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 Foundation.
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 tolerate it.
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(Drug information on 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 hygiene.
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.