Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Effect of high flow nasal oxygen on inspiratory effort of patients with acute hypoxic respiratory failure and do not intubate orders

High flow nasal oxygen (HFNO) is recommended as a first-line respiratory support during acute hypoxic respiratory failure (AHRF) and represents a proportionate treatment option for patients with do not intubate (DNI) orders. The aim of the study is to assess the effect of HFNO on inspiratory effort as assessed by esophageal manometry in a population of DNI patients suffering from AHRF. Patients with AHRF and DNI orders admitted to Respiratory intermediate Care Unit between January 1st, 2018 and May 31st, 2023 to receive HFNO and subjected to esophageal manometry were enrolled. Esophageal pressure swing (ΔPes), clinical variables before and after 2 h of HFNO and clinical outcome (including HFNO failure) were collected and compared as appropriate. The change in physiological and clinical parameters according to the intensity of baseline breathing effort was assessed and the correlation between baseline ΔPes values and the relative change in breathing effort and clinical variables after 2 h of HFNO was explored. Eighty-two consecutive patients were enrolled according to sample size calculation. Two hours after HFNO start, patients presented significant improvement in ΔPes (12 VS 16 cmH2O, p < 0.0001), respiratory rate (RR) (22 VS 28 bpm, p < 0.0001), PaO2/FiO2 (133 VS 126 mmHg, p < 0.0001), Heart rate, Acidosis, Consciousness, Oxygenation and respiratory rate (HACOR) score, (4 VS 6, p < 0.0001), Respiratory rate Oxygenation (ROX) index (8.5 VS 6.1, p < 0.0001) and BORG (1 VS 4, p < 000.1). Patients with baseline ΔPes below 20 cmH2O where those who improved all the explored variables, while patients with baseline ΔPes above 30 cmH2O did not report significant changes in physiological or clinical features. A significant correlation was found between baseline ΔPes values and after 2 h of HFNO (R2 = 0.9, p < 0.0001). ΔPes change 2 h after HFNO significantly correlated with change in BORG (p < 0.0001), ROX index (p < 0.0001), HACOR score (p < 0.001) and RR (p < 0.001). In DNI patients with AHRF, HFNO was effective in reducing breathing effort and improving respiratory and clinical variables only for those patients with not excessive inspiratory effort.

Use of non-invasive respiratory supports in high-intensity internal medicine setting during the first two waves of the COVID-19 pandemic emergency in Italy: a multicenter, real-life experience

During the first two waves of the COVID-19 emergency in Italy, internal medicine high-dependency wards (HDW) have been organized to manage patients with acute respiratory failure (ARF). There is heterogeneous evidence about the feasibility and outcomes of non-invasive respiratory supports (NIRS) in settings outside the intensive care unit (ICU), including in patients deemed not eligible for intubation (i.e., with do-not-intubate, DNI status). Few data are available about the different NIRS modalities applied to ARF patients in the newly assembled internal medicine HDW. The main aim of our study was to describe a real-life experience in this setting of cure, focusing on feasibility and outcomes. We retrospectively collected data from COVID-19 patients with ARF needing NIRS and admitted to internal medicine HDW. Patients were treated with different modalities, that is high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), or non-invasive mechanical ventilation (NIMV). Switching among different NIRS during the hospitalization and the success rate (weaning with the same NIRS) or failure (endotracheal intubation-ETI or in-hospital death) were recorded. Three hundred thirty four ARF patients (median age 74 years), of which 158 (54%) had a DNI status, were included. CPAP, NIMV, and HFNC's success rates were 54, 33, and 13%, respectively. Although DNI status was strongly associated with death (Gehan-Breslow-Wilcoxon test p < 0.001), an acceptable success rate was observed in these patients using CPAP (47%). Multivariate regression models showed older age (odds ratio-OR 4.74), chronic ischemic heart disease (OR 2.76), high respiratory rate after 24 h (OR 7.13), and suspected acute respiratory distress syndrome-ARDS (OR 21.1) as predictors of mortality risk or ETI. Our real-life experience shows that NIRS was feasible in internal medicine HDW with an acceptable success rate. Although DNI patients had a worse prognosis, the use of NIRS represented a reasonable chance of treatment.

A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units

Background

The end-of-life (EOL) decisions continue to be debated for their moral and legal standing. The acceptance of these decisions varies, based upon the perceptions and personal choices of the intensivists.

Materials and methods

An online questionnaire-based survey was designed and circulated among the practicing intensivists via Indian Society of Critical Care Medicine (ISCCM) e-mail.

Results

Out of 200 responses, 165 (82.5%) affirmed that EOL decisions are routinely undertaken in their intensive care units. The most prevalent reasons expressed for avoidance of EOL decisions are moral and ethical dilemmas and fear of litigation. There is notable variability in the practice of withholding (47.7%) vs withdrawal (3.5%) of therapies. A good proportion of intensivists follow do-not-intubate (91%) and do-not-resuscitate (86%) orders, whereas only 18% affirmed to be practicing terminal extubation. About 93% of the respondents acknowledged the use of monitoring toward the EOL, and 49% reported the use of preformatted documents. A meager 2% admitted to facing a medicolegal issue after taking an EOL decision.

