Communicating with conscious and mechanically ventilated critically ill patients #FOAMed

via Communicating with conscious and mechanically ventilated critically ill patients: a systematic review | Critical Care | Full Text

Topical and in my eyes, an area massively neglected at times. Patients lie in front of us, ‘wired for sound’ as we massage the monitors and attempt to normalise their physiological parameters. Speaking from my point of view, it is more than easy to forget there is someone’s mother, father, grandfather in front of you, probably scared stiff!

Intubation renders them mute, frustrated, stressed, anxious and depressed beyond all recognition. Surmounting to physical and mental torture! Rudimentary methods of communication are deployed, which undoubtedly ads to all of this.

  • lip reading
  • gestures
  • head nods

These are all inadequate. But there are alternatives out there that can be used by careers and the patients.

Are you all aware of augmentative and alternative communication (AAC)? These comprise all forms of communication, other than oral speech, used to get messages across. Interestingly, there are no protocols or guidelines about communication with intubated patients.

These authors set a primary objective to summarise the current published evidence on communication methods used with adult nonverbal mechanically ventilated patients on their ICU. Their secondary objective was to develop an algorithm for a structured approach of assistive communication devices with mechanically ventilated patients.

Methods

A systematic search included randomized clinical trials, quasi-experimental studies, and observational studies on all adult patients in the ICU, who were conscious with an oral tube or tracheostomy with inflated cuff. They excluded all patients with any cuffs down. They then looked at the use of communication techniques between healthcare professionals and patients.

To accomplish our secondary aim, an algorithm was developed based on the associations found between characteristics and communication methods, and an algorithm published by Williams in 1992. During the construct, the algorithm was discussed in a local working group on communication with critically ill patients, consisting of intensivists, critical nurses, and a PhD student.

Results

31 articles, representing 29 different studies, met all of the inclusion criteria. They identified four communication intervention types:

The outcomes reported contained a wide range of measures. Most commonly subjective assessments of improvement of communication or investigator-developed questionnaires were used.

Tools used

Communication boards
Icons and pictures representing basic needs. One study demonstrated that a planned communication with a picture board (comprised of 22 pictures with words) increased patient satisfaction, measured with the visual analog scale on satisfaction with communication, in the early postoperative intubation period after cardiac surgery. But, 70 % asked for items not indicated on the board.

The other two studies used a two-sided board with the alphabet, a picture of the human body, and a pain scale combined with sentences or illustrations. In another study, the majority (97 %) of patients reported in the structured interviews that the communication board would have been helpful in communicating effectively during mechanical ventilation and it would have decreased their frustration level. Another said that for 77.8 % the illustrated communication material was beneficial for communication between the medical staff and the intubated patients. Of the patients in their intervention group, 91.1 % used the alphabetical part of the board. Advantages mentioned by all three studies were an increased efficiency and speed of communicating, decreased frustration, and quicker expression of patients their needs.

Speaking tracheostomy tube with inflated cuff
Currently there are six types of specialized talking tracheostomy tubes available to allow communication with an inflated cuff. The Portex Trach-Talk and Communi-Trach I  were used with four case series. The Portex BLUSA Tracheostomy Tube was reported in one article with four case reports. These tracheostomy tubes have an additional lumen above the cuff through which air can flow into the larynx to facilitate verbal communication. Intelligible speech, measured by a subjective assessment of improvement of speech, was created in 100 % and 74 % using the Portex Trach Talk, in 90 % with the Communi-Trach I , and in 79 % using the Portex Trach-Talk and the Communi-Trach I (both or one of them were used). With the BLUSA tube, all patients achieved adequate phonation. It took an average of 2.1 days (Portex “Talk”) and 5.6 days (Communi-Trach I) before adequate voice intensity for intelligible speech was produced.

The Blom Tracheostomy Tube which was used in 2 case series incorporating two separate valve mechanisms, through which all of the ventilator-delivered inspiratory air is directed to the lungs and the expiratory air can escape via fenestrations to the upper airway to allow phonation. With the Blom Tracheostomy tube, 90 %, measured with a subjective assessment, and 100 %, assessed with the Assessment of Intelligibility of Dysarthric Speakers, were able to achieve intelligible speech. In the study by Leder et al., the time to audible voicing was 6.60 min. In both studies some of the subjects were also able to converse over the telephone. In the study by Kunduk et al., two subjects (20 %) experienced clinically important oxygen saturation decreases (<90 %). The other study with the Blom Tracheostomy Tube showed no significant differences in oxygen saturation.

