RESEARCH doi: 10.1111/nicc.12159
The effects of music therapy in endotracheal suctioning of mechanically ventilated patients Ye¸sim Yaman Akta¸s and Neziha Karabulut ABSTRACT Background: Endotracheal suctioning has been identified as a painful procedure for critically ill patients. Aim: To determine the effect of music therapy on pain intensity, sedation level and physiological parameters during endotracheal suctioning of mechanically ventilated patients in cardiovascular surgery intensive care unit (ICU). Design: Experimental survey. Methods: The study was conducted between May 2010 and June 2013 in Ordu Medical Park Hospital Cardiovascular Surgery Intensive Care Unit. The study sample consisted of 66 patients (33 experimental and 33 control) who complied with the criteria of inclusion for the study. Data was collected using the ‘Patient Information Form’, ‘Critical-Care Pain Observation Tool’, ‘Ramsay Sedation Scale’ and ‘Form of Physiological Parameters’. Results: The mean scores of the Ramsay Sedation Scale during endotracheal aspiration were respectively 1⋅88 and 1⋅55 in the experimental and control group and the difference between the groups was statistically significant (p = 0⋅003). The mean score of Critical-Care Pain Observation Tool during endotracheal suctioning in the experimental group was found to be lower statistically than those of the control group (p < 0⋅001). There were no significant differences before, during and 20 min after suctioning between the two groups with regard to systolic blood pressure, diastolic blood pressure, heart rate and oxygen saturation (p > 0⋅05). Conclusions: The results of this study implies that music therapy can be effective practice for nurses attempting to reduce patients’ pain and control sedation level in patients on mechanical ventilators during endotracheal suctioning. Relevance to clinical practice: It is recommended that music therapy should be added to the routine nursing care for mechanically ventilated patients. Key words: Critical care nursing • Mechanical ventilation • Pain assessment • Post-operative care • Sedation
INTRODUCTION Pain is defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage (Eti-Aslan, 2002; Gélinas et al., 2009). Although major advances and clinical guidelines in pain assessment and management have been made, pain is still an important clinical problem (Puntillo et al., 2001; Rotondi et al., 2002; Ashlers et al., 2008; Stolic and Mitchell, 2010). Critically ill patients in intensive care units (ICUs) may experience moderate Authors: Y. Yaman Akta¸s, PhD, Department of Surgical Nursing, The Faculty of Health Science, Giresun University, Giresun, Turkey; Karabulut, PhD, Department of Surgical Nursing, The Faculty oh Health Science, Atatürk University, Erzurum, Turkey Address for correspondence: N Karabulut, Department of Surgical Nursing, The Faculty oh Health Science, Atatürk University, Erzurum 25240, Turkey E-mail: [email protected]
© 2015 British Association of Critical Care Nurses
to severe pain (Rotondi et al., 2002; Li and Puntillo, 2006; Cazorla et al., 2007) due to surgery, trauma, immobilization, invasive procedures, monitoring and therapeutic devices (i.e. catheters, drains, endotracheal tubes, chest tubes and non-invasive masks) and certain nursing interventions (Puntillo et al., 2001; Pasero 2003; Siffleet et al., 2007; Eti Aslan et al., 2009). Of these nursing interventions, endotracheal suctioning, blood sample collection, wound care, drain removal procedures and turning or repositioning have been previously identified as major sources of pain (Puntillo et al., 2001; Siffleet et al., 2007). Endotracheal suctioning has been identified as the most painful procedure for critically ill patients with a mechanic ventilator (Puntillo et al., 2001; Aïssaoui et al., 2005; Chang et al., 2006; Siffleet et al., 2007; Arroyo-Novoa et al., 2008; Eti Aslan et al., 2009; Kabes et al., 2009). Suctioning is described as the mechanical aspiration of pulmonary secretions from a patient with an 1
Music interventions for mechanically ventilated patients
artificial airway in position (Day et al., 2002). Suctioning is a characterized by painful and discomforting sensations, and is a fearful, unpleasant and often choking including situation accompanied by loss of breath for the patients (Day et al., 2002; Patak et al., 2004; Pedersen et al., 2009). A vital step of intervention procedures such as endotracheal suctioning is evaluating and relieving the resulting pain results in ICU patients supported by mechanical ventilation (Czarnecki et al., 2011). Studies have shown that non-pharmacologic interventions, used alone or in conjunction with pharmacologic interventions, have the potential to reduce the pain associated with procedures like endotracheal suction and increase patient comfort (Friesner et al., 2006; Windich-Biermeier et al., 2007). Non-pharmacologic interventions have been recognized as valuable, simple and inexpensive adjuvants to pharmacologic approaches to pain management. Music therapy, which is one form of non-pharmacological treatment used to relieve procedural pain, is a promising approach for pain management in endotracheal suctioning procedures (Allred et al., 2010). Music influences the brain by prompting the secretion of endorphins, which is the body’s own morphine. Music therapy also leads to slower heart rate, calmer and more regular respiratory rate and lower blood pressure (Chlan et al., 2001; Tjellesen et al., 2001; Almerud and Petersson, 2003; Özer et al., 2013).
little to no effect on these parameters (Sendelbach et al., 2006; Nilsson, 2009a; Easter et al., 2010). Due to the differences in these research findings (Chlan et al., 2001; Aragon et al., 2002; Lee et al., 2005; Sendelbach et al., 2006; Nilsson, 2009a), further studies are necessary to investigate the effectiveness of music to alter physiologic parameters and control pain. Although there are studies examining the effect of music therapy on the pain, sedation, comfort and anxiety level of the patients, there is currently no study examining the efficiency of music therapy in pain management during the suctioning procedure. In their descriptive study which examined the pain levels of patients undergoing endotracheal suctioning, Arroyo-Novoa et al. (2008) stated that half of the patients (n = 775) experienced moderate to severe pain. They suggested that experimental studies needed to be carried out to examine the efficiency of pharmacological and/or non-pharmacological methods to relieve pain related to endotracheal suctioning. This study is an initial experimental response using the medium of music therapy.
METHODS Aim The purpose of this study was to examine the effect of music therapy on pain, sedation and physiologic parameters during endotracheal suctioning of mechanically ventilated patients.
BACKGROUND Music therapy was first used by Dr. Helen Bonny in coronary care units in 1983. Dr. Bonny used music during her own recovery from coronary artery bypass surgery. After her recovery, she persuaded a hospital to pilot a music-listening programme in the coronary care unit. Results from her early pilot work indicated that patients were less anxious and more comfortable after listening to classical music (Bonny, 1983; Chlan, 2002). Some studies in ICU and peri-operative settings suggest evidence that soothing music can inhibit stress by reducing anxiety and pain (Almerud and Petersson, 2003; Twiss et al., 2006; Chlan et al., 2007; Nilsson, 2008), whereas Nilsson (2009b) found no difference in patient pain levels. Music therapy may help physiological parameters such as blood pressure, pulse and breathing rates to become normal by activating the parasympathetic neural system and decreasing catecholamine secretion (Engwall, 2009). Some studies have indicated that music therapy improves some physiologic parameters such as systolic blood pressure, diastolic blood pressure, oxygen saturation and heart rate (Chlan et al., 2001; Aragon et al., 2002; Lee et al., 2005), whereas others showed that music has 2
Ethical considerations The study was approved by the ethics committee of the Health Sciences Institution at Atatürk University (date: 8 May 2012 and number: 2012⋅2.47), and written consent was obtained from the director of the institution (date: 30 July 2012 and number: 551). All participants were informed of the purpose and design of the study and written consent was obtained from those who agreed to enrol in the study. They were guaranteed anonymity and confidentiality. Participation in the study was voluntary. It was specified that patients’ decision not to participate in the study would not affect the nursing interventions applied to them. All patients scheduled for open heart surgery were approached in preadmission testing to assess criteria for inclusion in the study and to discuss potential participation in the study in the pre-operative period. It was also indicated that patients could withdraw from the study at any time.
Design This was a randomized, single-blind experimental study. The study carried out in the Cardiovascular © 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
Surgery Intensive Care Unit, Medical Park Hospital, Ordu, between May 2012 and June 2013.
Sample The study sample consisted of 66 patients (33 experimental and 33 control) who complied with the criteria of inclusion for the study. The sample size was based on a power analysis for repeated-measures analysis of variance with a large effect size to achieve a power of 0⋅90 and 𝛼 = 0⋅01. The sample of the research consisted of patients who had undergone open heart surgery between August 2012 and January 2013 and those accepted to participate in the study. The first 33 patients were recruited as the control arm, the subsequent 33 patients formed the experimental group. Strict inclusion and exclusion criteria were established to minimize sample variability. The subjects consisted of patients who were scheduled for a CABG or valve replacement that met these inclusion criteria: ≥18 years old, intubated and needing endotracheal suctioning and in the level of wakefulness 2 or 3 according to Ramsay Sedation Scale, with the first suctioning applied at said wakefulness level. Exclusion criteria included patients with an injection fraction of ≤25 %, unstable haemodynamic conditions, high dose inotrope support or those using neuromuscular blocker medication or medication prescribed for chronic pain.
