Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial Stefano Nava, Miguel Ferrer, Antonio Esquinas, Raff aele Scala, Paolo Groff, Roberto Cosentini, Davide Guido, Ching-Hsiung Lin, Anna Maria Cuomo, Mario Grassi Lancet Oncol 2013; 14: 219–27 혈액종양내과 R2 김다래 Prof. 맹치훈

Introduction Cancer and dyspnea –Respiratory symptoms and dyspnea are common in patients with solid tumor. (20% to 80%) –Despite best-possible medical management, many patients with end-stage cancer experience breathlessness, especially towards the end of their lives. Little research has been done into the effect of oxygen in patients with cancer with refractory dyspnea. There are some suggestions, that NIV might be an alternative option to relieve dyspnea in patients with end-stage cancer For this reason, We assessed the acceptability and effectiveness of 1) NIV vs. 2) oxygen therapy in decreasing dyspnea and the amount of opiates needed.

Methods Jan 15, 2008, and March 9, 2011 multicentre, stratified, randomised feasibility study seven centers in Italy, Spain, and Taiwan Patients - end-stage cancer - acute respiratory failure - life expectancy < 6months O2 supply 1)NIV (PSV, scheduled on patients’ request) 2)oxygen therapy (Venturi mask or reservoir mask) Primary endpoints –reducing dyspnea –amount of opiates needed

Patient selection Hypercapnic respiratory failure

Baseline characteristics = =

Results Adverse effect

Results Changes in dyspnea scores with time

Results Changes in dyspnea scores with time ** Hypercapnic respiratory failure

21.3%14.1%11.2%10.0%31.0%10.7%

Discussion Non-invasive ventilation –Best responders in hypercapnic respiratory failure –as similar good results in COPD AE, pneumonia, cardiogenic pulmonary edema hypercapnia : pump failure secondary to inability of respiratory muscles to sustain the task of breathing muscular fatigue –Breathing support assist fatigued respiratory muscles –ability to breathe unsupported at least for the remaining weeks of their life The provision of inspiratory and expiratory aid can help reduce the inspiratory burden in this acute setting

Discussion Sensation of dyspnea correlate strongly with inspiratory load, and NIV by improving gaseous exchange more quickly compared with oxygen therapy, might increase central and peripheral perfusion, circulation, could relieve the sense of breathlessness that is especially pronounced in terminally ill patients with solid tumors. NIV compared with oxygen therapy –well accepted by patients –more effective in reducing dyspnea –requires less morphine –the number of deaths in hypercapnic patients was smaller

Conclusion Non invasive ventilation in patients with end-stage cancer –more effective in reducing dyspnea –decreasing the doses of morphine needed Limitation of study –The use of NIV is restricted to centers with NIV equipment, our findings are not generalisable to all cancer or palliative care units