Management of post-extubation anxiety in the intensive care unit

INTRODUCTION

Post-extubation anxiety causes clinically significant distress in both intensive care unit (ICU) patients and family caregivers. Psychiatry is often consulted for recommendations in assisting the pulmonary-critical care team in the management of anxiety in patients who are mechanically ventilated, especially during the weaning process. This review provides treatment recommendations for managing anxiety during this process and will discuss the pathophysiology of anxiety in the ICU and evidence-based treatments currently available.

Potential factors that predispose patients to anxiety include cerebral vascular disease, endocrine disorders, cardiopulmonary decompensation, reduced brain and tissue perfusion, multiple medications, and disruption of sleep-wake cycles; the tense and stressful ICU environment also puts patients at risk. Panic attacks can be precipitated by stress-induced adrenergic hyperactivity, delirium that is marked by paranoid delusions, and visual or auditory hallucinations, which can be caused by dysregulated dopamine synthesis. It is important to recognize the underlying cause of anxiety in the ICU for effective treatment.¹ Study results have long indicated that the patients and their family members may have psychological symptoms, such as anxiety, depression, fear, guilt, helplessness, sadness, exhaustion, uncertainty, agitation, and even PTSD pre- and post-ICU admission.^2,3,4 These feelings include not only the fear of death but also concerns about potential disability in the future. These unhealthy conditions may lead to increased irritability, hypertension, tachycardia, cardiac ischemia, and psychological disruption in the patients.⁵ Mental health is a key component of health-related quality of life (HRQoL) post-ICU admission, and HRQoL is lower in the survivors of critical illness than in the general population.⁶

Anxiety is a state characterized by apprehension, agitation, increased motor tension, autonomic arousal, and fear.⁷ Patients receiving prolonged periods of mechanical ventilation report moderate to severe levels of anxiety despite receiving sedative and analgesic medications. Anxiety management is, therefore, a major treatment concern that should be considered as important as other components of disease management. Although there are suggested pathways to treat anxiety in outpatients, treatment guidelines for patients developing these conditions due to critical illness treated in ICUs are limited. Current studies support the fact that providing timely interventions that also meet the needs of family members are critical in reducing their anxiety. Despite this, studies in the literature on brief interventions that may treat stress and anxiety in patients treated for a critical illness are scarce. This review examines the utility of the various anxiety management techniques in patients treated in the ICU.

METHODS

A systematic review of publications was undertaken by two independent researchers using Google Scholar and PubMed. The focus was restricted to case reports, case series systematic reviews, and meta-analyses. The articles were searched using the keywords “Anxiety,” “ICU patients,” “critically ill patients,” and “post-extubation.” The articles with supporting words like “PTSD,” “dementia,” “delirium,” and “depression” were also included. The search was supplemented by reviewing all references of relevant articles and conducting thorough abstract reviews. The final selection included 21 articles; 2 dealt with managing anxiety in the family caregivers of ICU patients, 7 described anxiety and its management in ICU patients, 4 studied the effect of music therapy on anxiety management, 3 dealt with the use of antipsychotics. The use of dexmedetomidine, benzodiazepines, massage therapy, hypnosis and virtual reality, and aromatherapy was described in 1 article each. Article exclusion criteria included: 1) management of anxiety in a community setting; 2) articles not published in English; 3) articles that required institutional access; 4) articles published before 1980.

DISCUSSION

Anxiety is one of the most common and most difficult psychiatric symptoms to manage in patients in the ICU. Although delirium receives significant attention, inadequate anxiety management can negatively impact the mental, psychological, psychosocial, and physiological health of critically ill patients. Hence, it is critical to understand the treatment options available for treating anxiety in the ICU setting. The evidence supporting certain pharmacological and non-pharmacological treatment options for this purpose is summarized in the following paragraphs and in Table 1.

DEXMEDETOMIDINE

One study described the effectiveness of dexmedetomidine in decreasing time to extubation by indirectly reducing anxiety.⁸ Dexmedetomidine reduced time-to-extubation and ICU length of stay in difficult-to-wean patients. This drug is a selective alpha-2 receptor agonist, which produces light sedation and light analgesia with opioid-sparing effects and blunts stress response through its sympatholytic properties. It also blunts the usual withdrawal from sedatives and opiates; it reduces ventilator asynchrony and provides a faster and safer extubation.

ANTIPSYCHOTICS

Loxapine has not produced positive clinical outcomes in managing anxiety in critically ill patients.⁹ Although there are reports of quetiapine successfully treating delirium in ICU patients, there is not enough literature specifically discussing the use of quetiapine in reducing anxiety in the ICU patients while weaning ventilation. A case study by Messina et al. reported that quetiapine was effective in managing anxiety during ventilator weaning in ICU patients.¹⁰ Therefore, this case report describes a possible option to help patients with difficulty weaning from ventilation due to anxiety. Rosenthal et al. highlighted the anxiolytic effect of second-generation antipsychotics by successfully weaning a very anxious patient with a second-generation antipsychotic. Quetiapine was initiated for treating severe anxiety that was unresponsive to sedative-hypnotics. Once a therapeutic dose of quetiapine was reached, ventilator support was removed within 24 hours.¹¹

