Underestimation of Patient Breathlessness by Nurses and Physicians during a Spontaneous Breathing Trial

Haugdahl, Hege Selnes; Storli, Sissel Lisa; Meland, Barbro; Dybwik, Knut; Romild, Ulla; Klepstad, Pål

doi:10.1164/rccm.201503-0419oc

Cited by 75 publications

(59 citation statements)

References 48 publications

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“…Studies in which patients’ ratings of current dyspnea have been compared with concurrent physicians’ and nurses’ inference of dyspnea from observed signs have shown poor concordance as indicated by Cohen’s kappa for inter-rater agreement < 0.2 and/or coefficient of determination, r 2 , <0.2 [28, 29]. These studies show that both nurses and physicians tend to greatly underestimate dyspnea most of the time.…”

Section: Discussionmentioning

confidence: 99%

Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance

2017

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BackgroundDyspnea (breathing discomfort) is a common and distressing symptom. Routine assessment and documentation can improve management and relieve suffering. A major barrier to routine dyspnea documentation is the concern that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses. Nurses at our institution recently began to assess and document dyspnea on all medical-surgical patients upon admission and once per shift throughout their hospitalization. A year after dyspnea measurement was implemented we explored nurses’ approach to dyspnea assessment, their perception of patient response, and their perception of the utility and burden of dyspnea measurement.MethodsWe obtained feedback from nurses using a three-part assessment of practice: 1) a series of recorded focus group interviews with nurses, 2) a time-motion observation of nurses performing routine dyspnea and pain assessment, and 3) a randomized, anonymous on-line survey based, in part, on issues raised in focus groups.ResultsNinety-four percent of the nurses surveyed reported administering the dyspnea assessment is “easy” or “very easy”. None of the nurses reported that assessing dyspnea negatively impacted workflow and many reported that it positively improved their practice by increasing their awareness. Our time-motion data showed dyspnea assessment and documentation takes well less than a minute. Nurses endorsed the importance of routine measurement and agreed that most patients were able to provide a meaningful rating of their dyspnea. Nurses found the patient report very useful, and used it in conjunction with observed signs to respond to changes in a patient’s condition.ConclusionsIn this study, we have demonstrated that routine dyspnea assessment and documentation was widely accepted by the nurses at our institution. Our nurses fully incorporated routine dyspnea assessment and documentation into their practice and felt that it improved patient-centered care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12912-016-0196-9) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance

2017

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“…The authors found that patient breathlessness assessed by nurses or physicians was significantly underestimated as compared with breathlessness assessed by the patient him/herself (1). About two-thirds of the patients felt breathlessness, a rate markedly higher than that detected by nurses and physicians.…”

Section: At the Critical Time Of Deciding On Extubation It Is Too Lamentioning

confidence: 87%

“…In a recent issue of the Journal, Haugdahl and colleagues assessed the sensation of breathlessness felt during a spontaneous breathing trial by patients still intubated in the intensive care unit (ICU) (1). The authors found that patient breathlessness assessed by nurses or physicians was significantly underestimated as compared with breathlessness assessed by the patient him/herself (1).…”

Section: At the Critical Time Of Deciding On Extubation It Is Too Lamentioning

confidence: 99%

At the Critical Time of Deciding on Extubation, It Is Too Late to Assess Patient Breathlessness

Thille

Boissier

2016

Am J Respir Crit Care Med

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“…[8,15,16] Although both are manifestations of increased work of breathing,[17,18] we selected distress because physicians rely on their observations of patients in determining the need for respiratory support and do so independent of patients’ ability to express dyspnea or its severity. [2,19] This choice was reasonable also because the rating of respiratory distress by physicians predicts the need for mechanical ventilation,[4] and because it is as reproducible as dyspnea.…”

Section: Discussionmentioning

confidence: 99%

DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

Tulaimat

Trick

2017

PLoS ONE

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BackgroundThe assessment of the work of breathing in the definitions of respiratory failure is vague and variable.ObjectiveIdentify a parsimonious set of signs to describe the work of breathing in hypoxemic, acutely ill patients.MethodsWe examined consecutive medical ICU patients receiving oxygen with a mask, non-invasive ventilation, or T-piece. A physician inspected each patient for 10 seconds, rated the level of respiratory distress, and then examined the patient for vital signs and 17 other physical signs. We used the rating of distress as a surrogate for measuring the work of breathing, constructed three multivariate models to identify the one with the smallest number of signs and largest explained variance, and validated it with bootstrap analysis.ResultsWe performed 402 observations on 240 patients. Respiratory distress was absent in 78, mild in 157, moderate in 107, and severe in 60. Respiratory rate, hypoxia, heart rate, and frequency of most signs increased as distress increased. Respiratory rate and hypoxia explained 43% of the variance in respiratory distress. Diaphoresis, gasping, and contraction of the sternomastoid explained an additional 28%. Heart rate, blood pressure, alertness, agitation, body posture, nasal flaring, audible breathing, cyanosis, tracheal tug, retractions, paradox, scalene or abdominal muscles contraction did not increase the explained variance in respiratory distress.ConclusionMost of the variance is respiratory distress can be explained by five signs summarized by the mnemonic DiapHRaGM (diaphoresis, hypoxia, respiratory rate, gasping, accessory muscle). This set of signs may allow for efficient, standardized assessments of the work of breathing of hypoxic patients.

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Underestimation of Patient Breathlessness by Nurses and Physicians during a Spontaneous Breathing Trial

Abstract: Patients reported higher breathlessness after SBT compared with nurses and physicians. Clinical trial registered with www.clinicaltrials.gov (NCT 01928277).

Cited by 75 publications

References 48 publications

Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance

Routine dyspnea assessment and documentation: Nurses’ experience yields wide acceptance

At the Critical Time of Deciding on Extubation, It Is Too Late to Assess Patient Breathlessness

DiapHRaGM: A mnemonic to describe the work of breathing in patients with respiratory failure

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