Positive and negative effects of mechanical ventilation on sleep in the ICU: a review with clinical recommendations

Acupuncture reduces mechanical ventilation time in critically ill patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Mechanical Ventilation (MV) is an essential life support machine, frequently utilized in an Intensive Care Unit (ICU). Recently, a growing number of clinical trials have investigated the effect of acupuncture treatment on MV outcomes.

OBJECTIVES

This study investigated the safety and efficacy of acupuncture treatment for critically ill patients under MV.

METHODS

In this systematic review and meta-analysis of randomized controlled trials, the efficacy of acupuncture related interventions was compared to routine ICU treatments, and sham/control acupuncture as control interventions applied to ICU patients undergoing MV. The databases of PubMed, Cochrane Library, and Web of Science were extensively searched in the month of April 2022. The primary outcome measurements were defined as total MV time, ICU length of stay, and mortality. The Cochrane Collaboration risk of bias tool was employed to analyze the severity of bias. The meta-analysis was conducted using Review Manager 5.3 software. The quality of evidence was evaluated according to the GRADE approach.

RESULTS

A total of 10 clinical trials were included in this investigation. When comparing the performance of acupuncture-related interventions to that of the reported control interventions, the results of the meta-analysis revealed a significant reduction in the total number of MV days as well as the duration of ICU length of stay following acupuncture treatment (MD -2.06 [-3.33, -0.79] P = 0.001, I2 = 55 %, MD-1.26 [-2.00, -0.53] P = 0.0008, I2 = 77 %, respectively). A reduction in the total mortality was similarly observed (RR = 0.67 [0.47, 0.94] P = 0.02, I2 = 0 %).

CONCLUSION

This systematic review and meta-analysis identified a noteworthy reduction in the total MV days, time spent in the ICU, as well as the total mortality following acupuncture related interventions. However, the small sample size, risk of bias and existing heterogeneity should be taken into consideration. The results of this study are promising and further investigations in this field are warranted.

Factors Associated with and Prognosis Impact of Perceived Sleep Quality and Estimated Quantity in Patients Receiving Non-Invasive Ventilation for Acute Respiratory Failure

Background. The objectives of this study were (1) to determine factors associated with impaired sleep and (2) to evaluate the relationship between impaired sleep and the outcome. Methods. Secondary analysis of a prospective observational cohort study in 54 intensive care units in France and Belgium. Sleep quality was quantified by the patients with a semi-quantitative scale. Results. Among the 389 patients included, 40% reported poor sleep during the first night in the ICU and the median (interquartile) total sleep time was 4 h (2−5). Factors independently associated with poor sleep quality were the SOFA score (odds ratio [OR] 0.90, p = 0.037), anxiety (OR 0.43, p = 0.001) and the presence of air leaks (OR 0.52, p = 0.013). Factors independently associated with short-estimated sleep duration (<4 h) were the SOFA score (1.13, p = 0.005), dyspnea on admission (1.13, p = 0.031) and the presence of air leaks (1.92, p = 0.008). Non-invasive ventilation failure was independently associated with poor sleep quality (OR 3.02, p = 0.021) and short sleep duration (OR 0.77, p = 0.001). Sleep quality and duration were not associated with an increase in mortality or length of stay. Conclusions. The sleep of patients with ARF requiring NIV is impaired and is associated with a high rate of NIV failure.

Early Intensive Physical Rehabilitation Combined with a Protocolized Decannulation Process in Tracheostomized Survivors from Severe COVID-19 Pneumonia with Chronic Critical Illness

(1) Background: Intensive care unit (ICU) survivors from severe COVID-19 acute respiratory distress syndrome (CARDS) with chronic critical illness (CCI) may be considered vast resource consumers with a poor prognosis. We hypothesized that a holistic approach combining an early intensive rehabilitation with a protocol of difficult weaning would improve patient outcomes (2) Methods: A single-center retrospective study in a five-bed post-ICU weaning and intensive rehabilitation center with a dedicated fitness room specifically equipped to safely deliver physical activity sessions in frail patients with CCI. (3) Results: Among 502 CARDS patients admitted to the ICU from March 2020 to March 2022, 50 consecutive tracheostomized patients were included in the program. After a median of 39 ICU days, 25 days of rehabilitation were needed to restore patients’ autonomy (ADL, from 0 to 6; p < 0.001), to significantly improve their aerobic capacity (6-min walking test distance, from 0 to 253 m; p < 0.001) and to reduce patients’ vulnerability (frailty score, from 7 to 3; p < 0.001) and hospital anxiety and depression scale (HADS, from 18 to 10; p < 0.001). Forty-eight decannulated patients (96%) were discharged home. (4) Conclusions: A protocolized weaning strategy combined with early intensive rehabilitation in a dedicated specialized center boosted the physical and mental recovery.

