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Unrecognized suffering in the ICU: addressing dyspnea in mechanically ventilated patients

Matthieu Schmidt| Robert B. Banzett| Mathieu Raux| Capucine Morélot-Panzini| Laurence Dangers| Thomas Similowski| Alexandre Demoule
Review
Volume 40, Issue 1 / January , 2014

Pages 1 - 10

Abstract

Background

Intensive care unit (ICU) patients are exposed to many sources of discomfort. Although increasing attention is being given to the detection and treatment of pain, very little is given to the detection and treatment of dyspnea (defined as “breathing discomfort”).

Methods

Published information on the prevalence, mechanisms, and potential negative impacts of dyspnea in mechanically ventilated patients are reviewed. The most appropriate tools to detect and quantify dyspnea in ICU patients are also assessed.

Results/Conclusions

Growing evidence suggests that dyspnea is a frequent issue in mechanically ventilated ICU patients, is highly associated with anxiety and pain, and is improved in many patients by altering the ventilator settings.

Conclusions

Future studies are needed to better delineate the impact of dyspnea in the ICU and to define diagnostic, monitoring and therapeutic protocols.

Keywords

References

  1. Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, Mann C, Lefrant JY, Eledjam JJ (2006) Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 34:1691–1699
    • View reference on PubMed
    • View reference on publisher's website
  2. Payen JF, Bosson JL, Chanques G, Mantz J, Labarere J (2009) Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study. Anaesthesiology 111:1308–1316
    • View reference on publisher's website
  3. Banzett RB, Mulnier HE, Murphy K, Rosen SD, Wise RJ, Adams L (2000) Breathlessness in humans activates insular cortex. NeuroReport 11:2117–2120
    • View reference on PubMed
    • View reference on publisher's website
  4. Gracely RH, Undem BJ, Banzett RB (2007) Cough, pain and dyspnoea: similarities and differences. Pulm Pharmacol Ther 20:433–437
    • View reference on PubMed
    • View reference on publisher's website
  5. Morelot-Panzini C, Demoule A, Straus C, Zelter M, Derenne JP, Willer JC, Similowski T (2007) Dyspnea as a noxious sensation: inspiratory threshold loading may trigger diffuse noxious inhibitory controls in humans. J Neurophysiol 97:1396–1404
    • View reference on PubMed
    • View reference on publisher's website
  6. Kress JP, Pohlman AS, O’Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477
    • View reference on PubMed
    • View reference on publisher's website
  7. Henzler D, Pelosi P, Bensberg R, Dembinski R, Quintel M, Pielen V, Rossaint R, Kuhlen R (2006) Effects of partial ventilatory support modalities on respiratory function in severe hypoxemic lung injury. Crit Care Med 34:1738–1745
    • View reference on PubMed
    • View reference on publisher's website
  8. The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
    • View reference on publisher's website
  9. Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Esposito DC, Pasqualucci Mde O, Damasceno MC, Schultz MJ (2012) Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA 308:1651–1659
    • View reference on PubMed
    • View reference on publisher's website
  10. Lellouche F, Dionne S, Simard S, Bussieres J, Dagenais F (2012) High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anaesthesiology 116:1072–1082
    • View reference on publisher's website
  11. Lellouche F, Lipes J (2013) Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Int Care Med 39:6–15
    • View reference on publisher's website
  12. Hofbauer RK, Fiset P, Plourde G, Backman SB, Bushnell MC (2004) Dose-dependent effects of propofol on the central processing of thermal pain. Anaesthesiology 100:386–394
    • View reference on publisher's website
  13. Frolich MA, Zhang K, Ness TJ (2013) Effect of sedation on pain perception. Anaesthesiology 118:611–621
    • View reference on publisher's website
  14. Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O’Donnell DE (2012) An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 185:435–452
    • View reference on PubMed
    • View reference on publisher's website
  15. Manning HL, Schwartzstein RM (1995) Pathophysiology of dyspnea. N Engl J Med 333:1547–1553
    • View reference on PubMed
    • View reference on publisher's website
  16. O’Donnell DE, Banzett RB, Carrieri-Kohlman V, Casaburi R, Davenport PW, Gandevia SC, Gelb AF, Mahler DA, Webb KA (2007) Pathophysiology of dyspnea in chronic obstructive pulmonary disease: a roundtable. Proc Am Thorac Soc 4:145–168
