What is the next step in managing a patient with type 2 respiratory failure who has refused BiPAP (Bilevel Positive Airway Pressure) and ventilator support and is deteriorating?

Management of Type 2 Respiratory Failure in a Patient Who Has Refused BiPAP and Ventilator Support

For a deteriorating patient with type 2 respiratory failure who has refused BiPAP and ventilator support, the next step should be to initiate opioid therapy (morphine 2.5-10 mg PO q2h or 1-3 mg IV q2h) along with benzodiazepines if anxiety is present, while focusing on comfort measures and providing emotional support to the patient and family. 1

Assessment of Current Status

• Confirm type 2 respiratory failure (PaCO₂ ≥ 45 mmHg with pH < 7.35) 2
• Assess symptom intensity and level of distress
• Review advance care planning and confirm patient's wishes regarding refusal of BiPAP and ventilator support
• Determine if the patient is in the "weeks to days" category of estimated life expectancy based on clinical deterioration

Pharmacological Management

1. Opioid therapy:

   • If opioid naive: Morphine 2.5-10 mg PO q2h PRN or 1-3 mg IV q2h PRN 1
   • If already on chronic opioids: Consider increasing dose by 25% 1
   • Titrate as needed for symptom relief

2. Anxiety management:

   • If dyspnea is associated with anxiety, add benzodiazepines
   • If benzodiazepine naive: Lorazepam 0.5-1 mg PO q4h PRN 1
   • Titrate as needed for comfort

3. Secretion management:

   • If excessive secretions are present, consider:
     • Scopolamine 0.4 mg subcut q4h PRN or 1.5 mg patches (1-3 patches q3d)
     • Atropine 1% ophthalmic solution 1-2 drops SL q4h PRN
     • Glycopyrrolate 0.2-0.4 mg IV or subcut q4h PRN 1

Non-Pharmacological Interventions

1. Oxygen therapy:

   • Provide oxygen if hypoxic and/or subjective relief is reported 1
   • Target SpO₂ between 85-90% 1

2. Comfort measures:

   • Position patient upright or in most comfortable position
   • Use fans to reduce sensation of dyspnea 1
   • Maintain cooler room temperature 1
   • Provide emotional and spiritual support 1

3. Communication:

   • Provide anticipatory guidance to patient/family regarding the dying process of respiratory failure 1
   • Foster patient participation in preparing loved ones 1

Palliative Care Consultation

• Intensify palliative care interventions 1
• Consider consultation with a palliative care specialist 1
• Consider sedation for intractable symptoms if other measures fail 1

Important Considerations and Pitfalls

• Respect patient autonomy: The patient has given negative consent for BiPAP and ventilator support, which must be respected even as their condition deteriorates.

• Avoid delay in comfort measures: Since the patient has refused ventilatory support, promptly initiate comfort measures rather than attempting to convince the patient to accept BiPAP/ventilation.

• Document decision-making: Clearly document the patient's refusal of ventilatory support and the plan for comfort-focused care.

• Avoid inappropriate interventions: Recognize that in this scenario, interventions like diuretics or bronchodilators should only be used if they contribute to comfort, not with the aim of reversing the respiratory failure.

• Monitor response to therapy: Even though the focus is on comfort, regular assessment of the patient's response to interventions is essential to ensure optimal symptom management.

• Consider family support: Provide emotional support to family members who may be distressed by the patient's deterioration and decision to refuse ventilatory support.

By following this approach, you can provide compassionate care that respects the patient's wishes while ensuring comfort during the dying process.