Weaning from prolonged mechanical ventilation using an

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Weaning from prolonged mechanical ventilation using an pdf

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Brief Reports Weaning from prolonged mechanical ventilation using an antipsychotic agent in a patient with acute stress disorder Lisa J. Rosenthal, MD; Victor Kim, MD; Deborah R. Kim, MD Objective: To report the use of a second-generation antipsy- chotic agent to assist weaning from prolonged mechanical ven- tilation in an anxious patient. Design: Case report. Setting: Medical intensive care unit at the Hospital of the University of Pennsylvania. Patient: A 39-yr-old white female whose severe anxiety pro- hibited weaning from prolonged mechanical ventilation. Interventions: Initiation of quetiapine as treatment for severe anxiety that was unresponsive to sedative hypnotics. Measurements and Main Results: Once a therapeutic dose of quetiapine was reached, ventilator support was removed within 24 hrs. Conclusions: A second-generation antipsychotic agent was successfully used to facilitate weaning in a very anxious patient, possibly secondary to anxiolysis or direct effect on respiratory drive. Further investigations of pharmacologic in- tervention should be done to inform practice guidelines in difficult-to-wean patients suffering from severe anxiety. (Crit Care Med 2007; 35:2417–2419) K EY W ORDS : mechanical ventilation; ventilator weaning; anxiety disorder; posttraumatic stress disorder; stress disorders, trau- matic, acute; antipsychotic agents eaning from mechanical ventilation is reported by many patients to be a phys- ically and emotionally un- comfortable experience. Those patients with comorbid anxiety disorders may be particularly vulnerable to difficulties with weaning. Prolonged mechanical ventilation is associated with numerous medical com- plications as well as increased occupation of intensive care beds, resource consumption, and costs; it is therefore crucial that psy- chiatric barriers to weaning be addressed in the comprehensive care plan for difficult- to-wean patients (1–3). The evidence for using psychotropic medications in this population is extremely limited (4, 5). Although psychiatric comor- bidities are considered to be risk factors for ventilator dependency, no studies have been conducted and no expert recommen- dations are provided for pharmacologic anxiolysis during weaning (6). The use of W benzodiazepines seems to be common practice, but it is not effective for all pa- tients. We present a case report of facili- tated ventilator weaning using quetiapine, a second-generation antipsychotic agent. CASE REPORT This case report did not require Insti- tutional Review Board (IRB) review per the University of Pennsylvania IRB proto- col. The IRB was contacted regarding the inclusion of an author (VK) from another institution and granted permission that he be given access to patient medical data without identifying information. The patient was a 39-yr-old white female with a history of multiple myeloma, deep venous thrombosis and pulmonary embo- lism status post vena caval filter, and ad- justment disorder with depressed mood who underwent an autologous bone mar- row transplant. Four days after induction therapy the patient developed neutropenic fever, and 2 days later the patient was in- tubated for acute hypoxemic respiratory failure secondary to enterococcus pneumo- nia and staphylococcal bacteremia. The pa- tient was maintained on volume cycled ventilation. Septic shock developed despite several days of broad-spectrum antibiotics, requiring aggressive volume resuscitation and vasopressor support. The patient underwent tracheostomy and percutaneous gastrostomy after 3 wks of pro- From the University of Pennsylvania Department of Psychiatry, Philadelphia, PA (LJR, DRK); and Temple University School of Medicine, Division of Pulmonary and Critical Care Medicine, Philadelphia, PA (VK). The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000284493.89759.A5 longed mechanical ventilation. After extended courses of antibiotics, the patient defer- vesced, hypotension resolved, and gas ex- change improved, with a Pa O 2 /F IO 2 ratio of 240. Aggressive diuresis was performed be- cause of significant peripheral edema. Out- patient medications were restarted, includ- ing escitalopram for depression and metoprolol for hypertension. A spontane- ous breathing trial was initiated, but the patient became immediately tachypneic and was placed back on volume cycled ven- tilation. Pressure support ventilation was initiated as a weaning method. The patient was gradually weaned over several days to minimal pressure support (pressure sup- port ventilation, 3 mm Hg) with no patient discomfort and appropriate physiologic variables to discontinue mechanical venti- lation. Spontaneous breathing trials were reinitiated; the patient tolerated gradual in- creases in duration of independent ventila- tion, with acceptable gas exchange, hemo- dynamics, tidal volume, and respiratory rate. While she was undergoing mechanical ventilation, low-level pressure support ven- tilation was used, producing a respiratory rate of 10 –14 with tidal volumes of approx- imately 400 mL. However, she was never able to tolerate 1 hr off mechanical ven- tilation, with no identifiable cardiac, pul- monary, or infectious cause. This phenom- enon was attributed to anxiety. The intensive care unit team continued her es- 2417 Crit Care Med 2007 Vol. 35, No. 10
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Weaning from prolonged mechanical ventilation using an - page 2
