Airway Management of Patients in Hospice and Palliative Care

Around 1.4 million people living with a life-limiting illness receive care from hospices in the United States annually. To optimize the quality of life for patients in hospice and palliative care settings, healthcare providers must be knowledgeable about the unique breathing problems and airway emergencies these patients experience, along with the best methods for airway management and treatment.

Airway symptoms and emergencies 

Shortness of breath and coughing are both common respiratory symptoms in patients with advanced cancer or non-malignant disease, and they can create a heavy burden for patients and their caretakers and families. Just how these symptoms present may indicate different conditions, but any of them could indicate airway management will be necessary during an emergency.

• Dyspnea, a type of breathing discomfort that involves distinct sensations that vary in intensity, is frequently referred to as the “pain” of non-malignant disease because it becomes more common and severe for patients in the final stage of progressive disease. 
  
  

Dyspnea is caused by a combination of multiple physiological, social, and environmental factors and can result in strong physiological and behavioral reactions in individuals. If dyspnea persists even after thorough treatment of the underlying disease, then it becomes referred to as “refractory” and requires more strategic symptomatic treatment. 

• When coughing becomes chronic, it can worsen other symptoms like pain, dyspnea, incontinence, and sleep disturbance. When examining a patient’s cough, it’s important to consider the duration of the cough, trigger factors, whether the cough pattern is nocturnal or a daytime pattern, its severity, impact on quality of life, and the patient’s past medical history, such as history of asthma or chronic obstructive pulmonary disease (COPD). 

• Stridor, another common symptom in patients in hospice or palliative care, is a harsh, high-pitched wheezing or vibrating sound that results from turbulent airflow in the upper airways. This symptom usually results from a narrowing of the central airway or larynx caused by a foreign body or tumor pushing extrinsically or growing intrinsically, an infection, or edema).
  
  

The rapid obstruction or narrowing resulting from stridor can cause a palliative care emergency which leads to significant anxiety and panic for all patients, families, and healthcare providers involved. 

• Hemoptysis is a symptom that occurs when a patient coughs up blood from a pulmonary source. In palliative care populations, this often results from high-pressure bronchial circulation, but it can also be caused by erosion of a tumor. This symptom is most common in lung cancer patients, and roughly 20% of patients will experience this symptom over the course of their illness. 
  
  

Choosing equipment and treatment methods 

Since patients in hospice or palliative care settings are vulnerable in ways that are different from individuals in general patient populations, providers must consider patients’ unique needs, and the severity of their symptoms and disease when determining the right treatment methods to employ. 

Portable suction machines are a highly effective equipment choice, as they are often used when treating palliative care patients who may require assistance when they are unable to effectively clear their own secretions. When treating stridor, endotracheal intubation is the preferred intervention, and in cases of severe tracheal obstruction, the use of an open ventilating rigid bronchoscope is recommended for optimal airway control. 

According to recommendations, when treating large-volume hemoptysis, providers should secure the airway using a single-lumen endotracheal tube, and bronchoscopy to identify the source of bleeding, followed by endobronchial management. For non-large hemoptysis, providers should first identify the source of bleeding and then employ endobronchial management for visible central airway lesions. 

Stay Prepared

Patients in hospice or palliative care environments suffer from distinct respiratory symptoms. For this reason, providers treating these patient groups must be aware of factors that make patients vulnerable to airway crises. You and your team can be proactive in these treatment scenarios by remaining knowledgeable about the proper treatment methods to employ for airway management and to optimize patients’ comfort and quality of living throughout their illness.

Editor's Note: This blog was originally published in December 2022. It has been re-published with additional up to date content.