Psychiatry Newsletter - When Ventilating is Devastating
When Ventilating is Devastating
Date: July 30, 2009
Not long ago, success for people in the ICU with acute lung injury was easy to mark: It meant getting off the ventilator alive.
But as intensive care specialists began following patients once they left the ICU, they saw that too often, all wasn’t well for these formerly sickest of the sick. That prompted a rush to fine-tune ventilator use, and things improved: Simply cutting back air pressure, for example, helped lower a 70 percent risk of death to 40 percent.
Yet some patients—perhaps a third—haven’t snapped back to health weeks or months later. For them, lungs can heal in six months, but not so the mind. That’s of some concern to psychiatrist Joe Bienvenu. A specialist in anxiety disorders, he was recently asked to cover psychiatric parts of a new Hopkins study of post-ICU patients. The study—Improving Care of Acute Lung Injury Patients—follows the formerly “ventilated” from 11 Baltimore hospital intensive care units up to five years later.
Bienvenu was turned around by what he read and saw.
“I was hesitant at first to sign on,” he says. “When I heard that these patients suffered from PTSD, it seemed kind of far-fetched.” So he and Hopkins colleagues began by confirming the problem; they reviewed data from earlier, smaller studies of intensive care survivors. PTSD clearly looked genuine.
Yet it was seeing patients that most affected Bienvenu. “It only took a few and I was convinced,” he says.
Consider John Lyons,* an amiable, soft-spoken man whom Bienvenu invited to a departmental grand rounds. Lyons, a self-described perfectionist in his 40s, comes from “a family of worriers” and lives with his father. He was once treated for depression. But two years ago in the ICU, Lyons’ amiability disappeared. Viral pneumonia had made him septic. Suffering acute respiratory distress syndrome, he was sedated and intubated for a month to save his life. He became delirious.
In his delirium, Lyons was convinced he was being tortured in death’s basement where the walls dripped both blood and flesh—a common hallucination, it seems. Severely agitated, he punched nurses, requiring heavier sedation and restraint.
Once home, the newly frail man tried to be positive, but flashbacks and insomnia troubled him months before he sought help. With medication, his PTSD lifted, though he’s still uneasy at times.
“It’s no surprise that many patients suffer after-effects,” Bienvenu says: They’ve been acutely ill. Their shortness of breath alone is frightening. Their widespread inflammation surely includes the brain. They’re restrained. Intubation is painful, and many of the drugs they need—benzodiazepines and catecholamines—stress the psyche at high doses.
Bienvenu’s review brought out risk factors for PTSD that bear more investigating. Having a history of anxiety or depression is one. So is having intense memories. “For many patients,” says Bienvenu, “these experiences are oddly more real than daily experiences. And they last—they’re memories of fighting for your life.”
Medication is also suspect. The very benzodiazepines that ease breathing and damp down patients’ primal anxiety at being intubated are tied to both delirium in hospital and to PTSD once they’re out.
Now the task, says Bienvenu, is to get a coherent picture and see where changes could be made. One working hypothesis is that patients who’re sensitive by nature become more agitated in the ICU and need more medication. They suffer more potent hallucinations, perhaps, which, in turn trips anxiety attacks once they’re home. Only more work will tell. The five-year study should help, if only to confirm a need for ICU alternatives. Already, there’s a suggestion that administering steroids to damp down inflammation may shield the brain from severe effects.
Meanwhile, Bienvenue says, “just knowing who we should and shouldn’t worry about in the ICU could make a difference.” He is especially interested in what role temperament plays, how it might predict who needs more reassurance and watching. “It could be,” he says, “that intervening early goes a long way.”
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*To protect privacy, we’ve changed the name and details.