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1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC, FAMI, LMFT Craig Weinert, MD, MPH Debra Skaar, PharmD Mary Fran Tracy, PhD, RN, CCNS, FAAN University of Minnesota Medical Center, Fairview Kay Savik, MS, Biostatistician University of Minnesota CANS 2012
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1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Dec 13, 2015

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Page 1: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

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Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients

Linda Chlan, PhD, RNAnnie Heiderscheit, PhD, MT-BC, FAMI, LMFT

Craig Weinert, MD, MPH Debra Skaar, PharmD

Mary Fran Tracy, PhD, RN, CCNS, FAANUniversity of Minnesota Medical Center, Fairview

Kay Savik, MS, Biostatistician

University of MinnesotaCANS 2012

Page 2: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Special thanks to the Research Team

Page 3: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Grant Support

• NINR, NIH R01-NR009295

• L. Chlan, Principal Investigator

[email protected]

• Trial Registration #NCT00440700

Page 4: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

BACKGROUND

•Approximately 1 million patients receive mechanical ventilatory support yearly in the U.S.

•55,000 adults admitted daily to ICUs in the U.S.

•Commonly used ICU supportive modality

–34% require ventilatory support for > 48 hours; increasing

•ICUs are inherently stressful for patients and family

•Distress from noise, lack of sleep, social isolation, frustration

Page 5: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Patient Responses to Mechanical Ventilatory Support

• Physiological Stress

Stress of critical illness or infection + Delivery of mechanical breaths

– Critical illness or injury

– Lung injury

– Ventilator associated pneumonia

• Psychological stress• Anxiety: state; heightened arousal, tension, inability to

concentrate

• Fear

• Feel miserable

• Inability to speak; cannot convey needs, feelings, etc.

Page 6: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Anxiety Ratings in Mechanically Ventilated

Patients • Previous work limited to cross-sectional ratings

• State Anxiety Inventory (score range 20-80)

• < 5 days 48.6 + 12.0

• 6-21 days 50.2 + 12.5

• 22+ days 54.2 +11.9

• Chronic/long-term 45.8 +14.5

Chlan L. Description of anxiety levels by individual differences and clinical factor in patients receiving mechanical ventilatory support. Heart Lung 2003; 32:275-282.

Page 7: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Patient Symptom Reports

• 10-item checklist of physical and psychological symptoms (pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused)

• Presence (yes/no), intensity (mild, moderate, severe), distress (not very distressing, moderate, very distressing)

• 34% mechanically ventilated in two ICUs

• Anxiety, thirsty, tired reported by 50-75% of assessments

• No difference in intensity or distress if MV, except anxiety

• Dyspnea most distressing; inter-related with anxiety

Puntillo KA, Shoshana A, Cohen N, Gropper M. et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med 2010; 38:2155-2160.

Page 8: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

SUSTAINED ANXIETY

Physiological responses:

• SNS stimulation; CV responses; increased WOB and oxygen demand; myocardial stimulation

Psychological responses:

• Fear, inability to focus, inability to relax or sleep

Usual treatment for anxiety is sedative medications– Limitations and adverse side effects

Page 9: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Adjunctive Interventions

• Can non-pharmacologic, adjunctive interventions reduce anxiety over the course of mechanical ventilatory support?

– Limitations of sedative medications

• In addition to medical plan of care

• Relaxing Music intervention?

Page 10: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Why Music Intervention and not just Sedative Medications?

• Need for adjunctive interventions to reduce anxiety associated with ventilatory support

• Sedative agents are warranted at times yet induce adverse effects

• Not demanding for patients with communication challenges and low energy states

• Safe and scientifically sound interventions

• Does not induce adverse effects

Page 11: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Scientific Basis of Music to Reduce Stress: Brief Overview

• Music perceived as familiar and soothing

• Interrupts the stress response; facilitates relaxation

• Focused attention on pleasing stimuli of music reduces anxiety

• Music can be a powerful distractor

Page 12: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Music for Distraction

• Preferred, familiar music can be a powerful distractor

• Provides an alternative focus to a more pleasing, comforting stimulus, rather than focusing on stressful environmental stimuli or thoughts.

• Important to assess music preferences, familiarity, cultural context

Page 13: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Anxiety self-management for ICU Patients Receiving Mechanical

Ventilation

• Primary Aim: To determine if patient-directed music (PDM) reduces anxiety over the course of ventilatory support

R01 NR009295NCT00440700

Page 14: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

DESIGN• Three-group randomized clinical trial

• Remained on protocol as long as mechanically ventilated, up to 30 days

• Subjects randomized to:

• 1) Patient-directed music listening (experimental)

– Preferred , relaxing music

– Assessment of music preferences daily by music therapist

– Allows choice, control, and self-management of anxiety

– Prompts for PDM use

• 2) Noise-canceling headphones (active control)

• 3) Usual care (control)

Page 15: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

What is Relaxing Music?Conceptual Definition

• Tempo at or below resting heart rate (60-80 bpm)

• Predictable dynamics

• Fluid, melodic movement

• Pleasing harmonies

• Regular rhythm without sudden changes

• Simple compositions and soft tones

Page 16: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

SETTING and SAMPLE

• 5 medical centers in the Minneapolis-St. Paul urban area

• 12 ICUs total (medical, medical-surgical)

• Adult critically ill patients receiving acute mechanical ventilatory support for a primary pulmonary component

– Pneumonia, COPD, respiratory failure, pulmonary edema, etc.