Instruments The data was collected by the researcher using the ‘Patient Information Form’, ‘Critical-Care Pain Observation Tool’, ‘Ramsay Sedation Scale’ and ‘Form of Physiological Parameters’.
Patient information form The questionnaire was prepared by the researcher in accordance with the related literature (Gélinas et al., 2004; Aïssaoui et al., 2005; Gélinas, 2007; Gélinas and Johnston, 2007; Arroyo-Novoa et al., 2008; Gélinas et al., 2009; Stolic and Mitchell, 2010). The questionnaire form asked for demographic characteristics of the patients including age, gender, education, marital status, previous surgery, type of surgery, ejection fraction (EF) and duration of mechanic ventilation.
Critical-care pain observation tool The Critical-Care Pain Observation Tool (CPOT) is a behavioural measure recently developed by Gélinas et al. (2006) for pain assessment in critically ill, non-verbal adults. It includes four behaviours: facial expressions, body movements, muscle tension and © 2015 British Association of Critical Care Nurses
either compliance with the ventilator in intubated patients or vocalization in non-intubated patients. Each facet is rated from 0 to 2 with a possible total score ranging from 0 to 8 (Table 1). Its content validity was verified with 14 ICU nurses and physicians. The CPOT was tested among different ICU groups, including cardiac surgery patients. Inter-rater reliability and discriminate and concurrent validity were examined. Inter-rater reliability was supported with moderate to high agreement coefficients between the research team and trained ICU nurses [weighted kappa from 0⋅52 to 0⋅88, and intra-interclass coefficient (ICC) from 0⋅80 to 0⋅93] (Gélinas et al., 2006; Gélinas et al., 2008).
Ramsay sedation scale Participants’ consciousness levels were measured with the use of Ramsay scale. In the studies in which patients’ pain levels are determined using the behavioural pain scales, sedation levels are assessed by Ramsay scale (Payen et al., 2001; Gélinas et al., 2004; Aïssaoui et al., 2005; Gélinas et al., 2006). It was developed by Dr. Ramsay in 1974 in order to define patients’ sedation levels. This scale consists of six items of which three items define wakefulness level and three items define sedation level (Table 2). In this scale, points 1, 2 and 3 represent the wakefulness level and points 4, 5 and 6 represent the sedation level. The first three responses are assessed in conscious patients and the other three responses are evaluated using by a glabellar tap or a loud auditory stimulus. Each sub-item is used to explain wakefulness and sedation level. The points taken vary between 1 and 6, and increasing points show higher levels of sedation (Jacobi et al., 2002; Dikmen, 2012).
Form of physiological parameters Physiological parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen saturation (SpO2 ), measured using a MINDRAY BeneView T5 Critical Care Monitor.
Intervention During the music therapy application, patients listened to music for 20 min before and after suctioning. Patients who needed suctioning before the first 15 min of the music therapy were excluded from to the research. All patients used an ergonomic audio pillow (Creatone music pillow) during music therapy. The pillow contained two loudspeakers, connected to an MP3 player. Only the patient lying on the pillow heard the music, which was inaudible to other patients and the staff. The pillow was covered with a pillowcase and its case was changed after every patient had used it. 3
Music interventions for mechanically ventilated patients
Table 1 Description of the critical-care pain observation (Gélinas et al., 2006) Indicator
Description
Score
Facial expression
No muscular tension observed Presence of frowning, brow lowering, orbit tightening, and levator contraction All the above facial movements plus eyelid tightly closed Does not move at all (does not necessarily mean absence of pain) Slow cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, inability to complete them Alarms not activated, easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated
Relaxed, neutral Tense
0 1
Grimacing Absence of movements Protection
2 0 1
Restlessness
2
Relaxed Tense, rigid Very tense or rigid
0 1 2
Body movements
Muscle tension: Evaluation by passive flexion and extension of upper extremities
Compliance with the ventilator
Total, range
Table 2 Description of Ramsay sedation scale (Ramsay et al., 1974) Description
0 1 2 0–8
were chosen with the help of a lecturer specializing in the field of music. Score
Awake level Patient anxious, agitated or restless Patient cooperative, oriented and tranquil Patient responding only to verbal commands Sleep level Patient with brisk response to light glabella tap or auditory stimulus Patient with sluggish response to light glabella tap or auditory stimulus Patient with no response to light glabella tap or auditory stimulus
Procedure 1 2 3 4 5 6
For the music therapy, instrumental reed flute music with a low pace (60–80 rhythms/min) and without strong beat and fluctuating rhythms was chosen. The music is all instrumental without any words. In the study, the patients in the experimental group were required to listen to sufi musical compositions (Huseyni and Nihavend modes). Sufi music includes both a vocal and instrumental aspects and features a Turkish classical instrument called the ‘ney’ (a reed flute). The literature mentions that relaxing music may create relief and calm in the individual and as a result decreases blood pressure, pulse and breathing rate. Music is the most relaxing when it mimics the heart rate at rest, i.e. has a pace of 60–80 per minute and without high dynamic amplitude. Relaxing music can induce a relaxation response, thereby reversing the deleterious effects of the stress response (Bringman et al., 2009; Allred et al., 2010). At this time, all the musical compositions used during the music therapy 4
Tolerating ventilator or movement Coughing but tolerating Fighting ventilator
Totally 66 patients were included in the study. Simple randomization was performed using file numbers of patients, and eligible patients were randomly assigned into either a control or an experimental study group. After the suitability of the patients to the criteria required for the research was evaluated, informed consent was obtained from all participants. The patients in the experimental group were required to listen to instrumental reed flute music 20 min before, during and 20 min after the suctioning intervention. Before, during and after the intervention, pain, sedation level and physiological parameters were evaluated by the researcher. Pain was evaluated 20 min after endotracheal suctioning because the stress hormones, epinephrine and norepinephrine, which both have half-lives in the 1–3 min range, are presumably released by a stressful procedure such as endotracheal suctioning, although they are known to return normal levels after 15–20 min (Lee et al., 2013). Data was collected from the control group at the same intervals as the experimental group, although without making them listen to music. There was no intervention to the patients in control group conducted by nurses working in the ICU except suctioning.
Data analysis Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, Chicago, IL) for © 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
windows, version 18. The major statistical procedures applied were descriptive statistics, and Chi-squared and t test each used to evaluate the differences between the groups. To make a comparison of the means of pain intensity, sedation level and physiologic parameters before and after endotracheal suctioning the paired t test was used. Repeated-measures analyses of variance (ANOVA) were conducted to evaluate the effect of the intervention on pain and sedation scores and physiologic parameters. A p value below 0⋅05 was considered to indicate a statistically significant difference.
RESULTS Demographic information The groups were compared regarding age, gender, education, marital status, previous surgery, type of surgery, EF and duration of mechanic ventilation (Table 3). The mean ages of the participants were 63⋅4 (SD 14⋅5) and 66⋅7 (SD 9⋅6) years in the experimental and control group, respectively. More than half of the participants forming the experimental and control group were male (69⋅7 and 75⋅7%, respectively), and the majority of subjects were married (81⋅8 and 90⋅9%). No significant differences were found between the two groups in terms of demographic characteristics (p > .05).
Pain, sedation and physiologic parameters The comparison of the mean pain, sedation, SBP, DBP, HR and SpO2 before, during and 20 min after endotracheal suctioning between the groups is presented in Table 4. There were no differences in pre-values of pain intensity, sedation, SBP, DBP, HR and SpO2. To compare pain intensities before and after endotracheal suctioning, CPOT scores were assessed before, during, and 20 min after endotracheal suctioning. Pain scores in the experimental group were found to be significantly lower than those of the control group during suctioning (t = −4⋅94, p < .01). However, pain scores at 20 min after suctioning were not significantly different from those before suctioning between the groups (t = 1⋅23, p > .05). The difference between the median sedation levels of the two groups during suctioning was found to be statistically significant (U = 363⋅0, p < .01), although there was no difference between the groups at 20 min after suctioning (p > .05). There were no significant differences at any time between the two groups with regard to SBP, SBP, HR, and SpO2 (p > .05).
