Using Sound Therapy Among Mechanically Ventilated Adults to Reduce Anxiety
Paige Edwards
University of South Florida
Abstract
Clinical Problem: Patients who are mechanically ventilated have a high risk for anxiety, which increases the use of sedatives, the length of time on the ventilator, and the length of stay in the hospital.
Objective: The objective of this paper is to determine if using nature-based sounds or music therapy will lower anxiety in mechanically ventilated, adult patients.
Search Engines and Key Words: PubMed and CINAHL were the primary search engines that were used to obtain randomized control trials about the use of sound therapy to reduce anxiety. The key search terms that were used to obtain the trials were mechanical ventilation, anxiety, stress, music, nature-based sounds, and sound therapy.
Results: The randomized control trials demonstrated a decrease in symptoms of anxiety and a decrease in patient reported anxiety when sound therapy was used in mechanically ventilated patients.
Conclusion: In mechanically ventilated, adult patients who receive sound therapy, there is a statistically significant decreased rate of anxiety compared to those who do not receive sound therapy. Sound therapy is a non-invasive, low cost intervention that can be used in intensive care units to decrease symptoms and reports of anxiety in adults who are mechanically ventilated.
Using Sound Therapy Among Mechanically Ventilated Adults to Reduce Anxiety
In the critical care setting, mechanical ventilation is often a life-saving intervention for a variety of different respiratory conditions, but it can also be the source of physical and emotional distress in adult patients (Saadatmand, Rejeh, Heravi-Karimooi, Tardrisi, Zayeri, Vaismoradi, & Jasper, 2013). Anxiety increases the need for sedatives in mechanically ventilated patients and sedatives may prolong the length of time the patient requires ventilation (Bradt, Dileo, & Grocke, 2014). Sources of anxiety in ventilated patients include feeling breathless, the constant need for suctioning, the feeling of being fearful, and the inability to communicate effectively (Bradt, Dileo, & Grocke, 2014). Emotional distress and anxiety can delay the physiologic recovery of a patient, and a positive emotional state can promote physiologic recovery (Saadatmand et al., 2013). In comparison to the urban environment and sounds of the hospital, sounds of nature and musical sounds have been shown to have positive effects on emotional states (Saadatmand et al., 2013). Therefore, the use of sound therapy may be a viable intervention to reduce physical and emotional distress. This paper evaluates the efficacy of sound therapy to decrease anxiety levels in adult patients who are mechanically ventilated. In mechanically ventilated, adult patients, what is the effect of sound therapy compared to not using sound therapy on physical symptoms of anxiety over eight months?
Literature Search
PubMed and CINAHL were the search engines used to find and access randomized control trials (RCT’s) pertaining to sound therapy for reduction of anxiety. Key search terms included anxiety, stress, music, sound therapy, nature-based sounds, and mechanical ventilation.
Literature review
Four randomized controlled trials were used to evaluate the effectiveness of sound therapy to reduce anxiety in ventilated, adult patients. There are not yet any guidelines for this intervention. Using a randomized controlled trial, Aghaie et al. (2014) investigated the effect of the nature-based sound intervention on levels of anxiety during weaning from mechanical ventilation. Anxiety levels were measured by evaluating blood pressure, heart rate, respiratory rate, mean arterial pressure, and oxygen saturation. The sample size was 120 mechanically ventilated patients aged 45-65 years. The patients were randomized into an intervention group (n= 60) or a control group (n= 60). Patients in the intervention group listened to nature-based sounds through headphones and the control group was given headphones without sound. Vital signs were recorded initially, at twenty minute intervals throughout weaning, immediately after weaning, twenty minutes after, and thirty minutes after extubation. Anxiety and agitation were further assessed by using the Richmond Agitation Sedation Scale (RASS) and the Faces Anxiety Scale (FAS). Data was collected over eight months. The authors reported that the intervention group had significantly lower anxiety levels than the control group (p < .002). Strengths of the study included randomization to the two groups, concealment of random assignment from individuals who were first enrolling subjects into the study, and that the subjects and providers were blind to the study groups. Also, there were no subjects who did not complete the study, the control group was appropriate, the instruments used to measure the outcomes were valid and reliable, and the subjects had no statistically significant baseline differences. Weaknesses of the study included there were no long-term follow-up assessments, the control group was given noise canceling headphones and therefore, was not appropriate.
