Underestimation of Patient Breathlessness by Nurses and Physicians during a Spontaneous Breathing Trial

High Airway Occlusion Pressure Is Associated with Dyspnea and Increased Mortality in Critically Ill Mechanically Ventilated Patients

Rationale: Airway occlusion pressure at 100 ms (P0.1) reflects central respiratory drive. Objectives: We aimed to assess factors associated with P0.1 and whether an abnormally low or high P0.1 value is associated with higher mortality and longer duration of mechanical ventilation (MV). Methods: We performed a secondary analysis of a prospective cohort study conducted in 10 ICUs in France to evaluate dyspnea in communicative MV patients. In patients intubated for more than 24 hours, P0.1 was measured with dyspnea as soon as patients could communicate and the next day. Measurements and Main Results: Among 260 patients assessed after a median time of ventilation of 4 days, P0.1 was 1.9 (1-3.5) cm H2O at enrollment, 24% had P0.1 values >3.5 cm H2O, 37% had P0.1 values between 1.5 and 3.5 cm H2O, and 39% had P0.1 values <1.5 cm H2O. In multivariable linear regression, independent factors associated with P0.1 were the presence of dyspnea (P = 0.037), respiratory rate (P < 0.001), and PaO2 (P = 0.008). Ninety-day mortality was 33% in patients with P0.1 > 3.5 cm H2O versus 19% in those with P0.1 between 1.5 and 3.5 cm H2O and 17% in those with P0.1 < 1.5 cm H2O (P = 0.046). After adjustment for the main risk factors, P0.1 was associated with 90-day mortality (hazard ratio per 1 cm H2O, 1.19 [95% confidence interval, 1.04-1.37]; P = 0.011). P0.1 was also independently associated with a longer duration of MV (hazard ratio per 1 cm H2O, 1.10 [95% confidence interval, 1.02-1.19]; P = 0.016). Conclusions: In patients receiving invasive MV, abnormally high P0.1 values may suggest dyspnea and are associated with higher mortality and prolonged duration of MV.

Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis

BACKGROUND

Adults in the intensive care unit (ICU) commonly experience distressing symptoms and other concerns such as pain, delirium, and breathlessness. Breathlessness management is not supported by any ICU guidelines, unlike other symptoms.

AIM

To review the literature relating to (i) prevalence, intensity, assessment, and management of breathlessness in critically ill adults in the ICU receiving invasive and non-invasive mechanical ventilation (NIV) and high-flow oxygen therapy, (HFOT), (ii) the impact of breathlessness on ICU patients with regard to engagement with rehabilitation.

METHODS

A rapid review and narrative synthesis using the Cochrane Methods Group Recommendations was conducted and reported in accordance with PRISMA. All study designs investigating breathlessness in adult ICU patients receiving either invasive mechanical ventilation (IMV), NIV or HFOT were eligible. PubMed, MEDLINE, The Cochrane Library and CINAHL databased were searched from June 2013 to June 2023. Studies were quality appraised.

RESULTS

19 studies representing 2822 ICU patients were included (participants mean age 48 years to 71 years; proportion of males 43-100%). The weighted mean prevalence of breathlessness in ICU patients receiving IMV was 49% (range 34-66%). The proportion of patients receiving NIV self-reporting moderate to severe dyspnoea was 55% prior to initiation. Breathlessness assessment tools included visual analogue scale, (VAS), numerical rating scale, (NRS) and modified BORG scale, (mBORG). In patients receiving NIV the highest reported median (interquartile range [IQR]) VAS, NRS and mBORG scores were 6.2cm (0-10 cm), 5 (2-7) and 6 (2.3-7) respectively (moderate to severe breathlessness). In patients receiving either NIV or HFOT the highest reported median (IQR) VAS, NRS and mBORG scores were 3 cm (0-6 cm), 8 (5-10) and 4 (3-5) respectively.

CONCLUSION

Breathlessness in adults receiving IMV, NIV or HFOT in the ICU is prevalent and clinically important with median intensity ratings indicating the presence of moderate to severe symptoms.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Interventions Relieving Dyspnea in Intubated Patients Show Responsiveness of the Mechanical Ventilation-Respiratory Distress Observation Scale

Rationale: Breathing difficulties are highly stressful. In critically ill patients, they are associated with an increased risk of posttraumatic manifestations. Dyspnea, the corresponding symptom, cannot be directly assessed in noncommunicative patients. This difficulty can be circumvented using observation scales such as the mechanical ventilation-respiratory distress observation scale (MV-RDOS). Objective: To investigate the performance and responsiveness of the MV-RDOS to infer dyspnea in noncommunicative intubated patients. Methods: Communicative and noncommunicative patients exhibiting breathing difficulties under mechanical ventilation were prospectively included and assessed using a dyspnea visual analog scale, MV-RDOS, EMG activity of alae nasi and parasternal intercostals, and EEG signatures of respiratory-related cortical activation (preinspiratory potentials). Inspiratory-muscle EMG and preinspiratory cortical activities are surrogates of dyspnea. Assessments were conducted at baseline, after adjustment of ventilator settings, and, in some cases, after morphine administration. Measurements and Main Results: Fifty patients (age, 67 [(interquartile interval [IQR]), 61-76] yr; Simplified Acute Physiology Score II, 52 [IQR, 35-62]) were included, 25 of whom were noncommunicative. Relief occurred in 25 (50%) patients after ventilator adjustments and in 21 additional patients after morphine administration. In noncommunicative patients, MV-RDOS score decreased from 5.5 (IQR, 4.2-6.6) at baseline to 4.2 (IQR, 2.1-4.7; P < 0.001) after ventilator adjustments and 2.5 (IQR, 2.1-4.2; P = 0.024) after morphine administration. MV-RDOS and alae nasi/parasternal EMG activities were positively correlated (ρ = 0.41 and 0.37, respectively). MV-RDOS scores were higher in patients with EEG preinspiratory potentials (4.9 [IQR, 4.2-6.3] vs. 4.0 [IQR, 2.1-4.9]; P = 0.002). Conclusions: The MV-RDOS seems able to detect and monitor respiratory symptoms reasonably well in noncommunicative intubated patients. Clinical trial registered with www.clinicaltrials.gov (NCT02801838).

Care practices for patients requiring mechanical ventilation more than seven days in Swedish intensive care units: A national survey

OBJECTIVE

To identify care practices in Swedish intensive care units specific to patients requiring mechanical ventilation for >7 days.

