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Airway Management in End of Life Care

15 Oct 10:00 by Pete Bouvier

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This blog post was written by Matt Green, a paramedic for an NHS Trust, and originally published on the South East Health Education Blog . Follow him on Twitter @MLG1611

This case study looks at some of the airway complications in end of life care and clinical decision making in the context of a dying person. Also discussed are examples of techniques and medications a pre-hospital clinician might use to manage symptoms.

You’re called to a 66 year old female in a collapsed state. You find the patient laid in bed and complete a primary survey:

Danger : None 
Response : To voice 
Catastrophic haemorrhage : None 
Airway : Snoring, dry tongue with thick mucus secretions, very slack tone in facial and airway muscles 
Breathing : RR28, shallow, irregular with increased work of breathing. Audible stridor which is confirmed on auscultation. Occasional feeble and ineffective cough. Saturations 93% on air. 
Circulation : Strong and regular radial pulse, 51bpm, blood pressure 105/59 
Disability : Pupils 3mm BL, some facial grimace, GCS10/15; E3V2M5. Blood sugar=6.4 
Examination : Temperature 36.6C. Appears cachexic and thin but without wounds or pressure areas. The patient is almost supine, laying awkwardly on a single pillow. They have a urinary catheter which appears to be functioning well.

Your instincts are to resuscitate this patient, initially with airway management including tracheal suctioning, positioning, adjuncts, and oxygen before facilitating rapid transfer to hospital. However, you sense this patient has a complex medical history; there is a hoist near the bed and grab rails on the walls and you can see a NHS-branded file full of notes too.

Speaking with the patient’s family you learn that the patient has incurable brain cancer. She was diagnosed 4 years ago and has had repeated hospital admissions for various issues including aspiration pneumonia, seizures and headaches. Four weeks ago she was discharged for palliative care at home and it was agreed that further hospital admission was inappropriate if avoidable. When she was discharged, the patient was conscious and had capacity. The family show you a valid DNACPR and a comprehensive Advance Directive where the patient states she simply wishes to be made comfortable and to die at home. Her husband has evidence that he has Power of Attorney for Health and Welfare, and continues to support his wife’s Advance Directive. There is also an abundance of paperwork from the local palliative care team, hospice and district nursing service. The ambulance control room have a record from the patient’s GP that corroborates all the key facts. The patient has carers twice daily who help with personal care, give a thickened puree diet and administer oromorph and sodium valporate. Other medications such as statins and antihypertensives have been recently stopped by the GP as their long-term benefits are no longer relevant.

The family explain that they called 999 when the patient’s breathing started to become noisy and she was less responsive. They feel a little guilty for calling an ambulance but you can tell their genuine concern and realise they simply lost their nerve a little during this difficult stage.

Overall, you determine the patient is probably in the last days of life and that transfer to hospital would not be appropriate, potentially distressing and unlikely to positively alter the outcome.

You also consider that typical emergency aggressive airway management aims to stabilise the patient and be part of a package of resuscitation care to achieve definitive management and promote recovery. As this patient’s rapidly declining health makes recovery and short-term survival impossible, priorities in end of life care airway management focus on reducing discomfort and lessening symptoms without resorting to futile painful and invasive procedures with no long-term benefit.

You telephone the palliative care team for advice. They suggest to make the patient comfortable and if possible improve her airway symptoms. They are able to visit the patient later on, but it will be at least 3-4 hours until they can get there. The palliative care team tell you there is a box of prescribed `just in case` medication and equipment in a box at the bottom of the patient’s wardrobe. A chart for indications and recording administration is in there too.

You start by helping sit the patient up a little – the patient’s family help you slide her up the bed and use a few more pillows until the patient is semi-recumbent. Immediately, her snoring becomes less pronounced and airway patency improves, however the improved airflow increases the volume of the rattle caused by her secretions.

You use damp gauze to gently remove some of the thickened secretions around the patient’s lips but doubtful that suction would be effective without being excessively invasive and using a large catheter on high power for a prolonged period.

The patient’s family find the `just in case` box. Inside you find a range of vials as well as a range of syringes, needles and devices which look like sponges on sticks, which you realise are for safely giving the patient small amounts of water to wet their mouth without risking significant aspiration.

The documentation inside the box relating to stat doses (as opposed to syringe driver doses) states:

Medication

Indication

Route

Dose

Morphine

Pain

Breathlessness

Subcutaneous (SC)

2.5-5mg

Midazolam

Agitation

Breathlessness

SC

2.5-5mg

Levomepromazine

Nausea or vomiting

SC

2.5-5mg

Glycopyrronium

Excessive secretions

SC

200mcg

You decide to wet the patient’s mouth using the sponges, which loosens some secretions and makes them easier to remove with gauze. You also decide to administer a dose of Glycopyrronium.

Chemically related to atropine, glycopyrronium prevents muscarinic receptors’ stimulation by acetylcholine, which ordinarily is a normal process of the parasympathetic nervous system to release saliva. Reducing saliva reduces further secretion production and therefore relieves turbulent airway airflow.

After administering the medication, you consider undertaking further monitoring including blood pressure, a 12-lead ECG and end tidal carbon dioxide. However, you decide not to reattach the machine as the patient’s prognosis means her observations are likely to be deranged, and you would be unlikely to change your management as a result of any findings. Even if there was a life-threatening abnormality, treating it would probably not be in the patient’s best interests if it was not causing distress.

In order to know whether these interventions have been effective, you decide to remain with the patient for 30 minutes. While waiting you speak with the patient’s family and put their mind at rest about a range of issues. They feel much more prepared for the patient’s final days and confident they will be able to look after the patient until the palliative care team arrive later on.

Before leaving scene you review the patient:

Airway : Much less noisy with fewer secretions 
Breathing : 22/minute. Much less noisy but still shallow 
Circulation : There appears to be no change 
Disability : Less facial grimace and appears less distressed. Responds to voice by making sounds 
Examination : The patient is positioned more comfortably on the bed, with plenty of support to keep her safely in position

You return to the ambulance station and discuss the case with a trusted colleague to set your mind at rest and ensure you’re supported, as you know you can find end of life care particularly distressing.

Learning points :

  • Airway and breathing problems are common in end of life care

  • It is not always appropriate to aggressively resuscitate and transport patients with expected deterioration and a terminal diagnosis

  • Sources such as Advance Directives, conversation with the patient and their relatives, and clinical judgement can inform patient care

  • Advice and referral to a palliative care team, hospice or GP can be very effective

  • `Just in case` medications are commonly left at patients’ homes and intended for use by healthcare professionals, including ambulance clinicians. If in doubt, check your employer’s procedures for their use

Further reading :

2016’s JRCALC Clinical Practice Guidelines have a chapter on end of life care

The free to use online Electronic Medicines Compendium (EMC) details the pharmacology of Glycopyrronium

NICE guidelines NG31 `Care of dying adults in the last days of life` covers best practice in most of the themes highlighted by this case study