• Alert and interacting appropriately with nursing staff

• Provide own informed consent– IRB and intervention requirements

Page 17: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

MEASURES• Anxiety

– 100-mm Visual Analog Scale-Anxiety

– Assessed similar time each study day

• Illness severity (APACHE III)

• Length of time mechanically ventilated

• Length of ICU stay

• All daily medications

• Ventilator settings and weaning trials

• Music Assessment Tool (experimental)

Page 18: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Equipment for Experimental PDM

Page 19: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Subject Characteristics

• N = 373 enrolled; N = 286 considered for final analysis

• Age = 58.5 +14.4; Range 21-88

• 52% female; 86% White, 12% Black, 1%Native American, 1%Asian

• APACHE III 63.2 +21.6; Range 15-123

• 55% respiratory failure, 25% respiratory distress, 5% pneumonia, 3% COPD, 2% hypoxemia, 10% other

• Median total ICU days = 17 (1-86)

• Median total ventilator days = 10 (0-80)

• 5.7 + 6.4 days on protocol; Range 1-30 days

Page 20: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Participant Characteristics at Enrollment (N = 373)

Patient-directed Music

(n = 126)

Headphones(n = 122)

Usual Care(n = 125)

p-value

Age 60.4(15.4) 59.4(14.3) 57.8(13.5) .37

Male 58(46%) 66(54%) 56(45%) .28

APACHE III

63.1(18.7) 62.2(22.3) 65.6(23.5) .43

VAS-A 51.9 (32.4) 49 (30.1) 52.3 (29.7) .66

Page 21: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

MUSIC PREFERENCES BY GENRES

• Classical

• Rhythm & Blues

• Reggae

• New Age/Contemporary

• Country

• Jazz

• Sacred/Religious

• Alternative Rock

• Big Band

• Heavy Metal

• World Music

• Oldies (1950-1970)

• Rock

• Hip Hop

• Rap

• Pop Music

• Other

Page 22: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

RESULTS

• Baseline anxiety 48.8 +29.3; range 0-100– Moderate anxiety

– Highly variable and individual symptom

• PDM subjects listened to music 79.8 minutes/day

• Headphones subjects wore them for 34 minutes/day

Page 23: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Analysis of State Anxiety

• Change by assigned group first assessed using scatterplots

• Mixed-effects models for anxiety analysis

• Included anxiety data on subjects with 3 or more data points to model change over time (N = 193)

• Not all subjects able to report anxiety each day

Page 24: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

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Visual Analog Scale-Anxiety Final Models

Model 1/Model 2 β(se(β)) p-value

Intercept 40.6(6.8) / 40.9(6.8) <.001 / <.001

Day -.54(.28) / -.51(.28) .052 / .08

Patient-directed music -26.3(7.1) / -26.9(7.0) <.001* / <.001*

Headphones only -12.2(7.1) / -12.5(.08) .09 / .08

Final models control for APACHE III, sedative medications and interaction effects between treatment groups and VAS-A baseline; Usual care is

reference group.

Page 25: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Mean VAS-Anxiety Controlling for Sedation Intensity

Page 26: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Discussion of Results

• Participants self-initiated music listening when desired

– Individual control and management of highly variable symptom

• PDM significantly reduced anxiety during mechanical ventilatory support

– Anxiety reduced 26 points over time

– Controlled for sedative medications

• Patients report benefit with PDM use– “It’s the only thing that got me through….”

• Control group did not have reduced anxiety over time

Page 27: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,
Page 28: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Implications for Practice and Future Research

• Beneficial, effective adjunctive intervention – No documented adverse effects

– Integrate into ICU care; translation of findings to practice

• Self-directed and preferred music allows for choice and control; empowers patients

• Impact of PDM on other outcomes warrant future research

– Ventilator-free days?

– Weaning trials?

• Influence on post-ICU outcomes is unknown

Page 29: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

“There are two means of refuge from the miseries of life: Music and cats”.

~Albert Schweitzer, 1875-1965German medical missionary, theologian, musician,

philosopher

Page 30: 1 Effects of patient-initiated music listening on anxiety in mechanically ventilated ICU patients Linda Chlan, PhD, RN Annie Heiderscheit, PhD, MT-BC,

Thank you for your attention!