In the Journals

Detection, treatment of dyspnea inconsistent in ICU

Holly G. Prigerson, PhD
Holly G. Prigerson

Although the prevalence of dyspnea was at least as high as that of pain, the detection and treatment of moderate to severe dyspnea were more inconsistent than for pain among critically ill patients in the ICU, according to data published in the American Journal of Respiratory and Critical Care Medicine.

This study was undertaken as a result of concerns harbored by directors of the medical ICU at NewYork-Presbyterian Hospital about the lack of detection and proper management of dyspnea in the ICU, according to Holly G. Prigerson, PhD, Irving Sherwood Wright Professor in Geriatrics, professor of sociology in medicine and co-director of the Cornell Center for Research on End-of-Life Care.

In their final analysis, Prigerson and colleagues included 138 communicative patients who were hospitalized in the medical ICU (62% men; 67% white; mean age, 64.51 years). Of these patients, 101 had a personal caregiver at the bedside who also enrolled in the study and 37 did not have a caregiver present at the time of evaluation and had the capacity to consent for themselves.

Of all patients, 51 self-reported symptoms on a scale of 0 to 10 — of whom 47% reported moderate to severe dyspnea and 41% reported moderate to severe pain, with no statistically significant difference in frequency of these symptoms.

More patients had moderate to severe dyspnea than moderate to severe pain according to both caregiver evaluations (61% vs. 46%; P = .01) and nurse ratings (34% vs. 22%; P = .02).

For the 29 patients who had a complete set of evaluations — patient self-report plus both nurse and caregiver evaluations — personal caregiver ratings for presence or absence of moderate to severe dyspnea strongly agreed with patient ratings (Cohen’s kappa coefficient, 0.65; 95% CI, 0.4-0.9). However, there was not a strong association between nurse and patient ratings (Cohen’s kappa coefficient, 0.19; 95% CI, –0.1 to 0.48) — a finding that surprised the researchers.

“We did not expect the personal caregivers to be more accurate in the detection of dyspnea than the patients’ nurses,” Prigerson wrote in an email to Healio Pulmonology.

In terms of treatment, among all 138 patients, 77 (56%) received opioids, 30 (22%) received benzodiazepines and 42 (30%) received inhaled bronchodilators during the evaluated nurse’s shift. Of those who received opioids, 13 received them for pain, 16 for dyspnea, 27 for both and 21 for an unspecified reason.

Of all patients, 27 (20%) had their respiratory device changed. For those who remained on the same respiratory device throughout the shift, oxygen delivery was increased for seven patients (6%). Of the 74 patients who used ventilators throughout the entire shift, 23 (31%) had an adjustment in settings during the shift.

Patients whose nurses detected pain were about twice as likely to receive opioid medications during the evaluated nurse’s shift than those whose nurses did not detect moderate to severe pain (OR = 2.7; 95% CI, 1.1-6.6). However, the same was not true for dyspnea detection (OR = 0.72; 95% CI, 0.35-1.46).

The researchers also found no significant association between nurse detection of dyspnea or pain and the administration of benzodiazepines, inhaled bronchodilators, ventilator adjustments, supplemental oxygen or respiratory device changes (P values > .16).

“Nurses detected similar rates of dyspnea in the medical ICU studied, but the overlap with the patient and personal caregiver detection was limited. Improvement in the accuracy of nurse-detected dyspnea and the need for nurses to address dyspnea once it is detected is needed,” Prigerson said.

Moving forward, she and her colleagues have several goals in mind.

“We would like to see improvements in the clinical detection of dyspnea. We have developed the Cornell Work of Breathing screening instrument and are evaluating its performance and ability to improve clinical detection of dyspnea in the medical ICU by adding a few more behavioral indicators to improve screening specificity. We also want to enhance rates of proper management of dyspnea by developing and testing an intervention that provides guidelines for best practice in management of dyspnea in the medical ICU,” Prigerson told Healio Pulmonology. “Guidelines for treating pain exist and have proved helpful at minimizing pain in this setting. We believe that improvements in the detection, management, and evidence-based guidelines for care will reduce suffering associated with dyspnea in the ICU.”

Patients had been in the ICU for a median of 4 days before evaluation. The most common reason for ICU admission was respiratory failure, followed by hypotension, sepsis or septic shock and cardiac arrest. – by Melissa Foster

For more information:

Holly G. Prigerson, PhD, can be reached at: hgp2001@med.cornell.edu; Twitter: @wcmc_eol.

Disclosures: One author reports she received grants from the National Institute of Aging and her spouse works for Merck Animal Health. A second author reports she received grants from the American Geriatrics Society. A third author reports she received grants from National Cancer Institute. Prigerson and all other authors report no relevant financial disclosures.