    • View reference on PubMed
    • View reference on publisher's website
  17. Banzett RB, Similowski T, Brown R (2012) Addressing respiratory discomfort in the ventilated patient. In: Tobin MJ (ed) Principles and practice of mechanical ventilation, 3rd edn. McGraw Hill, New York
  18. Banzett RB, Lansing RW, Brown R, Topulos GP, Yager D, Steele SM, Londono B, Loring SH, Reid MB, Adams L et al (1990) ‘Air hunger’ from increased PCO2 persists after complete neuromuscular block in humans. Respir Physiol 81:1–17
    • View reference on PubMed
    • View reference on publisher's website
  19. Banzett RB, Pedersen SH, Schwartzstein RM, Lansing RW (2008) The affective dimension of laboratory dyspnea: air hunger is more unpleasant than work/effort. Am J Respir Crit Care Med 177:1384–1390
    • View reference on PubMed
    • View reference on publisher's website
  20. Banzett RB, Lansing RW, Reid MB, Adams L, Brown R (1989) ‘Air hunger’ arising from increased PCO2 in mechanically ventilated quadriplegics. Respir Physiol 76:53–67
    • View reference on PubMed
    • View reference on publisher's website
  21. Evans KC, Banzett RB, Adams L, McKay L, Frackowiak RS, Corfield DR (2002) BOLD fMRI identifies limbic, paralimbic, and cerebellar activation during air hunger. J Neurophysiol 88:1500–1511
    • View reference on PubMed
  22. Manning HL, Shea SA, Schwartzstein RM, Lansing RW, Brown R, Banzett RB (1992) Reduced tidal volume increases ‘air hunger’ at fixed PCO2 in ventilated quadriplegics. Respir Physiol 90:19–30
    • View reference on PubMed
    • View reference on publisher's website
  23. Fowler WS (1954) Breaking point of breath-holding. J Appl Physiol 6:539–545
    • View reference on PubMed
  24. Harty HR, Corfield DR, Schwartzstein RM, Adams L (1999) External thoracic restriction, respiratory sensation, and ventilation during exercise in men. J Appl Physiol 86:1142–1150
    • View reference on PubMed
  25. Simon PM, Schwartzstein RM, Weiss JW, Lahive K, Fencl V, Teghtsoonian M, Weinberger SE (1989) Distinguishable sensations of breathlessness induced in normal volunteers. Am Rev Respir Dis 140:1021–1027
    • View reference on PubMed
    • View reference on publisher's website
  26. Killian KJ, Gandevia SC, Summers E, Campbell EJ (1984) Effect of increased lung volume on perception of breathlessness, effort, and tension. J Appl Physiol 57:686–691
    • View reference on PubMed
  27. Schmidt M, Demoule A, Polito A, Porchet R, Aboab J, Siami S, Morelot-Panzini C, Similowski T, Sharshar T (2011) Dyspnea in mechanically ventilated critically ill patients. Crit Care Med 39:2059–2065
    • View reference on PubMed
    • View reference on publisher's website
  28. Lansing RW, Gracely RH, Banzett RB (2009) The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol 167:53–60
    • View reference on PubMed
    • View reference on publisher's website
  29. Chonan T, Mulholland MB, Cherniack NS, Altose MD (1987) Effects of voluntary constraining of thoracic displacement during hypercapnia. J Appl Physiol 63:1822–1828
    • View reference on PubMed
  30. Banzett RB, Lansing RW, Evans KC, Shea SA (1996) Stimulus-response characteristics of CO2-induced air hunger in normal subjects. Respir Physiol 103:19–31
    • View reference on PubMed
    • View reference on publisher's website
  31. Banzett RB, Adams L, O’Donnell CR, Gilman SA, Lansing RW, Schwartzstein RM (2011) Using laboratory models to test treatment: morphine reduces dyspnea and hypercapnic ventilatory response. Am J Respir Crit Care Med 184:920–927
    • View reference on PubMed
    • View reference on publisher's website
  32. Russell WC, Greer JR (2000) The comfort of breathing: a study with volunteers assessing the influence of various modes of assisted ventilation. Crit Care Med 28:3645–3648
    • View reference on PubMed
    • View reference on publisher's website
  33. Leung P, Jubran A, Tobin MJ (1997) Comparison of assisted ventilator modes on triggering, patient effort, and dyspnea. Am J Respir Crit Care Med 155:1940–1948
    • View reference on PubMed
    • View reference on publisher's website
  34. Mols G, von Ungern-Sternberg B, Rohr E, Haberthur C, Geiger K, Guttmann J (2000) Respiratory comfort and breathing pattern during volume proportional assist ventilation and pressure support ventilation: a study on volunteers with artificially reduced compliance. Crit Care Med 28:1940–1946
    • View reference on PubMed
    • View reference on publisher's website
  35. Manning HL, Molinary EJ, Leiter JC (1995) Effect of inspiratory flow rate on respiratory sensation and pattern of breathing. Am J Respir Crit Care Med 151:751–757