DISCUSSION In this study, music therapy was offered to patients to relieve pain, increase the sedation level and ensure © 2015 British Association of Critical Care Nurses
Table 3 Demographic and clinical characteristics of the sample Experimental group Control group (N = 33) (N = 33) n (%) n (%) p Value Gender∗ Female Male Education∗ Literate-Primary school High School-University Marital status∗ Married Single Previous surgery∗ Yes No Type of surgery† CABG AVR/MVR CABG (+) valve annuloplasty Age (years)[mean (SD)‡ EF (%)[mean (SD)]‡ Duration of MV (h)[mean (SD)]‡
10 (30⋅3) 23 (69⋅7)
8 (24⋅2) 25 (75⋅7)
.580
26 (78⋅7) 7 (21⋅2)
27 (81⋅8) 6 (18⋅1)
.756
27 (81⋅8) 6 (18⋅1)
30 (90⋅9) 3 (9⋅0)
.282
18 (54⋅5) 15 (45⋅5)
25 (75⋅8) 8 (24⋅2)
.071
29 (87⋅9) 3 (9⋅1) 1 (3⋅0) 63⋅36 (14⋅54) 62⋅30 (8⋅88) 3⋅81 (1⋅48)
30 (90⋅9) 2 (6⋅1) 1 (3⋅0) 66⋅67 (9⋅60) 59⋅24 (10⋅23) 4⋅28 (1⋅54)
.897
.280 .199 .211
EF, Ejection fraction; MV, Mechanic ventilation. ∗ Examined by t-test. † Examined by likelihood ratio. ‡ Examined by chi-square test.
maintenance of physiological parameters during endotracheal suctioning in patients with a mechanic ventilator. This study found that the CPOT scores of the groups differed during endotracheal suctioning process. The highest CPOT score averages were 2⋅27 ± 1⋅38 and 4⋅18 ± 1⋅74, respectively, for the experimental and control group during endotracheal suctioning. The results of other descriptive studies conducted in ICUs were similar to our findings and it was stated that endotracheal suctioning was one of the processes causing severe pain in critical care patients (Payen et al., 2001; Aïssaoui et al., 2005; Arroyo-Novoa et al., 2008; Esen et al., 2010; Lee et al., 2013). It was found that pain levels of the patients varied in three measurement times in both the experimental and control groups and the difference between the groups was statistically significant (F = 12⋅32, p < .001). Studies examining the physiological effects of music state that music therapy mitigates pain levels by causing changes in neuroendocrine system (Solanki et al., 2013). Studies showed that listening to music affected pain, mood and memory by increasing endogenous opioid secretion from the hypophysis and thus was an effective intervention for critical care patients (Koelsch et al., 2004; Chlan et al., 2007; Fredriksson et al., 2009; Solanki et al., 2013). In a randomized control trial study, Twiss et al. (2006) investigated the effect of music chosen by the patients on pain and anxiety during and 5
Music interventions for mechanically ventilated patients
Table 4 Comparison of pain, sedation and physiologic parameters between the experimental group (n = 33) and control group (n = 33)
Pain Experimental Control Sedation Experimental Control SBP (mmHg) Experimental Control DBP (mmHg) Experimental Control HR (bpm) Experimental Control SpO2 (%) Experimental Control
Before ES mean (SD)/median
During ES mean (SD)/median
20 min after ES mean (SD)/median
0⋅42 (0⋅61) 0⋅55 (0⋅90)
2⋅27 (1⋅38)* 4⋅18 (1⋅74)
2⋅24 (0⋅4)/2⋅0 2⋅27 (0⋅5)/2⋅0
F
Significant p
0⋅79 (1⋅17) 1⋅24 (1⋅77)
12⋅32
0⋅05). According to the literature, the physiologic effects of beta-blockers and antihypertensive agents could be a factor affecting SBP, DBP and HR results of patients in cardiovascular surgery ICUs (Sendelbach et al., 2006). The findings of this study were similar to other studies conducted by Wong et al. (2001), Nilsson (2009b), Dijkstra et al. (2010), Easter et al. (2010), Özer et al. (2013) and Phipps et al. (2010), in which no significant changes were observed for the physiologic parameters in patients who listened to music in the ICU and after cardiac surgery. In contrast © 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
to the present study results, other studies reported that music therapy decreased blood pressure, and a significant difference was found between the music and the control group (Almerud and Petersson, 2003; Angela et al., 2005; Loomba et al., 2012). In the present study, oxygen saturation levels decreased during the intervention and increased after the intervention; however, oxygen saturation averages between the groups were not statistically significant. Similar findings have also been reported in the literature. In a meta-analysis study by Bradt et al. (2010) which examined the effectiveness of music therapy for patients with mechanical ventilation, eight experimental studies were evaluated. Bradt et al. (2010) determined that music had no effect on oxygen saturation. Han et al. (2010) stated that music therapy for mechanically ventilated patients did not cause statistically significant changes oxygen saturation values. The studies with different patient groups confirmed that music therapy did not have an effect on oxygen saturation as confirmed in the current study.
CONCLUSION Pain scores were reduced significantly during endotracheal suctioning among patients who listened to music compared with those who did not, Sedation levels among patients who did not listen to music increased during painful procedures. However, there was no difference in physiological parameters between the groups. This study suggests that music has an influence that can be used as a therapeutic tool for lowering pain scores in mechanically ventilated patients. Music therapy is a non-invasive and inexpensive nursing intervention. Because it is a low-cost therapy that has no side effects music therapy can be applied with the advantage of managing pain in patients on mechanical ventilators.
STUDY LIMITATIONS The present study has several limitations. The study was conducted in only one ICU and the findings cannot be generalized to all patients who had undergone open heart surgery in Turkey nor to other countries. The limitation of the study also includes selection of music type. Sufi music which is traditional to Turkey was chosen instead of classical music as compared to other research. Patients were not able to select the type of music. To provide standards in the research, the choice of music was not left to patients, and sufi music, which is known to have a therapeutic effect, was used in the study. Finally, the intervention was not blind to the researcher making assessments of pain. Future studies are recommended to include larger samples and should also include a larger selection or different types of music.
IMPLICATIONS FOR PRACTICE These points can be suggested as results of this study: music therapy should be added to routine nursing care for patients on mechanical ventilation and nurses should be given in-service training programmes about pain management and non-pharmacological methods to provide pain relief. Critical care nurses might consider initiating a music protocol as a safe and inexpensive non-pharmacological means of assisting patients to perceive a lower level of pain. Different kinds of music should be studied in larger randomised controlled trials. Furthermore, this study should be repeated with different patients groups in order to measure changes in stress hormones such as corticotrophin, cortisol, epinephrine and norepinephrine, all biological indications of pain. The study limitations explored below require that this study should be repeated in various conditions, with a variety of musical options, and with a larger population.
WHAT IS KNOWN ABOUT THIS TOPIC • • •
Pain is still an important clinical problem in ICU settings. Endotracheal suctioning has been identified as the most painful procedure for critically ill patients. Music therapy decreases pain and anxiety levels and improves physiologic parameters.
WHAT THIS PAPER ADDS • • •
This study uses an experimental design to examine the effect of Sufi music on pain, sedation and physiologic parameters during endotracheal suctioning of mechanically ventilated patients. Music therapy is used as non-pharmacological method to relieve pain related to endotracheal suctioning. Music therapy is a nursing intervention which can be used in pain management for patients with mechanical ventilation.
© 2015 British Association of Critical Care Nurses
7
Music interventions for mechanically ventilated patients
REFERENCES Aïssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. (2005). Validation of a behavioural pain scale in critically ill, sedated, and mechanically ventilated patients. Anesthesia and Analgesia; 101: 1470–1476. Allred KD, Byers JF, Sole ML. (2010). The effect of music on postoperative pain and anxiety. Pain Management Nursing; 11: 15–25. Almerud S, Petersson K. (2003). Music therapy-a complementary treatment for mechanically ventilated intensive care patients. Intensive Critical Care Nursing; 19: 21–30. Angela O, Chang Y, Chan M, Chan W. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal of Clinical Nursing; 14: 609–622. Aragon D, Farris C, Byers JF. (2002). The effects of harp music in vascular and thoracic surgical patients. Alternative Therapies in Health and Medicine; 8: 52–60. Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, Stanik-Hutt J, Thompson CL, White C, Wild LR. (2008). Pain related to tracheal suctioning in awake acutely and critically ill adults: a descriptive study. Intensive and Critical Care Nursing; 24: 20–27. Ashlers SJ, van Gulik L, van der Veen AM, van Dongen HP, Bruins P, Belitser SV, de Boer A, Tibboel D, Knibbe CA. (2008). Comparison of different pain scoring systems in critically ill patients in a general ICU. Critical Care; 12: R15. Bonny H. (1983). Music listening for intensive coronary care units: a pilot project. Music Therapy; 3: 4–16. Bradt J, Dileo C, Grocke D. (2010). Music interventions for mechanically ventilated patients. Cochrane Database of Systematic Reviews; 8: 1–73. DOI:10/1002/14651858.CD006902.pub2 Bringman H, Giesecke K, Thörne A, Bringman S. (2009). Relaxing music as pre-medication before surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica; 53: 759–764. Cazorla C, Cravoisy A, Gibot S, Nace L, Levy B, Bollaert PE. (2007). Patients’ perception of their experience in the intensive care unit. Presse Médicale; 36: 211–216. Chang LH, Cherng CH, Yang JL, Hu SF, Liaw JJ. (2006). A preliminary study of the acute pain in patients hospitalized in the adult surgical intensive care unit. Taiwan Critical Care Medicine; 7: 165–175. Chlan L. (2002). Integrating nonpharmacological, adjunctive interventions into critical care practice: a means to humanize care. American Journal of Critical Care; 11: 14–16. Chlan L, Tracy MF, Nelson B, Walker J. (2001). Feasibility of a music intervention protocol for patients receiving mechanical ventilatory support. Alternative Therapies in Health and Medicine; 7: 80–83. Chlan LL, Engeland WC, Anthony A, Guttormson J. (2007). Influence of music on the stress response in patients receiving mechanical ventilatory support: a pilot study. American Journal of Critical Care; 16: 141–145. Czarnecki ML, Turner HN, Collins PM, Doellman D, Wrona S, Reynolds J. (2011). Procedural pain management: a position statement with clinical practice recommendations. Pain Management Nursing; 12: 95–111. Day T, Farnell S, Wilson-Barnett J. (2002). Suctioning: a review of current research recommendations. Intensive and Critical Care Nursing; 18: 79–89. ˘ J. (2010). Dijkstra BM, Gamel C, van der Bijl JJ, Bots ML, Kesecioglu The effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients. Journal of Clinical Nursing; 19: 1030–1039.
