CLEVELANDStandard respiratory therapy often must be modified
for the palliative care patient, David Haney, RRT, said at a
conference on palliative medicine held at the Cleveland Clinic
National guidelines, developed by the American Association for
Respiratory Care and the American Thoracic Society, define clinical
indications and care plans for various modes of respiratory therapy,
including aerosol therapy, bronchopul-monary hygiene, and
hyperinflation therapy. However, these guidelines frequently fail to
apply to patients with advanced cancer.
The problem is that palliative care patients dont
necessarily fall into those neat categories, said Mr. Haney, a
clinical specialist with the Respiratory Therapy Consult Service at
the Cleveland Clinic. Palliative care patients may require a
different set of indications, and modifications frequently must be
made to the therapy itself if the patient is going to be able to
Shortness of breath and dyspneic feelings are clinical indications
for aerosol therapy in palliative care patients, Mr. Haney said. This
differs from the clinical indications for aerosol therapy in the
general population as described by the national guidelines. Those
indications include bronchospasm, history of bronchospasm, thick
proteinaceous secretions, and airway inflammation.
Aerosol therapy for patients in palliative care may be modified to
include increased frequency of bronchodilator use, he said. Another
modification is the use of aerosolized morphine treatment. Although
the value of nebulized morphine continues to be widely debated, it
has been shown to be effective in several small studies of patients
with chronic lung disease and cardiac disease.
Patients with advanced cancer who have rhonchi or a nonproductive
cough may benefit from bronchopulmonary hygiene, which consists of
percussion and vibrations, and suctioning.
Yet palliative care patients may experience pain from side-to-side
percussion therapy. They may suffer discomfort from putting the head
of the bed flat, which is typically done during bronchopulmonary
In addition, certain types of lung cancer, or a platelet count of
less than 50,000, are contraindications for percussion and
vibrations, Mr. Haney commented.
Palliative care patients benefit from modifications to the
bronchopulmonary hygiene plan. Modifications include using a
mucolytic aerosol and suctioning with soft catheters. Postural
drainage with gravity can also be used to assist in mobilizing secretions.
Hyperinflation therapy involves the use of a face mask and either
IPPB (intermittent positive pressure breath) or CPAP (continuous
positive airway pressure). Both of these therapies require the
patient to increase the work of breathing. For this reason, the care
plan may need to be modified for the fatigued cancer patient. Family
members may also request therapy that is less aggressive than the use
of a face mask and positive airway pressure.
Modifications that can be made include using a high-flow cascade of
oxygen with a loose-fitting mask, Mr. Haney said. In addition, the
health care provider may decide to accept lower levels of blood gases
(PaO2 and SpO2) than the national standards call for. Rather than
accept the national values of 90% to 100%, the provider may
compromise to accept blood gas values in the low- to mid-80s.
These kinds of modifications demonstrate a need for protocols for the
respiratory therapy of palliative care patients, Mr. Haney said.
However, he added, further studies are required before such protocols
can be developed.