Linda L. Chlan

Promoting Effective Communication for Patients Receiving Mechanical Ventilation

Communicating effectively with ventilator-dependent patients is essential so that various basic physiological and psychological needs can be conveyed and decisions, wishes, and desires about the plan of care and end-of-life decision making can be expressed. Numerous methods can be used to communicate, including gestures, head nods, mouthing of words, writing, use of letter/picture boards and common words or phrases tailored to meet individualized patients needs. High-tech alternative communication devices are available for more complex cases. Various options for patients with a tracheostomy tube include partial or total cuff deflation and use of a speaking valve. It is important for nurses to assess communication needs; identify appropriate alternative communication strategies; create a customized care plan with the patient, the patients family, and other team members; ensure that the care plan is visible and accessible to all staff interacting with the patient; and continue to collaborate with colleagues from all disciplines to promote effective communication with nonvocal patients.

The Confusion Assessment Method for the Icu-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the Icu

Objectives: Delirium severity is independently associated with longer hospital stays, nursing home placement, and death in patients outside the ICU. Delirium severity in the ICU is not routinely measured because the available instruments are difficult to complete in critically ill patients. We designed our study to assess the reliability and validity of a new ICU delirium severity tool, the Confusion Assessment Method for the ICU-7 delirium severity scale. Design: Observational cohort study. Setting: Medical, surgical, and progressive ICUs of three academic hospitals. Patients: Five hundred eighteen adult (≥ 18 yr) patients. Interventions: None. Measurements and Main Results: Patients received the Confusion Assessment Method for the ICU, Richmond Agitation-Sedation Scale, and Delirium Rating Scale-Revised-98 assessments. A 7-point scale (0–7) was derived from responses to the Confusion Assessment Method for the ICU and Richmond Agitation-Sedation Scale items. Confusion Assessment Method for the ICU-7 showed high internal consistency (Cronbach’s &agr; = 0.85) and good correlation with Delirium Rating Scale-Revised-98 scores (correlation coefficient = 0.64). Known-groups validity was supported by the separation of mechanically ventilated and nonventilated assessments. Median Confusion Assessment Method for the ICU-7 scores demonstrated good predictive validity with higher odds (odds ratio = 1.47; 95% CI = 1.30–1.66) of in-hospital mortality and lower odds (odds ratio = 0.8; 95% CI = 0.72–0.9) of being discharged home after adjusting for age, race, gender, severity of illness, and chronic comorbidities. Higher Confusion Assessment Method for the ICU-7 scores were also associated with increased length of ICU stay (p = 0.001). Conclusions: Our results suggest that Confusion Assessment Method for the ICU-7 is a valid and reliable delirium severity measure among ICU patients. Further research comparing it to other delirium severity measures, its use in delirium efficacy trials, and real-life implementation is needed to determine its role in research and clinical practice.

Engaging Critically Ill Patients in Symptom Management: Thinking Outside the Box!

Caring for critically ill patients receiving mechanical ventilation in the intensive care unit (ICU) is an immense challenge for clinicians. Interventions to maintain physiological stability and life itself can cause a number of adverse effects that have a marked impact on patients beyond the period of critical illness or injury. These ICU-acquired conditions include but are not limited to weakness, depression, and post-intensive care syndrome, all of which markedly affect patients quality of life after they leave the unit. How best to manage the many symptoms experienced by patients undergoing mechanical ventilation without contributing to adverse ICU-acquired sequelae remains a daunting charge for clinicians and requires innovative out of the box approaches to address these complex issues. Systematic, cutting-edge research is needed to challenge the usual way of managing ICU patients in order to provide the best available evidence for practice integration that minimizes adverse, ICU-acquired sequelae and improves outcomes for the most vulnerable patients. This article highlights a program of research focused on interventions for managing symptoms in critically ill patients receiving mechanical ventilatory support, including the appropriate empowerment of symptom self-management by patients undergoing mechanical ventilation. Development and testing of innovative, nontraditional interventions specifically tailored for ICU patients receiving mechanical ventilatory support are presented. Music listening is highlighted as a nonpharmacological, adjunctive intervention to reduce anxiety associated with mechanical ventilation. Patient-controlled sedation is discussed as an alternative method to meet patients highly individual needs for sedative therapy to promote comfort.

