Non-invasive ventilation for a rapidly deteriorating palliative patient (1)

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1Green E, et al. BMJ Supportive & Palliative Care 2018;0:1–3. doi:10.1136/bmjspcare-2018-001528
Letter
Non-invasive ventilation 
for a rapidly deteriorating 
palliative patient
Background
Non-invasive ventilation (NIV) is a 
further option for oxygen delivery 
to an acutely unwell patient. 
However it is often overlooked as 
a tool within palliation. We report a 
case of a young woman presenting 
in extremis with type 1 respiratory 
failure.
case presentation
A 39-year-old Caucasian woman 
presented to the emergency depart-
ment with type 1 respiratory failure 
requiring 9 L of oxygen to main-
tain her saturations. This followed 
a 1-month history of breathless-
ness and pleuritic chest pain. Her 
medical history included anxiety, 
depression, smoking of both 
tobacco and marijuana, as well as 
pregnancy at 16 years old.
Clinical examination on admis-
sion revealed two masses in the 
right breast, a clear chest and 
upper abdominal tenderness. Chest 
X-ray displayed multiple lesions 
throughout both lungs and a left 
pleural effusion. CT scan revealed 
an extensive metastatic disease 
affecting the lung, liver, spleen, 
kidneys, and subcutaneous tissue 
in the chest, left flank and breast 
(figure 1). A prominent 12 cm mass 
in the lingula and marked emphy-
sema raised concern for a lung 
primary.
Aside from microcytic anaemia 
and a mildly raised alanine trans-
aminase, routine blood tests were 
unremarkable. A pregnancy test was 
positive and blood lactate dehydro-
genase, human chorionic gonad-
otropin and Ca125 proteinlevels 
were markedly raised. One of the 
breast lesions was biopsied under 
ultrasound and sent for histology.
The patient’s respiratory func-
tion deteriorated and a repeat chest 
X-ray 72 hours later suggested 
disease progression. High-flow 
nasal oxygen was initiated to 
stabilise her clinical condition. 
This allowed time for discussions 
with her and her family about the 
evolving diagnosis and subsequent 
management plan.
The pathology was sent to Charing 
Cross for a second opinion, which 
indicated the tumour could be 
consistent with a choriocarcinoma 
or choriocarcinomatous differentia-
tion within a carcinoma. Seven days 
after admission, with these results, 
etoposide and cisplatin induction 
chemotherapy was commenced 
with the aim of reducing disease 
burden, stabilising her condition and 
discharging her home for palliation.
The patient continued to desatu-
rate despite maximal NIV and, after 
discussion with her and her family, 
it was decided to focus on symptom 
control. She passed away on day 11 
of admission, still on high-flow nasal 
oxygen, with her family present.
Five weeks after her initial presen-
tation, a non-gestational tropho-
blastic tumour resulting from 
choriocarcinomatous differentiation 
within a high-grade primary tumour 
was confirmed through molecular 
genotyping, which was felt to be 
most likely of pulmonary origin.
discussion
Two aspects of this case are of 
particular interest: the challenges 
associated with accurate diagnosis 
of non-gestational choriocarci-
noma (NGCC) and the use of NIV 
for palliative patients.
Choriocarcinoma is a rare, highly 
malignant trophoblastic tumour.1 2 
The most common form is gesta-
tional, following a hydatidiform 
mole, normal pregnancy or spon-
taneous abortion, although this can 
occur many years later.1 2 NGCC 
is exceptionally rare, arising from 
pluripotent germ cells in the gonads 
or midline structures, or in asso-
ciation with a poorly differenti-
ated somatic carcinoma including 
primary tumours of the lung, cervix, 
endometrium, breast or colon.2 It is 
important to distinguish gestational 
choriocarcinoma from NGCC since 
NGCC carries a worse prognosis 
and is less chemosensitive,2 but 
this distinction can be challenging. 
In both types of choriocarcinoma, 
metastasis is most often seen in 
the lungs (80%), and there are no 
distinctive immunohistochemical 
or microscopic differences—delays 
in accurate diagnosis are therefore 
very common.3
In this patient extensive meta-
static spread and poor tumour 
differentiation made identification 
of the primary difficult. However, 
the clinical picture with a dominant 
mass in the lingula, marked emphy-
sema and a strong smoking history 
suggested that primary pulmonary 
choriocarcinoma was most likely. 
