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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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Bureau C, Schmidt M, Chommeloux J, Rivals I, Similowski T, Hékimian G, Luyt CE, Niérat MC, Dangers L, Dres M, Combes A, Morélot-Panzini C, Demoule A. Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study. Anesthesiology 2024; 141:87-99. [PMID: 38436930 DOI: 10.1097/aln.0000000000004962] [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: 03/05/2024]
Abstract
BACKGROUND Data on assessment and management of dyspnea in patients on venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock are lacking. The hypothesis was that increasing sweep gas flow through the venoarterial extracorporeal membrane oxygenator may decrease dyspnea in nonintubated venoarterial ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive. METHODS Nonintubated, spontaneously breathing, supine patients on venoarterial ECMO for cardiogenic shock who presented with a dyspnea visual analog scale (VAS) score of greater than or equal to 40/100 mm were included. Sweep gas flow was increased up to +6 l/min by three steps of +2 l/min each. Dyspnea was assessed with the dyspnea-VAS and the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles. RESULTS A total of 21 patients were included in the study. Upon inclusion, median dyspnea-VAS was 50 (interquartile range, 45 to 60) mm, and sweep gas flow was 1.0 l/min (0.5 to 2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50 [45 to 60] at baseline vs. 20 [10 to 30] at 6 l/min; P < 0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50% [-43 to -75]) than for the affective and emotional components (-17% [-0 to -25] and -12% [-0 to -17]; P < 0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23% [-36 to -10] and -20 [-41 to -0]; P < 0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r = -0.91; 95% CI, -0.94 to -0.87), between the respiratory drive and the sensory component of dyspnea (r = 0.29; 95% CI, 0.13 to 0.44) between the respiratory drive and the affective component of dyspnea (r = 0.29; 95% CI, 0.02 to 0.54) and between the sweep gas flow and the alae nasi and parasternal (r = -0.31; 95% CI, -0.44 to -0.22; and r = -0.25; 95% CI, -0.44 to -0.16). CONCLUSIONS In critically ill patients with venoarterial ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Isabelle Rivals
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Equipe de Statistique Appliquée, ESPCI Paris, Pitié Salpêtrière Research University, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Thomas Similowski
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris University Hospital Group, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière, Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Laurence Dangers
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière, Médecine Intensive-Réanimation Unit, Paris, France
| | - Martin Dres
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, F-75013, Paris, France
| | - Alain Combes
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris Sorbonne, Pitié-Salpêtrière Hospital, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Site Pitié-Salpêtrière, Service de Pneumologie, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, Paris, France
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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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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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Bureau C, Niérat MC, Decavèle M, Rivals I, Dangers L, Beurton A, Virolle S, Deleris R, Delemazure J, Mayaux J, Morélot-Panzini C, Dres M, Similowski T, Demoule A. Sensory interventions to relieve dyspnoea in critically ill mechanically ventilated patients. Eur Respir J 2024; 63:2202215. [PMID: 37678956 DOI: 10.1183/13993003.02215-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND In critically ill patients receiving mechanical ventilation, dyspnoea is frequent, severe and associated with an increased risk of neuropsychological sequelae. We evaluated the efficacy of sensory interventions targeting the brain rather than the respiratory system to relieve dyspnoea in mechanically ventilated patients. METHODS Patients receiving mechanical ventilation for ≥48 h and reporting dyspnoea (unidimensional dyspnoea visual analogue scale (Dyspnoea-VAS)) first underwent increased pressure support and then, in random order, auditory stimulation (relaxing music versus pink noise) and air flux stimulation (facial versus lower limb). Treatment responses were assessed using Dyspnoea-VAS, the Multidimensional Dyspnea Profile and measures of the neural drive to breathe (airway occlusion pressure (P 0.1) and electromyography of inspiratory muscles). RESULTS We included 46 patients (tracheotomy or intubation n=37; noninvasive ventilation n=9). Increasing pressure support decreased Dyspnoea-VAS by median 40 mm (p<0.001). Exposure to music decreased Dyspnoea-VAS compared with exposure to pink noise by median 40 mm (p<0.001). Exposure to facial air flux decreased Dyspnoea-VAS compared with limb air flux by median 30 mm (p<0.001). Increasing pressure support, but not music exposure and facial air flux, reduced P 0.1 by median 3.3 cmH2O (p<0.001). CONCLUSIONS In mechanically ventilated patients, sensory interventions can modulate the processing of respiratory signals by the brain irrespective of the intensity of the neural drive to breathe. It should therefore be possible to alleviate dyspnoea without resorting to pharmacological interventions or having to infringe the constraints of mechanical ventilation lung protection strategies by increasing ventilatory support.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Isabelle Rivals
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Equipe de Statistique Appliquée, ESPCI Paris, PSL Research University, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Laurence Dangers
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Alexandra Beurton
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Sara Virolle
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Robin Deleris
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Julie Delemazure
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Julien Mayaux
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Pneumologie (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire AP-HP-Sorbonne Université, site Pitié-Salpêtrière, Paris, 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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Bureau C, Van Hollebeke M, Dres M. Managing respiratory muscle weakness during weaning from invasive ventilation. Eur Respir Rev 2023; 32:32/168/220205. [PMID: 37019456 PMCID: PMC10074167 DOI: 10.1183/16000617.0205-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 04/07/2023] Open
Abstract
Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH2O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
| | - Marine Van Hollebeke
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Martin Dres
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
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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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