RESEARCH METHODOLOGY

We conducted a national cross-sectional survey inviting all adult Swedish ICUs (n = 79). Nurse managers were invited by email to complete a questionnaire by telephone. The questionnaire included seven domains: ventilator weaning, mobilisation, communication, nutrition, symptom assessment, psychosocial support and organisational characteristics.

RESULTS

We received responses from 77 units (response rate, 97%). Weaning protocols were available in 42 (55%) units, 52 (68%) used individualised weaning strategies and 50 (65%) involved physicians and nurses in collaborative decision making. In 48 units (62%), early mobilisation was prioritised using bed cycling but only 26 (34%) units had mobilisation protocols. Most of the intensive care units (74, 96%) had nutrition protocols but only 2 (3%) had dedicated dieticians. Delirium screening tools were available in 49 (64%) ICUs, 3 (4%) assessed anxiety and none assessed dyspnoea. Nineteen (25%) units employed a primary nursing model and 11 (14%) indicated person-centred care policies. Regular case conferences, including family participation, were held by 39 (51%) units.

CONCLUSION

We found that an individualised approach to ventilator weaning, decided by physicians and nurses in collaboration, was the predominant approach, although weaning protocols were available in some intensive care units. Most units prioritised early mobilisation, though few used protocols. Nutritional protocols were widely adopted, as few units had a dedicated dietician.

Provider-Documented Dyspnea in Intensive Care Unit After Lung Transplantation

BACKGROUND

Dyspnea is an important problem that might affect the clinical course after lung transplantation; however, the prevalence, risk factors, and relevant outcomes of dyspnea in the intensive care unit (ICU) after lung transplantation remain unknown.

METHODS

This retrospective, observational study enrolled consecutive patients aged ≥ 20 years who were admitted to the ICU after lung transplantation between January 2010 and December 2020. The main outcome measure was provider-documented dyspnea identified based on a comprehensive retrospective chart review to extract dyspnea episodes (e.g., documented words related to "dyspnea," "shortness of breath," or "breathlessness").

RESULTS

This study included 184 lung transplant recipients, including 115 bilateral (63%) and 69 single (37%) lung transplants. Fifty-four transplants were from living donors (29%), and 130 were from deceased donors (71%). Dyspnea was documented in 116 patients (63%). Multivariate analysis identified bilateral lung transplantation (odds ratio = 5.127; 95% confidence interval, 2.020-13.014; P < .001) as a risk factor for dyspnea. In addition, postoperative anxiety (odds ratio = 18.605; 95% confidence interval, 7.748-44.674; P < .001) was independently associated with dyspnea. Patients with documented dyspnea showed delayed rehabilitation (P < .001) and weaning from mechanical ventilation (P < .001) and a longer ICU stay (P < .001).

CONCLUSION

This study demonstrated that the prevalence of dyspnea in the ICU after lung transplantation was frequent and identified bilateral lung transplantation as a risk factor. Dyspnea caused a delay in rehabilitation and weaning from mechanical ventilation. Extensive evaluation and care for dyspnea and anxiety may enhance patient recovery.

Dyspnea and the electromyographic activity of inspiratory muscles during weaning from mechanical ventilation

Rationale

Dyspnea, a key symptom of acute respiratory failure, is not among the criteria for spontaneous breathing trial (SBT) failure. Here, we sought (1) to determine whether dyspnea is a reliable failure criterion for SBT failure; (2) to quantify the relationship between dyspnea and the respective electromyographic activity of the diaphragm (EMGdi), the parasternal (EMGpa) and the Alae nasi (EMGan).

Methods

Mechanically ventilated patients undergoing an SBT were included. Dyspnea intensity was measured by the Dyspnea-Visual Analogic Scale (Dyspnea-VAS) at the initiation and end of the SBT. During the 30-min SBT or until SBT failure, the EMGdi was continuously measured with a multi-electrode nasogastric catheter and the EMGan and EMGpa with surface electrodes.

Results

Thirty-one patients were included, SAPS 2 (median [interquartile range]) 53 (37‒74), mechanically ventilated for 6 (3‒10) days. Seventeen patients (45%) failed the SBT. The increase in Dyspnea-VAS along the SBT was higher in patients who failed (6 [4‒8] cm) than in those who passed (0 [0‒1] cm, p = 0.01). The area under the receiver operating characteristics curve for Dyspnea-VAS was 0.909 (0.786–1.032). The increase in Dyspnea-VAS was significantly correlated to the increase in EMGan (Rho = 0.42 [0.04‒0.70], p < 0.05), but not to the increase in EMGpa (Rho = − 0.121 [− 0.495 to − 0.290], p = 0.555) and EMGdi (Rho = − 0.26 [− 0.68 to 0.28], p = 0.289).

Conclusion

Dyspnea is a reliable criterion of SBT failure, suggesting that Dyspnea-VAS could be used as a monitoring tool of the SBT. In addition, dyspnea seems to be more closely related to the electromyographic activity of the Alae nasi than of the diaphragm.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01025-5.

Respiratory distress observation scales to predict weaning outcome

Background

Whether dyspnea is present before starting a spontaneous breathing trial (SBT) and whether it may affect the outcome of the SBT is unknown. Mechanical Ventilation—Respiratory Distress Observation Scale (MV-RDOS) has been proposed as a reliable surrogate of dyspnea in non-communicative intubated patients. In the present study, we sought (1) to describe the evolution of the MV-RDOS during a SBT and (2) to investigate whether MV-RDOS can predict the outcome of the SBT.

Methods

Prospective, single-center study in a twenty-two bed ICU in a tertiary center. Patients intubated since more 48 h who had failed a first SBT were eligible if they meet classical readiness to wean criteria. The MV-RDOS was assessed before, at 2-min, 15-min and 30-min (end) of the SBT. The presence of clinically important dyspnea was inferred by a MV-RDOS value ≥  2.6.

Results

Fifty-eight patients (age 63 [51–70], SAPS II 66 [51–76]; med [IQR]) were included. Thirty-three (57%) patients failed the SBT, whose 18 (55%) failed before 15-min. Twenty-five (43%) patients successfully passed the SBT. A MV-RDOS ≥ 2.6 was present in ten (17%) patients before to start the SBT. All these ten patients subsequently failed the SBT. A MV-RDOS ≥ 2.6 at 2-min predicted a SBT failure with a 51% sensibility and a 88% specificity (AUC 0.741 95% confidence interval [CI] 0.616–0.866, p = 0.002). Best cut-off value at 2-min was 4.3 and predicted SBT failure with a 27% sensibility and a 96% specificity.