Sleep Spindles and K-Complexes Are Favorable Prognostic Biomarkers in Critically Ill Patients

SUMMARY

In this narrative review, we summarize recent research on the prognostic significance of biomarkers of sleep in continuous EEG and polysomnographic recordings in intensive care unit patients. Recent studies show the EEG biosignatures of non-rapid eye movement 2 sleep (sleep spindles and K-complexes) on continuous EEG in critically ill patients better predict functional outcomes and mortality than the ictal-interictal continuum patterns. Emergence of more complex and better organized sleep architecture has been shown to parallel neurocognitive recovery and correlate with functional outcomes in traumatic brain injury and strokes. Particularly interesting are studies which suggest intravenous dexmedetomidine may induce a more biomimetic non-rapid eye movement sleep state than intravenous propofol, potentially providing more restorative sleep and lessening delirium. Protocols to improve intensive care unit sleep and neurophysiological studies evaluating the effect of these on sleep and sleep architecture are here reviewed.

The effect of music therapy on the anxiety, depression and sleep quality in intensive care unit patients: A protocol for systematic review and meta-analysis

BACKGROUND

Music therapy serves as a non-pharmacological intervention for a variety of disorders with promising results. However, the effect of music therapy on improving anxiety, depression, and sleep quality in intensive care unit (ICU) patients remains unclear. This meta-analysis aims to evaluate the effect of music therapy on improving anxiety, depression, and sleep quality in ICU patients, thus providing evidences to support music therapy as a novel complementary alternative therapy.

METHODS

Randomized controlled trials (RCTs) reporting the efficacy of music therapy on improving anxiety, depression and sleep quality in ICU patients published before January 2022 will be searched in online databases, including the PubMed, the Cochrane Library, Web of Science, Embase, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP Database, and WanFang Database. Literature screening, data extraction, and evaluation of risk of bias will be independently performed by two investigators. Meta-analysis will be performed using Stata 14.0 software.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide reliable evidence-based evidence for the effect of music therapy on anxiety, depression, and sleep quality in ICU patients.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/EXAZ6.

The Effect of Clusters of Double Triggering and Ineffective Efforts in Critically Ill Patients

OBJECTIVES

To characterize clusters of double triggering and ineffective inspiratory efforts throughout mechanical ventilation and investigate their associations with mortality and duration of ICU stay and mechanical ventilation.

DESIGN

Registry-based, real-world study.

BACKGROUND

Asynchronies during invasive mechanical ventilation can occur as isolated events or in clusters and might be related to clinical outcomes.

SUBJECTS

Adults requiring mechanical ventilation greater than 24 hours for whom greater than or equal to 70% of ventilator waveforms were available.

INTERVENTIONS

We identified clusters of double triggering and ineffective inspiratory efforts and determined their power and duration. We used Fine-Gray's competing risk model to analyze their effects on mortality and generalized linear models to analyze their effects on duration of mechanical ventilation and ICU stay.

MEASUREMENTS AND MAIN RESULTS

We analyzed 58,625,796 breaths from 180 patients. All patients had clusters (mean/d, 8.2 [5.4-10.6]; mean power, 54.5 [29.6-111.4]; mean duration, 20.3 min [12.2-34.9 min]). Clusters were less frequent during the first 48 hours (5.5 [2.5-10] vs 7.6 [4.4-9.9] in the remaining period [p = 0.027]). Total number of clusters/d was positively associated with the probability of being discharged alive considering the total period of mechanical ventilation (p = 0.001). Power and duration were similar in the two periods. Power was associated with the probability of being discharged dead (p = 0.03), longer mechanical ventilation (p < 0.001), and longer ICU stay (p = 0.035); cluster duration was associated with longer ICU stay (p = 0.027).

CONCLUSIONS

Clusters of double triggering and ineffective inspiratory efforts are common. Although higher numbers of clusters might indicate better chances of survival, clusters with greater power and duration indicate a risk of worse clinical outcomes.

Respective Impact of Day and Night Bed Baths on Critical Care Patients

BACKGROUND

Despite data supporting the reduction of interactions with patients during nighttime, bed bathing is sometimes performed within this period in sedated patients unable to manage their own hygiene care.

OBJECTIVES

To compare patient physiologic variables and adverse effect incidence between night and day bed baths.