    • View reference on PubMed
    • View reference on publisher's website
  36. Fernandez R, Mendez M, Younes M (1999) Effect of ventilator flow rate on respiratory timing in normal humans. Am J Respir Crit Care Med 159:710–719
    • View reference on PubMed
    • View reference on publisher's website
  37. Vitacca M, Bianchi L, Zanotti E, Vianello A, Barbano L, Porta R, Clini E (2004) Assessment of physiologic variables and subjective comfort under different levels of pressure support ventilation. Chest 126:851–859
    • View reference on PubMed
    • View reference on publisher's website
  38. Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, Im K, Donahoe M, Pinsky MR (2002) Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med 30:746–752
    • View reference on PubMed
    • View reference on publisher's website
  39. Shaw RJ, Harvey JE, Bernard R, Gunary R, Tiley M, Steiner H (2009) Comparison of short-term psychological outcomes of respiratory failure treated by either invasive or non-invasive ventilation. Psychosomatics 50:586–591
    • View reference on PubMed
  40. de Miranda S, Pochard F, Chaize M, Megarbane B, Cuvelier A, Bele N, Gonzalez-Bermejo J, Aboab J, Lautrette A, Lemiale V, Roche N, Thirion M, Chevret S, Schlemmer B, Similowski T, Azoulay E (2011) Postintensive care unit psychological burden in patients with chronic obstructive pulmonary disease and informal caregivers: a multicenter study. Crit Care Med 39:112–118
    • View reference on PubMed
    • View reference on publisher's website
  41. Lush MT, Janson-Bjerklie S, Carrieri VK, Lovejoy N (1988) Dyspnea in the ventilator-assisted patient. Heart Lung 17:528–535
    • View reference on PubMed
  42. Borgbjerg FM, Nielsen K, Franks J (1996) Experimental pain stimulates respiration and attenuates morphine-induced respiratory depression: a controlled study in human volunteers. Pain 64:123–128
    • View reference on PubMed
    • View reference on publisher's website
  43. Bouley GH, Froman R, Shah H (1992) The experience of dyspnea during weaning. Heart Lung 21:471–476
    • View reference on PubMed
  44. Knebel AR, Janson-Bjerklie SL, Malley JD, Wilson AG, Marini JJ (1994) Comparison of breathing comfort during weaning with two ventilatory modes. Am J Respir Crit Care Med 149:14–18
    • View reference on PubMed
    • View reference on publisher's website
  45. Powers J, Bennett SJ (1999) Measurement of dyspnea in patients treated with mechanical ventilation. Am J Crit Care 8:254–261
    • View reference on PubMed
  46. Connelly B, Gunzerath L, Knebel A (2000) A pilot study exploring mood state and dyspnea in mechanically ventilated patients. Heart Lung 29:173–179
    • View reference on PubMed
    • View reference on publisher's website
  47. Karampela I, Hansen-Flachen J, Smith S, Reily D, Fuchs BD (2002) A dyspnea evaluation protocol for respiratory therapists: a feasibility study. Respir Care 47:1158–1161
    • View reference on PubMed
  48. Twibell R, Siela D, Mahmoodi M (2003) Subjective perceptions and physiological variables during weaning from mechanical ventilation. Am J Crit Care 12:101–112
    • View reference on PubMed
  49. Shacham S (1983) A shortened version of the profile of mood states. J Pers Assess 47:305–306
    • View reference on PubMed
    • View reference on publisher's website
  50. Wilson PR (1992) Clinical practice guideline: acute pain management. Clin J Pain 8:187–188
    • View reference on PubMed
    • View reference on publisher's website
  51. Bergbom-Engberg I, Haljamae H (1989) Assessment of patients’ experience of discomforts during respirator therapy. Crit Care Med 17:1068–1072
    • View reference on PubMed
    • View reference on publisher's website
  52. O’Donnell CR, Schwartzstein RM, Lansing RW, Guilfoyle T, Elkin D, Banzett RB (2013) Dyspnea affective response: comparing COPD patients with healthy volunteers and laboratory model with activities of daily living. BMC Pulm Med 13:27
    • View reference on PubMed
    • View reference on publisher's website
  53. Scragg P, Jones A, Fauvel N (2001) Psychological problems following ICU treatment. Anaesthesia 56:9–14
    • View reference on PubMed
    • View reference on publisher's website
  54. Schelling G (2002) Effects of stress hormones on traumatic memory formation and the development of posttraumatic stress disorder in critically ill patients. Neurobiol Learn Mem 78:596–609
    • View reference on PubMed
    • View reference on publisher's website
  55. Cuthbertson BH, Hull A, Strachan M, Scott J (2004) Post-traumatic stress disorder after critical illness requiring general intensive care. Int Care Med 30:450–455