Conclusion

Despite patients met classical readiness to wean criteria, respiratory distress assessed with the MV-RDOS was frequent at the beginning of SBT. Measuring MV-RDOS before to initiate a SBT could avoid undue procedure and reduce patient’s exposure to unnecessary mechanical ventilation weaning failure and distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04028-7.

Patients’ and their caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD: a qualitative study

Introduction

Regular, low-dose, sustained-release morphine is effective in reducing chronic breathlessness in people with advanced disease, particularly in patients with chronic obstructive pulmonary disease (COPD). Despite experiencing a reduction in breathlessness, some patients choose not to continue long-term treatment.

Aim

This study aimed to explore patients’ and caregivers’ experiences with regular, low-dose, sustained-release morphine for chronic breathlessness associated with COPD.

Methods

A qualitative study embedded in a randomised controlled trial (RCT) of regular low-dose, sustained-release morphine for chronic breathlessness for people with COPD and modified Medical Research Council breathlessness scale 3–4. After completing the RCT or withdrawing, patients and their caregivers were invited to participate in interviews in their homes focused on their experiences with the trial medication while still blinded to the arm to which they had been allocated. Data analysis used a constant comparative method informed by the principles of grounded theory.

Results

Thirteen patients and nine caregivers participated. Four themes were identified: (1) Receptivity and knowledge; (2) Function as a priority; (3) Harmful and helpful side effects; and (4) Therapy-centred aspects. The concept of ‘net effect’ emerged from the interplay between themes, subthemes and the decision to continue taking sustained-release morphine during the trial and after trial completion.

Conclusion

Clinicians’ support and preconceived ideas about morphine influence the decision to commence sustained-release morphine. The hope for functional improvement is the great driver influencing positively the decision to take sustained-release morphine in the long term. The degree of symptom reduction, improved function, side-effects’ severity and caregivers’ availability creates a net effect driving patients’ decisions to continue or discontinue the medication.

Identification of Uncontrolled Symptoms in Cancer Patients Using Natural Language Processing

CONTEXT

For patients with cancer, uncontrolled pain and other symptoms are the leading cause of unplanned hospitalizations. Early access to specialty palliative care (PC) is effective to reduce symptom burden, but more efficient approaches are needed for rapid identification and referral. Information on symptom burden largely exists in free-text notes, limiting its utility as a trigger for best practice alerts or automated referrals.

OBJECTIVES

To evaluate whether natural language processing (NLP) can be used to identify uncontrolled symptoms (pain, dyspnea, or nausea/vomiting) in the electronic health record (EHR) among hospitalized cancer patients with advanced disease.

METHODS

The dataset included 1,644 hospitalization encounters for cancer patients admitted from 1/2017 -6/2019. We randomly sampled 296 encounters, which included 15,580 clinical notes. We manually reviewed the notes and recorded symptom severity. The primary endpoint was an indicator for whether a symptom was labeled as "controlled" (none, mild, not reported) or as "uncontrolled" (moderate or severe). We randomly split the data into training and test sets and used the Random Forest algorithm to evaluate final model performance.

RESULTS

Our models predicted presence of an uncontrolled symptom with the following performance: pain with 61% accuracy, 69% sensitivity, and 46% specificity (F1: 69.5); nausea/vomiting with 68% accuracy, 21% sensitivity, and 90% specificity (F1: 29.4); and dyspnea with 80% accuracy, 22% sensitivity, and 88% specificity (F1: 21.1).

CONCLUSION

This study demonstrated initial feasibility of using NLP to identify hospitalized cancer patients with uncontrolled symptoms. Further model development is needed before these algorithms could be implemented to trigger early access to PC.

Which symptoms pose the highest risk in patients calling for an ambulance? A population-based cohort study from Denmark

BACKGROUND

Emergency medical service patients are a vulnerable population and the risk of mortality is considerable. In Denmark, healthcare professionals receive 112-emergency calls and assess the main reason for calling. The main aim was to investigate which of these reasons, i.e. which symptoms or mechanism of injury, contributed to short-term risk of death. Secondary aim was to study 1-30 day-mortality for each symptom/ injury.

METHODS

Historic population-based cohort study of emergency medical service patients calling 112 in the North Denmark Region between 01.01.2016-31.12.2018. We defined 1-day mortality as death on the same or the following day. The frequency of each symptom and cumulative number of deaths on day 1 and 30 together with 1- and 30-day mortality for each symptom/mechanism of injury is presented in proportions. Poisson regression with robust variance estimation was used to estimate incident rates (IR) of mortality with 95% confidence intervals (CI), crude and age and sex adjusted, mortality rates on day 1 per 100,000 person-year in the population.

RESULTS

The five most frequent reasons for calling 112 were "chest pain" (15.9%), "unclear problem" (11.9%), "accidents" (11.2%), "possible stroke" (10.9%), and "breathing difficulties" (8.3%). Four of these contributed to the highest numbers of deaths: "breathing difficulties" (17.2%), "unclear problem" (13.2%), "possible stroke" (8.7%), and "chest pain" (4.7%), all exceeded by "unconscious adult - possible cardiac arrest" (25.3%). Age and sex adjusted IR of mortality per 100,000 person-year was 3.65 (CI 3.01-4.44) for "unconscious adult - possible cardiac arrest" followed by "breathing difficulties" (0.45, CI 0.37-0.54), "unclear problem"(0.30, CI 0.11-0.17), "possible stroke"(0.13, CI 0.11-0.17) and "chest pain"(0.07, CI 0.05-0.09).

CONCLUSION

In terms of risk of death on the same day and the day after the 112-call, "unconscious adult/possible cardiac arrest" was the most deadly symptom, about eight times more deadly than "breathing difficulties", 12 times more deadly than "unclear problem", 28 times more deadly than "possible stroke", and 52 times more deadly than "chest pain". "Breathing difficulties" and "unclear problem" as presented when calling 112 are among the top three contributing to short term deaths when calling 112, exceeding both stroke symptoms and chest pain.

