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Richardson BR, Decavèle M, Demoule A, Murtagh FEM, Johnson MJ. Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis. Ann Intensive Care 2024; 14:107. [PMID: 38967813 PMCID: PMC11229436 DOI: 10.1186/s13613-024-01338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/18/2024] [Indexed: 07/06/2024] Open
Abstract
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.
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Affiliation(s)
- Ben R Richardson
- School of Health and Life Sciences, Teesside University, Tees Valley, Middlesbrough, TS1 3BX, UK
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), 75013, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), 75013, Paris, France
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Cottingham Road, Hull, HU6 7RX, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Cottingham Road, Hull, HU6 7RX, UK.
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Eur Respir J 2024; 63:2300347. [PMID: 38387998 DOI: 10.1183/13993003.00347-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
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.
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Affiliation(s)
- Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Maxens Decavele
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behaviorial Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- L. Heunks and T. Similowski contributed equally to the manuscript
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, F-75013 Paris, France
- L. Heunks and T. Similowski contributed equally to the manuscript
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Camporota L, Rose L, Andrews PL, Nieman GF, Habashi NM. Airway pressure release ventilation for lung protection in acute respiratory distress syndrome: an alternative way to recruit the lungs. Curr Opin Crit Care 2024; 30:76-84. [PMID: 38085878 DOI: 10.1097/mcc.0000000000001123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Airway pressure release ventilation (APRV) is a modality of ventilation in which high inspiratory continuous positive airway pressure (CPAP) alternates with brief releases. In this review, we will discuss the rationale for APRV as a lung protective strategy and then provide a practical introduction to initiating APRV using the time-controlled adaptive ventilation (TCAV) method. RECENT FINDINGS APRV using the TCAV method uses an extended inspiratory time and brief expiratory release to first stabilize and then gradually recruit collapsed lung (over hours/days), by progressively 'ratcheting' open a small volume of collapsed tissue with each breath. The brief expiratory release acts as a 'brake' preventing newly recruited units from re-collapsing, reversing the main drivers of ventilator-induced lung injury (VILI). The precise timing of each release is based on analysis of expiratory flow and is set to achieve termination of expiratory flow at 75% of the peak expiratory flow. Optimization of the release time reflects the changes in elastance and, therefore, is personalized (i.e. conforms to individual patient pathophysiology), and adaptive (i.e. responds to changes in elastance over time). SUMMARY APRV using the TCAV method is a paradigm shift in protective lung ventilation, which primarily aims to stabilize the lung and gradually reopen collapsed tissue to achieve lung homogeneity eliminating the main mechanistic drivers of VILI.
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Affiliation(s)
- Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences
| | - Louise Rose
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust
- Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK
| | - Penny L Andrews
- Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Gary F Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York, USA
| | - Nader M Habashi
- Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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4
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Intensive Care Med 2024; 50:159-180. [PMID: 38388984 DOI: 10.1007/s00134-023-07246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
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.
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.
| | - Maxens Decavele
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behavioral Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
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Sher Y, Desai N, Sole J, D'souza MP. Dyspnea and Dyspnea-Associated Anxiety in the ICU Patient Population: A Narrative Review for CL Psychiatrists. J Acad Consult Liaison Psychiatry 2024; 65:54-65. [PMID: 37952697 DOI: 10.1016/j.jaclp.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Consultation-liaison psychiatrists frequently address dyspnea in intensive care unit (ICU) patients. Dyspnea is common in this patient population, but is frequently misunderstood and underappreciated in noncommunicative ICU patients. OBJECTIVE This paper provides an updated review on dyspnea specifically in the ICU population, including its pathophysiology and management, pharmacological and nonpharmacological, aimed at consultation-liaison psychiatrists consulting in ICU. METHODS A literature review was conducted with PubMed, querying published articles for topics associated with dyspnea and dyspnea-associated anxiety in ICU patient populations. When literature in ICU populations was limited, information was deduced from dyspnea and anxiety management from non-ICU populations. Articles discussing the definition of dyspnea, mechanistic pathways, screening tools, and pharmacologic and nonpharmacologic management were included. RESULTS A reference guide was created to help consultation-liaison psychiatrists and intensivists in the screening and treatment of dyspnea and dyspnea-associated anxiety in critically ill patients. CONCLUSIONS Dyspnea is frequently associated with anxiety, prolonged days on mechanical ventilation, and worse quality of life after discharge. It can also increase the risk of posttraumatic stress disorder post-ICU discharge. However, it is not routinely screened for, identified, or addressed in the ICU. This manuscript provides an updated review on dyspnea and dyspnea-associated anxietyin the ICU population, including its pathophysiology and management, and offers a useful reference for consultation-liaison psychiatrists to provide treatment recommendations.
