Clinical PotpourriQuality of life improves with return of voice in tracheostomy patients in intensive care: An observational study☆,☆☆
Introduction
Admission to an intensive care unit (ICU) can have a deleterious effect on a patient's mood and quality of life (QOL) [1]. Altered mood, with a dominance of negative emotions including fear, depression and anxiety, occurs in patients while in the ICU [2], [3], [4], [5] and after discharge from the hospital [3], [5], [6], [7], [8], [9], [10], [11], [12]. Up to 75% of patients experience anxiety and 40% report depressive symptoms from being in ICU [13].
A tracheostomy is a procedure commonly used to manage long-term ventilated patients in the ICU. The presence of a tracheostomy tube with an inflated cuff significantly impacts upon an individual's ability to effectively communicate, to interact, and to participate within the health system. Approximately 24% of mechanically ventilated patients within an ICU require a tracheostomy tube [14] and annually are within the top diagnostic reference groups that account for the most admitted bed days in Australia [15].
The act of communication is understood to be paramount to an individual's ability to participate in any activity of daily living and therefore is related to QOL [16]. Ineffective communication and loss of voice are reported as leading directly to anxiety [19], [20], [21], frustration [17], [20], [22], [23], [24], [25], anger [17], fear [17], [23], [24], [26], a sense of depersonalization [22], [24], [25], [27], powerlessness [22], [23], [24], [28], and a sense of futility [29]. Loss of the ability to communicate accurately within the ICU also prompted a sense of lost personal identity [17], flat affect/depression [18], and withdrawal of patient participation [22].
Chlan [19] quantified the severity of mood disturbance experienced by patients during the intubation period and found that moderate levels of anxiety were reported from a cohort of 192 patients (mean scores were 49 on a scale from 20 to 80, where higher scores indicate greater anxiety). Menzel [26] quantified emotional responses to voicelessness during intubation in 29 ICU patients. Mean scores were 23 on a 0 to 60 scale for anger and 12 on a 0 to 25 scale for worry/fear, with higher scores indicating increased levels of that emotion. The differences in scores reported during intubation and after extubation were not statistically significant. Patak et al [20] interviewed 29 patients after extubation about their intubation period as well as asking them to rate their frustration levels on 1 to 5 scale, with 62% of patients reporting high levels of frustration (score 4 or 5) associated with voicelessness.
The quantitative data from existing studies does, however, have some limitations. Only 4 of the emotions identified by the qualitative research have been quantified. Some of the data were collected retrospectively, which introduces important potential for bias toward underestimation of the severity of the mood disturbance [26]. Perhaps most importantly, none of the studies have specifically investigated the change in mood with return of voice. This is despite a recent increase in reporting of general health-related QOL in patients admitted to ICU who received mechanical ventilation at various time points [1], [30], [31], [32], [33]. Data about the rapid decline in health-related QOL during ICU admission identify poor communication as one of the most annoying factors during mechanical ventilation [32]. However, the absence of quantitative data specifically from around the time of return of voice is important because patients may attribute their mood disturbance to voicelessness, but this may be confounded by patients in ICU having reduced mood regardless of voice status, as discussed above.
Real-time quantitative data on a comprehensive range of emotions both before and after return of voice are needed specifically from tracheostomy patients in ICU. This is because the effects on mood may be more relevant in tracheostomy patients than in patients with an endotracheal tube due to tracheostomy patients typically being more alert and aware of their circumstances. This study, therefore, sought to describe the changes in communication-related QOL and general health status that occur with the return of voice, as reported by patients who have been without their voice due to the presence of a tracheostomy while in an ICU.
Section snippets
Participants and setting
Adult patients in a large metropolitan Australian ICU participated in the study. Participants were recruited from within a larger randomized trial of communication intervention [34]. Recruitment and enrollment are outlined below. All tracheostomy patients were consecutively screened during the scheduled recruitment periods and enrolled if eligibility criteria were met. Written consent was gained from each participant or person responsible. Recruitment continued until the sample size was
Results
Twenty-five patients were recruited and undertook the daily and weekly measures, but 3 did not regain their voice during their time in the ICU (see Fig. 1 for participant flow). The remaining 22 patients completed the study (see Table 1 for demographics). Participants were recruited between August 2010 and 2014. Responses on the outcome measurement tools were not available for all scheduled days due to tests off the ICU, low level of alertness, or lack of cooperation. Incomplete responses
Discussion
Admission to hospital and the ICU is a stressful and traumatic experience for patients for numerous reasons including the physical environment, physiological deterioration, and, at times, the unknown prognosis for recovery [17], [44]. Loss of voice experienced by patients further compounds the situation [23]. Data that quantify these measures of mood are also necessary to document the severity of the mood disturbance, to plan intervention studies to improve the problem, and to calculate the
Conclusions
A change in the ability to communicate by return of voice of tracheostomy patients in the ICU coincides with an improvement in patient-reported cheerfulness and the ability to be understood by others. Improved patient self-esteem, including mood, is a significant factor in the consideration of the provision of therapy for restoration of voice. The return of voice may be associated with a positive change in health status and influence change in QOL; however, additional data are needed to
Acknowledgments
A special thank you to Katherine Watson and Elyse Green for their significant contribution to treatment and outcome data collection. Thank you also to the Speech Pathology Department, staff from the Intensive Care Service, and participants for their assistance and support.
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