Holly G. Prigerson, PhD
Holly G. Prigerson

Although the prevalence of dyspnea was at least as high as that of pain, the detection and treatment of moderate to severe dyspnea were more inconsistent than for pain among critically ill patients in the ICU, according to data published in the American Journal of Respiratory and Critical Care Medicine.

This study was undertaken as a result of concerns harbored by directors of the medical ICU at NewYork-Presbyterian Hospital about the lack of detection and proper management of dyspnea in the ICU, according to Holly G. Prigerson, PhD, Irving Sherwood Wright Professor in Geriatrics, professor of sociology in medicine and co-director of the Cornell Center for Research on End-of-Life Care.

In their final analysis, Prigerson and colleagues included 138 communicative patients who were hospitalized in the medical ICU (62% men; 67% white; mean age, 64.51 years). Of these patients, 101 had a personal caregiver at the bedside who also enrolled in the study and 37 did not have a caregiver present at the time of evaluation and had the capacity to consent for themselves.

Of all patients, 51 self-reported symptoms on a scale of 0 to 10 — of whom 47% reported moderate to severe dyspnea and 41% reported moderate to severe pain, with no statistically significant difference in frequency of these symptoms.

More patients had moderate to severe dyspnea than moderate to severe pain according to both caregiver evaluations (61% vs. 46%; P = .01) and nurse ratings (34% vs. 22%; P = .02).

For the 29 patients who had a complete set of evaluations — patient self-report plus both nurse and caregiver evaluations — personal caregiver ratings for presence or absence of moderate to severe dyspnea strongly agreed with patient ratings (Cohen’s kappa coefficient, 0.65; 95% CI, 0.4-0.9). However, there was not a strong association between nurse and patient ratings (Cohen’s kappa coefficient, 0.19; 95% CI, –0.1 to 0.48) — a finding that surprised the researchers.

“We did not expect the personal caregivers to be more accurate in the detection of dyspnea than the patients’ nurses,” Prigerson wrote in an email to Healio Pulmonology.

In terms of treatment, among all 138 patients, 77 (56%) received opioids, 30 (22%) received benzodiazepines and 42 (30%) received inhaled bronchodilators during the evaluated nurse’s shift. Of those who received opioids, 13 received them for pain, 16 for dyspnea, 27 for both and 21 for an unspecified reason.

Of all patients, 27 (20%) had their respiratory device changed. For those who remained on the same respiratory device throughout the shift, oxygen delivery was increased for seven patients (6%). Of the 74 patients who used ventilators throughout the entire shift, 23 (31%) had an adjustment in settings during the shift.

Patients whose nurses detected pain were about twice as likely to receive opioid medications during the evaluated nurse’s shift than those whose nurses did not detect moderate to severe pain (OR = 2.7; 95% CI, 1.1-6.6). However, the same was not true for dyspnea detection (OR = 0.72; 95% CI, 0.35-1.46).

The researchers also found no significant association between nurse detection of dyspnea or pain and the administration of benzodiazepines, inhaled bronchodilators, ventilator adjustments, supplemental oxygen or respiratory device changes (P values > .16).

“Nurses detected similar rates of dyspnea in the medical ICU studied, but the overlap with the patient and personal caregiver detection was limited. Improvement in the accuracy of nurse-detected dyspnea and the need for nurses to address dyspnea once it is detected is needed,” Prigerson said.

Moving forward, she and her colleagues have several goals in mind.

“We would like to see improvements in the clinical detection of dyspnea. We have developed the Cornell Work of Breathing screening instrument and are evaluating its performance and ability to improve clinical detection of dyspnea in the medical ICU by adding a few more behavioral indicators to improve screening specificity. We also want to enhance rates of proper management of dyspnea by developing and testing an intervention that provides guidelines for best practice in management of dyspnea in the medical ICU,” Prigerson told Healio Pulmonology. “Guidelines for treating pain exist and have proved helpful at minimizing pain in this setting. We believe that improvements in the detection, management, and evidence-based guidelines for care will reduce suffering associated with dyspnea in the ICU.”

Patients had been in the ICU for a median of 4 days before evaluation. The most common reason for ICU admission was respiratory failure, followed by hypotension, sepsis or septic shock and cardiac arrest. – by Melissa Foster

For more information:

Holly G. Prigerson, PhD, can be reached at: hgp2001@med.cornell.edu; Twitter: @wcmc_eol.

Disclosures: One author reports she received grants from the National Institute of Aging and her spouse works for Merck Animal Health. A second author reports she received grants from the American Geriatrics Society. A third author reports she received grants from National Cancer Institute. Prigerson and all other authors report no relevant financial disclosures.