METHODS

This was a single-center prospective observational study in a 12-bed intensive care unit during 2 months. Night period was defined to run from 10 pm to 6 am. Night bed baths were provided to sedated ventilated patients whatever their sedation, if their Richmond Agitation Sedation Scale score was -2 or deeper. Bed bath-induced changes in physiological variables, treatments, and related unscheduled events were registered during both night and day bed baths.

RESULTS

Twenty-one patients (aged 62.9 [52.5-73.2] years, 14 male patients) were included. We registered 97 night bed baths and 95 day bed baths. Heart rate increased only after day bed baths (85 beats/min [bpm] [69-97 bpm] vs 88 bpm [73-98 bpm], P = .02). Increase in Richmond Agitation Sedation Scale score occurred, respectively, during 13 (13.4%) and 8 (8.4%) night and day bed baths, without significant differences. Body temperature significantly decreased during both night and day bed baths (respectively, 37°C [36.6°C-37.4°C] vs 36.6°C [36.2°C-37.2°C], P < .0001; and 36.9°C [36.5°C-37.2°C] vs 36.7°C [36.2°C-37.2°C], P = .0006). Overall, unscheduled events, whether physiologic changes, pain, or calling a physician in rescue occurred in 97 procedures (50.5%), irrespective of their timing (night vs day, respectively 53% [54.6%] vs 44% [46.3%], P = .31).

DISCUSSION

Although unscheduled events occurred in half of bed baths, differences evidenced between nighttime and daytime bed baths were scarce. The appropriateness of nighttime bed bathing remains questionable.

The physiological underpinnings of life-saving respiratory support

Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to "buy time" while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient.

Effect of Opioids on Sleep

Opioid medications are often used to manage pain in the intensive care unit. Opioids, whether used as recreational drugs or for hospital patient pain management, impact the quality of sleep. Nurses should assess for pain and provide appropriate amounts of pain medications, while minimizing opioid use once the patient can tolerate non-narcotic medications. Nurses should assess the intensive care unit patient's sleep quality and be mindful of the effect that opioid medications have on sleep quality.

Sleep Architecture in Mechanically Ventilated Pediatric ICU Patients Receiving Goal-Directed, Dexmedetomidine- and Opioid-based Sedation

This single-center prospective observational study aimed to evaluate sleep architecture in mechanically ventilated pediatric intensive care unit (PICU) patients receiving protocolized light sedation. We enrolled 18 children, 6 months to 17 years of age, receiving mechanical ventilation and standard, protocolized sedation for acute respiratory failure, and monitored them with 24 hours of limited (10 channels) polysomnogram (PSG). The PSG was scored by a sleep technician and reviewed by a pediatric sleep medicine physician. Sixteen children had adequate PSG data for sleep stage scoring. All received continuous opioid infusions, 15 (94%) received dexmedetomidine, and 7 (44%) received intermittent benzodiazepines. Total sleep time was above the age-matched normal reference range (median 867 vs. 641 minutes, p = 0.002), attributable to increased stage N1 and N2 sleep. Diurnal variation was absent, with a median of 47% of sleep occurring during night-time hours. Rapid eye movement (REM) sleep was observed as absent in most patients (n = 12, 75%). Sleep was substantially disrupted, with more awakenings per hour than normal for age (median 2.2 vs. 1.1, p = 0.008), resulting in a median average sleep period duration (sleep before awakening) of only 25 minutes (interquartile range [IQR]: 14–36) versus normal 72 minutes (IQR: 65–86, p = 0.001). Higher ketamine and propofol doses were associated with increased sleep disruption. Children receiving targeted, opioid-, and dexmedetomidine-based sedation to facilitate mechanical ventilation for acute respiratory failure have substantial sleep disruption and abnormal sleep architecture, achieving little to no REM sleep. Dexmedetomidine-based sedation does not ensure quality sleep in this population.

Promoting Sleep in the Intensive Care Unit

Introduction

Intensive care nurses face several challenges to facilitating sleep in their critically ill patients. With its high noise levels, hectic around-the-clock activity and constant artificial lights, the intensive care environment does not foster sleep. Intensive care unit patients have significant alterations in their sleep architecture with frequent awakenings and lighter sleep; up to 50% of this sleep also occurs during the daytime. Sleep loss increases the risk of developing delirium (especially in elderly patients) and immune system impairment, which prolongs healing. The aim of this article was to develop an evidence-based bundle of nursing care activities that promote adult intensive care patients’ sleep.

Methods

A broad search was conducted in PubMed, CINAHL, Cochrane Library, and McMaster plus using search words and Medical Subject Headings terms, such as sleep, intensive care unit, intensive care, critical care nursing, sleep promotion, music, white noise, earplugs, pain relief, absence of pain, nonpharmacological intervention, and mechanical ventilation. Eight recommendations emerged from this review: reduce noise, use earplugs and eye masks, use music, promote a natural circadian rhythm, manage pain, use quiet time, cluster nursing care activities at night, and optimize ventilator modes.