Dyspnea and respiratory muscles ultrasound to predict extubation failure

This study investigated dyspnea intensity and respiratory muscles ultrasound early after extubation to predict extubation failure.It was conducted prospectively in two intensive care units in France and Canada. Patients intubated for at least 48 h were studied within 2 h after an extubation following a successful spontaneous breathing trial. Dyspnea was evaluated by the Dyspnea-Visual Analog Scale from 0 to 10 cm (VAS) and the Intensive Care - Respiratory Distress Observational Scale (range 0-10). The ultrasound thickening fraction of the parasternal intercostal and the diaphragm were measured; limb muscle strength was evaluated using the Medical Research Council score (MRC) (range 0-60).Extubation failure occurred in 21 of the 122 enrolled patients (17%). Dyspnea-VAS and Intensive Care - Respiratory Distress Observational scale were higher in patients with extubation failure versus success: 7 (5-9) cm versus 3 (1-5) cm respectively (p<0.001) and 4.4 (2.5-6.5) versus 2.4 (2.1-2.8) respectively (p<0.001). The ratio of intercostal muscle to diaphragm thickening fraction was significantly higher and MRC was lower in patients with failure (0.9 [0.4-3.0] versus 0.3 [0.2-0.5], p<0.001, and 45 [36-50] versus 52 [44-60], p=0.012). The thickening fraction of the intercostal and its ratio to diaphragm thickening showed the highest area under the receiver operating characteristic curves for an early prediction of extubation failure (0.81). Areas under the receiver operating characteristic curves of Dyspnea-VAS and Intensive Care - Respiratory Distress Observational scale reached 0.78 and 0.74 respectively.Respiratory muscle ultrasound and dyspnea measured within 2 h after extubation predict subsequent extubation failure.

Respiratory Distress Observation Scale Italian Version: Cultural-Linguistic Validation and Psychometric Properties

Dyspnea can be assessed using self-rating scales but, as death approaches, self-reporting becomes difficult. The validated Respiratory Distress Observation Scale measures dyspnea distress. The aim of this study was to develop the Italian version of the Respiratory Distress Observation Scale and to examine its psychometric properties. This was a cross-sectional study, analyzing cultural and linguistic validation, content validity, and psychometric properties. Eighty-nine palliative care subjects were enrolled to validate the Italian version of the Respiratory Distress Observation Scale. Patients had an average age of 74.5 (SD, 11.6) years, and 52% (n = 46) were female. Fourteen experts in palliative care evaluated the Italian Respiratory Distress Observation Scale in terms of the content validity ratio and the content validity index (CVI). The Italian Respiratory Distress Observation Scale was reported with an internal consistency (Cronbach α value) of .72 and an overall substantial interrater reliability (Cohen κ method). The Italian Respiratory Distress Observation Scale achieved a scale-level CVI of 93%, an items-level CVI of greater than 86%, and a minimum content validity ratio value of 0.71. A weak positive correlation was found between the Respiratory Distress Observation Scale and the Dyspnea Visual Analog Scale scores (0.374; P < .001). The Italian Respiratory Distress Observation Scale showed good reliability and validity for patients in palliative care. The Respiratory Distress Observation Scale measured respiratory distress in patients nearest to death.

Air Hunger: A Primal Sensation and a Primary Element of Dyspnea

The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe "air hunger." Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloquially, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations. © 2021 American Physiological Society. Compr Physiol 11:1449-1483, 2021.

Neck and Inspiratory Muscle Recruitment during Inspiratory Loading and Neck Flexion

PURPOSE

This study aimed to compare muscle activation of the diaphragm (DIA), scalenes (SA), parasternal intercostals (PS), and sternomastoid (SM) during submaximal intermittent neck flexion (INF) versus submaximal inspiratory threshold loading (ITL) until task failure in healthy adults.

METHODS

Twelve healthy adults performed submaximal ITL or INF tests in random order for 2 d. Surface electromyography was monitored to acquire root mean square (RMS) and median power frequency (MPF) from the SA, PS, SM, and DIA. Maximal inspiratory pressures and maximal voluntary contraction for neck flexion were determined. Next, participants performed the first submaximal test-ITL or INF-targeting 50% ± 5% of the maximal inspiratory pressure or maximal voluntary contraction, respectively, until task failure. After a rest, they performed the other test until task failure. Two days later, they performed ITL and INF but in the opposite order. The Borg scale assessed breathlessness and perceived exertion.

RESULTS

Endurance times for ITL and INF were 38.1 and 26.3 min, respectively. INF activated three of four inspiratory muscles at higher average RMS (PS, SM, and SA) and at different MPF (PS, SM, and DIA but not SA) compared with ITL. During ITL, RMS did not change in the four inspiratory muscles over time, but MPF decreased in PS, SM, and SA (P < 0.04). In contrast, RMS increased in three of four inspiratory muscles (SM, PS, and SA) during INF, but MPF did not change throughout its duration. Borg rating was 3.9-fold greater than ITL compared with INF.

CONCLUSION

At a similar percentage of maximal load, INF evokes greater activation of primary muscles of inspiration (PS and SA) and a major accessory muscle of inspiration (SM) compared with ITL during a prolonged submaximal protocol.

Competence in caring for patients with respiratory insufficiency: A cross-sectional study

OBJECTIVES

To compare nurses' self-assessed competence and perceived need for more training in intensive care units treating patients with respiratory insufficiency before and after completion of a seven-hour educational programme, and to assess whether factors such as age, educational level, years of experience and percentage of employment are associated with these outcomes.

RESEARCH METHODOLOGY

The study had a quantitative, cross-sectional, descriptive design, with two measurement times. The ProffNurse SAS questionnaire was used to assess nurses' self-assessed competence and perceived need for more training.

SETTING

Nurses in one medical/surgical intensive care unit and one medical intensive care unit in a hospital in Norway.

MAIN OUTCOME MEASURES

Nurses' self-assessed competence and perceived need for more training.

RESULTS

The pre- and post-education studies comprised responses from 85 (52%) and 52 (32%) nurses, respectively. The educational programme contributed to increased self-assessed competence in seven items. Self-assessed competence was significantly associated with nurses' educational level, and critical care nurses reported higher self-assessed competence than registered nurses on 50% of the items.

CONCLUSION

The findings fill a gap in knowledge about nurses' competence in treating patients with respiratory insufficiency in intensive care units. Both education days and further education have beneficial effects on self-assessed competence.

Nurse-initiated spontaneous breathing trials in adult intensive care unit patients: a scoping review

OBJECTIVE

The objective of this scoping review was to explore existing literature on protocols initiated by nurses for a spontaneous breathing trial in adult intensive care unit (ICU) patients in order to examine and conceptually map the evidence, and identify gaps in the literature.

INTRODUCTION

Nurses are vital in the care of the critically ill mechanically ventilated patient. By involving the nurse in the weaning process through implementing the final stage of the weaning process, the spontaneous breathing trial, patients may liberate from mechanical ventilation more readily, thereby reducing the cost of care and number of complications associated with prolonged ventilation.