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Affiliation(s)
- Yelizaveta Sher
- Division of Medical Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.
| | - Nikita Desai
- Division of Critical Care Medicine, Department of Medicine, Stanford University School of Medicine
| | - Jon Sole
- Division of Medical Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine
| | - Melissa Patricia D'souza
- Division of Critical Care Medicine, Department of Medicine, Stanford University School of Medicine
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Medrinal C, Machefert M, Lamia B, Bonnevie T, Gravier FE, Hilfiker R, Prieur G, Combret Y. Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study. Crit Care 2023; 27:338. [PMID: 37649092 PMCID: PMC10469422 DOI: 10.1186/s13054-023-04597-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. METHODS We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. RESULTS Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. CONCLUSION TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. TRIAL REGISTRATION Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.
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Affiliation(s)
- Clément Medrinal
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France.
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France.
| | - Margaux Machefert
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Physiotherapy Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Bouchra Lamia
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology, Respiratory Department, Rouen University Hospital, Rouen, France
| | - Tristan Bonnevie
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Adir Association, 76230, Bois Guillaume, France
| | - Francis-Edouard Gravier
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Adir Association, 76230, Bois Guillaume, France
| | - Roger Hilfiker
- Research and Independent Studies in Private Physiotherapy (RISE), 3902, Brig, Switzerland
| | - Guillaume Prieur
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Yann Combret
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
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Decavèle M, Bureau C, Campion S, Nierat MC, Rivals I, Wattiez N, Faure M, Mayaux J, Morawiec E, Raux M, Similowski T, Demoule A. Interventions Relieving Dyspnea in Intubated Patients Show Responsiveness of the Mechanical Ventilation-Respiratory Distress Observation Scale. Am J Respir Crit Care Med 2023; 208:39-48. [PMID: 36973007 DOI: 10.1164/rccm.202301-0188oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/27/2023] [Indexed: 03/29/2023] Open
Abstract
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).
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Affiliation(s)
- Maxens Decavèle
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S) and
| | - Côme Bureau
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S) and
| | - Sébastien Campion
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Département d'Anesthésie Réanimation, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, site Pitié-Salpêtrière, Paris, France; and
| | - Marie-Cécile Nierat
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Isabelle Rivals
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Equipe de Statistique Appliquée, Ecole Supérieure de Physique et de Chimie Industrielles Paris, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Nicolas Wattiez
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Morgane Faure
- Service de Médecine Intensive et Réanimation (Département R3S) and
| | - Julien Mayaux
- Service de Médecine Intensive et Réanimation (Département R3S) and
| | - Elise Morawiec
- Service de Médecine Intensive et Réanimation (Département R3S) and
| | - Mathieu Raux
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Département d'Anesthésie Réanimation, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, site Pitié-Salpêtrière, Paris, France; and
| | - Thomas Similowski
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Département d'Anesthésie Réanimation, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, site Pitié-Salpêtrière, Paris, France; and
| | - Alexandre Demoule
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche en Santé 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S) and
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Schwartzstein RM, Sturley R. DYSPNEA AND MECHANICAL VENTILATION: APPLYING PHYSIOLOGY TO GUIDE THERAPY. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2023; 133:162-180. [PMID: 37701590 PMCID: PMC10493724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
While advances in our understanding of mechanical ventilation have improved mortality from acute respiratory distress syndrome, recent studies indicate a rising incidence of post-ventilation mental health sequelae, including post-traumatic stress disorder (PTSD). Concurrent research on the physiology of dyspnea provides insights about the role of multiple sources of sensory information underlying respiratory discomfort along with the contribution of efferent-afferent dissociation to dyspnea, and the subsequent relationship of dyspnea to a range of affective responses, including fear and anxiety. An understanding of the mechanisms of dyspnea may provide holistic approaches to managing acute respiratory failure that can achieve the best physical and emotional outcomes for patients requiring mechanical ventilation.
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