citalopram and metoprolol, started clonaz- epam, and administered as needed doses of lorazepam before weaning trials, but the patient reported no relief. After 3 wks of unsuccessful weaning at- tempts, the psychosomatic consultation service was consulted to aid in the manage- ment of anxiety, which was believed by the medical intensive care unit (MICU) team to prohibit weaning from mechanical ventila- tion. The patient reported extreme anxiety during spontaneous breathing trials; she became tachypneic, tachycardic, and dia- phoretic and begged staff and family to re- start mechanical ventilation. She was in- consolable at these times and neither trusted bedside monitors nor accepted re- assurances from staff and family that she was breathing independently. Her level of distress prevented implementation of relax- ation techniques, and she was convinced that the sensation of dyspnea signaled im- pending death. Additional fears included dying while asleep, even during ventilator assistance. She endorsed multiple symp- toms on the Acute Stress Disorder Scale (7), including feelings of unreality, night- mares, intrusive thoughts, and hyper- arousal, all of which were focused on the experience of respiratory failure. Psychiatric recommendations included increasing the escitalopram dose and initi- ating quetiapine 50 mg in the morning, 50 mg at noon, and 100 mg at night. Initially the patient denied any relief of anxiety, but her family and the MICU team reported a lower level of anxiety exemplified by fewer requests for assisted ventilation. Quetiapine was increased to 100 mg every 8 hrs after 3 days, and nursing staff reported immediate symptomatic improvement. Within a day, the patient was able to maintain spontane- ous breathing and became ventilator inde- pendent. She continued to express anxiety and a belief that she would stop breathing; however, requests for reinitiation of me- chanical ventilation ceased. Her QTc was not affected by the addition of quetiapine. She was subsequently discharged to a long- term rehabilitation facility. DISCUSSION Qualitative descriptions of patient ex- perience during weaning from ventilation include frustration, uncertainty, hopeless- ness, fear, and lack of mastery (8). Anxiety can be associated with many medical disor- ders, particularly respiratory disease, but many patients find ventilator weaning to be especially anxiety provoking. Generally, with reassurance about medical stability 2418 and clinical improvement, anxiety wanes over time. In this patient, the MICU team ruled out any medical etiology causing fail- ure to wean and determined that anxiety was the primary barrier to successful wean- ing attempts. The differential diagnosis of anxiety in this patient includes panic disorder, adjustment disorder with anxious mood, de- lirium, anxiety secondary to a medical condi- tion, and acute stress disorder. Panic attacks are characterized by dis- crete episodes of overwhelming fear, a sense of loss of control, and physical symp- toms of hyperarousal such as difficulty breathing, diaphoresis, and tremor. Panic attacks are typically short-lived, peaking in intensity within 10 mins of onset. Panic disorder is defined by panic attacks that occur repeatedly and spontaneously. This patient did not experience spontaneous panic attacks, and although her anxiety did vary in intensify over time, she was never anxiety free. The diagnosis of adjustment disorder with anxiety is made when a patient ex- periences anxiety that is overwhelming and out of proportion to the stressor. Once the stressor is removed, the anxiety improves. However, patients who meet the strict criteria for more severe anxiety syndromes no longer qualify for the diag- nosis of adjustment disorder, even if their symptoms are precipitated by a stressor. Delirium also was considered in this case. The patient was too anxious to com- plete a detailed survey of her cognitive function, so it is possible that delirium influenced her beliefs about weaning. However, she demonstrated that she was fully oriented, addressed questions appro- priately, and nursing staff denied waxing and waning confusion or periods of al- tered consciousness. In addition, the MICU team did not find any medical pa- thology that could explain her anxiety, making anxiety secondary to a medical condition unlikely. Most likely this patient’s anxiety was a reaction to the trauma of severe illness and the experience of respiratory failure. Along with the experience of a life- threatening event, the diagnosis of acute stress disorder (ASD) includes dissocia- tive symptoms, such as numbness or de- tachment, derealization, depersonaliza- tion, or dissociative amnesia, avoidance, and hyperarousal, which occur within 2 days to 4 wks of the stressor (9). Our patient had experienced a life-threatening medical emergency and endorsed most of the symptomatic criterion for ASD. ASD is an early response to a traumatic event, whereas posttraumatic stress disorder de- velops later with or without a previous diagnosis of ASD. There is a growing body of literature reporting ASD and posttrau- matic stress disorder following intensive care treatment (10, 11). The patient’s belief that she would die off the ventilator could be described as a fixed, false belief, or a delusion. However, her fears were based on past experience and therefore were not necessarily irra- tional. In this case, her belief is better conceptualized as an overvalued idea and a manifestation of anxiety. Extreme, irra- tional fear is common in severe anxiety and has been described in patients who have been exposed to traumatic events. Medical and nursing guidelines stress the importance of addressing psychological factors during weaning (6). Unfortunately, there are no published trials of pharmaco- therapy for difficult-to-wean patients with anxiety. Current published research on treatments for psychological suffering dur- ing ventilator weaning includes investiga- tions of hypnosis