Beaulieu-Boire et al. (2013) created a randomized controlled crossover study in order to explore the effect of slow-tempo music therapy on anxiety in mechanically ventilated patients in the intensive care unit (ICU). The sample size was 49 patients and included two groups (n=24 and n=25). Inclusion criteria were 18 years or older, able to hear, and stabilized overall health condition. The patients in each group alternated the order in which they were exposed to the intervention, which was slow-paced music through headphones. The group who was experiencing the intervention for the day listened to the music at ten o’clock in the morning and eight o’clock in the evening for one hour each time. On day one, group A received the music intervention. On day three, group B received the music intervention. Day two was a regular medicine day for both groups. On days one and three, the placebo group was given headphones with no music. Vitals and blood tests were measured before and after each intervention. The outcomes of this trial were measured by assessing vital signs, sedative consumption, and stress markers in the blood before and after the intervention. The authors reported that there were no clinically significant differences in vital signs or narcotic consumption between the control and intervention group. Conversely, there were significant decreases in blood cortisol levels in the intervention group compared to the control group (p=.02). Strengths of this study were random assignment to groups, and concealment from all researchers and providers in the study. Also, there were ten patients who did not complete the study and reasons were provided as the why they did not. Other strengths included reliable and valid instruments used to measure outcomes and no significant differences in baseline clinical variables between the groups. There were no long-term follow-up assessments conducted and this could be considered a weakness. Also, the control group was not fully appropriate because they were given headphones which may have cancelled out the normal hospital noises.
Liang et al. (2016) designed a randomized controlled crossover trial to explore the effect of music intervention on dyspnea, anxiety, and weaning duration in mechanically ventilated patients undergoing daily weaning trials. Two groups of patients were randomly assigned to either music intervention or no-music intervention on the first day. The groups each switched between music days and no-music days, so each subject served as his or her own control and was also compared to the control group for each day. The outcomes were measured using physiological signs such as heart rate, respiratory rate, blood pressure, and oxygen saturation. The visual analog scale was used to further assess dyspnea and anxiety. Using a 100 millimeter (mm) vertical line, patients pointed to a position on the line between zero and one hundred. The bottom of the line, or zero, meant “no anxiety” or “no trouble breathing” and the top of the line, or one hundred, meant “extremely anxious” or “extremely short of breath.” The sample size was 31 patients older than 21 years, but eight patients were withdrawn due to a deterioration in condition. Each subject was randomized to either music or no music on the first intervention day and alternated for the next six days, so each patient received three music days and three no-music days. During the music days, data were collected for 30 minutes before the intervention and continued for the 60-minute intervention. On no-music days, data were collected for a full 90 minutes. The results of the study showed significant differences in heart rate, respiratory rate, anxiety, and dyspnea when using music therapy (p <.01). Major strengths of this study were random assignment and concealment of groups from those who were first enrolling subjects into the study. Also, subjects were analyzed in the group to which they were assigned. The instruments used to measure the outcomes in this study were vital signs and therefore, were valid and reliable. Lastly, there were no significant differences in baseline clinical variables between the two groups. Weaknesses of this study included that it was only done in a single setting, the subjects and providers were not blinded to the study group, the authors did not give reasons why ten patients refused to participate, and long-term follow-ups were not conducted.
Saadatmand et al. (2013) designed a randomized controlled trial to identify and evaluate the effects of nature-based sounds on mechanically ventilated patients’ anxiety levels. The symptoms of anxiety were measured by assessing blood pressure, heart rate, and respiratory rate. The sample size was 60 subjects aged 18-65 years. The patients were randomized into a control group (n= 30) or an intervention group (n= 30). The patients in the intervention group listened to nature-based sounds through headphones for 90 minutes. Patients’ vital signs were taken prior to the intervention and at 30, 60, and 90 minutes during the intervention. Vitals were also taken 30 minutes after the procedure concluded. Further assessments of anxiety and agitation were collected using the Faces Anxiety Scale (FAS) and the Richmond Agitation Sedation Scale (RASS), respectively. This study was conducted over the course of eight months. The authors reported that a significant decrease in anxiety level was found between the two groups (p < .001). These results suggest that nature-based sounds can provide an effective method of decreasing potentially harmful physiological and emotional responses arising from anxiety in mechanically ventilated patients. Strengths of the study included randomization to experimental and control groups, subjects and providers were blind to assignments, there were no subjects who did not complete the study, the study was conducted over an appropriate amount of time (8 months). Also, the instruments used to measure the outcomes were valid and the subjects in each of the groups had no baseline clinical variables that were statistically significant. Weaknesses of the study included that it was conducted in a single study site, the FACES scale is valid, but not reliable, and the control group was given noise canceling headphones, so the control group did not hear the usual hospital noises that are assumed to cause the anxiety.