Decreasing Delirium through Music (DDM) in critically ill, mechanically ventilated patients in the intensive care unit: study protocol for a pilot randomized controlled trial

BackgroundDelirium is a highly prevalent and morbid syndrome in intensive care units (ICUs). Changing the stressful environment within the ICU via music may be an effective and a scalable way to reduce the burden of delirium.Methods/designThe Decreasing Delirium through Music (DDM) study is a three-arm, single-blind, randomized controlled feasibility trial.Sixty patients admitted to the ICU with respiratory failure requiring mechanical ventilation will be randomized to one of three arms (20 participants per arm): (1) personalized music, (2) non-personalized relaxing music, or (3) attention-control. Music preferences will be obtained from all enrolled participants or their family caregivers. Participants will receive two 1-h audio sessions a day through noise-cancelling headphones and mp3 players. Our primary aim is to determine the feasibility of the trial design (recruitment, adherence, participant retention, design and delivery of the music intervention). Our secondary aim is to estimate the potential effect size of patient-preferred music listening in reducing delirium, as measured by the Confusion Assessment Method for the ICU (CAM-ICU). Participants will receive twice daily assessments for level of sedation and presence of delirium. Enrolled participants will be followed in the hospital until death, discharge, or up to 28xa0days, and seen in the Critical Care Recovery Clinic at 90xa0days.DiscussionDDM is a feasibility trial to provide personalized and non-personalized music interventions for critically ill, mechanically ventilated patients. Our trial will also estimate the preliminary efficacy of music interventions on reducing delirium incidence and severity.Trial registrationClinicalTrials.gov, Identifier: NCT03095443. Registered on 23 March 2017.

Predictive associations of music, anxiety, and sedative exposure on mechanical ventilation weaning trials

Background Weaning from mechanical ventilation requires increased respiratory effort, which can heighten anxiety and later prolong the need for mechanical ventilation. Objectives To examine the predictive associations of music intervention, anxiety, sedative exposure, and patients characteristics on time to initiation and duration of weaning trials of patients receiving mechanical ventilation. Methods A descriptive, correlational design was used for a secondary analysis of data from a randomized trial. Music listening was defined as self‐initiated, patient‐directed music via headphones. Anxiety was measured daily with a visual analog scale. Sedative exposure was operationalized as a daily sedation intensity score and a sedative dose frequency. Analyses consisted of descriptive statistics, graphing, survival analysis, Cox proportional hazards regression, and linear regression. Results Of 307 patients, 52% were women and 86% were white. Mean age was 59.3 (SD, 14.4) years, mean Acute Physiology and Chronic Health Evaluation III score was 62.9 (SD, 21.6), mean duration of ventilatory support was 8 (range, 1‐52) days, and mean stay in the intensive care unit was 18 (range, 2‐71) days. Music listening, anxiety levels, and sedative exposure did not influence time to initial weaning trial or duration of trials. Clinical factors of illness severity, days of weaning trials, and tracheostomy placement influenced weaning patterns in this sample. Conclusions Prospective studies of music intervention and other psychophysiological factors during weaning from mechanical ventilation are needed to better understand factors that promote successful weaning.

Time for a paradigm shift: Assessing for anxiety in patients receiving mechanical ventilation

More than 5.7 million people are admitted to intensive care units (ICU) in the United States each year.1 Many ICU patients require endotracheal intubation and mechanical ventilatory support to assist with breathing. Pharmacological interventions are used to manage intubated patient’s pain and agitation. The Richmond Agitation-Sedation Scale (RASS), a motor arousal scale, is used to guide the amount of medications needed.2 Sedation practices for patients receiving mechanical ventilatory support have evolved considerably over the last ten years.2,3 ICU practice has changed from continuous medication infusions which promote deep sedation to minimal sedationwith daily medication interruptions. Goals of daily sedation interruption are to assess pain and neurological status while facilitating spontaneous breathing trials. This use of minimal sedation is the goal of the current Pain, Agitation, and Delirium (PAD) guidelines. These guidelines emphasize validated PAD monitoring tools and the use of both pharmacological and non-pharmacological methods in managing PAD in ICU patients.2 While there have been improvements in the assessment and intervention of PAD in ICU patients, the need for mechanical ventilation frequently induces anxiety.3e7 Unfortunately, this commonly experienced symptom is frequently overlooked by ICU clinicians. Anxiety, defined as a heightened state of arousal, is a subjective symptom that is intense, distressing, and highly variable among patients.5,6,8 In the presence of an endotracheal tube, patients are unable to verbally communicate their anxiety, potentially yielding ineffective patient participation in their care progression. Lack of patient involvement and the presence of anxiety can lead to spiraling effects of more mechanical ventilation days resulting in ventilator-associated complications, increased incidence of delirium, longer ICU and hospital length of stay, as well as situational depression.5 Patients receiving mechanical ventilation experience anxiety due to multiple factors and are frequently unable to communicate their needs effectively to care providers.3e5 They are often emotionally overwhelmed by their illness, in addition to the unusual noises, lights, and unfamiliar care providers. Patients also experience sensations of thirst, dyspnea, and difficulty swallowing from having the endotracheal tube in place.1,3e6,8 They may worry about the uncertainty of their illness, finances, and their family members including pets left at homewith no one to provide care.3e5,7,8 Patients receiving mechanical ventilatory support can exhibit physiological and behavioral manifestations associated with anxiety such as elevated blood pressure, elevated heart rate, restlessness, agitation,