and biofeedback (12). One study on biofeedback showed a decrease in the duration of mechanical ventilation (13). A case report of a patient with severe anx- iety and posttraumatic symptoms from multiple life-threatening medical crises re- ported successful weaning using hypnosis techniques (14). In the circumstances of this case, the patient was so anxious that she was unable to focus on relaxation im- agery, and she was not reassured by cardiac and respiratory monitors demonstrating normal hemodynamics and oxygenation during weaning trials. Despite therapeutic doses of benzodi- azepines, the patient’s anxiety prevented implementation of appropriate and nec- essary medical treatments. Increasing the escitalopram dose would not have been immediately helpful, so a second-genera- tion antipsychotic agent was considered. Second-generation antipsychotic agents are thought to be different from first- generation antipsychotic agents, such as haloperidol, because of their affinity for serotonergic receptors and faster rates of dissociation from dopamine receptors. In addition, they are less likely to induce extrapyramidal symptoms or hyperpro- lactinemia. Quetiapine is an antagonist at multiple neurotransmitter receptors in- cluding serotonin 5-HT1A and 5-HT2, do- pamine D1 and D2, histamine H1, and adrenergic 1- and 2-receptors. It does not demonstrate affinity for muscarinic or benzodiazepine receptors. There are some data supporting the use of second- Crit Care Med 2007 Vol. 35, No. 10
Weaning from prolonged mechanical ventilation using an - page 3
generation antipsychotic agents for anxiety disorders as adjunctive pharmacotherapy (15–17). Second-generation antipsychotic agents should be used with caution in the elderly demented population due to the in- creased risk of death from cardiac and re- spiratory complications. The diagnosis of ASD provides a pos- sible explanation for this patient’s limited response to benzodiazepines; ASD and posttraumatic stress disorder are thought to be less responsive to sedative-hypnot- ics than other anxiety disorders (18). Al- ternatively, her improvement may have been due to resolution of her belief that she would stop breathing if not mechan- ically ventilated. Her communication was limited by tracheostomy, but she endorsed this idea “100%” when questioned. The ad- dition of an antipsychotic agent may have provided benefit as a treatment for psycho- sis; however, this conviction remained fol- lowing weaning. The benefit from quetiap- ine seemed to be secondary to anxiolysis and not related to resolution of her beliefs about independent ventilation. A possible physiologic mechanism for improvement with quetiapine might in- clude the effect of peripheral and central D2 blockade on respiratory drive. Admin- istration of low-dose dopamine in healthy volunteers decreases the autonomic re- sponse to hypoxia through D2 receptors in the carotid body (19). Consequently, dopamine should be used with caution in patients weaning from mechanical venti- lation. Pedersen et al. (20) demonstrated that administering haloperidol to eucap- nic, healthy volunteers could increase acute ventilatory response to hypoxia. It is possible that the addition of quetiapine increased this patient’s ventilatory drive, but whether it affected her subjective sense of dyspnea is unknown. It is also unclear whether dopamine antagonism of ventilatory drive is clinically relevant to the circumstances of this case. Anxiety can be caused or exacerbated by a number of factors present in an inten- sive care setting such as medications, sleep deprivation, and psychological stress result- ing from coping with severe medical illness. It is important to consider these systemic and environmental issues when diagnosing an anxiety disorder in the intensive care unit and to address them before initiating phar- macotherapy for anxiety. This case illus- trates use of a second-generation antipsy- chotic agent to facilitate weaning in a patient with acute stress disorder. Anxious patients on prolonged mechanical ventila- tion whose symptoms are unresponsive to sedative hypnotics may benefit from short- term treatment with quetiapine. ACKNOWLEDGMENT We thank Dr. Robert M. Weinrieb for assistance and support. REFERENCES 1. Kalb TH, Lorin S: Infection in the chroni- cally critically ill: Unique risk profile in a newly defined population. Crit Care Clin 2002; 18:529 –552 2. Cohen IL, Booth FV: Cost containment and mechanical ventilation in the United States. New Horiz 1994; 2:283–290 3. Scheinhorn DJ, Char DC, Hassenpflug MS, et al: Post-ICU weaning from mechanical ven- tilation: The role of long-term facilities. Chest 2001; 120(6 Suppl):482S– 484S 4. Gimenez AM, Serrano P, Marin B: Clinical validation of dysfunctional ventilatory wean- ing response: The Spanish experience. Int J Nurs Terminol Classif 2003; 14:53– 64 5. Thomas LA: Clinical management of stres- sors perceived by patients on mechanical ventilation. AACN Clin Issues 2003; 14: 73– 81 6. MacIntyre NR, Cook DJ, Ely EW, et al: Evi- dence-based guidelines for weaning and dis- continuing ventilatory support. A collective task force facilitated by the American College of Chest Physicians; the American Associa- tion for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120(6 Suppl):375S–395S 7. 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J Clin Psychiatry 2004; 65(Suppl 5):29 –33 19. Ciarka A, Vincent JL, van de Borne P: The effects of dopamine on the respiratory sys- tem: Friend or foe? Pulm Pharmacol Ther 2006 Oct 27; [Epub ahead of print] 20. Pedersen M, Dorrington KL, Robbins PA: Ef- fects of haloperidol on ventilation during iso- capnic hypoxia in humans. J Appl Physiol 1997; 83:1110 –1115 Crit Care Med 2007 Vol. 35, No. 10 2419
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