    • View reference on publisher's website
  56. Rattray JE, Hull AM (2008) Emotional outcome after intensive care: literature review. J Adv Nurs 64:2–13
    • View reference on PubMed
    • View reference on publisher's website
  57. Ranieri VM, Grasso S, Mascia L, Martino S, Fiore T, Brienza A, Giuliani R (1997) Effects of proportional assist ventilation on inspiratory muscle effort in patients with chronic obstructive pulmonary disease and acute respiratory failure. Anaesthesiology 86:79–91
    • View reference on publisher's website
  58. Campbell ML (2008) Psychometric testing of a respiratory distress observation scale. J Palliat Med 11:44–50
    • View reference on PubMed
    • View reference on publisher's website
  59. Campbell ML, Templin T, Walch J (2010) A respiratory distress observation scale for patients unable to self-report dyspnea. J Palliat Med 13:285–290
    • View reference on PubMed
    • View reference on publisher's website
  60. Hopkinson NS, Sharshar T, Dayer MJ, Lofaso F, Moxham J, Polkey MI (2012) The effect of acute non-invasive ventilation on corticospinal pathways to the respiratory muscles in chronic obstructive pulmonary disease. Respir Physiol Neurobiol 183:41–47
    • View reference on PubMed
    • View reference on publisher's website
  61. Schmidt M, Kindler F, Gottfried SB, Raux M, Hug F, Similowski T, Demoule A (2013) Dyspnea and surface inspiratory electromyograms in mechanically ventilated patients. Int Care Med 39(8):1368–1376
    • View reference on publisher's website
  62. Sinderby C, Spahija J, Beck J (2001) Changes in respiratory effort sensation over time are linked to the frequency content of diaphragm electrical activity. Am J Respir Crit Care Med 163:905–910
    • View reference on PubMed
    • View reference on publisher's website
  63. Murphy PB, Kumar A, Reilly C, Jolley C, Walterspacher S, Fedele F, Hopkinson NS, Man WD, Polkey MI, Moxham J, Hart N (2011) Neural respiratory drive as a physiological biomarker to monitor change during acute exacerbations of COPD. Thorax 66:602–608
    • View reference on PubMed
    • View reference on publisher's website
  64. Reilly CC, Ward K, Jolley CJ, Lunt AC, Steier J, Elston C, Polkey MI, Rafferty GF, Moxham J (2011) Neural respiratory drive, pulmonary mechanics and breathlessness in patients with cystic fibrosis. Thorax 66:240–246
    • View reference on PubMed
    • View reference on publisher's website
  65. Luo YM, Li RF, Jolley C, Wu HD, Steier J, Moxham J, Zhong NS (2011) Neural respiratory drive in patients with COPD during exercise tests. Respiration 81:294–301
    • View reference on PubMed
    • View reference on publisher's website
  66. Chiti L, Biondi G, Morelot-Panzini C, Raux M, Similowski T, Hug F (2008) Scalene muscle activity during progressive inspiratory loading under pressure support ventilation in normal humans. Respir Physiol Neurobiol 164:441–448
    • View reference on PubMed
    • View reference on publisher's website
  67. Hug F, Raux M, Morelot-Panzini C, Similowski T (2011) Surface EMG to assess and quantify upper airway dilators activity during non-invasive ventilation. Respir Physiol Neurobiol 178:341–345
    • View reference on PubMed
    • View reference on publisher's website
  68. Ward ME, Corbeil C, Gibbons W, Newman S, Macklem PT (1988) Optimization of respiratory muscle relaxation during mechanical ventilation. Anaesthesiology 69:29–35
    • View reference on publisher's website
  69. Parthasarathy S, Jubran A, Laghi F, Tobin MJ (2007) Sternomastoid, rib cage, and expiratory muscle activity during weaning failure. J Appl Physiol 103:140–147
    • View reference on PubMed
    • View reference on publisher's website
  70. Schmidt M, Chiti L, Hug F, Demoule A, Similowski T (2011) Surface electromyogram of inspiratory muscles: a possible routine monitoring tool in the intensive care unit. Br J Anaesth 106:913–914
    • View reference on PubMed
    • View reference on publisher's website
  71. Raux M, Straus C, Redolfi S, Morelot-Panzini C, Couturier A, Hug F, Similowski T (2007) Electroencephalographic evidence for pre-motor cortex activation during inspiratory loading in humans. J Physiol 578:569–578
    • View reference on PubMed
    • View reference on publisher's website
  72. Raux M, Ray P, Prella M, Duguet A, Demoule A, Similowski T (2007) Cerebral cortex activation during experimentally induced ventilator fighting in normal humans receiving noninvasive mechanical ventilation. Anaesthesiology 107:746–755
    • View reference on publisher's website

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