Underdetection and Undertreatment of Dyspnea in Critically Ill Patients

Gentzler, Eliza; Derry, Heather M.; Ouyang, Daniel; Lief, Lindsay; Berlin, David; Xu, Cici Jiehui; Maciejewski, Paul K.; Prigerson, Holly G.

doi:10.1164/rccm.201805-0996oc

Cited by 52 publications

(50 citation statements)

References 34 publications

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“…The level of inspiratory effort during the first 3 days of ventilation was recently shown to predict the duration of ventilation and ICU admission [6]. Respiratory drive and effort are frequently elevated in patients with respiratory failure because of pain, anxiety, delirium, inadequate ventilatory assistance, and dyspnea [7, 8]. Therefore, patient inspiratory effort merits close attention during mechanical ventilation.…”

Section: Introductionmentioning

confidence: 99%

A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation

et al. 2019

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BackgroundExcessive respiratory muscle effort during mechanical ventilation may cause patient self-inflicted lung injury and load-induced diaphragm myotrauma, but there are no non-invasive methods to reliably detect elevated transpulmonary driving pressure and elevated respiratory muscle effort during assisted ventilation. We hypothesized that the swing in airway pressure generated by respiratory muscle effort under assisted ventilation when the airway is briefly occluded (ΔPocc) could be used as a highly feasible non-invasive technique to screen for these conditions.MethodsRespiratory muscle pressure (Pmus), dynamic transpulmonary driving pressure (ΔPL,dyn, the difference between peak and end-expiratory transpulmonary pressure), and ΔPocc were measured daily in mechanically ventilated patients in two ICUs in Toronto, Canada. A conversion factor to predict ΔPL,dyn and Pmus from ΔPocc was derived and validated using cross-validation. External validity was assessed in an independent cohort (Nanjing, China).ResultsFifty-two daily recordings were collected in 16 patients. In this sample, Pmus and ΔPL were frequently excessively high: Pmus exceeded 10 cm H2O on 84% of study days and ΔPL,dyn exceeded 15 cm H2O on 53% of study days. ΔPocc measurements accurately detected Pmus > 10 cm H2O (AUROC 0.92, 95% CI 0.83–0.97) and ΔPL,dyn > 15 cm H2O (AUROC 0.93, 95% CI 0.86–0.99). In the external validation cohort (n = 12), estimating Pmus and ΔPL,dyn from ΔPocc measurements detected excessively high Pmus and ΔPL,dyn with similar accuracy (AUROC ≥ 0.94).ConclusionsMeasuring ΔPocc enables accurate non-invasive detection of elevated respiratory muscle pressure and transpulmonary driving pressure. Excessive respiratory effort and transpulmonary driving pressure may be frequent in spontaneously breathing ventilated patients.

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Section: Introductionmentioning

confidence: 99%

A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation

et al. 2019

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“…38,45 However, numerous studies indicate minimal and often delayed opioid use. 7,46 One study showed that only 49% of patients with ILD receive opioids to manage dyspnea, despite improvement of symptoms in the study. 3 Opiates were initiated a median of 105 days before death in 88% of our home/hospice cohort; 82% of our home/hospice death cohort were prescribed oral mucosal opiates compared to 24% in the hospital death cohort.…”

Section: Discussionmentioning

confidence: 99%

Early Integrated Palliative Care Bundle Impacts Location of Death in Interstitial Lung Disease: A Pilot Retrospective Study

Archibald

Bakal

Richman‐Eisenstat

et al. 2020

Am J Hosp Palliat Care

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Background: Interstitial lung diseases (ILDs) comprise a heterogeneous group of fibrotic, progressive pulmonary diseases characterized by poor end-of-life care and hospital deaths. In 2012, we launched our Multidisciplinary Collaborative (MDC) ILD clinic to deliver integrated palliative approach throughout disease trajectory to improve care. We sought to explore the effects of palliative care and other factors on location of death (LOD) of patients with ILD. Methods: The MDC-ILD clinic implemented a palliative care bundle including advance care planning (ACP), opiates use, allied health home care engagement, and use of supplemental oxygen and early caregiver engagement in care. Data from patients with ILD who attended the clinic and died between 2012 and 2019 were used to generate scores representing the components and duration of palliative care (palliative care bundle score) and caregiver involvement (caregiver engagement score). We examined the impact of these scores on patients’ LOD. Results: A total of 92 MDC-ILD clinic patients were included, 57 (62%) had home or hospice deaths. Patients who died at home or hospice had higher palliative care bundle scores (10.0 ± 4.0 vs 7.8 ± 3.9, P = .01) and caregiver engagement scores (1.7 ± 0.6 vs 1.3 ± 0.7, P = .01) compared to those who died in hospital. Patients were 1.13 times more likely to die at home or hospice following a 1-point increase in palliative care bundle score (95% CI: 1.01-1.29, P = .04) and 2.38 times more likely following a 1-point increase in caregiver engagement score (95% CI: 1.17-5.15, P = .02). Conclusions: Home and hospice deaths are feasible in ILD. Early initiation of palliative care bundle components such as ACP discussions, symptom self-management, caregiver engagement, and close collaboration with allied health home care supports can promote adherence to patient preference for home or hospice deaths.

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“…Although dyspnea is not uncommon, published literature on the topic suggests that clinicians often underestimate its presence. [78][79][80] Binks et al 78 reported that significant breathing discomfort is as common as pain in mechanically ventilated subjects and that clinicians misjudge its occurrence. In a prospective, multi-center study, Haugdahl and colleagues 79 assessed agreement between physicians, nurses, and mechanically ventilated subjects' rated breathlessness during spontaneous breathing trials.…”

Section: Monitoring Dyspneamentioning

confidence: 99%

“…The results indicated that subjects reported more breathlessness after undergoing spontaneous breathing trials compared to assessments made by physicians and nurses. More recently, Gentzler et al 80 assessed the frequency of dyspnea relative to pain as well as the accuracy of nurses' and personal caregivers' dyspnea ratings relative to patient-reported dyspnea in subjects admitted to the medical ICU. The study results indicated that 47% of subjects reported moderate-to-severe dyspnea and 41% reported moderate to severe pain.…”

Section: Monitoring Dyspneamentioning

confidence: 99%

Monitoring Breathing Frequency, Pattern, and Effort

Scott

Kaur

2020

Respir Care

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Monitoring respiratory values such as breathing frequency, minute ventilation, breathing effort, and dyspnea are common in acute care. There is evidence that accurate monitoring and interpretation of these values leads to early identification and treatment of impending respiratory failure. Despite this evidence, some values, such as breathing frequency, are largely undervalued in the clinical setting. The undervaluation of breathing frequency is complex and will require a multifaceted approach, including education and improved technology, to reestablish its clinical potential. Many questions remain regarding how to most efficiently and effectively monitor other respiratory values, like noninvasive minute volume and breathing effort, as well. As technology continues to improve alongside the understanding of respiratory physiology, clinicians are able to apply basic clinical assessment skills and technology together to improve patient safety and outcomes.

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Underdetection and Undertreatment of Dyspnea in Critically Ill Patients

Cited by 52 publications

References 34 publications

A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation

A novel non-invasive method to detect excessively high respiratory effort and dynamic transpulmonary driving pressure during mechanical ventilation

Early Integrated Palliative Care Bundle Impacts Location of Death in Interstitial Lung Disease: A Pilot Retrospective Study

Monitoring Breathing Frequency, Pattern, and Effort

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