Rationale: No systematic investigation into dyspnea in patients receiving prolonged ventilation (>21 d) after recovering from critical illness has been published. Objectives: We sought to determine the magnitude, nature, and pathophysiological basis of dyspnea during an unassisted-breathing trial in patients receiving prolonged ventilation. Methods: Dyspnea intensity and descriptor selection were investigated in 27 patients receiving prolonged ventilation during a 60-minute unassisted-breathing trial. Pressure-time product, respiratory mechanics, and Ptc_CO₂ were also measured. Measurements and Main Results: Of 10 patients who reported dyspnea during assist-control ventilation, 9 (90.0%) selected "Not getting enough air" to characterize dyspnea. Vt setting was lower in dyspneic than in nondyspneic patients (480.0 vs. 559.4 ml), P < 0.046. During the unassisted-breathing trial (n = 26), patients developed increases in dyspnea (P < 0.01) and Ptc_CO₂ (P < 0.01) but no change in [Formula: see text]e. Dyspnea score was strongly linked to Ptc_CO₂ (P < 0.012) and airway resistance (P < 0.013) but not respiratory work (although pressure-time product was almost three times higher than normal). At 60 minutes into the trial, 83.3% of patients selected "Not getting enough air" on its own or in combination with "Too much effort" to describe discomfort, whereas only 16.7% selected "Too much effort" on its own (P < 0.001). Across the dyspnea spectrum, patients chose "Not getting enough air" overwhelmingly over other descriptor options (P < 0.001). Conclusions: Patients developed increases in dyspnea and Ptc_CO₂ but unchanged [Formula: see text]e and work of breathing during an unassisted-breathing trial; patients selected air-hunger descriptors overwhelmingly over excessive effort. The observations support the belief that air hunger results from heightened respiratory center stimulation combined with the incapacity to increase [Formula: see text]e.

01 May 2024·CHEST

Effect of Atypical Sleep EEG Patterns on Weaning From Prolonged Mechanical Ventilation

Article

Author: Jubran, Amal ; Shaikh, Hameeda ; Ionita, Ramona ; Tobin, Martin J ; Khan, Usman ; Laghi, Franco ; Park, Youngsook

BACKGROUNDApproximately one-third of acute ICU patients display atypical sleep patterns that cannot be interpreted by using standard EEG criteria for sleep. Atypical sleep patterns have been associated with poor weaning outcomes in acute ICUs.RESEARCH QUESTIONDo patients being weaned from prolonged mechanical ventilation experience atypical sleep EEG patterns, and are these patterns linked with weaning outcomes?STUDY DESIGN AND METHODSEEG power spectral analysis during wakefulness and overnight polysomnogram were performed on alert, nondelirious patients at a long-term acute care facility.RESULTSForty-four patients had been ventilated for a median duration of 38 days at the time of the polysomnogram study. Eleven patients (25%) exhibited atypical sleep EEG. During wakefulness, relative EEG power spectral analysis revealed higher relative delta power in patients with atypical sleep than in patients with usual sleep (53% vs 41%; P < .001) and a higher slow-to-fast power ratio during wakefulness: 4.39 vs 2.17 (P < .001). Patients with atypical sleep displayed more subsyndromal delirium (36% vs 6%; P = .027) and less rapid eye movement sleep (4% vs 11% total sleep time; P < .02). Weaning failure was more common in the atypical sleep group than in the usual sleep group: 91% vs 45% (P = .013).INTERPRETATIONThis study provides the first evidence that patients in a long-term acute care facility being weaned from prolonged ventilation exhibit atypical sleep EEG patterns that are associated with weaning failure. Patients with atypical sleep EEG patterns had higher rates of subsyndromal delirium and slowing of the wakeful EEG, suggesting that these two findings represent a biological signal for brain dysfunction.

01 Dec 2023·PEC Innovation

Clinician-initiated written communication for families of patients at a long-term acute care hospital

Article

Author: Podzimek, Glenn ; Schwartz, Nathaniel H ; Glover, Crystal M ; Lawm, Gerald ; Giesing, Connor ; Swiderski, Sara ; Reeter, Roger ; Teed, Don N ; Basapur, Santosh ; Greenberg, Jared A ; Schorfheide, Laura ; Blodgett, Carly

ObjectiveTo assess the experience of families and clinicians at a long term acute care hospital (LTACH) after implementing a written communication intervention.MethodsWritten communication templates were developed for six clinical disciplines. LTACH clinicians used templates to describe the condition of 30 mechanically ventilated patients at up to three time points. Completed templates were the basis for written summaries that were sent to families. Impressions of the intervention among families (n = 21) and clinicians (n = 17) were assessed using a descriptive correlational design. Interviews were analyzed using thematic content analysis.ResultsWe identified four themes during interviews with families: Written summaries 1) facilitated communication with LTACH staff, 2) reduced stress related to COVID-19 visitor restrictions, 3) facilitated understanding of the patient condition, prognosis, and goals and 4) facilitated communication among family members. Although clinicians understood why families would appreciate written material, they did not feel that the intervention addressed their main challenge - overly optimistic expectations for patient recovery among families.ConclusionWritten communication positively affected the experience of families of LTACH patients, but was less useful for clinicians.InnovationUse of written patient care updates helps LTACH clinicians initiate communication with families.

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