INCLUSION CRITERIA

This review considered experimental and quasi-experimental study designs, analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational studies, qualitative studies, and text and opinion papers. Adult ICU patients, aged 18 and over who were mechanically ventilated and candidates for weaning to spontaneous breathing trials, were included in the review. Adult ICUs included but were not limited to burn ICUs, cardiovascular ICUs, medical ICUs, neurological ICUs, surgical ICUs and trauma ICUs in all geographic locations. This scoping review considered studies that examined the use of nurse-initiated protocols for a spontaneous breathing trial.

METHODS

The Joanna Briggs Institute scoping review methodology was used. Key information sources searched were Cochrane Database of Systematic Reviews, PubMed, PROSPERO, DARE, CINAHL, Embase, Scopus, Academic Search Premier, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, MedNar, ProQuest Dissertations and Theses, Papers First and societal websites with information relevant to the scoping review. Only studies published in English were included, and no date limits were applied. The data extraction tool was developed by the authors to examine information retrieved from the studies.

RESULTS

Four studies, with 430 participants, were included in this review. One study was a non-randomized controlled trial, two were randomized controlled studies, and one was a text and opinion paper. The four studies included in the review identified both eligibility criteria for spontaneous breathing trial initiation, detailed elements of a spontaneous breathing trial, and criteria for success. Three of the four studies reported outcomes with the use of protocols for spontaneous breathing trials initiated by nurses.

CONCLUSIONS

All included studies support the utilization of protocols and allowing the nurse to initiate the protocol, however variations in the eligibility criteria, details of the spontaneous breathing trial and success criteria create ambiguity in practice.

Dyspnea, Acute Respiratory Failure, Psychological Trauma, and Post-ICU Mental Health: A Caution and a Call for Research

Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.

Nursing perspectives and strategies in patients with respiratory insufficiency

BACKGROUND

Approximately 30% of patients admitted to an intensive care unit experience respiratory distress. The COVID-19 pandemic has led to an enormous increase in patients with respiratory symptoms. Nurse competence is essential for ensuring quality treatment and care for these patients; however, research on nursing strategies for patients with respiratory insufficiency is limited.

AIM

This study explored nurses' perspectives on and nursing strategies in patients with respiratory insufficiency when admitted to three different intensive care units.

DESIGN

The study had an exploratory, descriptive, qualitative design.

METHODS

Four focus group interviews with a total of 20 nurses, critical care nurses, and critical care nursing students were conducted. Data were analysed using content analysis.

RESULTS

Participants' perspectives fell into two main themes: "nurse competence" and "the art of balancing." "Nurse competence" incorporated the sub-themes "observations and assessments," "to make decisions," and "collaboration." The theme 'the art of balancing' incorporated the sub-themes "nursing interventions," "patients feeling safe," and "patient participation."

CONCLUSION

This study contributes new knowledge about nurses' perspectives on patients with respiratory insufficiency. Nurse competence was assumed essential to observe, assess, and treat patients with respiratory insufficiency. Nursing strategies included balancing nursing interventions, conducting medical treatment, and taking a whole-person approach to patients' needs.

RELEVANCE TO CLINICAL PRACTICE

The COVID-19 pandemic has shown the need for nurse competence in caring for patients with respiratory insufficiency. This study adds to existing literature emphasizing the need for competence in health care services. Caring for patients with respiratory insufficiency requires nurses with experience; competence in observation, assessment, and medical treatment; and a whole-person approach to patients' needs.

Standardized measurement of breathlessness during exercise

PURPOSE OF REVIEW

Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion.

RECENT FINDINGS

Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time.

SUMMARY

To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus.

Predicting outcome for ambulance patients with dyspnea: a prospective cohort study

OBJECTIVE

To validate the discrimination and classification accuracy of a novel acute dyspnea scale for identifying outcomes of out-of-hospital patients with acute dyspnea.

METHODS

Prospective observational population-based study in the North Denmark Region. We included patients from July 1, 2017 to September 24, 2019 assessed as having acute dyspnea by the emergency dispatcher or by emergency medical services (EMS) personnel. Patients rated dyspnea using the 11-point acute dyspnea scale. The primary outcomes were hospitalization >2 days, ICU admission within 48 hours of ambulance run, and 30-day mortality. We used 5-fold cross-validation and area under receiver operating curves (AUC) to assess predictive properties of the acute dyspnea scale score alone and combined with vital data, age, and sex.

RESULTS

We included 3144 EMS patients with reported dyspnea. Median acute dyspnea scale score was 7 (interquartile range 5 to 8). The outcomes were: 1966 (63%) hospitalized, 164 (5%) ICU stay, and 224 (9%) died within 30 days of calling the ambulance. The acute dyspnea scale score alone showed poor discrimination for hospitalization (AUC 0.56, 95% confidence intervals: 0.54-0.58), intensive care unit admission (0.58, 0.53-0.62), and mortality (0.46, 0.41-0.50). Vital signs (respiratory rate, blood oxygen saturation, blood pressure, and heart rate) showed similarly poor discrimination for all outcomes. The combination of [vital signs + acute dyspnea scale score] showed better discrimination for hospitalization, ICU admission, and mortality (AUC 0.71-0.72). Patients not able to report an acute dyspnea scale score worse outcomes on all parameters.

CONCLUSION

The dyspnea scale showed poor accuracy and discrimination when predicting hospitalization, stay at intensive care unit, and mortality on its own. However, the dyspnea scale may be beneficial as performance measure and indicator of out-of-hospital care.

Patient experience of severe acute dyspnoea and relief during treatment in ambulances: a prospective observational study

Background

Acute dyspnoea is common among ambulance patients, but little is known of the patients’ experience of symptom. We aimed to investigate ambulance patients initial perceived intensity of acute dyspnoea, and whether they experienced relief during prehospital treatment. Furthermore, to investigate the validity and feasibility of using a subjective dyspnoea score in the ambulance, and its association with objectively measured vital signs.

Methods

We performed a prospective observational study in the North Denmark Region from 1. July 2017 to 30. March 2019. We studied patients over the age of 18 to whom an ambulance was dispatched. Patients with acute dyspnoea assessed either at the emergency call or by ambulance professionals on scene were included. Patients were asked to assess dyspnoea on a 0 to 10 verbal numeric rating scale at the primary contact with the ambulance personnel and immediately before release at the scene or arrival at the hospital. Patients received usual prehospital medical treatment. We used visual inspection and Wilcoxon matched-pairs signed-ranks test, to assess dyspnoea scores and change hereof. Scatterplots and linear regression analyses were used to assess associations between the dyspnoea score and vital signs.

