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Abstract
Objective To report data of the use of high-flow nasal therapy (HFNT) in the palliative care setting.
Methods Five hypoxaemic patients were treated by HFNT in a 1-year period in a palliative care setting, either in the last days of life or as part of an intensive treatment for a reversible cause of hypoxic dyspnoea.
Results Four patients had a similar clinical pattern. After starting HFNT, dyspnoea intensity decreased and oxygen saturation improved, providing a clinical improvement for a duration of 2–3 days, but after 48–72 hours, their conditions deteriorated and patients underwent palliative sedation. Indeed, one patient with pulmonary embolism and pneumonia was treated by HFNT successfully and was discharged home 2 weeks after admission.
Conclusions HFNT may be helpful for severely hypoxaemic patients who are unresponsive to common measures adopted in the last weeks/days of life of patients with advanced cancer or to treat reversible conditions. The findings of this case series showed the ethical and psychological aspects of end of life, particularly for caregivers. Future studies should assess an early use of this device in combination with lower doses of opioids or as an alternative to their use.
- Cancer
- Lung
- Hospital care
- Hospice care
- Dyspnoea
- Terminal care
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Introduction
Dyspnoea is one of the most distressing symptoms in patients with advanced cancer, particularly in the last weeks of life.1 It is the most frequent reason for emergency hospital admission close to the time of death2 and is the most frequent clinical problem in the last hours of life, requiring palliative sedation.3 The main pharmacological option for the management of dyspnoea in the last weeks/days of life, after other therapeutic interventions fail, including oxygen therapy, is the use of opioids.1 However, many patients experience severe dyspnoea despite these interventions. With the COVID-19 pandemic, many palliative care physicians have gained experience with high-flow nasal therapy (HFNT), and literature on HFNT has expanded significantly. The evidence base for HFNT is rapidly growing and offers promise in relieving troublesome symptoms for people receiving palliative care.3 HFNT constitutes a device delivering high flows of fully humidified inspired gas driven by a turbine at 20–60 L/min through nasal prongs. In comparison with other non-invasive ventilation by mask, HFNT does not produce skin lesions and excessive burden for nurses. Moreover, patients can speak, actively cough, eat and maintain some daily activities. Although data for HFNT in palliative care are lacking, we have been accumulating experience with this non-invasive ventilation method.4 We report our experience of hypoxaemic patients who were treated by HFNT in 2021 in a palliative care setting, either in the last days of life or as a part of an intensive treatment for a reversible cause of hypoxic dyspnoea.
Description of cases
In 2021, we used HFNT in five patients, four admitted to the hospice and one to the acute supportive/palliative care unit. HFNT was used to treat dyspnoea in the four hypoxaemic patients admitted to the hospice who were close to death. For these four patients, on starting HFNT, dyspnoea intensity decreased and oxygen saturation (SO2) improved for 2–3 days. The patients were able to talk to their relatives by phone or tablet, watch TV, eat and drink. Opioid doses were not increased. However, after 48–72 hours, their condition deteriorated; SO2 decreased; dyspnoea worsened; and agitation developed. Palliative care sedation was started, and all patients died within 24 hours. Details of patients are reported in table 1. Good days were determined by the number of days patients could engage in daily activities such as talking, watching TV, eating and drinking.
Age, G, SO2-a and SO2-b (before and after HFNT SO2), dyspnoea intensities a and b (0–10 scale, before and after HFNT), and opioids a and b (before and after HFNT)
One 67-year-old patient with lung cancer and bone metastases was admitted to the acute supportive/palliative care unit for uncontrolled pain. During admission, he became dyspnoeic and hypoxic (SO2 of 87%). After laboratory and imaging studies, pulmonary embolism and concomitant bilateral pneumonia were diagnosed. Antibiotics and high doses of low-molecular-weight heparin were started. Intravenous morphine was titrated up to 80 mg/24 hours, providing adequate analgesia and partially reducing dyspnoea. HFNT was started and rapid resolution of dyspnoea was observed (decreased from 8 to 5/10) with SO2 of 94%. The patient progressively improved and was slowly weaned from HFNT, and oxygen by Venturi mask was given. The patient was discharged 2 weeks later with oral morphine 60 mg/day, oxygen 5 L/min. Pain intensity was 3/10 and dyspnoea was 4/10.
Discussion
Refractory dyspnoea is challenging for physicians treating patients near the end of life. The cases presented here show that HFNT can improve SO2 and dyspnoea in the last days of life, allowing 2–3 ‘good days’, possibly postponing the need for palliative sedation and the date of death. Typically, 1–2 days before dying, the control of dyspnoea was lost and patients developed delirium that required palliative sedation. Interestingly, HFNT may be useful when treating patients with possible reversible causes, such as pulmonary infection or thromboembolism. These conditions are characterised by an oxygenation deficit due to deteriorated blood–alveolar gas exchanges. HFNT is the least invasive method to improve SO2 when simple oxygen delivery is not enough. A prolonged course of HFNT is better tolerated than typical non invasive ventilarion (NIV) delivered by facial or nasal masks. HFNT offers a less traumatic interface in terms of skin breakdown and is less burdensome for the team. Furthermore, the patient is able to speak and eat, making HFNT suitable as a first-line therapy to relieve severe dyspnoea in many conditions.3 The principal mechanisms of action of HFNT include enhanced pharyngeal oxygen concentration, washout of nasopharyngeal dead space, better lung mucociliary clearance and humidification, reduced metabolic expenditure of gas conditioning, attenuation of the inspiratory resistances by splinting nasopharyngeal boundaries and decrease of the inspiratory resistances, leading to an amelioration of dyspnoea by reducing the work of breathing due to less need for increasing alveolar ventilation.3
Information about the use of ventilator support in a palliative care setting, particularly at the end of life, is lacking. Experimental studies showed the feasibility of HFNT, although they were not exactly applicable in a clinical setting.5 The cases presented here are clinical examples of hypoxaemic patients with advanced cancer not responsive to increased doses of opioids and oxygen given by mask. Moreover, HFNT may be useful in reversible causes of hypoxaemia in patients who have complications during the course of the disease, not necessarily when death is approaching.
HFNT may be helpful for severely hypoxaemic patients who are unresponsive to common measures adopted in the last weeks/days of life of patients with advanced cancer. The relief of dyspnoea provided by HFNT is expected to be exhausted after 2–3 days, when the dying process develops with a general state of distress which may require palliative sedation. Are these good days worthwhile for the intervention described in this case series? We do not know if this time is acceptable in terms of residual quality of life or may represent a form of delaying death. This question warrants study of the ethical and psychological aspects, particularly for caregivers. Future studies should assess an early use of this device in combination with lower doses of opioids or as an alternative to their use.
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Footnotes
Twitter @#sebmercadante
Correction notice The article title has been corrected since it was first published.
Contributors SM: planning and reporting; CA, PF, FG and YG: conduct.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.