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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Eur Respir J 2024; 63:2300347. [PMID: 38387998 DOI: 10.1183/13993003.00347-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Maxens Decavele
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behaviorial Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- L. Heunks and T. Similowski contributed equally to the manuscript
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, F-75013 Paris, France
- L. Heunks and T. Similowski contributed equally to the manuscript
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Intensive Care Med 2024; 50:159-180. [PMID: 38388984 DOI: 10.1007/s00134-023-07246-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.
| | - Maxens Decavele
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behavioral Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
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Raux M, Navarro-Sune X, Wattiez N, Kindler F, Le Corre M, Decavele M, Demiri S, Demoule A, Chavez M, Similowski T. Adjusting ventilator settings to relieve dyspnoea modifies brain activity in critically ill patients: an electroencephalogram pilot study. Sci Rep 2019; 9:16572. [PMID: 31719608 PMCID: PMC6851109 DOI: 10.1038/s41598-019-53152-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022] Open
Abstract
Dyspnoea is frequent and distressing in patients receiving mechanical ventilation, but it is often not properly evaluated by caregivers. Electroencephalographic signatures of dyspnoea have been identified experimentally in healthy subjects. We hypothesized that adjusting ventilator settings to relieve dyspnoea in MV patients would induce EEG changes. This was a first-of-its-kind observational study in a convenience population of 12 dyspnoeic, mechanically ventilated patients for whom a decision to adjust the ventilator settings was taken by the physician in charge (adjustments of pressure support, slope, or trigger). Pre- and post-ventilator adjustment electroencephalogram recordings were processed using covariance matrix statistical classifiers and pre-inspiratory potentials. The pre-ventilator adjustment median dyspnoea visual analogue scale was 3.0 (interquartile range: 2.5–4.0; minimum-maximum: 1–5) and decreased by (median) 3.0 post-ventilator adjustment. Statistical classifiers adequately detected electroencephalographic changes in 8 cases (area under the curve ≥0.7). Previously present pre-inspiratory potentials disappeared in 7 cases post-ventilator adjustment. Dyspnoea improvement was consistent with electroencephalographic changes in 9 cases. Adjusting ventilator settings to relieve dyspnoea produced detectable changes in brain activity. This paves the way for studies aimed at determining whether monitoring respiratory-related electroencephalographic activity can improve outcomes in critically ill patients under mechanical ventilation.
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Affiliation(s)
- Mathieu Raux
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France.,AP-HP, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Département d'Anesthésie-Réanimation, F-75013, Paris, France
| | - Xavier Navarro-Sune
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France.,Sorbonne Université, INSERM UMR 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle Épinière, Paris, France
| | - Nicolas Wattiez
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France
| | - Felix Kindler
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France
| | - Marine Le Corre
- AP-HP, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Département d'Anesthésie-Réanimation, F-75013, Paris, France
| | - Maxens Decavele
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France.,AP-HP, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, F-75013, Paris, France
| | - Suela Demiri
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France.,AP-HP, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, F-75013, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France.,AP-HP, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, F-75013, Paris, France
| | - Mario Chavez
- Sorbonne Université, INSERM UMR 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle Épinière, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,AP-HP, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, F-75013, Paris, France.
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Affiliation(s)
- Alexandre Demoule
- 1 Service de Pneumologie, Médecine Intensive et Réanimation Hôpital Pitié-Salpêtrière Paris, France and.,2 INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique Sorbonne Université Paris, France
| | - Thomas Similowski
- 1 Service de Pneumologie, Médecine Intensive et Réanimation Hôpital Pitié-Salpêtrière Paris, France and.,2 INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique Sorbonne Université Paris, France
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