV support, Palliative Care input, reasons for and medications used during NIV withdrawal, and provision of holistic care.
Results 588 COVID-19 patients were admitted during this time. 239 received NIV, and 136 died during this admission. The Palliative Care team were involved in 63 of 293 patients who received NIV. NIV was withdrawn in 82.5% (n=52) of patients known to Palliative Care, most frequently due to clinical deterioration (60.0%, n=31). All patients known to Palliative Care were prescribed anticipatory medications; 71.4% (n=45) were commenced on a continuous subcutaneous infusion (CSCI). In all Palliative-Care-led NIV withdrawals (n=24), symptoms were managed effectively with PRN opioids/benzodiazepines. Patients remained comfortable at the time of death, and no concerns were raised by patients, families or clinical teams regarding the decisions or process of NIV withdrawal. 11 remained on NIV until death due to several reasons, including patient request.
Conclusions Local guidelines were adhered to during NIV withdrawal and provided a clear strategy for symptom management in critically unwell COVID-19 patients. Early involvement of Palliative Care team allowed a holistic and proactive approach in complex cases.
Evans L, Atkinson C, Byrne A: Lessons from the First Wave: Developing symptom control guidance for COVID-19 patients who are deteriorating despite non-invasive ventilation (NIV) as their ceiling of treatment). BMJ Supportive & Palliative Care. Nov 2020 https://blogs.bmj.com/spcare/2020/11/16/lesson-from-the-first-wave-developing-symptom-control-guidance-for-covid-19-patients-who-are-deteriorating-despite-non-invasive-ventilation-niv-as-their-ceiling-of-treatment/
National Health Service (NHS). Guidance for the role and use of non-invasive respiratory support in adult patients with coronavirus (confirmed or suspected). NHS, 2020. https://anaesthetists.org/Portals/0/PDFs/COVID-19/CLEARED_Specialty-guide_-NIV- respiratory-support-and-coronavirus-v2-26-March-003.pdf
Ashish A, Unsworth A, Martindale J, et al. CPAP management of COVID-19 respiratory failure: a first quantitative analysis from an inpatient service evaluation. BMJ Open Respiratory Research 2020;7:e000692. doi: 10.1136/bmjresp-2020-000692
Webber N, Avari M, Harridge G, et al. Implementing a novel protocol for withdrawal of CPAP support in COVID-19 patients: a case series. Clinical Medicine 2021;21(3). doi:10.7861/clinmed.2020-1086
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.