PITTSBURGH—A stay in the intensive care unit (ICU) may be more stressful—both physically and psychologically—for patients than most physicians realize. Although a significant number of ICU survivors have no memory of their stay in the unit, those who remember their experiences recall feeling moderately to severely bothered by such factors as pain, anxiety, and loss of control.[1] Having an endotracheal tube (ETT) in place may be particularly stressful.

Researchers from the University of Pittsburgh developed a 32-item questionnaire to gauge patients’ reactions to mechanical ventilation and intensive care. The questionnaire was administered at an East Coast university hospital that had four ICUs. Adult patients who had received mechanical ventilation continuously for at least 48 hours were interviewed while still in the hospital, after discharge from the ICU. The questionnaire contained 10 questions about the ETT and 22 questions about stressful experiences associated with the ICU in general. Patients were first asked if they remembered the ETT. If they answered yes, they rated their ETT discomfort level on an 11-point scale (0 = “no discomfort”; 10 = “discomfort as bad as you can imagine”). Then, patients were asked if they remembered being in the ICU and whether they were bothered by specific experiences in the ICU (and, if so, by how much, using a 5-point scale ranging from “not at all” to “extremely” bothered).

WORST STRESS WITH INTUBATION

Of the 817 patients treated in the ICUs during the study, 263 died and 310 could not be interviewed either because they were not sufficiently alert and oriented to permit them to answer the questionnaire or because of other medical reasons. Another 94 patients were discharged before they could be interviewed. Of the remaining patients, 50 could recall neither being intubated nor being treated in the ICU; thus, only 100 patients completed the questionnaire.

Of the 75 patients who remembered the ETT, 44% rated their level of ETT pain at its worst, a 10. The median ratings for ETT pain at least and average were 5 and 6, respectively. The most stressful experiences associated with the ETT were not being able to speak (66%), pain (56%), and anxiety (59%).

Ninety-seven patients remembered specific ICU experiences other than intubation, and 66% or more reported being moderately or severely bothered by them. The five experiences that bothered the greatest number of patients were trouble speaking (65%), being thirsty (62%), feeling tense (46%), not being in control (46%), and difficulty swallowing (44%). Only 32% of patients remembered periods of terror or panic, but this experience was the most stressful to those who experienced it: More than 90% reported being bothered moderately to extremely.

Having an ETT is an extremely stressful experience, noted Armando Rotondi, PhD, the study’s principal investigator and an Assistant Professor of Health Systems Engineering in the Departments of Critical Care Medicine and Health Policy and Management at the University of Pittsburgh. He told PULMONARY REVIEWS, “I was involved in another study in which we talked to people who had had coronary artery bypass grafts. Almost without exception, the most stressful experience these patients reported was waking up with an endotracheal tube.”

Upon questioning, the hospital staff said that, in every case, they had told the patients about the ETT. However, Dr. Rotondi noted, “You do not know how the staff explained it. They might have only told the patients ‘when you wake up there will be a tube to help you breathe.’ You also do not know how attentively the patients were listening at the time.”

MORE TO LEARN

Dr. Rotondi pointed out that the study raised many questions for which no data were available. “Were patient experiences different among ICUs or did they vary by procedure? Did medications help to alleviate some stressful experiences? It’s hard to do comparisons among ICUs without knowledge of patients’ medications,” he observed. “We also could not look at the effect of patient experiences in the ICU on outcomes because we did not have the follow-up data.” In the future, Dr. Rotondi and colleagues will look at patients’ recollections of the ICU at two months, six months, and one year after discharge to observe any changes that occur with time.

He added that specific physical and psychological problems—sleep disturbances, spells of terror, and feeling nervous when left alone—were all highly associated with ETT use. By carefully explaining to patients what they may experience while in the ICU on mechanical ventilation, discussing procedures, and assessing comfort levels, caregivers can help reduce patients’ stress and possibly improve the quality of their ICU stays.

—Gale Jurasek

Reference
1. Rotondi AJ, Chelluri L, Sirio C, et al. Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30:746-752.

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