8
Dikmen Y. (2012). Mechanical Ventilation-Fundamentals of Clinical Practice. Ankara: Günes Medical Press. Easter B, DeBoer L, Settlemyre G, Starnes C, Marlowe V, Tart RC. (2010). The impact of music on the PACU patient’s perception of discomfort. Journal of Perianesthesia Nursing; 25: 79–87. Engwall M. (2009). Music as a nursing intervention for postoperative pain: a systematic review. Journal of Perianesthesia Nursing; 24: 370–383. Esen H, Öntürk ZK, Bad𝚤r A, Eti AF. (2010). Pain behaviours of intubated and sedated intensive care patients during positioning and aspiration. Ac𝚤badem University Journal of Health Sciences; 1: 89–93. Eti Aslan F, Bad𝚤r A, Arli SK, Çakmakç𝚤 H. (2009). Patients’ experience of pain after cardiac surgery. Contemporary Nurse; 34: 48–54. Eti-Aslan F. (2002). Pain assessment methods. Cumhuriyet University Journal of Nursing School; 6: 9–16. Fredriksson AC, Hellstrom L, Nilsson U. (2009). Patients’ perception of music versus ordinary sound in a postanesthesia care unit: a randomized crossover trial. Intensive and Critical Care Nursing; 25: 208–213. Friesner SA, Curry DM, Moddeman GR. (2006). Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone. Heart and Lung; 35: 269–276. Gélinas C. (2007). Management of pain in cardiac surgery ICU patients: have we improved over time? Intensive and Critical Care Nursing; 23: 298–303. Gélinas C, Johnston C. (2007). Pain assessment in the critically ill ventilated adult: validation of critical- care pain observation tool and physiologic indicators. Clinical Journal of Pain; 23: 497–505. Gélinas C, Fortier M, Viens C, Fillion L, Puntillo K. (2004). Pain assessment and management in critically ill intubated patients: a retrospective study. American Journal of Critical Care; 13: 126–135. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. (2006). Validation of the critical-care pain observation tool in adult patients. American Journal of Critical Care; 15: 420–427. Gélinas C, Loiselle CG, Sylvie LM, Ranger M, Bouchard E, McCormack D. (2008). Theoretical, psychometric, and pragmatic issues in pain measurement. Pain Management Nursing; 9: 120–130. Gélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. (2009). Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain and Symptom Management; 37: 58–67. Han L, Li JP, Sit JW, Chung L, Jiao ZY, Ma WG. (2010). Effects of music intervention on physiological stress response and anxiety level of mechanically ventilated patients in China: a randomised controlled trial. Journal of Clinical Nursing; 19: 978–987. Jacobi J, Fraser G, Coursin DB, Riker RR. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine; 30: 119–141. Kabes AM, Graves JK, Norris J. (2009). Further validation of the nonverbal pain scale in intensive care patients. Critical Care Nurse; 29: 59–66. Koelsch S, Kasper E, Sammler D, Schulze K, Gunter T, Friederici AD. (2004). Music, language and meaning: brain signatures of semantic processing. Nature Neuroscience; 7: 302–307. Lee OK, Chung YF, Chan MF, Chan WM. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal of Clinical Nursing; 14: 609–620.
© 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
Lee K, Oh H, Suh Y, Seo W. (2013). Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool. Pain Management Nursing; 14: 259–267. Li DT, Puntillo K. (2006). A pilot study on coexisting symptoms in intensive care units. Applied Nursing Research; 19: 216–219. Loomba RS, Shah PH, Chandrasekar S, Arora R, Molnar J. (2012). Effects of music on systolic blood pressure, diastolic blood pressure, and heart rate: a meta-analysis. Indian Heart Journal; 64: 309–313. Nilsson U. (2008). The anxiety and pain-reducing effects of music interventions: a systematic review. AORN Journal; 87: 780–807. Nilsson U. (2009a). The effect of music intervention in stress response to cardiac surgery in a randomized clinical trial. Heart and Lung; 38: 201–207. Nilsson U. (2009b). Soothing music can increase oxytocin levels during bed rest after open heart surgery: a randomised control trial. Journal of Clinical Nursing; 18: 2153–2161. Özer N, Özlü ZK, Arslan S, Güne¸s N. (2013). Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Management Nursing; 14: 20–28. Pasero C. (2003). Pain in the critically ill patient. Journal of Perianesthesia Nursing; 6: 422–425. Patak L, Gawlinski A, Fung I, Doering L, Berg J. (2004). Patients’ reports of health care practitioner interventions that are related to communication during mechanical ventilation. Heart and Lung; 33: 308–321. Payen J, Bru O, Bosson J, Lagrasta A, Novel E, Deschaux I, Lavagne P, Jacquot C. (2001). Assessing pain in critically ill patients by using a behavioral pain scale. Critical Care Medicine; 29: 2258–2263. Pedersen CM, Rosendahl-Nielsen M, Hjermind J, Egerod I. (2009). Endotracheal suctioning of the adult intubated patient-what is the evidence? Intensive and Critical Care Nursing; 25: 21–30. Phipps MA, Carroll DL, Tsiantoulas A. (2010). Music as a therapeutic intervention on an inpatient neuroscience unit. Complementary Therapies in Clinical Practice; 16: 138–142. Puntillo KA, White C, Morris AB, Perdue ST, Stanik-Hutt J, Thompson CL, Wild LR. (2001). Patients’ perceptions and
© 2015 British Association of Critical Care Nurses
responses to procedural pain: results from Thunder Project II. American Journal of Critical Care; 10: 238–251. Ramsay MA, Savage TM, Simpson BR, Goodwin R. (1974). Controlled sedation with alphaxone-alphadone. British Medical Journal; 2: 656–659. Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, Im K, Donahoe M, Pisnky MR. (2002). Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Critical Care Medicine; 30: 746–752. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. (2006). The effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery. Journal of Cardiovascular Nursing; 21: 194–200. Siffleet J, Young J, Nikoletti S, Shaw T. (2007). Patients’ self-report of procedural pain in the intensive care unit. Journal of Clinical Nursing; 16: 2142–2148. Solanki MS, Zafar M, Rastogi R. (2013). Music as a therapy: role in psychiatry. Asian Journal of Psychiatry; 6: 193–199. Stolic S, Mitchell ML. (2010). Pain management for patients in cardiac surgical intensive care units has not improved over time. Australian Critical Care; 23: 157–159. Tjellesen DG, Yurkovich EE, Gragert M. (2001). Use of music therapy and other ITNIs in acute care. Journal of Psychosocial Nursing and Mental Health Services; 39: 26–37. Twiss E, Seaver J, McCaffery R. (2006). The effect of music listening on older adults undergoing cardiovascular surgery. Nursing in Critical Care; 11: 224–231. Voss JA, Good M, Yates B, Baun MM, Thompson A, Hertzog M. (2004). Sedative music reduces anxiety and pain during chair rest after open-heart surgery. Pain; 112: 197–203. Windich-Biermeier A, Sjoberg I, Dale JC, Eshelman D, Guzzetta CE. (2007). Effects of distraction on pain, fear and distress during venous port access and venipuncture in children and adolescents with cancer. Journal of Paediatric Oncology Nursing; 24: 8–19. Wong HL, Lopez-Nahas V, Molassiotis A. (2001). Effects of music therapy on anxiety in ventilator-dependent patients. Heart and Lung; 30: 376–387.
