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Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RNAnnie Heiderscheit, PhD, MT-BC, FAMI, LMFT Craig Weinert, MD, MPH Debra Skaar, PharmDMary Fran Tracy, PhD, RN, CCNS, FAANUniversity of Minnesota Medical Center, FairviewKay Savik, MS, BiostatisticianUniversity of Minnesota CANS 2012
Grant Support • NINR, NIH R01-NR009295 • L. Chlan, Principal Investigator • chlan001@umn.edu • Trial Registration #NCT00440700
BACKGROUND • Approximately 1 million patients receive mechanical ventilatory support yearly in the U.S. • 55,000 adults admitted daily to ICUs in the U.S. • Commonly used ICU supportive modality • 34% require ventilatory support for > 48 hours; increasing • ICUs are inherently stressful for patients and family • Distress from noise, lack of sleep, social isolation, frustration
Patient Responses to Mechanical Ventilatory Support • Physiological Stress Stress of critical illness or infection + Delivery of mechanical breaths • Critical illness or injury • Lung injury • Ventilator associated pneumonia • Psychological stress • Anxiety: state;heightened arousal, tension, inability to concentrate • Fear • Feel miserable • Inability to speak; cannot convey needs, feelings, etc.
Anxiety Ratings in Mechanically Ventilated Patients • Previous work limited to cross-sectional ratings • State Anxiety Inventory (score range 20-80) • < 5 days 48.6 + 12.0 • 6-21 days 50.2 + 12.5 • 22+ days 54.2 +11.9 • Chronic/long-term 45.8 +14.5 Chlan L. Description of anxiety levels by individual differences and clinical factor in patients receiving mechanical ventilatory support. Heart Lung 2003; 32:275-282.
Patient Symptom Reports • 10-item checklist of physical and psychological symptoms (pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused) • Presence (yes/no), intensity (mild, moderate, severe), distress (not very distressing, moderate, very distressing) • 34% mechanically ventilated in two ICUs • Anxiety, thirsty, tired reported by 50-75% of assessments • No difference in intensity or distress if MV, except anxiety • Dyspnea most distressing; inter-related with anxiety Puntillo KA, Shoshana A, Cohen N, Gropper M. et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med 2010; 38:2155-2160.
SUSTAINED ANXIETY Physiological responses: • SNS stimulation; CV responses; increased WOB and oxygen demand; myocardial stimulation Psychological responses: • Fear, inability to focus, inability to relax or sleep Usual treatment for anxiety is sedative medications • Limitations and adverse side effects
Adjunctive Interventions • Can non-pharmacologic, adjunctive interventions reduce anxiety over the course of mechanical ventilatory support? • Limitations of sedative medications • In addition to medical plan of care • Relaxing Music intervention?
Why Music Intervention and not just Sedative Medications? • Need for adjunctive interventions to reduce anxiety associated with ventilatory support • Sedative agents are warranted at times yet induce adverse effects • Not demanding for patients with communication challenges and low energy states • Safe and scientifically sound interventions • Does not induce adverse effects
Scientific Basis of Music to Reduce Stress: Brief Overview • Music perceived as familiar and soothing • Interrupts the stress response; facilitates relaxation • Focused attention on pleasing stimuli of music reduces anxiety • Music can be a powerful distractor
Music for Distraction • Preferred, familiar music can be a powerful distractor • Provides an alternative focus to a more pleasing, comforting stimulus, rather than focusing on stressful environmental stimuli or thoughts. • Important to assess music preferences, familiarity, cultural context
Anxiety self-management for ICU Patients Receiving Mechanical Ventilation • Primary Aim: To determine if patient-directed music (PDM) reduces anxiety over the course of ventilatory support R01 NR009295 NCT00440700
DESIGN • Three-group randomized clinical trial • Remained on protocol as long as mechanically ventilated, up to 30 days • Subjects randomized to: • 1) Patient-directed music listening (experimental) • Preferred , relaxing music • Assessment of music preferences daily by music therapist • Allows choice, control, and self-management of anxiety • Prompts for PDM use • 2) Noise-canceling headphones (active control) • 3) Usual care (control)
What is Relaxing Music?Conceptual Definition • Tempo at or below resting heart rate (60-80 bpm) • Predictable dynamics • Fluid, melodic movement • Pleasing harmonies • Regular rhythm without sudden changes • Simple compositions and soft tones
SETTING and SAMPLE • 5 medical centers in the Minneapolis-St. Paul urban area • 12 ICUs total (medical, medical-surgical) • Adult critically ill patients receiving acute mechanical ventilatory support for a primary pulmonary component • Pneumonia, COPD, respiratory failure, pulmonary edema, etc. • Alert and interacting appropriately with nursing staff • Provide own informed consent • IRB and intervention requirements
MEASURES • Anxiety • 100-mm Visual Analog Scale-Anxiety • Assessed similar time each study day • Illness severity (APACHE III) • Length of time mechanically ventilated • Length of ICU stay • All daily medications • Ventilator settings and weaning trials • Music Assessment Tool (experimental)
Subject Characteristics • N = 373 enrolled; N = 286 considered for final analysis • Age = 58.5 +14.4; Range 21-88 • 52% female; 86% White, 12% Black, 1%Native American, 1%Asian • APACHE III 63.2 +21.6; Range 15-123 • 55% respiratory failure, 25% respiratory distress, 5% pneumonia, 3% COPD, 2% hypoxemia, 10% other • Median total ICU days = 17 (1-86) • Median total ventilator days = 10 (0-80) • 5.7 + 6.4 days on protocol; Range 1-30 days
MUSIC PREFERENCES BY GENRES • Classical • Rhythm & Blues • Reggae • New Age/Contemporary • Country • Jazz • Sacred/Religious • Alternative Rock • Big Band • Heavy Metal • World Music • Oldies (1950-1970) • Rock • Hip Hop • Rap • Pop Music • Other
RESULTS • Baseline anxiety 48.8 +29.3; range 0-100 • Moderate anxiety • Highly variable and individual symptom • PDM subjects listened to music 79.8 minutes/day • Headphones subjects wore them for 34 minutes/day
Analysis of State Anxiety • Change by assigned group first assessed using scatterplots • Mixed-effects models for anxiety analysis • Included anxiety data on subjects with 3 or more data points to model change over time (N = 193) • Not all subjects able to report anxiety each day
Visual Analog Scale-Anxiety Final Models Final models control for APACHE III, sedative medications and interaction effects between treatment groups and VAS-A baseline; Usual care is reference group.
Discussion of Results • Participants self-initiated music listening when desired • Individual control and management of highly variable symptom • PDM significantly reduced anxiety during mechanical ventilatory support • Anxiety reduced 26 points over time • Controlled for sedative medications • Patients report benefit with PDM use • “It’s the only thing that got me through….” • Control group did not have reduced anxiety over time
Implications for Practice and Future Research • Beneficial, effective adjunctive intervention • No documented adverse effects • Integrate into ICU care; translation of findings to practice • Self-directed and preferred music allows for choice and control; empowers patients • Impact of PDM on other outcomes warrant future research • Ventilator-free days? • Weaning trials? • Influence on post-ICU outcomes is unknown
“There are two means of refuge from the miseries of life: Music and cats”.~Albert Schweitzer, 1875-1965German medical missionary, theologian, musician, philosopher