Oxigenoterapia

Respiratory Equipment

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Control of symptoms such as dyspnea, agitation, and delirium must be aggressive. In those with progressive hypercapnia, some hyperactive delirium may occur, but mostly they experience somnolence and sedation and die peacefully (see Chapter 179). Others may have an increased symptom burden that may require palliative sedation. Morphine infusionat low doses is usually sufficient to relieve the sense of dyspnea and suffocation. Titrating opioids for comfort should be done in an organized fashion based on observed symptoms, not the level of alertness. Another important measure is reduction of bronchial secretions in the dying, which helps respiration and minimizes death rattles and the family’s discomfort. This is achieved byanticholinergic agents such as hyoscyamine or glycopyrrolate. Many patients with respiratory failure are intubated and started on mechanical ventilation. Some may never be weaned off successfully and are considered terminal. The decision to withdraw life support from patients with irreversible respiratory failure is ethical and appropriate, especially if it reflects their previously stated wishes. When suchdecisions are made, premedication with opioids and antisecretory agents must be done, and the family should be educated regarding expectations of the patient’s survival off ventilation (see Chapter 180). Educating the families regarding respiratory failure and the predicted course of events is important for coping with death. Usually, family members detect the patient’s discomfort and ask about theneed for adjusting symptom management. Hospice care is an optimal service that can be offered to patients with advanced respiratory failure and their families. If care is becoming too complicated for the family, inpatient hospice units can relieve families from complex caregiving, and it allows them to be available for support.

6. Ringbaek TJ. Continuous oxygen therapy for hypoxic pulmonarydisease. Treat Respir Med 2005;4:397-408. 7. Nava S, Cuomo AM. Acute respiratory failure in the cancer patient: The role of non-invasive mechanical ventilation. Crit Rev Oncol Hematol 2004;51:91-103. 8. Wedzicha JA, Muir JF. Noninvasive ventilation in chronic obstructive pulmonary disease, bronchiectasis and cystic fibrosis. Eur Respir J 2002;20:777-784. 9. Studer SM, Levy RD, McNeil K, et al. Lungtransplant outcomes: A review of survival, graft function, physiology, health-related quality of life and cost-effectiveness. Eur Respir J 2004;24:674-685. 10. Simonds AK. Living and dying with respiratory failure: Facilitating decision making. Chron Respir Dis 2004;1:56-59.

SUGGESTED READING

Curtis JR, Cook DJ, Sinuff T, et al. Noninvasive positive pressure ventilation in critical andpalliative care settings: Understanding the goals of therapy. Crit Care Med 2007;35:932-939. Markou NK, Myrianthefs PM, Baltopoulos GJ. Respiratory failure: An overview. Crit Care Nurse Q 2004;27:353-379. Robinson W. Palliative care in cystic fibrosis. J Palliat Med 2000;3:187-192. Seamark DA, Seamark CJ, Halpin DMG. Palliative care in chronic obstructive pulmonary disease: A review for clinicians. J R SocMed 2007;100:225-233.

CHAPTER

186

Respiratory Equipment
Robert E. McQuown

CONTROVERSIES AND RESEARCH OPPORTUNITIES
The use of nebulized opioids has been subject to criticism regarding their effectiveness in relieving dyspnea in patients with the respiratory symptoms of advanced respiratory diseases. The use of these drugs in this patient population should be a subject for largerstudies. Empirical oxygen use in patients with respiratory failure, even when oxygen saturation levels are adequate, is controversial. Oxygen is frequently supplemented in hospice patients without evidence of hypoxia, and symptom response may be related to the air current rather than elevated O2 levels. Nebulized N-acetylcysteine and other mucolytics are commonly used for secretion management in...