Electrolarynx
The EL is a battery-powered handheld device which is pressed onto the skin of the neck to transmit the vibrated electronic sound into the oropharyngeal cavity, where the user modulates it to create speech via articulation. Results of 7 studies showed successful communication, by creating intelligible speech, with the EL in patients with a tracheostomy in all of the case series. Creating intelligible speech with the EL  was also possible with intubated patients. One study reported the use of an EL with a nasotracheal tube, of which 50 % (n = 2) had good results, meaning good value of the EL as a means of communication. All but one of the studies measured the success of the EL with a subjective assessment of improved communication. In the study by Ewing (1975), the EL was the most preferred by the patients and staff over other available basic communication methods (lip movement, sign language, and writing). In the case series of Summers (1973),  clear intelligible speech was produced after 15–30 min of instruction in 60 % (n = 3) and 1–2 hours in 40 % of patients.

High-tech communication intervention
All electronic AAC devices described in the nine studies had common topics about basic communication needs in the ICU on the main screens (e.g., emergency, pain, and emotions). Two case series reported the use of voice output communication aids (VOCAs), which are a subset of handheld AAC devices with which patients touch a word–picture icon on a keypad to produce a prerecorded voice message. In both studies, all patients were able to successfully generate valid messages. In 70 % and 94 % of the observed communication events, more than one method of communication was applied (e.g., gesture, mouthing words, head nods, and writing).

The computerized AAC devices are specialized computers that contain a database of prestored phrases or pictorials. The selected phrases are voiced by a speech synthesiser. The LiveVoice computer of the pilot study by Miglietta (2004) uses various control devices for navigation through the menus; infrared eye-blink detector, touch buttons, or a touch-sensitive screen. Over 90 % of the patients felt that the system assisted them in obtaining their needs (pain management, hygiene, comfort, and anxiety). Of the hospital staff, 96 % (n = 42) felt that the LiveVoice improved patient care; this was not further specified. Various computer keyboard based devices have been trialled as well, but with lower satisfaction scores that devices requiring gesture or eye based commands.

Multiple AAC interventions
Dowden et al. (1986) [28, 55] described the use of AAC strategies for 50 temporarily nonspeaking ICU patients. The oral approaches (e.g., EL, speaking valve) and fine motor approaches (e.g., communication board) were the most recommended techniques. The most successfully served patients were those who were able to use several approaches simultaneously (70–82 % communication needs met). Reasons for intervention failure were decreased cognitive status (51 %), patient’s rejection of the intervention type (27 %), and decreased motor control (20 %).

The SPEACS trial by Happ et al. (2014) measured the impact of two levels of interventions on communication interactions between nurses and intubated ICU patients. They conducted a three-phase clinical trial:

(1) usual care

(2) basic communication skills training

(3) additional training in electronic AAC devices

Use of an AAC was 0.84 % (Phase 1), 0.51 % (Phase 2), and 6.31 % (Phase 3). The results demonstrated an increase in communication frequency in one ICU setting for both intervention groups. The Phase 3 intervention added significant improvements to patients’ perceptions about communication ease. No device limitations were mentioned.

When won’t these work?!

You have to be as orientated as possible, clearly. Delirium may become an issue and is common in ICU! They need to be able to see well enough to read the prints and have no linguistic problems.

Some boards contained too much information, didn’t have what was required on them and were difficult to position.

All tracheostomized patients in which the talking tracheostomy tubes were used were generally good responders, unless there were associated upper airway or muscle-neuro weaknesses.

The EL was well utilised, but sometimes g=hard to position. They also took a while to get used to (Americanised robotic voices etc).

High-tech communication interventions required good enough muscular power. Gaze-controlled and eye-tracking devices were used in paralysed (Not with NMB’s!!) or physically limited patients to good effect.  Primary barriers to using the VOCAs were poor device positioning, deterioration of motor and/or cognitive function, and unfamiliarity of healthcare professionals with the use of the VOCA.

 

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Discussion

So, clearly from the case series looked at, numbers are small and little attention is place on this vital area in research.

Offering these interventions can have massive implications on the psychological well being of our sick rehabilitating ICU patients. Little money is diverted into this area of care and it is, in my opinion, neglected too often. The other problem is, you have to have relatively good use of your limbs in order to get most of them to work – ruling out many critical care neuromyopathic patients.

Most of the studies however, had poor to moderate methodological quality, which has important implications for the generalizability of the results. There are no RCT’s for example. You also can’t really blind study participants / researchers / staff from the interventions!Was the Hawthorne effect coming into play here!! more attention, new machines, more interest paid to patients – could only be uplifting compared to lying in a bed, immobile and frustrated as the ward round passes by.

The fact is, there are very simple things we can do to help our patients communicate better. Particularly so if they have a trache in situ.

There are also many mobile communication apps available to enhance communication for individuals in the ICU. These new devices need to be studied in future trials to define their effectiveness and role in communication with ventilated patients. You can download various of them below, but they are expensive!!!

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Communication app. to download 

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Perhaps we need to develop a protocol ladder of approach to these patients, offering a selectivity sifter to aid us in decision making as to which type we choose and what works best for which ventilated patient? We also need further studies, higher numbers and perhaps better cohort analyses.

Let’s not leave our patients silent, as they are people, not just numbers on a monitor!

 

 

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