Dyspnea in the Ventilated Patient: A Call for Patient-Centered Mechanical Ventilation

In recent years, most research on mechanical ventilation has focused on improving physiologic measures of cardiopulmonary function and increasing short-term survival. By comparison, remarkably little research has aimed at improving the subjective experience of patients undergoing mechanical ventilation. Less than 10 studies published in English report measurements of dyspnea during mechanical ventilation. These reports demonstrate that many endotracheally intubated patients can communicate the severity of their dyspnea by means of conventional measures such as numeric and visual analogue scales. They also suggest that dyspnea is common during mechanical ventilation and that adjustments of tidal volume, inspiratory flow, and level of ventilatory assistance may alleviate dyspnea in some instances. Much remains to be learned about the incidence, characteristics, and treatment of dyspnea during mechanical ventilation. In the meantime, respiratory therapists can help usher in a new era of "patient-centered mechanical ventilation" by routinely asking patients during bedside visits whether they are experiencing dyspnea. Therapists should ask two questions: "Are you short of breath right now?" and, if yes, "Is your shortness of breath mild, moderate, or severe?" The response can be recorded in the medical record using a 4-point scale: 0 = no shortness of breath, 1 = mild, 2 = moderate, 3 = severe, X = unable to answer. If the answer is 2 or 3, the therapist should endeavor to reduce dyspnea by adjusting ventilator settings within predetermined limits or by seeking additional assistance. By this approach, patient comfort can become a new parameter for routine adjustment of ventilator settings in the management of respiratory failure.