9
The effects of music therapy in endotracheal suctioning of mechanically ventilated patients Ye¸sim Yaman Akta¸s and Neziha Karabulut ABSTRACT Background: Endotracheal suctioning has been identified as a painful procedure for critically ill patients. Aim: To determine the effect of music therapy on pain intensity, sedation level and physiological parameters during endotracheal suctioning of mechanically ventilated patients in cardiovascular surgery intensive care unit (ICU). Design: Experimental survey. Methods: The study was conducted between May 2010 and June 2013 in Ordu Medical Park Hospital Cardiovascular Surgery Intensive Care Unit. The study sample consisted of 66 patients (33 experimental and 33 control) who complied with the criteria of inclusion for the study. Data was collected using the ‘Patient Information Form’, ‘Critical-Care Pain Observation Tool’, ‘Ramsay Sedation Scale’ and ‘Form of Physiological Parameters’. Results: The mean scores of the Ramsay Sedation Scale during endotracheal aspiration were respectively 1⋅88 and 1⋅55 in the experimental and control group and the difference between the groups was statistically significant (p = 0⋅003). The mean score of Critical-Care Pain Observation Tool during endotracheal suctioning in the experimental group was found to be lower statistically than those of the control group (p < 0⋅001). There were no significant differences before, during and 20 min after suctioning between the two groups with regard to systolic blood pressure, diastolic blood pressure, heart rate and oxygen saturation (p > 0⋅05). Conclusions: The results of this study implies that music therapy can be effective practice for nurses attempting to reduce patients’ pain and control sedation level in patients on mechanical ventilators during endotracheal suctioning. Relevance to clinical practice: It is recommended that music therapy should be added to the routine nursing care for mechanically ventilated patients. Key words: Critical care nursing • Mechanical ventilation • Pain assessment • Post-operative care • Sedation
INTRODUCTION Pain is defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage (Eti-Aslan, 2002; Gélinas et al., 2009). Although major advances and clinical guidelines in pain assessment and management have been made, pain is still an important clinical problem (Puntillo et al., 2001; Rotondi et al., 2002; Ashlers et al., 2008; Stolic and Mitchell, 2010). Critically ill patients in intensive care units (ICUs) may experience moderate Authors: Y. Yaman Akta¸s, PhD, Department of Surgical Nursing, The Faculty of Health Science, Giresun University, Giresun, Turkey; Karabulut, PhD, Department of Surgical Nursing, The Faculty oh Health Science, Atatürk University, Erzurum, Turkey Address for correspondence: N Karabulut, Department of Surgical Nursing, The Faculty oh Health Science, Atatürk University, Erzurum 25240, Turkey E-mail: [email protected]
© 2015 British Association of Critical Care Nurses
to severe pain (Rotondi et al., 2002; Li and Puntillo, 2006; Cazorla et al., 2007) due to surgery, trauma, immobilization, invasive procedures, monitoring and therapeutic devices (i.e. catheters, drains, endotracheal tubes, chest tubes and non-invasive masks) and certain nursing interventions (Puntillo et al., 2001; Pasero 2003; Siffleet et al., 2007; Eti Aslan et al., 2009). Of these nursing interventions, endotracheal suctioning, blood sample collection, wound care, drain removal procedures and turning or repositioning have been previously identified as major sources of pain (Puntillo et al., 2001; Siffleet et al., 2007). Endotracheal suctioning has been identified as the most painful procedure for critically ill patients with a mechanic ventilator (Puntillo et al., 2001; Aïssaoui et al., 2005; Chang et al., 2006; Siffleet et al., 2007; Arroyo-Novoa et al., 2008; Eti Aslan et al., 2009; Kabes et al., 2009). Suctioning is described as the mechanical aspiration of pulmonary secretions from a patient with an 1
Music interventions for mechanically ventilated patients
artificial airway in position (Day et al., 2002). Suctioning is a characterized by painful and discomforting sensations, and is a fearful, unpleasant and often choking including situation accompanied by loss of breath for the patients (Day et al., 2002; Patak et al., 2004; Pedersen et al., 2009). A vital step of intervention procedures such as endotracheal suctioning is evaluating and relieving the resulting pain results in ICU patients supported by mechanical ventilation (Czarnecki et al., 2011). Studies have shown that non-pharmacologic interventions, used alone or in conjunction with pharmacologic interventions, have the potential to reduce the pain associated with procedures like endotracheal suction and increase patient comfort (Friesner et al., 2006; Windich-Biermeier et al., 2007). Non-pharmacologic interventions have been recognized as valuable, simple and inexpensive adjuvants to pharmacologic approaches to pain management. Music therapy, which is one form of non-pharmacological treatment used to relieve procedural pain, is a promising approach for pain management in endotracheal suctioning procedures (Allred et al., 2010). Music influences the brain by prompting the secretion of endorphins, which is the body’s own morphine. Music therapy also leads to slower heart rate, calmer and more regular respiratory rate and lower blood pressure (Chlan et al., 2001; Tjellesen et al., 2001; Almerud and Petersson, 2003; Özer et al., 2013).
little to no effect on these parameters (Sendelbach et al., 2006; Nilsson, 2009a; Easter et al., 2010). Due to the differences in these research findings (Chlan et al., 2001; Aragon et al., 2002; Lee et al., 2005; Sendelbach et al., 2006; Nilsson, 2009a), further studies are necessary to investigate the effectiveness of music to alter physiologic parameters and control pain. Although there are studies examining the effect of music therapy on the pain, sedation, comfort and anxiety level of the patients, there is currently no study examining the efficiency of music therapy in pain management during the suctioning procedure. In their descriptive study which examined the pain levels of patients undergoing endotracheal suctioning, Arroyo-Novoa et al. (2008) stated that half of the patients (n = 775) experienced moderate to severe pain. They suggested that experimental studies needed to be carried out to examine the efficiency of pharmacological and/or non-pharmacological methods to relieve pain related to endotracheal suctioning. This study is an initial experimental response using the medium of music therapy.
METHODS Aim The purpose of this study was to examine the effect of music therapy on pain, sedation and physiologic parameters during endotracheal suctioning of mechanically ventilated patients.
BACKGROUND Music therapy was first used by Dr. Helen Bonny in coronary care units in 1983. Dr. Bonny used music during her own recovery from coronary artery bypass surgery. After her recovery, she persuaded a hospital to pilot a music-listening programme in the coronary care unit. Results from her early pilot work indicated that patients were less anxious and more comfortable after listening to classical music (Bonny, 1983; Chlan, 2002). Some studies in ICU and peri-operative settings suggest evidence that soothing music can inhibit stress by reducing anxiety and pain (Almerud and Petersson, 2003; Twiss et al., 2006; Chlan et al., 2007; Nilsson, 2008), whereas Nilsson (2009b) found no difference in patient pain levels. Music therapy may help physiological parameters such as blood pressure, pulse and breathing rates to become normal by activating the parasympathetic neural system and decreasing catecholamine secretion (Engwall, 2009). Some studies have indicated that music therapy improves some physiologic parameters such as systolic blood pressure, diastolic blood pressure, oxygen saturation and heart rate (Chlan et al., 2001; Aragon et al., 2002; Lee et al., 2005), whereas others showed that music has 2
Ethical considerations The study was approved by the ethics committee of the Health Sciences Institution at Atatürk University (date: 8 May 2012 and number: 2012⋅2.47), and written consent was obtained from the director of the institution (date: 30 July 2012 and number: 551). All participants were informed of the purpose and design of the study and written consent was obtained from those who agreed to enrol in the study. They were guaranteed anonymity and confidentiality. Participation in the study was voluntary. It was specified that patients’ decision not to participate in the study would not affect the nursing interventions applied to them. All patients scheduled for open heart surgery were approached in preadmission testing to assess criteria for inclusion in the study and to discuss potential participation in the study in the pre-operative period. It was also indicated that patients could withdraw from the study at any time.
Design This was a randomized, single-blind experimental study. The study carried out in the Cardiovascular © 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
Surgery Intensive Care Unit, Medical Park Hospital, Ordu, between May 2012 and June 2013.
Sample The study sample consisted of 66 patients (33 experimental and 33 control) who complied with the criteria of inclusion for the study. The sample size was based on a power analysis for repeated-measures analysis of variance with a large effect size to achieve a power of 0⋅90 and 𝛼 = 0⋅01. The sample of the research consisted of patients who had undergone open heart surgery between August 2012 and January 2013 and those accepted to participate in the study. The first 33 patients were recruited as the control arm, the subsequent 33 patients formed the experimental group. Strict inclusion and exclusion criteria were established to minimize sample variability. The subjects consisted of patients who were scheduled for a CABG or valve replacement that met these inclusion criteria: ≥18 years old, intubated and needing endotracheal suctioning and in the level of wakefulness 2 or 3 according to Ramsay Sedation Scale, with the first suctioning applied at said wakefulness level. Exclusion criteria included patients with an injection fraction of ≤25 %, unstable haemodynamic conditions, high dose inotrope support or those using neuromuscular blocker medication or medication prescribed for chronic pain.
Instruments The data was collected by the researcher using the ‘Patient Information Form’, ‘Critical-Care Pain Observation Tool’, ‘Ramsay Sedation Scale’ and ‘Form of Physiological Parameters’.