Conclusion

Promoting sleep within this patient population needs to be a higher priority for intensive care nurses. Sleep should be a focus throughout the day and night, in order to sustain patients’ natural circadian rhythms. Novel research in this field could change the strength of these recommendations and add new recommendations to the bundle.

Validity of an under-mattress sensor for objective sleep measurement in critically ill patients: a prospective observational study

Background

Considering the adverse effects of sleep disturbance in critical care settings, accurate assessment could aid therapy; however, methodological inadequacies mean that no viable option is currently available. Research in healthy population has recently shown that a non-wearable sleep measurement device placed under the mattress of the bed could be beneficial in intensive care settings. Therefore, we aimed to validate this device compared with polysomnography (PSG) and to assess how it related to subjective sleep evaluations.

Methods

This observational study measured the sleep of critically ill adult patients. The primary goal was to validate the Nemuri SCAN (NSCAN; Paramount Bed Co., Ltd., Tokyo, Japan) against the reference standard PSG for 24 h. The secondary goal was to evaluate the association between the objective parameters obtained from NSCAN and PSG and the subjective report data obtained using the Richards–Campbell Sleep Questionnaire (RCSQ) for the nighttime.

Results

Eleven participants were evaluated. The median of the total sleep time scored by PSG was 456.0 (353.0–517.5) min during the nighttime and 305.0 (186.2–542.5) min during the daytime. PSG over 24 h revealed significant decreases in restorative sleep, with excessive daytime sleep, but with a normal quantity of nighttime sleep. The agreement, sensitivity, and specificity rates (with 95% confidence intervals) for the NSCAN compared with PSG were 68.4% (67.9–69.0%), 90.1% (89.7–90.6%), and 38.7% (37.9–39.7%), respectively. The median RCSQ value when subjectively evaluating nighttime sleep was 68.0 (26.3–83.5); this showed no correlation with the NSCAN sleep parameters, despite a positive correlation with the ratio of the stage N2 isolated or combined with restorative sleep in the PSG assessment.

Conclusions

NSCAN had moderate agreement, high sensitivity, and poor specificity in intensive care settings, which is most likely due to its inability to identify immobile wakefulness often observed in critically ill patients or sleep depth. This remains a barrier to its use in the assessment of subjective sleep quality.

Trial registration

This investigation was part of an interventional trial registered with the University Hospital Medical Information Network Individual Clinical Trials Registry (UMIN000026350, http://www.umin.ac.jp/icdr/index-j.html) on March 1, 2017.

Sleep and Delirium in Adults Who Are Critically Ill: A Contemporary Review

Sleep is important to health and well-being, and studies in healthy adults have demonstrated that sleep deprivation impacts respiratory, immune, and cognitive function. Historically, because of the nature of critical illness, sleep has not been considered a priority for patient care in the ICU. More recently, research has demonstrated that sleep is markedly abnormal in patients who are critically ill. In addition, there is often disruption of circadian rhythms. Delirium is a syndrome of acute alteration in mental status that occurs in the setting of contributing factors such as serious illness, medication, and drug or alcohol intoxication or withdrawal. Delirium is a frequent occurrence in critical illness, and research has demonstrated several adverse outcomes associated with delirium including persistent cognitive impairment and increased mortality. Sleep deprivation and delirium share many common symptoms. The similarity in symptoms between sleep disruption and delirium have prompted experts to draw links between the two and question both the relationship and its direction. In addition, the inclusion of sleep disturbance to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition in its constellation of symptoms used in diagnosing delirium has increased awareness of the link between sleep and delirium. This paper will review the literature on sleep in critical illness and the potential mechanisms and pathways that may connect sleep and delirium.

Effects of deep sedation on sleep in critically ill medical patients on mechanical ventilation

