How do you comanage anxiety in patients with mechanical ventilator dependence?

From the Guidelines

To effectively comanage anxiety in mechanically ventilated patients, a multimodal approach combining pharmacological and non-pharmacological interventions should be implemented, prioritizing nonbenzodiazepine sedatives like propofol or dexmedetomidine over benzodiazepines due to improved short-term outcomes such as reduced ICU length of stay and duration of mechanical ventilation, as suggested by the 2018 clinical practice guidelines 1.

Key Considerations

• The choice of sedative is crucial, with nonbenzodiazepine sedatives being preferable for mechanically ventilated adults due to their association with improved outcomes 1.
• Minimizing sedation is also a key approach, with the use of protocols to minimize sedation and the implementation of ventilator liberation protocols being recommended 1.
• Non-pharmacological interventions, such as establishing reliable communication methods, maintaining day-night cycles, ensuring adequate pain control, and promoting family presence, are equally important in managing anxiety in mechanically ventilated patients.
• Daily sedation interruptions should be performed to assess neurological status and prevent oversedation, aiming to maintain a lightly sedated state (Richmond Agitation-Sedation Scale of -2 to 0) where the patient is comfortable but arousable 1.

Pharmacological Management

• For longer-term sedation, propofol (5-50 mcg/kg/min) or dexmedetomidine (0.2-0.7 mcg/kg/hr) may be preferred as they allow for easier daily awakening trials and are associated with improved outcomes compared to benzodiazepines 1.
• Antipsychotics like haloperidol can help manage delirium-associated agitation, but their use should be carefully considered due to potential side effects.

Non-Pharmacological Interventions

• Establishing reliable communication methods, such as communication boards, eye blinks, or hand signals, is crucial for reducing anxiety and improving patient comfort.
• Maintaining day-night cycles, ensuring adequate pain control, frequent reorientation, and promoting family presence when possible are also important non-pharmacological interventions.
• Music therapy and other forms of relaxation techniques can also be beneficial in reducing anxiety in mechanically ventilated patients.

From the FDA Drug Label

Infusions of propofol injectable emulsion should be adjusted to maintain a light level of sedation prior to weaning patients from mechanical ventilatory support. Throughout the weaning process, this level of sedation may be maintained in the absence of respiratory depression. Because of the rapid clearance of propofol injectable emulsion, abrupt discontinuation of a patient's infusion may result in rapid awakening with associated anxiety, agitation, and resistance to mechanical ventilation, making weaning from mechanical ventilation difficult. It is therefore recommended that administration of propofol injectable emulsion be continued in order to maintain a light level of sedation throughout the weaning process until 10 minutes to 15 minutes prior to extubation, at which time the infusion can be discontinued. Abrupt discontinuation of propofol injectable emulsion prior to weaning or for daily evaluation of sedation levels should be avoided. This may result in rapid awakening with associated anxiety, agitation, and resistance to mechanical ventilation.

To comanage anxiety in patients with mechanical ventilator dependence, propofol injectable emulsion should be administered to maintain a light level of sedation prior to and throughout the weaning process from mechanical ventilation. The infusion should be continued until 10-15 minutes before extubation to avoid rapid awakening and associated anxiety and agitation 2.

Additionally, lorazepam injection may be considered for patients requiring relief of anxiety and/or diminished recall of events while being mechanically ventilated, but its use is contraindicated in patients with severe respiratory insufficiency, except in those cases 3.

• Key considerations:
  • Maintain light level of sedation
  • Avoid abrupt discontinuation of propofol injectable emulsion
  • Consider alternative sedation methods if necessary
  • Monitor patients closely for signs of anxiety, agitation, and respiratory depression 2.

From the Research

Comanaging Anxiety in Patients with Mechanical Ventilator Dependence

Comanaging anxiety in patients with mechanical ventilator dependence is crucial to improve their overall well-being and reduce the risk of complications. The following strategies can be employed:

• Music Interventions: Music listening has been shown to be beneficial for anxiety reduction in mechanically ventilated patients 4, 5. It can help reduce respiratory rate and systolic blood pressure, suggesting a relaxation response.
• Psychological Support: Psychological support should be offered to patients and their family members to help them cope with the stress and anxiety associated with mechanical ventilation 6. This support can be provided before discharge and during ambulatory sessions.
• Assessment and Intervention: Anxiety ratings should be assessed regularly, and interventions should be implemented to manage anxiety over the duration of mechanical ventilatory support 7. This can include music interventions, sedation management, and other non-pharmacological interventions.
• Sedation Management: Sedative and adjunctive medications should be prescribed and managed carefully to optimize sedation and minimize adverse effects 8. This can help reduce discomfort, fear, anxiety, and pain in patients on mechanical ventilators.

Key Considerations

When comanaging anxiety in patients with mechanical ventilator dependence, the following key considerations should be taken into account:

• Individualized Care: Anxiety is an individual patient experience that requires ongoing management with appropriate assessment and intervention.
• Non-Pharmacological Interventions: Non-pharmacological interventions, such as music interventions and psychological support, can be effective in reducing anxiety and improving patient outcomes.
• Sedation Management: Sedation management is critical to optimize sedation and minimize adverse effects.
• Family Support: Family support and communication are essential to help patients and their family members cope with the stress and anxiety associated with mechanical ventilation.