Patient information form The questionnaire was prepared by the researcher in accordance with the related literature (Gélinas et al., 2004; Aïssaoui et al., 2005; Gélinas, 2007; Gélinas and Johnston, 2007; Arroyo-Novoa et al., 2008; Gélinas et al., 2009; Stolic and Mitchell, 2010). The questionnaire form asked for demographic characteristics of the patients including age, gender, education, marital status, previous surgery, type of surgery, ejection fraction (EF) and duration of mechanic ventilation.
Critical-care pain observation tool The Critical-Care Pain Observation Tool (CPOT) is a behavioural measure recently developed by Gélinas et al. (2006) for pain assessment in critically ill, non-verbal adults. It includes four behaviours: facial expressions, body movements, muscle tension and © 2015 British Association of Critical Care Nurses
either compliance with the ventilator in intubated patients or vocalization in non-intubated patients. Each facet is rated from 0 to 2 with a possible total score ranging from 0 to 8 (Table 1). Its content validity was verified with 14 ICU nurses and physicians. The CPOT was tested among different ICU groups, including cardiac surgery patients. Inter-rater reliability and discriminate and concurrent validity were examined. Inter-rater reliability was supported with moderate to high agreement coefficients between the research team and trained ICU nurses [weighted kappa from 0⋅52 to 0⋅88, and intra-interclass coefficient (ICC) from 0⋅80 to 0⋅93] (Gélinas et al., 2006; Gélinas et al., 2008).
Ramsay sedation scale Participants’ consciousness levels were measured with the use of Ramsay scale. In the studies in which patients’ pain levels are determined using the behavioural pain scales, sedation levels are assessed by Ramsay scale (Payen et al., 2001; Gélinas et al., 2004; Aïssaoui et al., 2005; Gélinas et al., 2006). It was developed by Dr. Ramsay in 1974 in order to define patients’ sedation levels. This scale consists of six items of which three items define wakefulness level and three items define sedation level (Table 2). In this scale, points 1, 2 and 3 represent the wakefulness level and points 4, 5 and 6 represent the sedation level. The first three responses are assessed in conscious patients and the other three responses are evaluated using by a glabellar tap or a loud auditory stimulus. Each sub-item is used to explain wakefulness and sedation level. The points taken vary between 1 and 6, and increasing points show higher levels of sedation (Jacobi et al., 2002; Dikmen, 2012).
Form of physiological parameters Physiological parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and oxygen saturation (SpO2 ), measured using a MINDRAY BeneView T5 Critical Care Monitor.
Intervention During the music therapy application, patients listened to music for 20 min before and after suctioning. Patients who needed suctioning before the first 15 min of the music therapy were excluded from to the research. All patients used an ergonomic audio pillow (Creatone music pillow) during music therapy. The pillow contained two loudspeakers, connected to an MP3 player. Only the patient lying on the pillow heard the music, which was inaudible to other patients and the staff. The pillow was covered with a pillowcase and its case was changed after every patient had used it. 3
Music interventions for mechanically ventilated patients
Table 1 Description of the critical-care pain observation (Gélinas et al., 2006) Indicator
Description
Score
Facial expression
No muscular tension observed Presence of frowning, brow lowering, orbit tightening, and levator contraction All the above facial movements plus eyelid tightly closed Does not move at all (does not necessarily mean absence of pain) Slow cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, inability to complete them Alarms not activated, easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated
Relaxed, neutral Tense
0 1
Grimacing Absence of movements Protection
2 0 1
Restlessness
2
Relaxed Tense, rigid Very tense or rigid
0 1 2
Body movements
Muscle tension: Evaluation by passive flexion and extension of upper extremities
Compliance with the ventilator
Total, range
Table 2 Description of Ramsay sedation scale (Ramsay et al., 1974) Description
0 1 2 0–8
were chosen with the help of a lecturer specializing in the field of music. Score
Awake level Patient anxious, agitated or restless Patient cooperative, oriented and tranquil Patient responding only to verbal commands Sleep level Patient with brisk response to light glabella tap or auditory stimulus Patient with sluggish response to light glabella tap or auditory stimulus Patient with no response to light glabella tap or auditory stimulus
Procedure 1 2 3 4 5 6
For the music therapy, instrumental reed flute music with a low pace (60–80 rhythms/min) and without strong beat and fluctuating rhythms was chosen. The music is all instrumental without any words. In the study, the patients in the experimental group were required to listen to sufi musical compositions (Huseyni and Nihavend modes). Sufi music includes both a vocal and instrumental aspects and features a Turkish classical instrument called the ‘ney’ (a reed flute). The literature mentions that relaxing music may create relief and calm in the individual and as a result decreases blood pressure, pulse and breathing rate. Music is the most relaxing when it mimics the heart rate at rest, i.e. has a pace of 60–80 per minute and without high dynamic amplitude. Relaxing music can induce a relaxation response, thereby reversing the deleterious effects of the stress response (Bringman et al., 2009; Allred et al., 2010). At this time, all the musical compositions used during the music therapy 4
Tolerating ventilator or movement Coughing but tolerating Fighting ventilator
Totally 66 patients were included in the study. Simple randomization was performed using file numbers of patients, and eligible patients were randomly assigned into either a control or an experimental study group. After the suitability of the patients to the criteria required for the research was evaluated, informed consent was obtained from all participants. The patients in the experimental group were required to listen to instrumental reed flute music 20 min before, during and 20 min after the suctioning intervention. Before, during and after the intervention, pain, sedation level and physiological parameters were evaluated by the researcher. Pain was evaluated 20 min after endotracheal suctioning because the stress hormones, epinephrine and norepinephrine, which both have half-lives in the 1–3 min range, are presumably released by a stressful procedure such as endotracheal suctioning, although they are known to return normal levels after 15–20 min (Lee et al., 2013). Data was collected from the control group at the same intervals as the experimental group, although without making them listen to music. There was no intervention to the patients in control group conducted by nurses working in the ICU except suctioning.
Data analysis Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, Chicago, IL) for © 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
windows, version 18. The major statistical procedures applied were descriptive statistics, and Chi-squared and t test each used to evaluate the differences between the groups. To make a comparison of the means of pain intensity, sedation level and physiologic parameters before and after endotracheal suctioning the paired t test was used. Repeated-measures analyses of variance (ANOVA) were conducted to evaluate the effect of the intervention on pain and sedation scores and physiologic parameters. A p value below 0⋅05 was considered to indicate a statistically significant difference.
RESULTS Demographic information The groups were compared regarding age, gender, education, marital status, previous surgery, type of surgery, EF and duration of mechanic ventilation (Table 3). The mean ages of the participants were 63⋅4 (SD 14⋅5) and 66⋅7 (SD 9⋅6) years in the experimental and control group, respectively. More than half of the participants forming the experimental and control group were male (69⋅7 and 75⋅7%, respectively), and the majority of subjects were married (81⋅8 and 90⋅9%). No significant differences were found between the two groups in terms of demographic characteristics (p > .05).
Pain, sedation and physiologic parameters The comparison of the mean pain, sedation, SBP, DBP, HR and SpO2 before, during and 20 min after endotracheal suctioning between the groups is presented in Table 4. There were no differences in pre-values of pain intensity, sedation, SBP, DBP, HR and SpO2. To compare pain intensities before and after endotracheal suctioning, CPOT scores were assessed before, during, and 20 min after endotracheal suctioning. Pain scores in the experimental group were found to be significantly lower than those of the control group during suctioning (t = −4⋅94, p < .01). However, pain scores at 20 min after suctioning were not significantly different from those before suctioning between the groups (t = 1⋅23, p > .05). The difference between the median sedation levels of the two groups during suctioning was found to be statistically significant (U = 363⋅0, p < .01), although there was no difference between the groups at 20 min after suctioning (p > .05). There were no significant differences at any time between the two groups with regard to SBP, SBP, HR, and SpO2 (p > .05).
