Detection and management of dyspnea in mechanically ventilated patients

Abstract

Financial support and sponsorship none Conflicts of interestMaxens Decavèle has non conflicts of interest to declare. Thomas Similowski has received grant research from Coviden, Philips, Pierre Fabre Médicaments, Air Liquide Medical Systems; he has also received personal fees from Takeda, Teva Pharma, Lungpacer Inc, Almirall France, Pierre Fabre Médicaments, Novartis, Mundipharma, Invacare, Astra Zeneca, Boehringer Ingelheim and GlaxoSmithKline. Alexandre Demoule has signed research contracts with Covidien, Maquet, Philips and Ait Liquide Santé; he has also received personal fees from Covidien, Maquet and MSD. AbstractPurpose of the review. In intensive care unit (ICU) patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management.Recent findings. As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering (median dyspnea visual analog scale of 5 [4][5][6][7]). In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one third of critically ill patients are noncommunicative, and therefore at high risk of misdiagnosis.Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report. Summary.Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to non-communicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed.Over the past decade, growing attention has been given to the detection and treatment of pain in intensive care unit (ICU) patients. Interestingly, during the same period, very little attention has been given to dyspnea. Indeed, data regarding dyspnea in ICU patients are scarce and there are basically no recommendations regarding the assessment and the management of dyspnea in ICU patients. Beyond being a major source of discomfort, dyspnea shares many physiological and clinical features with pain. This should make it a major preoccupation for ICU physicians and nurses whose mission is to relieve symptoms in addition to treating disease processes. However, it might be a challenging issue in mechanically ventilated patients whose ability to communicate is limited.The objective of the present review is to provide information regarding the prevalence and the risk factors of dyspnea in mechanically ventilated ICU patients. It is also to suggest some approaches to detect, quantify and manage dyspnea in these patients.

Detection of strong inspiratory efforts from the analysis of central venous pressure swings: a preliminary clinical study

“…A clinical diagnosis of respiratory distress is usually based on the presence of tachypnea, tachycardia, and hypoxia. 34,35 In our study population, respiratory rate, heart rate, and arterial oxygenation were not associated with the strength of inspiration. This was true for other possible signs of increased work of breathing, such as anxiety and central venous oxygen desaturation.…”

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

“…It has therefore been identified as one of the symptoms that should be assessed systematically in intensive care unit (ICU) patients 2 . Improving the management of dyspnoea is a clinical priority 3 and can often be relieved very simply, for example by adjusting ventilator settings for patients with dyspnoea under MV 1 .…”

Dyspnoea and respiratory muscle ultrasound to predict extubation failure

“…Presence and severity of dyspnea were evaluated by using self-evaluation of dyspnea and dyspnea observation scales [17], depending on whether patients were communicative or noncommunicative. Patients were considered as communicative when the Richmond Agitation-Sedation Scale (RASS) was between -1 and +1 and if they were able to consistently self-report dyspnea, attested by a dyspnea visual analog scale (Dyspnea-VAS) variation not exceeding 1 cm for three consecutive measures [18,19].…”