Results

We included 3199 patients with at least one dyspnoea score. Of these, 2219 (69%) had two registered dyspnoea scores. The initial median dyspnoea score for all patients was median 8 (interquartile range 6–10). In 1676 (76%) of patients with two scores, the first score decreased from 8 (6–9) to 4 (2–5) during prehospital treatment. The score was unchanged for 370 (17%) and increased for 51 (2%) patients. Higher respiratory rate, blood pressure, and heart rate was seen with higher dyspnoea scores whereas blood oxygen saturation lowered.

Conclusions

We found that acute dyspnoea scored by ambulance patients, was high on a verbal numerical rating scale but decreased before arrival at hospital, suggesting relief of symptoms. The acute dyspnoea score was statistically associated with vital signs, but of limited clinical relevance; this stresses the importance of patients’ experience of symptoms. To this end, the dyspnoea scale appears feasible in the prehospital setting.

Intensive Care Nurses' Perceptions of Routine Dyspnea Assessment

BACKGROUND

Dyspnea (breathing discomfort) is commonly experienced by critically ill patients and at this time is not routinely assessed and documented. Intensive care unit nurses at the study institution recently instituted routine assessment and documentation of dyspnea in all patients able to report using a numeric scale ranging from 0 to 10.

OBJECTIVE

To assess nurses' perceptions of the utility of routine dyspnea measurement, patients' comprehension of assessment questions, and the impact on nursing practice and to gather nurses' suggestions for improvement.

METHODS

Data were obtained from interviews with intensive care unit nurses in small focus groups and an anonymous online survey randomly distributed to nurses representing all intensive care units.

RESULTS

Intensive care unit nurses affirmed the importance of routine dyspnea assessment and documentation. Before implementing the measurement tool, nurses often assessed for breathing discomfort in patients by using observed signs. Most nurses agreed that routine assessment can be used to predict patients' outcomes and improve patient-centered care. Nurses found the assessment tool easy to use and reported that it did not interfere with workflow. Nurses felt that patients were able to provide meaningful ratings of dyspnea, similar to ratings of pain, and often used patients' ratings in conjunction with observed physical signs to optimize patient care.

CONCLUSION

Our study shows that nurses understand the importance of routine dyspnea assessment and that the addition of a simple patient report scale can improve care delivery and does not add to the burden of work-flow.

Underdetection and Undertreatment of Dyspnea in Critically Ill Patients

Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.

Detection and management of dyspnea in mechanically ventilated patients

PURPOSE OF REVIEW

In ICU patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management.

RECENT FINDINGS

As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering [median dyspnea visual analog scale of 5 (4-7)]. In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one-third of critically ill patients are noncommunicative, and therefore, at high risk of misdiagnosis. Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report.

SUMMARY

Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to noncommunicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed.

Adjusting ventilator settings to relieve dyspnoea modifies brain activity in critically ill patients: an electroencephalogram pilot study

Dyspnoea is frequent and distressing in patients receiving mechanical ventilation, but it is often not properly evaluated by caregivers. Electroencephalographic signatures of dyspnoea have been identified experimentally in healthy subjects. We hypothesized that adjusting ventilator settings to relieve dyspnoea in MV patients would induce EEG changes. This was a first-of-its-kind observational study in a convenience population of 12 dyspnoeic, mechanically ventilated patients for whom a decision to adjust the ventilator settings was taken by the physician in charge (adjustments of pressure support, slope, or trigger). Pre- and post-ventilator adjustment electroencephalogram recordings were processed using covariance matrix statistical classifiers and pre-inspiratory potentials. The pre-ventilator adjustment median dyspnoea visual analogue scale was 3.0 (interquartile range: 2.5–4.0; minimum-maximum: 1–5) and decreased by (median) 3.0 post-ventilator adjustment. Statistical classifiers adequately detected electroencephalographic changes in 8 cases (area under the curve ≥0.7). Previously present pre-inspiratory potentials disappeared in 7 cases post-ventilator adjustment. Dyspnoea improvement was consistent with electroencephalographic changes in 9 cases. Adjusting ventilator settings to relieve dyspnoea produced detectable changes in brain activity. This paves the way for studies aimed at determining whether monitoring respiratory-related electroencephalographic activity can improve outcomes in critically ill patients under mechanical ventilation.

Dyspnea in amyotrophic lateral sclerosis: The Dyspnea-ALS-Scale (DALS-15) essentially contributes to the diagnosis of respiratory impairment

BACKGROUND

Dyspnea is a cardinal but often underestimated symptom in amyotrophic lateral sclerosis (ALS). The newly developed Dyspnea-ALS-Scale (DALS-15) is highly relevant for therapeutic decisions because dyspnea is a separate criterion to consider noninvasive ventilation (NIV) in ALS. In comparison to the limited effects of neuroprotective compounds, NIV has the greatest impact on survival and improves quality of life.

OBJECTIVE

To investigate whether dyspnea corresponds to parameters of respiratory status mainly used in clinical neurological practice. We also investigated if the DALS-15 could help identify patients for consideration of NIV in whom neither spirometry nor blood gas parameters indicate the need for NIV (forced vital capacity (FVC) < 50% or probable <75%, pCO₂ ≥45  mmHg).

METHODS

Seventy ALS patients with dyspnea according to the DALS-15 obtained blood gas analysis and spirometry (FVC in sitting and supine positions). The supine decline in FVC was calculated.

RESULTS

There was no linear relationship between dyspnea and spirometry as well as blood gases. 83% of our patients had an upright FVC still greater than 50% and no daytime hypercapnia.

CONCLUSIONS

Our study clearly shows that dyspnea can occur independently of objective indicators of respiratory impairment like spirometry or blood gases. Hence, the DALS-15 covers another aspect of respiratory impairment than these tests and refers to the subjective component of respiratory impairment. It detects dyspnea in a considerable proportion of patients in whom NIV should thus be considered although their spirometric and blood gas results do not point towards NIV. The DALS-15 therefore may help to improve the stratification of patients with respiratory impairment for more efficient symptom management and timely coordination of care.

Nurse initiated protocols for spontaneous breathing trials in adult intensive care unit patients: a scoping review protocol

REVIEW OBJECTIVES/QUESTIONS

The objectives of this scoping review are to explore the existing literature regarding protocols initated by nurses for a spontaneous breathing trial (SBT) in adult intensive care unit (ICU) patients, to examine and conceptually map the evidence, and to identify any gaps in the literature.The questions of this review are.