DISCUSSION In this study, music therapy was offered to patients to relieve pain, increase the sedation level and ensure © 2015 British Association of Critical Care Nurses
Table 3 Demographic and clinical characteristics of the sample Experimental group Control group (N = 33) (N = 33) n (%) n (%) p Value Gender∗ Female Male Education∗ Literate-Primary school High School-University Marital status∗ Married Single Previous surgery∗ Yes No Type of surgery† CABG AVR/MVR CABG (+) valve annuloplasty Age (years)[mean (SD)‡ EF (%)[mean (SD)]‡ Duration of MV (h)[mean (SD)]‡
10 (30⋅3) 23 (69⋅7)
8 (24⋅2) 25 (75⋅7)
.580
26 (78⋅7) 7 (21⋅2)
27 (81⋅8) 6 (18⋅1)
.756
27 (81⋅8) 6 (18⋅1)
30 (90⋅9) 3 (9⋅0)
.282
18 (54⋅5) 15 (45⋅5)
25 (75⋅8) 8 (24⋅2)
.071
29 (87⋅9) 3 (9⋅1) 1 (3⋅0) 63⋅36 (14⋅54) 62⋅30 (8⋅88) 3⋅81 (1⋅48)
30 (90⋅9) 2 (6⋅1) 1 (3⋅0) 66⋅67 (9⋅60) 59⋅24 (10⋅23) 4⋅28 (1⋅54)
.897
.280 .199 .211
EF, Ejection fraction; MV, Mechanic ventilation. ∗ Examined by t-test. † Examined by likelihood ratio. ‡ Examined by chi-square test.
maintenance of physiological parameters during endotracheal suctioning in patients with a mechanic ventilator. This study found that the CPOT scores of the groups differed during endotracheal suctioning process. The highest CPOT score averages were 2⋅27 ± 1⋅38 and 4⋅18 ± 1⋅74, respectively, for the experimental and control group during endotracheal suctioning. The results of other descriptive studies conducted in ICUs were similar to our findings and it was stated that endotracheal suctioning was one of the processes causing severe pain in critical care patients (Payen et al., 2001; Aïssaoui et al., 2005; Arroyo-Novoa et al., 2008; Esen et al., 2010; Lee et al., 2013). It was found that pain levels of the patients varied in three measurement times in both the experimental and control groups and the difference between the groups was statistically significant (F = 12⋅32, p < .001). Studies examining the physiological effects of music state that music therapy mitigates pain levels by causing changes in neuroendocrine system (Solanki et al., 2013). Studies showed that listening to music affected pain, mood and memory by increasing endogenous opioid secretion from the hypophysis and thus was an effective intervention for critical care patients (Koelsch et al., 2004; Chlan et al., 2007; Fredriksson et al., 2009; Solanki et al., 2013). In a randomized control trial study, Twiss et al. (2006) investigated the effect of music chosen by the patients on pain and anxiety during and 5
Music interventions for mechanically ventilated patients
Table 4 Comparison of pain, sedation and physiologic parameters between the experimental group (n = 33) and control group (n = 33)
Pain Experimental Control Sedation Experimental Control SBP (mmHg) Experimental Control DBP (mmHg) Experimental Control HR (bpm) Experimental Control SpO2 (%) Experimental Control
Before ES mean (SD)/median
During ES mean (SD)/median
20 min after ES mean (SD)/median
0⋅42 (0⋅61) 0⋅55 (0⋅90)
2⋅27 (1⋅38)* 4⋅18 (1⋅74)
2⋅24 (0⋅4)/2⋅0 2⋅27 (0⋅5)/2⋅0
F
Significant p
0⋅79 (1⋅17) 1⋅24 (1⋅77)
12⋅32
0⋅05). According to the literature, the physiologic effects of beta-blockers and antihypertensive agents could be a factor affecting SBP, DBP and HR results of patients in cardiovascular surgery ICUs (Sendelbach et al., 2006). The findings of this study were similar to other studies conducted by Wong et al. (2001), Nilsson (2009b), Dijkstra et al. (2010), Easter et al. (2010), Özer et al. (2013) and Phipps et al. (2010), in which no significant changes were observed for the physiologic parameters in patients who listened to music in the ICU and after cardiac surgery. In contrast © 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
to the present study results, other studies reported that music therapy decreased blood pressure, and a significant difference was found between the music and the control group (Almerud and Petersson, 2003; Angela et al., 2005; Loomba et al., 2012). In the present study, oxygen saturation levels decreased during the intervention and increased after the intervention; however, oxygen saturation averages between the groups were not statistically significant. Similar findings have also been reported in the literature. In a meta-analysis study by Bradt et al. (2010) which examined the effectiveness of music therapy for patients with mechanical ventilation, eight experimental studies were evaluated. Bradt et al. (2010) determined that music had no effect on oxygen saturation. Han et al. (2010) stated that music therapy for mechanically ventilated patients did not cause statistically significant changes oxygen saturation values. The studies with different patient groups confirmed that music therapy did not have an effect on oxygen saturation as confirmed in the current study.
CONCLUSION Pain scores were reduced significantly during endotracheal suctioning among patients who listened to music compared with those who did not, Sedation levels among patients who did not listen to music increased during painful procedures. However, there was no difference in physiological parameters between the groups. This study suggests that music has an influence that can be used as a therapeutic tool for lowering pain scores in mechanically ventilated patients. Music therapy is a non-invasive and inexpensive nursing intervention. Because it is a low-cost therapy that has no side effects music therapy can be applied with the advantage of managing pain in patients on mechanical ventilators.
STUDY LIMITATIONS The present study has several limitations. The study was conducted in only one ICU and the findings cannot be generalized to all patients who had undergone open heart surgery in Turkey nor to other countries. The limitation of the study also includes selection of music type. Sufi music which is traditional to Turkey was chosen instead of classical music as compared to other research. Patients were not able to select the type of music. To provide standards in the research, the choice of music was not left to patients, and sufi music, which is known to have a therapeutic effect, was used in the study. Finally, the intervention was not blind to the researcher making assessments of pain. Future studies are recommended to include larger samples and should also include a larger selection or different types of music.
IMPLICATIONS FOR PRACTICE These points can be suggested as results of this study: music therapy should be added to routine nursing care for patients on mechanical ventilation and nurses should be given in-service training programmes about pain management and non-pharmacological methods to provide pain relief. Critical care nurses might consider initiating a music protocol as a safe and inexpensive non-pharmacological means of assisting patients to perceive a lower level of pain. Different kinds of music should be studied in larger randomised controlled trials. Furthermore, this study should be repeated with different patients groups in order to measure changes in stress hormones such as corticotrophin, cortisol, epinephrine and norepinephrine, all biological indications of pain. The study limitations explored below require that this study should be repeated in various conditions, with a variety of musical options, and with a larger population.
WHAT IS KNOWN ABOUT THIS TOPIC • • •
Pain is still an important clinical problem in ICU settings. Endotracheal suctioning has been identified as the most painful procedure for critically ill patients. Music therapy decreases pain and anxiety levels and improves physiologic parameters.
WHAT THIS PAPER ADDS • • •
This study uses an experimental design to examine the effect of Sufi music on pain, sedation and physiologic parameters during endotracheal suctioning of mechanically ventilated patients. Music therapy is used as non-pharmacological method to relieve pain related to endotracheal suctioning. Music therapy is a nursing intervention which can be used in pain management for patients with mechanical ventilation.
© 2015 British Association of Critical Care Nurses
7
Music interventions for mechanically ventilated patients
REFERENCES Aïssaoui Y, Zeggwagh AA, Zekraoui A, Abidi K, Abouqal R. (2005). Validation of a behavioural pain scale in critically ill, sedated, and mechanically ventilated patients. Anesthesia and Analgesia; 101: 1470–1476. Allred KD, Byers JF, Sole ML. (2010). The effect of music on postoperative pain and anxiety. Pain Management Nursing; 11: 15–25. Almerud S, Petersson K. (2003). Music therapy-a complementary treatment for mechanically ventilated intensive care patients. Intensive Critical Care Nursing; 19: 21–30. Angela O, Chang Y, Chan M, Chan W. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal of Clinical Nursing; 14: 609–622. Aragon D, Farris C, Byers JF. (2002). The effects of harp music in vascular and thoracic surgical patients. Alternative Therapies in Health and Medicine; 8: 52–60. Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, Stanik-Hutt J, Thompson CL, White C, Wild LR. (2008). Pain related to tracheal suctioning in awake acutely and critically ill adults: a descriptive study. Intensive and Critical Care Nursing; 24: 20–27. Ashlers SJ, van Gulik L, van der Veen AM, van Dongen HP, Bruins P, Belitser SV, de Boer A, Tibboel D, Knibbe CA. (2008). Comparison of different pain scoring systems in critically ill patients in a general ICU. Critical Care; 12: R15. Bonny H. (1983). Music listening for intensive coronary care units: a pilot project. Music Therapy; 3: 4–16. Bradt J, Dileo C, Grocke D. (2010). Music interventions for mechanically ventilated patients. Cochrane Database of Systematic Reviews; 8: 1–73. DOI:10/1002/14651858.CD006902.pub2 Bringman H, Giesecke K, Thörne A, Bringman S. (2009). Relaxing music as pre-medication before surgery: a randomised controlled trial. Acta Anaesthesiologica Scandinavica; 53: 759–764. Cazorla C, Cravoisy A, Gibot S, Nace L, Levy B, Bollaert PE. (2007). Patients’ perception of their experience in the intensive care unit. Presse Médicale; 36: 211–216. Chang LH, Cherng CH, Yang JL, Hu SF, Liaw JJ. (2006). A preliminary study of the acute pain in patients hospitalized in the adult surgical intensive care unit. Taiwan Critical Care Medicine; 7: 165–175. Chlan L. (2002). Integrating nonpharmacological, adjunctive interventions into critical care practice: a means to humanize care. American Journal of Critical Care; 11: 14–16. Chlan L, Tracy MF, Nelson B, Walker J. (2001). Feasibility of a music intervention protocol for patients receiving mechanical ventilatory support. Alternative Therapies in Health and Medicine; 7: 80–83. Chlan LL, Engeland WC, Anthony A, Guttormson J. (2007). Influence of music on the stress response in patients receiving mechanical ventilatory support: a pilot study. American Journal of Critical Care; 16: 141–145. Czarnecki ML, Turner HN, Collins PM, Doellman D, Wrona S, Reynolds J. (2011). Procedural pain management: a position statement with clinical practice recommendations. Pain Management Nursing; 12: 95–111. Day T, Farnell S, Wilson-Barnett J. (2002). Suctioning: a review of current research recommendations. Intensive and Critical Care Nursing; 18: 79–89. ˘ J. (2010). Dijkstra BM, Gamel C, van der Bijl JJ, Bots ML, Kesecioglu The effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients. Journal of Clinical Nursing; 19: 1030–1039.