Synthesis
Aghaie et al. (2014) assessed vital signs, the RASS, and the FAS in order to demonstrate that patients had a significant decrease in anxiety after sound therapy than the control group (p < .002). Likewise, Saadatmand et al. (2013) used the same measures and demonstrated that a significant decrease in anxiety level was found between the intervention group and the control group (p < .001). In the study done by Liang et al. (2016), there was a significant decrease in heart rate, respiratory rate, anxiety, and dyspnea in the intervention group compared to the control group (p <.01). Beaulieu-Boire et al. (2013) did not recognize significant differences in vital signs between the two groups, but did demonstrate that blood cortisol levels were lower in the intervention group than in the control group (p=.02).
Research suggests that sound therapy may be an effective non-pharmacological method to reduce anxiety in mechanically ventilated patients. Because anxiety is related to longer mechanical ventilation times, sound therapy is a feasible and non-invasive option that could decrease the length of time a patient is ventilated. Further research is needed to prove that sound therapy has a direct correlation to length of time on mechanical ventilation. The major weakness of all four of these studies is the use of noise-cancelling headphones in each control group. A major source of anxiety in the hospital arises from the numerous sounds and alarms in the hospital setting. Noise-cancelling headphones may have skewed the results and lessened the impact of the sound therapy, so further studies need to be conducted with a more appropriate control group that simulates what patients hear with usual care.
Clinical Recommendations
There are not yet any guidelines about this intervention to reduce anxiety in mechanically ventilated patients, but research suggests that this could be a low-cost, non-invasive method to reduce anxiety, especially if the patient is alert and able to pick his or her own sounds or music. Research confirms that using sound therapy for 60 to 90 minutes for one to two times per day can reduce anxiety levels in mechanically ventilated patients (Aghaie et al., 2014); (Saadatmand et al., 2013); (Liang et al., 2016); (Beaulieu-Boire et al., 2013). Although continued research needs to be done to further demonstrate a correlation between ventilation length and sound therapy, sound therapy is an intervention that has no adverse effects and can be implemented as an adjunct therapy to reduce short-term anxiety in the clinical setting (Liang et al., 2016).
References
Aghaie, B., Rejeh, N., Heravi-Karimooi, M., Ebadi, A., Moradian, S. T., Vaismoradi, M., & Jasper, M. (2014). Effect of nature-based sound therapy on agitation and anxiety in coronary artery bypass graft patients during the weaning of mechanical ventilation: A randomised clinical trial. International Journal of Nursing Studies, 51(4), 526-538. doi:10.1016/j.ijnurstu.2013.08.003
Beaulieu-Boire, G., Bourque, S., Chagnon, F., Chouinard, L., Gallo-Payet, N., & Lesur, O. (2013). Music and biological stress dampening in mechanically-ventilated patients at the intensive care unit ward—a prospective interventional randomized crossover trial. Journal Of Critical Care, 28(4), 442-450. doi:10.1016/j.jcrc.2013.01.007
Bradt, J., Dileo, C., & Grocke, D. (2014). Music interventions for mechanically ventilated patients. Cochrane Database of Systematic Reviews, (12), N.PAG.
Liang, Z., Ren, D., Choi, J., Happ, M. B., Hravnak, M., & Hoffman, L. A. (2016). Music intervention during daily weaning trials-A 6 day prospective randomized crossover trial. Complementary Therapies In Medicine, 2972-77. doi:10.1016/j.ctim.2016.09.003
Saadatmand, V., Rejeh, N., Heravi-Karimooi, M., Tadrisi, S. D., Zayeri, F., Vaismoradi, M., & Jasper, M. (2013). Effect of nature-based sounds’ intervention on agitation, anxiety, and stress in patients under mechanical ventilator support: A randomised controlled trial. International Journal of Nursing Studies, 50(7), 895-904. doi:10.1016/j.ijnurstu.2012.11.018