The value of dynamic preload variables during spontaneous ventilation

PURPOSE OF REVIEW

To discuss the physiological significance and clinical value of dynamic preload variables in spontaneously breathing patients.

RECENT FINDINGS

Dynamic preload variables reflect the response of the cardiac output to a modification of preload and can therefore be used to assess fluid responsiveness. Continuous dynamic parameters that are calculated from the variations in the arterial and plethysmographic waveforms following a mechanical breath have been shown to predict fluid responsiveness much better than static preload parameters. These parameters are displayed on many patient monitors though their use is limited to mechanically ventilated patients. However, spontaneous breathing may also induce significant hemodynamic changes because of the repetitive negative swings in the pleural pressure. By better understanding the physiological basis of these changes, the same 'dynamic parameters' can be used to gain unique physiological insights during spontaneous breathing. These include the ability to identify and/or monitor respiratory rate, respiratory effort (e.g., patient-ventilator asynchrony), fluid responsiveness (to some degree), pulsus paradoxus (e.g. asthma, cardiac tamponade), and, importantly, upper airway obstruction.

SUMMARY

Although originally intended to be used only during mechanical ventilation, 'dynamic parameters' may offer valuable clinical information in spontaneously breathing patients.

Observing dyspnoea in others elicits dyspnoea, negative affect and brain responses

Dyspnoea is usually caused by diagnosable cardiorespiratory mechanisms. However, frequently dyspnoea relates only weakly or not at all to cardiorespiratory functioning, suggesting that additional neuropsychosocial processes contribute to its experience. We tested whether the mere observation of dyspnoea in others constitutes such a process and would elicit dyspnoea, negative affect and increased brain responses in the observer.

In three studies, series of pictures and videos were presented, which either depicted persons suffering from dyspnoea or nondyspnoeic control stimuli. Self-reports of dyspnoea and affective state were obtained in all studies. Additionally, respiratory variables and brain responses during picture viewing (late positive potentials in electroencephalograms) were measured in one study.

In all studies, dyspnoea-related pictures and videos elicited mild-to-moderate dyspnoea and increased negative affect compared to control stimuli. This was paralleled by increased late positive potentials for dyspnoea-related pictures while respiratory variables did not change. Moreover, increased dyspnoea correlated modestly with higher levels of empathy in observers.

The present results demonstrate that observing dyspnoea in others elicits mild-to-moderate dyspnoea, negative affect, and increased brain responses in the absence of respiratory changes. This vicarious dyspnoea has clinical relevance, as it might increase suffering in the family and medical caregivers of dyspnoeic patients.

Older patients with late-stage COPD: Their illness experiences and involvement in decision-making regarding mechanical ventilation and noninvasive ventilation

AIMS AND OBJECTIVES

To explore the illness experiences of older patients with late-stage chronic obstructive pulmonary disease and to develop knowledge about how patients perceive their preferences to be taken into account in decision-making processes concerning mechanical ventilation and/or noninvasive ventilation.

BACKGROUND

Decisions about whether older patients with late-stage chronic obstructive pulmonary disease will benefit from noninvasive ventilation treatment or whether the time has come for palliative treatment are complicated, both medically and ethically. Knowledge regarding patients' values and preferences concerning ventilation support is crucial yet often lacking.

DESIGN

Qualitative design with a hermeneutic-phenomenological approach.

METHODS

The data consist of qualitative in-depth interviews with 12 patients from Norway diagnosed with late-stage chronic obstructive pulmonary disease. The data were analysed within the three interpretative contexts described by Kvale and Brinkmann.

RESULTS

The participants described their lives as fragile and burdensome, frequently interrupted by unpredictable and frightening exacerbations. They lacked information about their diagnosis and prognosis and were often not included in decisions about noninvasive ventilation or mechanical ventilation.

CONCLUSION

Findings indicate that these patients are highly vulnerable and have complex needs in terms of nursing care and medical treatment. Moreover, they need access to proactive advanced care planning and an opportunity to discuss their wishes for treatment and care.

RELEVANCE TO CLINICAL PRACTICE

To provide competent care for these patients, healthcare personnel must be aware of how patients experience being seriously ill. Advanced care planning and shared decision-making should be initiated alongside the curative treatment.

Neurally Adjusted Ventilatory Assist (NAVA) or Pressure Support Ventilation (PSV) during spontaneous breathing trials in critically ill patients: a crossover trial

Background

Neurally Adjusted Ventilatory Assist (NAVA) is a proportional ventilatory mode that uses the electrical activity of the diaphragm (EAdi) to offer ventilatory assistance in proportion to patient effort. NAVA has been increasingly used for critically ill patients, but it has not been evaluated during spontaneous breathing trials (SBT). We designed a pilot trial to assess the feasibility of using NAVA during SBTs, and to compare the breathing pattern and patient-ventilator asynchrony of NAVA with Pressure Support (PSV) during SBTs.

Methods

We conducted a crossover trial in the ICU of a university hospital in Brazil and included mechanically ventilated patients considered ready to undergo an SBT on the day of the study. Patients underwent two SBTs in randomized order: 30 min in PSV of 5 cmH₂O or NAVA titrated to generate equivalent peak airway pressure (Paw), with a positive end-expiratory pressure of 5 cmH₂O. The ICU team, blinded to ventilatory mode, evaluated whether patients passed each SBT. We captured flow, Paw and electrical activity of the diaphragm (EAdi) from the ventilator and used it to calculate respiratory rate (RR), tidal volume (VT), and EAdi. Detection of asynchrony events used waveform analysis and we calculated the asynchrony index as the number of asynchrony events divided by the number of neural cycles.

Results

We included 20 patients in the study. All patients passed the SBT in PSV, and three failed the SBT in NAVA. Five patients were reintubated and the extubation failure rate was 25% (95% CI 9–49%). Respiratory parameters were similar in the two modes: VT = 6.1 (5.5–6.5) mL/Kg in NAVA vs. 5.5 (4.8–6.1) mL/Kg in PSV (p = 0.076) and RR = 27 (17–30) rpm in NAVA vs. 26 (20–30) rpm in PSV, p = 0.55. NAVA reduced AI, with a median of 11.5% (4.2–19.7) compared to 24.3% (6.3–34.3) in PSV (p = 0.033).