In a previous study of NGCC, 
83% arose from the lung and were 
uniformly fatal. However the use of 
induction etoposide and cisplatin 
before EMA-CO (etoposide, MTX, 
Act-D, cyclophosphomide and 
vincristine) reduced the risk of 
early death from pulmonary haem-
orrhage from rapid tumour destruc-
tion.1 Given her extensive disease 
and presentation in extremis, the 
aim of the medical team was to 
stabilise the patient’s clinical condi-
tion long enough for her to get 
home, her preferred place of death.
High-flow nasal cannula (HFNC) 
allows high-flow, concentrated 
oxygen to be delivered and is used 
for the treatment of type 1 respira-
tory failure.4 In comparison with 
traditional NIV (continuous posi-
tive airway pressure or biphasic 
positive airway pressure), HFNC 
has several clinical advantages: 
decreased oxygen dilution, reduced 
respiratory dead space and positive 
airway pressure.4 5 Importantly in 
the context of this case, HFNC is 
also more comfortable for patients 
for several reasons, including the 
ability to eat, drink and communi-
cate, together with the lack of mask 
intolerance/anxiety and a reduction 
in xerostomia (because of the use 
of humidified oxygen).4 As they 
approach the end of life, patients 
are commonly deemed inappro-
priate candidates for NIV and the 
possibility of using HFNC may be 
overlooked.
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2 Green E, et al. BMJ Supportive & Palliative Care 2018;0:1–3. doi:10.1136/bmjspcare-2018-001528
Letter
The use of NIV in this case was 
not with curative intent, but to alle-
viate dyspnoea, buy time to find a 
diagnosis, attempt treatment and 
allow communication with the 
patient and her family. The exten-
sive metastatic disease, alongside 
her very unstable clinical condi-
tion, made it clear early on that this 
disease was not curable, but it was 
hoped that chemotherapy would 
stabilise her condition enough to 
get her home. Clear communica-
tion surrounding prognosis has 
been shown to directly correlate 
with depression scores of widows 
and dependent children.5 Without 
HFNC it would not have been 
possible to give her and her family 
any diagnosis premortem, trial a 
treatment, or discuss palliation and 
end of life.
conclusion
This case demonstrates the merit of 
NIV, in highly selective cases, with 
regard to facilitating communica-
tion, symptom control and psycho-
logical support. HFNC is rarely an 
appropriate treatment option in 
advanced metastatic malignancy; 
however, it should be considered 
in cases presenting as a new diag-
nosis with potential meaningful 
treatment options, if a patient’s 
respiratory distress would other-
wise exclude these. This case also 
discusses a metastatic NGCC arising 
from a high-grade carcinoma. To our 
knowledge this is the first description 
of a patient presenting in extremis 
where an accurate diagnosis was not 
achieved before death and illustrates 
the difficulty in diagnosing NGCCs 
and initiating management without 
histological diagnosis.
Elizabeth Green, Louisa Stockton, 
Emma De Winton
Oncology Department, Royal United Hospital, Bath, 
UK
Correspondence to Dr Elizabeth Green, Royal 
United Hospital, Bath BA1 3NG, UK; 
 elliegreen1@ nhs. net
Contributors EG and LS read the 
patient’s notes and the surrounding 
literature and wrote the paper. EDW 
supported the project and highlighted 
the patient as a suitable case. All authors 
read and approved the paper before 
submission.
Competing interests Nonedeclared.
Patient consent Next of kin consent 
obtained.
Provenance and peer review Not 
commissioned; internally peer reviewed.
© Article author(s) (or their employer(s) 
unless otherwise stated in the text of 
the article) 2018. All rights reserved. 
No commercial use is permitted unless 
otherwise expressly granted.
To cite Green E, Stockton L, De Winton E. BMJ 
Supportive & Palliative Care Epub ahead of print: 
[please include Day Month Year]. doi:10.1136/
bmjspcare-2018-001528
Received 2 March 2018
Revised 5 May 2018
Accepted 9 May 2018
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Figure 1 CT image showing metastatic lesions in multiple organs.
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Letter
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	Non-invasive ventilation for a rapidly deteriorating palliative patient
	Background
	Case presentation
	Discussion
	Conclusion
	References