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![Page 1: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,](https://reader035.fdocuments.in/reader035/viewer/2022062407/56649f4d5503460f94c6d5bd/html5/thumbnails/1.jpg)
1
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, PharmD
Mary Fran Tracy, PhD, RN, CCNS, FAANUniversity of Minnesota Medical Center, Fairview
Kay Savik, MS, Biostatistician
University of MinnesotaCANS 2012
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Special thanks to the Research Team
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Grant Support
• NINR, NIH R01-NR009295
• L. Chlan, Principal Investigator
• Trial Registration #NCT00440700
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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
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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.
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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.
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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.
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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
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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?
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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
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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
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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
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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 NR009295NCT00440700
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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)
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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
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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
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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)
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Equipment for Experimental PDM
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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
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Participant Characteristics at Enrollment (N = 373)
Patient-directed Music
(n = 126)
Headphones(n = 122)
Usual Care(n = 125)
p-value
Age 60.4(15.4) 59.4(14.3) 57.8(13.5) .37
Male 58(46%) 66(54%) 56(45%) .28
APACHE III
63.1(18.7) 62.2(22.3) 65.6(23.5) .43
VAS-A 51.9 (32.4) 49 (30.1) 52.3 (29.7) .66
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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
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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
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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
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Visual Analog Scale-Anxiety Final Models
Model 1/Model 2 β(se(β)) p-value
Intercept 40.6(6.8) / 40.9(6.8) <.001 / <.001
Day -.54(.28) / -.51(.28) .052 / .08
Patient-directed music -26.3(7.1) / -26.9(7.0) <.001* / <.001*
Headphones only -12.2(7.1) / -12.5(.08) .09 / .08
Final models control for APACHE III, sedative medications and interaction effects between treatment groups and VAS-A baseline; Usual care is
reference group.
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Mean VAS-Anxiety Controlling for Sedation Intensity
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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
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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
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“There are two means of refuge from the miseries of life: Music and cats”.
~Albert Schweitzer, 1875-1965German medical missionary, theologian, musician,
philosopher
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Thank you for your attention!