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Respiratory failure -- the inability to breathe well enough to maintain life -- is a very common consequence of a broad spectrum of medical illnesses. In fact, it is the final consequence of any illness that gets bad enough to cause death; people stop breathing and their hearts stop beating. The exception are people who suffer from a heart rhythm abnormality which causes their heart to stop prior to their losing the ability to breathe. In both cases, without further medical intervention, death ensues.
For many, respiratory failure represents a natural death. For example, patients in hospice who are no longer benefiting from treatments directed to the management of their illnesses will get sicker until they eventually suffer respiratory failure. It is the hope of the hospice team that they will be able to enjoy the time that remains to them when while they are in hospice as much as possible before this eventuality.
For others, respiratory failure may happen while they are still experiencing and seeking treatment for a manageable or even curable illness. For example, someone with cancer may be benefiting from treatment directed towards its cure but still suffer pneumonia serious enough to cause respiratory failure. Without urgent respiratory support, that patient will die.
This is where intubation comes in. This straightforward process involves inserting a tube called an endotracheal tube into a patient's trachea, or windpipe, fixing it into place, and attaching it to a machine called a ventilator that will do the patient’s breathing for him or her. This keeps the patient alive while doctors treat the pneumonia – or a wide variety of other problems -- and hopefully cure it, allowing the patient to breathe on their own once again.
In some cases, patients may be treated with so-called noninvasive ventilation, meaning that rather than inserting an endotracheal tube -- or intubating -- a mask that covers the nose and mouth is strapped tightly on the patient and a combination of air and oxygen blown forcibly into the patient's lungs. Called CPAP or BiPAP, this procedure is a bit like driving a car at 60 miles an hour and putting your head out the window face first into the wind. Other people have partial respiratory failure. They can breathe on their own for a period of hours and then become exhausted, after which they are provided noninvasive ventilation to both keep them breathing and give them a rest.
Sometimes, despite being treated for the condition that caused respiratory failure, patients are not able to breathe unassisted and doctors are unable to “extubate” them -- or remove the endotracheal tube. Many such patients are wide awake and enjoying a good quality of life and elect to remain on ventilator support. The intubation tube, however, cannot be left in long term. It has a doughnut shaped balloon at the end, which is inflated after insertion to hold it in place. This causes pressure on the delicate walls of the windpipe. Over the long term, this causes damage and scarring that can dangerously narrow the windpipe. Instead, a tracheostomy is performed. In this procedure, a hole is cut into the windpipe well below the upper trachea, where scarring is most likely, and a short J-shaped tube inserted into it to be connected to the ventilator. This tube can be taken out for cleaning and replaced, improving hygiene. It even allows the placement of a speaking valve that can return the ability to speak out loud to a patient who hasn't been able to do so for a period of days or even weeks.
The decision about whether to accept intubation and ventilator support is highly personal. People who have treatable or even curable serious or life threatening illness may elect to be intubated while undergoing treatment in the hopes that, should they suffer respiratory failure from a complication like pneumonia, they will regain the ability to breathe on their own and resume treatment for their underlying illness. Others, with terminal illness where progression is inevitable may elect to decline intubation and ventilatory support and live out their lives in comfort and die a natural death at home in the company of family and friends while in hospice care.
Many patients receiving care at home from The Connecticut Hospice use CPAP and BiPAP, and some have used invasive ventilation with a tracheostomy at home. All three are options at our Branford inpatient unit.
Should you or someone you know be facing a decision about intubation and ventilatory support, the Connecticut Hospice Stand by Me Palliative Care program can provide additional counseling on treatment options in serious illness. We are here to help.
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