Special Feature

Reducing Patient Discomfort During Mechanical Ventilatory Support — An Integrated Approach

By Linda L. Chlan, RN, PhD, School of Nursing, University of Minnesota, is Associate Editor for Critical Care Alert.

Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.

INTRODUCTION

Patients have referred to receiving mechanical ventilatory support as, "the most inhumane ever experienced"....1 While mechanical ventilation is one of the most commonly used treatment modalities in the ICU, this life-saving modality causes great anxiety, distress, and discomfort in patients. The purpose of this article is to present to the reader patient perceptions of being mechanically ventilated, and how those experiences can be used to inform the implementation of selected, low-tech interventions to reduce discomfort and distress in critically ill patients receiving mechanical ventilatory support. This article is intended to serve as a reminder to clinicians that the ICU environment is "foreign" to a majority of patients and their loved ones. It is an environment that induces great fear and anxiety, which is easily forgotten by clinicians who are accustomed to the high-tech, life-and-death nature of the ICU.

This article is not intended to be an exhaustive review; it will focus on selected non-pharmacologic interventions for which there is evidence of effectiveness that can be integrated into the usual medical plan of care to reduce discomfort, including communication. All clinicians desire that their patients be comfortable. However, reducing discomfort can be an immense challenge in this complex patient population.

DEFINITION OF KEY TERMS

To begin with, the key terms of discomfort, comfort, and pain need to be defined. Discomfort can be defined as to make uncomfortable or uneasy; distress, grief, mental or physical uneasiness; annoyance.2 Comfort, on the other hand, can be defined as a feeling of relief or encouragement; contented well-being; a satisfying or enjoyable experience; to give hope and strength.2 In contrast, pain is defined by the International Association for the Study of Pain3 as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Alleviation of pain and suffering are important goals for clinicians, and many articles have already been written on this salient topic. However, this article will not address pain management interventions per se, but will focus only on interventions for reducing discomfort in critically ill patients receiving mechanical ventilatory support given the frequency with which discomfort is reported by patients. The appropriate use of very simple and effective interventions can be implemented at times to relieve discomfort without pharmacologic means.

SOURCES OF DISCOMFORT FOR PATIENTS RECEIVING MECHANICAL VENTILATORY SUPPORT

It can be argued that the goal of mechanical ventilation is for weaning to take place as soon as medically possible, in order to facilitate the removal of mechanical ventilatory support to avoid lung injury, ventilator-associated pneumonia, and other adverse sequelae associated with this treatment modality. However, this can be a challenge at times as evidenced by the increasing population of patients requiring prolonged mechanical ventilatory support, which can be defined as support for more than 96 hours.4 The need for prolonged mechanical ventilatory support is not projected to decrease in the next 10 years. In fact, a recent study reported that by 2020 there will be an increased need for prolonged ventilatory support in adults, most prominently in those 18-64 years of age.4 Given the complexity and intensity of services surrounding the care of these patients, effective symptom management approaches will be needed that do not prolong ventilator days or ICU stays, nor induce adverse sequelae in these high-intensity patients.

Patients receiving mechanical ventilatory support report a number of distressing and bothersome symptoms. Bothersome and distressing symptoms recalled by ICU patients include both physiological and psychological sources for this distress. These symptoms include anxiety, thirst, fear, discomfort and pain, fatigue, restlessness, inability to sleep, lack of control, loneliness,5 and immense communication challenges to name but a few.5-7 Despite receiving intravenous sedative and analgesic agents, a majority of patients vividly recall their ICU experiences.5,8 Specifically, intubated patients have recalled spells of terror, feeling nervous when left alone, and poor sleeping patterns.5 In fact, patients who had prolonged periods of ventilatory support and ICU stay report being most bothered by the endotracheal tube.8 Patients who received the highest cumulative doses of sedatives and opioids were bothered quite a bit by nightmares, and they also had fewer periods of wakefulness and more agitation that was quite distressing.8 The significance of these findings is that patients still report distressing and uncomfortable symptoms associated with ventilatory support despite the receipt of sedative and opioid medications that are intended to palliate these symptoms. There is much opportunity for improvement in the area of symptom management for these patients.