8
Dikmen Y. (2012). Mechanical Ventilation-Fundamentals of Clinical Practice. Ankara: Günes Medical Press. Easter B, DeBoer L, Settlemyre G, Starnes C, Marlowe V, Tart RC. (2010). The impact of music on the PACU patient’s perception of discomfort. Journal of Perianesthesia Nursing; 25: 79–87. Engwall M. (2009). Music as a nursing intervention for postoperative pain: a systematic review. Journal of Perianesthesia Nursing; 24: 370–383. Esen H, Öntürk ZK, Bad𝚤r A, Eti AF. (2010). Pain behaviours of intubated and sedated intensive care patients during positioning and aspiration. Ac𝚤badem University Journal of Health Sciences; 1: 89–93. Eti Aslan F, Bad𝚤r A, Arli SK, Çakmakç𝚤 H. (2009). Patients’ experience of pain after cardiac surgery. Contemporary Nurse; 34: 48–54. Eti-Aslan F. (2002). Pain assessment methods. Cumhuriyet University Journal of Nursing School; 6: 9–16. Fredriksson AC, Hellstrom L, Nilsson U. (2009). Patients’ perception of music versus ordinary sound in a postanesthesia care unit: a randomized crossover trial. Intensive and Critical Care Nursing; 25: 208–213. Friesner SA, Curry DM, Moddeman GR. (2006). Comparison of two pain-management strategies during chest tube removal: Relaxation exercise with opioids and opioids alone. Heart and Lung; 35: 269–276. Gélinas C. (2007). Management of pain in cardiac surgery ICU patients: have we improved over time? Intensive and Critical Care Nursing; 23: 298–303. Gélinas C, Johnston C. (2007). Pain assessment in the critically ill ventilated adult: validation of critical- care pain observation tool and physiologic indicators. Clinical Journal of Pain; 23: 497–505. Gélinas C, Fortier M, Viens C, Fillion L, Puntillo K. (2004). Pain assessment and management in critically ill intubated patients: a retrospective study. American Journal of Critical Care; 13: 126–135. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. (2006). Validation of the critical-care pain observation tool in adult patients. American Journal of Critical Care; 15: 420–427. Gélinas C, Loiselle CG, Sylvie LM, Ranger M, Bouchard E, McCormack D. (2008). Theoretical, psychometric, and pragmatic issues in pain measurement. Pain Management Nursing; 9: 120–130. Gélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. (2009). Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain and Symptom Management; 37: 58–67. Han L, Li JP, Sit JW, Chung L, Jiao ZY, Ma WG. (2010). Effects of music intervention on physiological stress response and anxiety level of mechanically ventilated patients in China: a randomised controlled trial. Journal of Clinical Nursing; 19: 978–987. Jacobi J, Fraser G, Coursin DB, Riker RR. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine; 30: 119–141. Kabes AM, Graves JK, Norris J. (2009). Further validation of the nonverbal pain scale in intensive care patients. Critical Care Nurse; 29: 59–66. Koelsch S, Kasper E, Sammler D, Schulze K, Gunter T, Friederici AD. (2004). Music, language and meaning: brain signatures of semantic processing. Nature Neuroscience; 7: 302–307. Lee OK, Chung YF, Chan MF, Chan WM. (2005). Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study. Journal of Clinical Nursing; 14: 609–620.
© 2015 British Association of Critical Care Nurses
Music interventions for mechanically ventilated patients
Lee K, Oh H, Suh Y, Seo W. (2013). Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool. Pain Management Nursing; 14: 259–267. Li DT, Puntillo K. (2006). A pilot study on coexisting symptoms in intensive care units. Applied Nursing Research; 19: 216–219. Loomba RS, Shah PH, Chandrasekar S, Arora R, Molnar J. (2012). Effects of music on systolic blood pressure, diastolic blood pressure, and heart rate: a meta-analysis. Indian Heart Journal; 64: 309–313. Nilsson U. (2008). The anxiety and pain-reducing effects of music interventions: a systematic review. AORN Journal; 87: 780–807. Nilsson U. (2009a). The effect of music intervention in stress response to cardiac surgery in a randomized clinical trial. Heart and Lung; 38: 201–207. Nilsson U. (2009b). Soothing music can increase oxytocin levels during bed rest after open heart surgery: a randomised control trial. Journal of Clinical Nursing; 18: 2153–2161. Özer N, Özlü ZK, Arslan S, Güne¸s N. (2013). Effect of music on postoperative pain and physiologic parameters of patients after open heart surgery. Pain Management Nursing; 14: 20–28. Pasero C. (2003). Pain in the critically ill patient. Journal of Perianesthesia Nursing; 6: 422–425. Patak L, Gawlinski A, Fung I, Doering L, Berg J. (2004). Patients’ reports of health care practitioner interventions that are related to communication during mechanical ventilation. Heart and Lung; 33: 308–321. Payen J, Bru O, Bosson J, Lagrasta A, Novel E, Deschaux I, Lavagne P, Jacquot C. (2001). Assessing pain in critically ill patients by using a behavioral pain scale. Critical Care Medicine; 29: 2258–2263. Pedersen CM, Rosendahl-Nielsen M, Hjermind J, Egerod I. (2009). Endotracheal suctioning of the adult intubated patient-what is the evidence? Intensive and Critical Care Nursing; 25: 21–30. Phipps MA, Carroll DL, Tsiantoulas A. (2010). Music as a therapeutic intervention on an inpatient neuroscience unit. Complementary Therapies in Clinical Practice; 16: 138–142. Puntillo KA, White C, Morris AB, Perdue ST, Stanik-Hutt J, Thompson CL, Wild LR. (2001). Patients’ perceptions and
© 2015 British Association of Critical Care Nurses
responses to procedural pain: results from Thunder Project II. American Journal of Critical Care; 10: 238–251. Ramsay MA, Savage TM, Simpson BR, Goodwin R. (1974). Controlled sedation with alphaxone-alphadone. British Medical Journal; 2: 656–659. Rotondi AJ, Chelluri L, Sirio C, Mendelsohn A, Schulz R, Belle S, Im K, Donahoe M, Pisnky MR. (2002). Patients’ recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Critical Care Medicine; 30: 746–752. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P. (2006). The effects of music therapy on physiological and psychological outcomes for patients undergoing cardiac surgery. Journal of Cardiovascular Nursing; 21: 194–200. Siffleet J, Young J, Nikoletti S, Shaw T. (2007). Patients’ self-report of procedural pain in the intensive care unit. Journal of Clinical Nursing; 16: 2142–2148. Solanki MS, Zafar M, Rastogi R. (2013). Music as a therapy: role in psychiatry. Asian Journal of Psychiatry; 6: 193–199. Stolic S, Mitchell ML. (2010). Pain management for patients in cardiac surgical intensive care units has not improved over time. Australian Critical Care; 23: 157–159. Tjellesen DG, Yurkovich EE, Gragert M. (2001). Use of music therapy and other ITNIs in acute care. Journal of Psychosocial Nursing and Mental Health Services; 39: 26–37. Twiss E, Seaver J, McCaffery R. (2006). The effect of music listening on older adults undergoing cardiovascular surgery. Nursing in Critical Care; 11: 224–231. Voss JA, Good M, Yates B, Baun MM, Thompson A, Hertzog M. (2004). Sedative music reduces anxiety and pain during chair rest after open-heart surgery. Pain; 112: 197–203. Windich-Biermeier A, Sjoberg I, Dale JC, Eshelman D, Guzzetta CE. (2007). Effects of distraction on pain, fear and distress during venous port access and venipuncture in children and adolescents with cancer. Journal of Paediatric Oncology Nursing; 24: 8–19. Wong HL, Lopez-Nahas V, Molassiotis A. (2001). Effects of music therapy on anxiety in ventilator-dependent patients. Heart and Lung; 30: 376–387.
9