Conclusions

NAVA reduces patient-ventilator asynchrony index and generates a respiratory pattern similar to PSV during SBTs. Patients considered ready for mechanical ventilation liberation may be submitted to an SBT in NAVA using the same objective criteria used for SBTs in PSV.

Trial registration

ClinicalTrials.gov (NCT01337271), registered April 12, 2011.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0484-5) contains supplementary material, which is available to authorized users.

Dyspnea

Dyspnea is a subjective experience of breathing discomfort that can only be known through a patient's report. Numeric rating or visual analog scales allow assessment of intensity when the patient can self-report. The Respiratory Distress Observation Scale is a valid, reliable tool for estimating distress when self-report cannot be elicited. Treating dyspnea begins with managing the underlying condition. Other dyspnea-specific evidence-based interventions include morphine and fentanyl, upright positioning, oxygen, invasive and noninvasive ventilation, and balancing rest with activity. Effectiveness has not been established for benzodiazepines, nebulized furosemide, oxygen in the face of normoxemia, other opioids, and nebulized fentanyl.

Update in Critical Care 2015

This review documents important progress made in 2015 in the field of critical care. Significant advances in 2015 included further evidence for early implementation of low tidal volume ventilation as well as new insights into the role of open lung biopsy, diaphragmatic dysfunction, and a potential mechanism for ventilator-induced fibroproliferation. New therapies, including a novel low-flow extracorporeal CO2 removal technique and mesenchymal stem cell-derived microparticles, have also been studied. Several studies examining the role of improved diagnosis and prevention of ventilator-associated pneumonia also showed relevant results. This review examines articles published in the American Journal of Respiratory and Critical Care Medicine and other major journals that have made significant advances in the field of critical care in 2015.

DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

Background

The assessment of the work of breathing in the definitions of respiratory failure is vague and variable.

Objective

Identify a parsimonious set of signs to describe the work of breathing in hypoxemic, acutely ill patients.

Methods

We examined consecutive medical ICU patients receiving oxygen with a mask, non-invasive ventilation, or T-piece. A physician inspected each patient for 10 seconds, rated the level of respiratory distress, and then examined the patient for vital signs and 17 other physical signs. We used the rating of distress as a surrogate for measuring the work of breathing, constructed three multivariate models to identify the one with the smallest number of signs and largest explained variance, and validated it with bootstrap analysis.

Results

We performed 402 observations on 240 patients. Respiratory distress was absent in 78, mild in 157, moderate in 107, and severe in 60. Respiratory rate, hypoxia, heart rate, and frequency of most signs increased as distress increased. Respiratory rate and hypoxia explained 43% of the variance in respiratory distress. Diaphoresis, gasping, and contraction of the sternomastoid explained an additional 28%. Heart rate, blood pressure, alertness, agitation, body posture, nasal flaring, audible breathing, cyanosis, tracheal tug, retractions, paradox, scalene or abdominal muscles contraction did not increase the explained variance in respiratory distress.

Conclusion

Most of the variance is respiratory distress can be explained by five signs summarized by the mnemonic DiapHRaGM (diaphoresis, hypoxia, respiratory rate, gasping, accessory muscle). This set of signs may allow for efficient, standardized assessments of the work of breathing of hypoxic patients.

The breath of life. Patients' experiences of breathing during and after mechanical ventilation

INTRODUCTION

Breathlessness is a prevalent and distressing symptom in intensive care, underestimated by nurses and physicians. Therefore, to develop a more comprehensive understanding of this problem, the study had two aims: to compare patients' self-reported scores of breathlessness obtained during mechanical ventilation (MV) with experiences of breathlessness later recalled by patients and: to explore the lived experience of breathing during and after MV.

METHOD

A qualitatively driven sequential mixed method design combining prospective observational breathlessness data at the end of a spontaneous breathing trial (SBT) and follow up data from 11 post-discharge interviews.

FINDINGS

Four out of six patients who reported breathlessness at the end of an SBT did not remember being breathless in retrospect. Experiences of breathing intertwined with the whole illness experience and were described in four themes: existential threat; the tough time; an amorphous and boundless body and getting through.

CONCLUSION

Breathing was not always a clearly separate experience, but intertwined with the whole illness experience. This may explain the poor correspondence between patients' and clinicians assessments of breathlessness. The results suggest patients' own reports of breathing should form part of nursing interventions and follow-up to support patients' quest for meaning.

Routine dyspnea assessment and documentation: Nurses' experience yields wide acceptance

Background

Dyspnea (breathing discomfort) is a common and distressing symptom. Routine assessment and documentation can improve management and relieve suffering. A major barrier to routine dyspnea documentation is the concern that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses. Nurses at our institution recently began to assess and document dyspnea on all medical-surgical patients upon admission and once per shift throughout their hospitalization. A year after dyspnea measurement was implemented we explored nurses’ approach to dyspnea assessment, their perception of patient response, and their perception of the utility and burden of dyspnea measurement.

Methods

We obtained feedback from nurses using a three-part assessment of practice: 1) a series of recorded focus group interviews with nurses, 2) a time-motion observation of nurses performing routine dyspnea and pain assessment, and 3) a randomized, anonymous on-line survey based, in part, on issues raised in focus groups.

Results

Ninety-four percent of the nurses surveyed reported administering the dyspnea assessment is “easy” or “very easy”. None of the nurses reported that assessing dyspnea negatively impacted workflow and many reported that it positively improved their practice by increasing their awareness. Our time-motion data showed dyspnea assessment and documentation takes well less than a minute. Nurses endorsed the importance of routine measurement and agreed that most patients were able to provide a meaningful rating of their dyspnea. Nurses found the patient report very useful, and used it in conjunction with observed signs to respond to changes in a patient’s condition.

Conclusions

In this study, we have demonstrated that routine dyspnea assessment and documentation was widely accepted by the nurses at our institution. Our nurses fully incorporated routine dyspnea assessment and documentation into their practice and felt that it improved patient-centered care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-016-0196-9) contains supplementary material, which is available to authorized users.

How well do patients and providers agree on the severity of dyspnea?

BACKGROUND

Understanding the severity of patients' dyspnea is critical to avoid under- or overtreatment of patients with acute cardiopulmonary conditions.

OBJECTIVE

To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment.

DESIGN, SETTINGS AND PARTICIPANTS

Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital.

INTERVENTION AND MEASUREMENTS

A numerical rating scale (0-10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over- or underestimations. The relationship between patient self-perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient.

RESULTS

Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient-physician and 138 patient-nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance.

CONCLUSIONS

Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016;11:701-707. © 2016 Society of Hospital Medicine.