Despite widespread use and incorporation into hospital guidelines, there is no significant evidence from placebo-controlled trials that support the use of haloperidol or any antipsychotics in the management of ICU-associated delirium or anxiety related to extubation. The use of high-dose haloperidol, especially given intravenously, presents the risk of QTc interval prolongation. At least one study has suggested that dexmedetomidine provides a safer alternative option in comparison with haloperidol. It effectively reduced the time to extubation and ICU length of stay, facilitated liberation from mechanical support, reduced the need for supplementary sedation, reduced the risk of QTc interval prolongation, and decreased the need for tracheostomy.¹²

BENZODIAZEPINES

According to Kok and colleagues, the use of benzodiazepine in the ICU is associated with anxiety, delirium, and symptoms of PTSD.¹³ Benzodiazepine use can often cause paradoxical agitation and combination with opiates can lead to significant respiratory suppression.

AROMATHERAPY

Aromatherapy, i.e., the use of plant essences for therapeutic purposes, might be effective in reducing anxiety and improving sleep quality.¹⁴ It is considered a complimentary option to improve anxiety and sleep quality in intensive care patients since it is safe, cost-effective, and easy to use.

MUSIC THERAPY

Umbrello et al. reviewed music therapy and its therapeutic effects in managing anxiety, as assessed by heart and respiratory rate and blood pressure in ICU patients.¹⁵ Music therapy is defined as listening to music with the idea of a change in the emotional or physical state of health, and it has been specifically used for its effect in critically ill patients. Listening to music reduces anxiety through its intricate networks in the central nervous system and affects the neurohormonal pathways in the brain and autonomic system at several conscious and unconscious levels. It modifies the production of endorphins, cytokines, and endogenous opiates. This study also examined music’s effects in reducing the need for sedation and analgesia during interventional procedures and reducing anxiety in critically ill mechanically-ventilated patients. Music intervention was associated with a significant reduction in self-reported magnitude of anxiety and reduced scales of respiratory rate, heart rate, and blood pressure. Physiologic studies have shown that heart rate and respiratory rate may synchronize with the characteristics of the music to which one listens, through the activation of the autonomic system.¹⁶ A randomized control trial evaluated music as an alternative to sedative medications to alleviate the anxiety associated with the use of mechanical ventilation. Daily assessments of anxiety (on the 100-mm visual analog scale) and two aggregate measures of sedative exposure (intensity and frequency) showed a greater reduction in anxiety compared with usual care. Patient-directed music intervention resulted in a greater reduction in sedation frequency compared with usual care and a greater reduction in sedation intensity compared with usual care, but not compared with noise canceling headphones.¹⁷

CAREGIVING APPROACH

Another qualitative study by Sabeti et al. studied non-pharmacological pain and anxiety management and its barriers in the pediatric ICU. The study showed that increasing the open presence of parents, using communication based on the child’s interests, and providing psychological training of nurses and parents can reduce anxiety.¹⁸ Monsalve-Duarte and colleagues provided evidence for the therapeutic effectiveness of music interventions for managing pain and mental health in adult burn patients.¹⁹ The effect of hand massage has also been studied on the pain and anxiety of the cardiac surgery critically ill patients. It has been suggested that hand massage can reduce intensity of anxiety by two points on average on a 0–10 scale and is a potent complement to other pharmacological treatments. Twenty minutes of moderate-pressure massage over the hands in calm uninterrupted surroundings is necessary for a significant reduction of pain and anxiety.²⁰ A randomized control trial by Rousseaux et al. compared and combined hypnosis and virtual reality effects on anxiety and pain in patients before and after cardiac surgery. After randomly assigning the patients to four arms (control, hypnosis, virtual reality, and virtual reality hypnosis) and having 20 minutes of one of the techniques the day before and the day after surgery, anxiety, pain, fatigue, relaxation, physiological parameters, and opioid use were evaluated before and after each session in this study.²¹ This study that anxiety decreased even though pain still increased from baseline to the postoperative day and relaxation increased in both pre-and post-operative periods.

CONCLUSIONS

In summary, anxiety during weaning off sedation presents a management dilemma for the ICU team and family caregivers alike. Current evidence is limited on the use of medications for this purpose, and FDA-approved treatments are lacking. It is reasonable to employ non-pharmacological approaches initially, and when this fails, pharmacological treatment options can be considered. More research is needed to adequately identify post-extubation anxiety and provide guidance on choosing a single agent at a dose that presents the minimum risk to the patient while alleviating symptoms.

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Article citation: Oberoi V, Sekhon AK, Sarangi A. Management of post-extubation anxiety in the intensive care unit. The Southwest Respiratory and Critical Care Chronicles 2024;12(52):8–14
From: Government Medical College (VO), Amritsar, India; Sri Guru Ram Das Institute of Medical Sciences and Research (AKS), Amritsar, India; Department of Clinical Psychiatry (AS), University of Missouri-Columbia, Columbia, Missouri.
Submitted: 6/18/2024
Accepted: 6/30/2024
Conflicts of interest: none
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