Conclusion

The survey establishes a general acceptance among the Indian intensivists regarding providing compassionate care to terminally ill patients, especially toward the EOL. The pattern of responses, however, indicates significant dilemmas and hesitancy with regard to the decision-making process.

How to cite this article

Kumar A, Sinha S, Mani RK. A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units. Indian J Crit Care Med 2023;27(8):531-536.

Treatment of patients with 'do not intubate orders'

PURPOSE OF REVIEW

Do-not-intubate (DNI) orders are more frequently encountered over time. This widespread diffusion of DNI orders make it essential to develop therapeutic strategies matching patient's and his family willingness. The present review sheds light on the therapeutic approaches employed to support respiratory function of patients with DNI orders.

RECENT FINDINGS

In DNI patients, several approaches have been described to relieve dyspnoea and address acute respiratory failure (ARF). Despite its extensive use, supplemental oxygen is not so useful in assuring dyspnoea relief. Noninvasive respiratory support (NIRS) is frequently employed to treat ARF in DNI patients. Also, to enhance DNI patients comfort during NIRS, it is worthy to point out the role of analgo-sedative medications. Lastly, a particular aspect concerns the first waves of coronavirus disease 2019 pandemic, when DNI orders have been pursued on factors unrelated to patient's wishes, in the total absence of family support due to the lockdown policy. In this setting, NIRS has been extensively employed in DNI patients with a survival rate of around 20%.

SUMMARY

In dealing with DNI patients, the individualization of treatments is of pivotal importance to respect patient's preferences and improve quality of life at the same time.

Nurses' strategies to enable continuous positive airway pressure therapy in a general medical ward context: A qualitative study

BACKGROUND

Continuous positive airway pressure is a non-invasive therapy beneficial for patients with acute respiratory failure. The need for this therapy outside intensive care units is growing, but nurses face many challenges to enable this therapy in general medical wards.

AIMS AND OBJECTIVES

The aim of the study was to explore nurses' strategies for enabling continuous positive airway pressure therapy in a general medical ward context.

METHOD

An explorative qualitative design was used including semi-structured interviews with 15 Swedish nurses. Data were analysed using a conventional content analysis.

RESULTS

The nurses' strategies included a non-hierarchical approach when utilising an intra- and interprofessional collaboration. Inexperience was compensated for by collaboration. Nurses' strategies involved advanced patient-centred care using interventions to manage and ease the patient's treatment and discomfort. The creation of an alliance with the patient was crucial to prevent treatment failure. The strategies were interrelated and considered as parts of a whole.

CONCLUSION

Nurses described the strategy of a dynamic team that could be enlarged or decreased in tandem with other professionals, depending on the situation and the nurses' needs. Nurses need to have an attentive response to the patients' physical, psychosocial and relational needs and to maintain trust for a positive therapy outcome.

Fluid resuscitation of at least 30 mL/kg was not associated with decreased mortality in patients with infection, signs of hypoperfusion, and a do-not-intubate order

Aim

Administration of at least 30 mL/kg of fluid as fluid resuscitation is recommended for patients with sepsis and signs of hypoperfusion. However, it is not clear whether this is appropriate for patients with a do‐not‐intubate (DNI) order. This study evaluated the association between volume of fluid resuscitation and outcomes in patients with infection, signs of hypoperfusion, and a DNI order in an emergency department.

Methods

This was a single‐center retrospective cohort study. We classified the infected patients with signs of hypoperfusion and a DNI order seen in our emergency department between April 1, 2015 and November 31, 2020 into the standard fluid resuscitation group (≥30 mL/kg) and the restricted fluid resuscitation group (<30 mL/kg). We compared with in‐hospital mortality and the rate of discharge to home in two groups.

Results

Of 367 patients, 149 received standard fluid resuscitation and 218 received restricted fluid resuscitation. In‐hospital mortality was similar in each group (40/149 and 62/218, respectively). Standard fluid resuscitation was not associated with in‐hospital mortality (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.62–1.77, P = 0.86), but was associated with a significantly lower rate of discharge to home (aOR, 0.55; 95% CI, 0.30–0.98, P = 0.043). There was no significant difference in respiratory rate or need for oxygen therapy post‐resuscitation between the two groups.

Conclusion

This study suggests that fluid resuscitation may be not beneficial for infected patients with signs of hypoperfusion and a DNI order. Further studies should be conducted on the options for resuscitation management for these patients.

Prognostic factors for advanced lung cancer patients with do-not-intubate order in intensive care unit: a retrospective study

Background

The survival of patients with lung cancer undergoing critical care has improved. An increasing number of patients with lung cancer have signed a predefined do-not-intubate (DNI) order before admission to the intensive care unit (ICU). These patients may still be transferred to the ICU and even receive non-invasive ventilation (NIV) support. However, there is still a lack of prognostic predictions in this cohort. Whether patients will benefit from ICU care remains unclear.