While this statement is not intended to criticize ICU caregivers, patients receiving mechanical ventilatory support feel as though clinicians pay more attention to the machine (ventilator) and not to them as a person.8 Patients report that they feel "invisible," that they are merely an extension of the apparatus (ventilator system) reduced to organs, objects, or diagnoses.9 Further, patients desire to have their loved ones with them in their immediate presence during this fearful time, as family generally are a source of great comfort and reassurance for patients. Patients desire to know what is happening and require frequent reassurance and reorientation given memory issues with the receipt of sedative and opioid medications. This does not mean that patients desire to be so sedated that they are not aware of their surroundings. This is further from the truth as patients report that they do not like having fragmented memories or not being able to recall their ICU experiences factually.8

INTEGRATED APPROACH TO REDUCE DISCOMFORT AND SYMPTOMS OF DISTRESS ASSOCIATED WITH MECHANICAL VENTILATORY SUPPORT

While the extensive list of distressful patient experiences may seem overwhelming and daunting to manage, there are options other than relying solely on the sometimes automatic, stand-by administration of sedative and opioid medications. While warranted at times, these medications are limited in their effectiveness, given that patients continue to report discomfort and distressing symptoms.5 It is not the intent of this article to discount the practice of medication administration to manage symptoms. Medications are indicated at times to promote synchrony with the mechanical, artificial breaths delivered by the ventilator and reduce the stress response. What is needed is an integrated approach to manage and treat these bothersome symptoms. For the purpose of this article, integrated is defined as the best of pharmacologic therapy and the best of non-pharmacologic therapy to realize the best outcomes for patients. Given the extensive attention in the literature over the recent past on sedation practices and protocols, the remainder of this article will focus on suggested areas for non-pharmacologic interventions to promote an integrated approach to symptom management.

Many ICU patients can remain awake or lightly sedated if they are comfortable.10 There are several "low-tech," non-pharmacologic interventions that can be integrated into ICU care practices to reduce patient discomfort and promote patient comfort. The first area for consideration is that of the many integrative therapies that might be safely implemented with mechanically ventilated patients. Integrative therapies can be defined as those complementary and alternative medicine treatments, modalities, and practices that are combined with conventional medical treatment, and for which there is some evidence of safety and efficacy.11

A recent review article advanced several suggestions for implementing integrative therapies in the ICU beginning with an appraisal of the physical environment.12 Simple enhancements can promote a more healing environment such as noise reduction from alarms, telephones, and clinicians' conversations; promoting day-night cycles with access to natural lighting and less use of artificial lighting during night-time hours; and uninterrupted sleep periods including refraining from performing unnecessary care interventions, such as bathing, during the middle of the night. Other suggestions for managing anxiety and agitation associated with mechanical ventilatory support include uncovering possible causes for these symptoms and appropriate administration of pharmacologic agents coupled with non-pharmacologic adjunctive therapies such as listening to preferred relaxing music, massage, or animal-assisted therapy. Other overlooked "low-tech" integrative interventions include presence and reassurance in a calming manner, given the common symptom of fear reported by these ICU patients.12

DON'T OVERLOOK COMMUNICATION

Compounding the plethora of distressful and bothersome symptoms reported by mechanically ventilated patients are the immense challenges experienced by these non-verbal patients surrounding communication. Communication difficulty is a common, distressing symptom for mechanically ventilated patients.13 Patients report immense frustration, along with increased anxiety and distress, with inadequate communication.14,15 To reduce discomfort through the appropriate management of the myriad of symptoms experienced by these patients, the assessment of symptoms and the effectiveness of interventions must be documented. Just because a patient is mechanically ventilated does not mean that an assessment cannot be performed. There are several communication aids that can be implemented to enhance communication. To reduce patient discomfort, the clinician needs to know or attempt to discern what is bothersome to an individual patient in order to treat and manage symptoms appropriately.

At the core of performing any assessment is communication. Effective communication can be achieved, even in the non-vocal mechanically ventilated patient with a concerted effort, patience, and the assistance of very inexpensive communication aids. While indeed communication attempts can be frustrating to the clinician, several simple and low-cost strategies are proposed to promote effective communication.16 One strategy is to establish a communication-friendly environment that includes speaking directly to the patient and minimizing background noise. Being aware of a patient's visual and hearing acuity, as well as handedness and muscle strength for writing, are important. Clinicians should refrain from speaking rapidly and asking more than one question at a time. They should focus on "yes-no" type questions and supplement verbal communication with letter boards, note-writing, or communication boards.16 Assistive and augmentative devices are available to facilitate communication.16 The clinician is advised to refer to a recent article for more detailed strategies to promote effective communication with mechanically ventilated patients, including a communication assessment tool, communication kit, and picture board with communication symbols.16

SUMMARY AND KEY POINTS

The purpose of this article was to call the clinician's attention to the discomfort and distress reported by patients receiving mechanical ventilatory support, and to offer suggestions for an integrated approach to effectively reduce discomfort and promote comfort for these patients. An integrated approach includes the judicious use of sedatives and analgesics, implementation of safe and effective integrative therapies, such as preferred relaxing music, and the central importance of communication. Patients receiving mechanical ventilatory support report communication difficulties as immensely bothersome and stressful, which only compounds discomfort and distress when clinicians cannot discern the source(s) of these many symptoms. The clinician is advised to keep in mind that the ICU environment is extremely fearful and stressful for patients and their loved ones; communication difficulties compound these experiences.

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