airway management in end of life care; resuscitate or palliate
TRANSCRIPT
Airway management in end of life care
Matt Green @MLG1611
Originally published on www.seh-education.org
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