Symptom assessment in non-vocal or cognitively impaired ICU patients: Implications for practice and future research

Background Symptom assessment in critically ill patients is challenging because many cannot provide a self‐report. Objectives To describe the state of the science on symptom communication and the assessment of selected physical symptoms in non‐vocal ICU patients. Methods This paper summarizes a 2014 American Thoracic Society Annual International Conference symposium presenting current evidence on symptom communication, delirium, and the assessment of common physical symptoms (i.e., dyspnea, pain, weakness, and fatigue) experienced by non‐vocal ICU patients. Results Symptom assessment begins with accurate assessment, which includes an evaluation of delirium, and assistance in symptom communication. Simple self‐report measures (e.g., 0–10 numeric rating scale), observational measures (e.g., Respiratory Distress Observation Scale and Critical‐Care Pain Observation Tool), or objective measures (e.g., manual muscle testing and hand dynamometry) have demonstrated utility among this population. Conclusion Optimizing symptom assessment with valid and reliable instruments with minimum patient burden is necessary to advance clinical practice and research in this field.

Safety and Acceptability of Patient-Administered Sedatives During Mechanical Ventilation

Background Safety and acceptability of sedative selfadministration by patients receiving mechanical ventilation is unknown. Objectives To determine if self‐administration of dexmedetomidine by patients is safe and acceptable for selfmanagement of anxiety during ventilatory support. Methods In a pilot trial in 3 intensive care units, 17 intubated patients were randomly assigned to dexmedetomidine and 20 to usual care. Dexmedetomidine was administered via standard pumps for patient‐controlled analgesia, with a basal infusion (0.1–0.7 &mgr;g/kg per hour) titrated by the number of patient‐triggered doses (0.25 &mgr;g/kg per dose). Safety goals were heart rate greater than 40/min, systolic blood pressure greater than 80 mm Hg, and diastolic blood pressure greater than 50 mm Hg. Acceptability was based on patients’ self‐reported satisfaction and ability to administer the sedative. A 100‐mm visual analog scale was used daily to assess patients’ anxiety. Results The sample was 59% male and 89% white. Mean values were age, 50.6 years; score on the Acute Physiology and Chronic Health Evaluation, 60.1; and protocol duration, 3.4 days. Five dexmedetomidine patients had blood pressure and/or heart rate lower than safety parameters, necessitating short‐term treatment. Nurses’ adherence to reporting of safety parameters was 100%; adherence to the dexmedetomidine titration algorithm was 73%. Overall baseline anxiety score was 38.4 and did not change significantly (&bgr;day = 2.1; SE, 2.5; P = .40). Most dexmedetomidine patients (92%) were satisfied or very satisfied with their ability to self‐administer medication. Conclusions For select patients, self‐administration of dexmedetomidine is safe and acceptable.

Effects of music intervention on inflammatory markers in critically ill and post-operative patients: A systematic review of the literature

Background: Music listening has been shown to reduce anxiety, stress, and patient tolerance of procedures. Music may also have beneficial effects on inflammatory biomarkers in intensive care and post‐operative patients, but the quality of evidence is not clear. Objectives: We conducted a systematic review to evaluate the effects of music on inflammatory biomarkers in intensive care, and post‐operative patients. Methods: A comprehensive search of the literature was performed. After screening 1570 references, full text review of 26 studies was performed. Fourteen studies were selected for inclusion. Results: Seven studies showed a significant decrease in cortisol levels, but the level of evidence was low. Three studies had low risk of methodological bias, while 11 studies had high risk of bias. Conclusions: Music intervention may decrease cortisol levels, but other biomarkers remain unchanged. Given the low level of evidence, further research on music effects on inflammatory biomarkers is needed.

Letting the Patient Decide: A Case Report of Self-Administered Sedation During Mechanical Ventilation

&NA; It is common for critical care nurses to administer sedative medications to patients receiving mechanical ventilation. Although patient‐controlled analgesia is frequently used in practice to promote effective selfmanagement of pain by patients, it is not known if patient‐controlled sedation can be used to promote effective self‐management of distressing symptoms associated with mechanical ventilation. A randomized pilot trial was conducted to evaluate whether patient self‐administered sedation with dexmedetomidine is safe and acceptable for self‐management of anxiety during ventilator support. This case report details the experiences of one patient enrolled in the pilot trial who was randomly assigned to the experimental dexmedetomidine intervention, completed the study protocol, and provided feedback. In a poststudy survey, the patient responded positively to the use of self‐administered sedation with dexmedetomidine during ventilator support.