The Science Journal of the American Association for Respiratory Care

Original Contributions

October 2002 / Volume 47 / Number 10 / Page 1158

A Dyspnea Evaluation Protocol for Respiratory Therapists: A Feasibility Study

Irene Karampela MD, John Hansen-Flaschen MD, Steven Smith RRT, Daniel Reily RRT, and Barry D Fuchs MD

PURPOSE: We tested the feasibility of incorporating a dyspnea evaluation protocol into bedside assessments routinely performed by respiratory therapists (RTs) on mechanically ventilated patients at a university teaching hospital. METHODS: A dyspnea assessment protocol was incorporated into the RT assessments performed at 4-hour intervals on endotracheally intubated, mechanically ventilated patients in our medical and surgical intensive care units. RTs were asked to inquire of all responsive patients: "Are you feeling short of breath right now?" and, if yes, "Is your shortness of breath mild, moderate, or severe?" We analyzed 324 consecutive patient ventilator flow sheets from 77 medical and 161 surgical intensive care unit patients. RESULTS: Dyspnea scores were recorded during 1,870 of 2,539 scheduled RT patient assessments. The protocol compliance rate was 74%. Patients were sufficiently responsive to answer the protocol questions during 32.1% of the bedside assessments. Dyspnea was recorded in 11% (67/600) of those encounters. Dyspnea was described most often as mild. CONCLUSIONS: Initial implementation of a dyspnea evaluation protocol was moderately successful in prompting RTs to ask mechanically ventilated patients whether they felt short of breath during scheduled bedside visits. A rapid bedside evaluation for dyspnea may prove useful in evaluating the effect on patient distress of implementing protocols designed to optimize ventilator settings or the use of sedating drugs during mechanical ventilation. By this approach RTs may also be able to promote a patient-centered approach to managing respiratory failure in the intensive care unit.
Key words: dyspnea, dyspnea evaluation protocol, shortness of breath scale, mechanical ventilation, respiratory therapists.
[Respir Care 2002;47(10):1158–1161]

Introduction

Even when adequate arterial blood gas values and acid-base balance are restored, mechanical ventilation does not invariably alleviate dyspnea experienced by patients in respiratory failure. Because they are endotracheally intubated, mechanically ventilated patients are unable to speak and therefore cannot complain about shortness of breath or other forms of distress unless asked specifically. Although mechanically ventilated patients often appear apprehensive or resistive when short of breath, there are no physical findings associated specifically with dyspnea. Thus, shortness of breath can develop or become worse during mechanical ventilation without the awareness of bedside caregivers.

Clinical investigators have begun to study the prevalence and severity of dyspnea experienced by patients undergoing mechanical ventilation, using symptom assessment scales or numerical or visual analogue scales. Published studies have shown that these scales can serve as useful tools for quantifying dyspnea during the progress of respiratory failure and in response to therapy.

The observation that dyspnea in mechanically ventilated patients can be evaluated quantitatively raises the question of whether systematic dyspnea assessment can facilitate clinical quality improvement efforts and thus improve regular patient care. Nurses at many hospitals now routinely assess mechanically ventilated patients for the presence and severity of pain, especially after trauma or surgery. Might similar approaches also be employed to detect and treat shortness of breath during mechanical ventilation? If so, respiratory therapists (RTs) may be ideally suited to conduct those assessments. RTs routinely perform and record detailed physiologic assessments of mechanically ventilated patients, at frequent intervals throughout the day and night. Along with the assessment of the ventilator settings and alarms it is also important to assess the patient-ventilator interface. An evaluation of patient dyspnea is essential in that assessment. Addition of a brief dyspnea assessment to physiologic evaluations might add little time to regularly scheduled bedside visits. Therapists are suitably trained to evaluate dyspnea in the context of the other information on respiratory and ventilator function obtained during their visits. RTs may also be able to alleviate dyspnea directly in some instances by such interventions as adjusting the ventilator, suctioning the airway, or administering a bronchodilator.

In this study we sought to evaluate the feasibility of adding a brief dyspnea evaluation protocol to routine bedside assessments of mechanically ventilated patients in the medical and surgical intensive care units (ICUs) of a university teaching hospital by measuring the average time required to complete the protocol and the compliance rate of RTs assigned to use the protocol. This study also afforded an opportunity to estimate the prevalence of dyspnea in the diverse population of patients undergoing mechanical ventilation at our hospital.

The entire text of this article is available in the printed version of the October 2002 RESPIRATORY CARE.

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