Atypical EEG patterns not consistent with standard sleep staging criteria have been observed in medical intensive care unit (ICU) patients. Our aim was to examine the relationship between sleep architecture and sedation in critically ill mechanically ventilated patients pre- and post-extubation. We performed a prospective observational repeated measures study where 50 mechanically ventilated patients with 31 paired analyses were examined at an academic medical centre. The sleep efficiency was 58.3 ± 25.4% for intubated patients and 45.6 ± 25.4% for extubated patients (p = .02). Intubated patients spent 76.33 ± 3.34% of time in non-rapid eye movement (NREM) sleep compared to 64.66 ± 4.06% of time for extubated patients (p = .02). REM sleep constituted 1.36 ± 0.67% of total sleep time in intubated patients and 2.06 ± 1.09% in extubated patients (p = .58). Relative sleep atypia was higher in intubated patients compared to extubated patients (3.38 ± 0.87 versus 2.79 ± 0.42; p < .001). Eleven patients were sedated with propofol only, 18 patients with fentanyl only, 11 patients with fentanyl and propofol, and 10 patients had no sedation. The mean sleep times on "propofol", "fentanyl", "propofol and fentanyl," and "no sedation" were 6.54 ± 0.64, 4.88 ± 0.75, 6.20 ± 0.75 and 4.02 ± 0.62 hr, respectively. The sigma/alpha values for patients on "propofol", "fentanyl", "propofol and fentanyl" and "no sedation" were 0.69 ± 0.04, 0.54 ± 0.01, 0.62 ± 0.02 and 0.57 ± 0.02, respectively. Sedated patients on mechanical ventilation had higher sleep efficiency and more atypia compared to the same patients following extubation. Propofol was associated with higher sleep duration and less disrupted sleep architecture compared to fentanyl, propofol and fentanyl, or no sedation.

Patient-ventilator asynchrony

Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.

The effects of mechanical ventilation on the quality of sleep of hospitalised patients in the Intensive Care Unit

Aim

To examine the effects of mechanical ventilation on the quality of sleep in patients in the intensive care unit (ICU) using recent and relevant literature.

Methods

To verify the examined objective, the results of the analysis of available original scientific works have been used including defined inclusion/exclusion criteria and search strategy. Appropriate works found were analysed further. The applied methodology was in line with the general principles of Evidence-Based Medicine. The following literary databases were used: CINAHL, Medline and gray literature: Google Scholar.

Results

A total of 91 trials were found. Eleven of these relevant to the follow-up analysis were selected: all trials were carried out under real ICU conditions and the total of 192 patients were included in the review. There is an agreement within all trials that sleep in patients requiring mechanical ventilation is disturbed. Most reviewed trials have shown that mechanical ventilation is probably not the main factor causing sleep disturbances, but an appropriate ventilation strategy can significantly help to improve its quality by reducing the frequency of the patient-ventilator asynchrony.

Conclusion

Based on the analysis, it appears that an appropriate ventilation mode setting can have a beneficial effect on the quality of sleep in ICU patients.

Patient-ventilator asynchrony

Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.

Repeated sleep-quality assessment and use of sleep-promoting interventions in ICU

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep-promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep-promoting interventions has not been widely reported. An observational study was conducted in a 58-bed adult intensive care unit. Sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep-promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open-ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep-promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards-Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards-Campbell Sleep Questionnaire was used on repeated occasions, and sleep-promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards-Campbell Sleep Questionnaire for the subjective self-assessment of sleep quality in intensive care unit patients and the implementation of simple-promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context.

Using Clinically Accessible Tools to Measure Sound Levels and Sleep Disruption in the ICU: A Prospective Multicenter Observational Study

OBJECTIVES

To use clinically accessible tools to determine unit-level and individual patient factors associated with sound levels and sleep disruption in a range of representative ICUs.

DESIGN

A cross-sectional, observational study.

SETTING

Australian and New Zealand ICUs.

PATIENTS

All patients 16 years or over occupying an ICU bed on one of two Point Prevalence study days in 2015.

INTERVENTIONS

Ambient sound was measured for 1 minute using an application downloaded to a personal mobile device. Bedside nurses also recorded the total time and number of awakening for each patient overnight.

MEASUREMENTS AND MAIN RESULTS

The study included 539 participants with sound level recorded using an application downloaded to a personal mobile device from 39 ICUs. Maximum and mean sound levels were 78 dB (SD, 9) and 62 dB (SD, 8), respectively. Maximum sound levels were higher in ICUs with a sleep policy or protocol compared with those without maximum sound levels 81 dB (95% CI, 79-83) versus 77 dB (95% CI, 77-78), mean difference 4 dB (95% CI, 0-2), p < 0.001. There was no significant difference in sound levels regardless of single room occupancy, mechanical ventilation status, or illness severity. Clinical nursing staff in all 39 ICUs were able to record sleep assessment in 15-minute intervals. The median time awake and number of prolonged disruptions were 3 hours (interquartile range, 1-4) and three (interquartile range, 2-5), respectively.

CONCLUSIONS

Across a large number of ICUs, patients were exposed to high sound levels and substantial sleep disruption irrespective of factors including previous implementation of a sleep policy. Sound and sleep measurement using simple and accessible tools can facilitate future studies and could feasibly be implemented into clinical practice.