Methods

We retrospectively collected data from patients with advanced lung cancer who had signed a DNI order before ICU admission in a tertiary medical center between 2014 and 2016. The clinical characteristics and survival outcomes were discussed.

Results

A total of 140 patients (median age, 73 years; 62.1% were male) were included, had been diagnosed with stage III or IV non-small cell lung cancer (NSCLC) (AJCC 7th edition), and signed a DNI. Most patients received NIV during ICU stay. The median APACHE II score was 14 (standard error [SE], ± 0.66) and the mean PaO2/FiO2 ratio (P/F ratio) was 174.2 (SD, ± 104 mmHg). The APACHE II score was significantly lower in 28-day survivors (survivor: 12 (± 0.98) vs. non-survivor: 15 (± 0.83); p = 0.019). The P/F ratio of the survivors was higher than that of non-survivors (survivors: 209.6 ± 111.4 vs. non-survivors: 157.9 ± 96.7; p = 0.006). Patients with a P/F ratio ≥ 150 had better 28-day survival (p = 0.005). By combining P/F ratio ≥ 150 and APACHE II score < 16, those with high P/F ratios and low APACHE II scores during ICU admission had a notable 28-day survival compared with the rest (p < 0.001). These prognostic factors could also be applied to 90-day survival (p = 0.003). The prediction model was significant for those with driver mutations in 90-day survival (p = 0.021).

Conclusions

P/F ratio ≥ 150 and APACHE II score < 16 were significant prognostic factors for critically ill patients with lung cancer and DNI. This prediction could be applied to 90-day survival in patients with driver mutations. These findings are informative for clinical practice and decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02042-7.

[High flow oxygen via nasal cannula: Palliative care and ethical considerations]

High flow oxygen via nasal cannula (HFO₂NC) has become the first-line reference symptomatic treatment for hypoxemic acute respiratory failure. This non-invasive technique can be addressed, as palliative therapeutic care, to frail patients near end-of-life with a do-not-intubate order. A distinction will be made between those with an imminent and inevitable fatal outcome (pallitative end-of-life management) and those with hope for transient clinical remission (meliorative management). This review focuses on the expected physiological benefits and technical benefits/risks incurred by HFO₂NC use in this population. Its main purpose is to highlight the ethical principles governing the palliative management of patients in acute respiratory failure with a do-not-intubate order, and to discuss the various elements to be considered when defining the patient's palliative care plan, in a holistic, individual-centered approach.

Noninvasive respiratory support outside the intensive care unit for acute respiratory failure related to coronavirus-19 disease: a systematic review and meta-analysis

BACKGROUND

Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU.

METHODS

We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with 'do-not-intubate' (DNI) orders.

RESULTS

Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30-41%]. 26% [21-30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36-54%]. 23% [15-32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65-78%]. Oxygenation on admission was the main source of between-study heterogeneity.

CONCLUSIONS

During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance.

REGISTRATION

PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.

Characteristics and Prognosis of Patients Who Receive Noninvasive Ventilation and Present Limitation of Life Support Treatment: The LLST-NIVCat Multicenter Cohort Study

BACKGROUND

Patients who receive noninvasive ventilation (NIV) in the emergency department (ED) sometimes have a limitation of life support treatment (LLST). The characteristics and prognosis in these patients may be worse, however, few studies have been carried out in this respect.

OBJECTIVE

Analyze the differences between patients receiving NIV in the ED with LLST (NIV-LLST) or without LLST (NIV-noLLST) and their impact on in-hospital mortality, as well as investigate in-hospital mortality in the NIV-LLST group.

METHOD

We performed a secondary analysis of data from the NIVCat registry. This was a prospective, multicenter, analytical cohort study with consecutive inclusion of patients receiving NIV from February to March 2015 in 11 hospital EDs in Spain. Data on the baseline characteristics, the acute episode, and final patient destination were collected. The dependent variable was all-cause in-hospital mortality.

RESULTS

We analyzed 152 cases receiving NIV, 66 (43.4%) of whom had NIV-LLTS. Age ≥ 75 years was associated with NIV-LLST. In-hospital mortality was higher in the NIV-LLST group, with an adjusted hazard ratio of 2.50 (95% confidence interval [CI] 1.03-6.06). Patients with NIV-LLST presenting an exacerbation of chronic obstructive pulmonary disease (COPD) presented the lowest mortality, with an odds ratio of 0.27 (95% confidence interval 0.08-0.93), compared with the remaining patients.

CONCLUSION

In our cohort of patients receiving NIV in the ED, the presence of LLST is frequent and is associated with high hospital mortality. The NIV-LLST patients with a COPD exacerbation have a better prognosis than NIV-LLST patients with other diseases.