Effects of patient-initiated music listening on
anxiety in mechanically ventilated ICU patients
Linda Chlan, PhD, RN
Annie Heiderscheit, PhD, MT-BC, FAMI, LMFT
Craig Weinert, MD, MPH
Debra Skaar, PharmD
Mary Fran Tracy, PhD, RN, CCNS, FAAN
University of Minnesota Medical Center, Fairview
Kay Savik, MS, Biostatistician
University of Minnesota
CANS 20121
Special thanks to the Research Team
Grant Support
• NINR, NIH R01-NR009295
• L. Chlan, Principal Investigator
• chlan001@umn.edu
• Trial Registration #NCT00440700
BACKGROUND
•Approximately 1 million patients receive mechanical
ventilatory support yearly in the U.S.
•55,000 adults admitted daily to ICUs in the U.S.
•Commonly used ICU supportive modality
–34% require ventilatory support for > 48 hours; increasing
•ICUs are inherently stressful for patients and family
•Distress from noise, lack of sleep, social isolation,
frustration
Patient Responses to Mechanical
Ventilatory Support
• Physiological Stress
Stress of critical illness or infection + Delivery of mechanical
breaths
– Critical illness or injury
– Lung injury
– Ventilator associated pneumonia
• Psychological stress
• Anxiety: state; heightened arousal, tension, inability to
concentrate
• Fear
• Feel miserable
• Inability to speak; cannot convey needs, feelings, etc.
Anxiety Ratings in
Mechanically Ventilated
Patients
• Previous work limited to cross-sectional ratings
• State Anxiety Inventory (score range 20-80)
• < 5 days 48.6 + 12.0
• 6-21 days 50.2 + 12.5
• 22+ days 54.2 +11.9
• Chronic/long-term 45.8 +14.5
Chlan L. Description of anxiety levels by individual differences and clinical factor in patients
receiving mechanical ventilatory support. Heart Lung 2003; 32:275-282.
Patient Symptom Reports
• 10-item checklist of physical and psychological
symptoms (pain, tired, short of breath, restless, anxious,
sad, hungry, scared, thirsty, confused)
• Presence (yes/no), intensity (mild, moderate, severe),
distress (not very distressing, moderate, very
distressing)
• 34% mechanically ventilated in two ICUs
• Anxiety, thirsty, tired reported by 50-75% of assessments
• No difference in intensity or distress if MV, except anxiety
• Dyspnea most distressing; inter-related with anxiety
Puntillo KA, Shoshana A, Cohen N, Gropper M. et al. Symptoms experienced by intensive care unit
patients at high risk of dying. Crit Care Med 2010; 38:2155-2160.
SUSTAINED ANXIETY
Physiological responses:
• SNS stimulation; CV responses; increased WOB and
oxygen demand; myocardial stimulation
Psychological responses:
• Fear, inability to focus, inability to relax or sleep
Usual treatment for anxiety is sedative medications
– Limitations and adverse side effects
Adjunctive Interventions
• Can non-pharmacologic, adjunctive interventions
reduce anxiety over the course of mechanical
ventilatory support?
– Limitations of sedative medications
• In addition to medical plan of care
• Relaxing Music intervention?
Why Music Intervention and not
just Sedative Medications?
• Need for adjunctive interventions to reduce anxiety
associated with ventilatory support
• Sedative agents are warranted at times yet induce adverse
effects
• Not demanding for patients with communication challenges
and low energy states
• Safe and scientifically sound interventions
• Does not induce adverse effects
Scientific Basis of Music to
Reduce Stress: Brief Overview
• Music perceived as familiar and soothing
• Interrupts the stress response; facilitates relaxation
• Focused attention on pleasing stimuli of music
reduces anxiety
• Music can be a powerful distractor
Music for Distraction
• Preferred, familiar music can be a powerful
distractor
• Provides an alternative focus to a more pleasing,
comforting stimulus, rather than focusing on
stressful environmental stimuli or thoughts.
• Important to assess music preferences, familiarity,
cultural context
Anxiety self-management for ICU
Patients Receiving Mechanical
Ventilation
• Primary Aim: To determine if patient-directed music
(PDM) reduces anxiety over the course of
ventilatory support
R01 NR009295
NCT00440700
DESIGN
• Three-group randomized clinical trial
• Remained on protocol as long as mechanically
ventilated, up to 30 days
• Subjects randomized to:
• 1) Patient-directed music listening (experimental)
– Preferred , relaxing music
– Assessment of music preferences daily by music therapist
– Allows choice, control, and self-management of anxiety
– Prompts for PDM use
• 2) Noise-canceling headphones (active control)
• 3) Usual care (control)
What is Relaxing Music?
Conceptual Definition
• Tempo at or below resting heart rate (60-80 bpm)
• Predictable dynamics
• Fluid, melodic movement
• Pleasing harmonies
• Regular rhythm without sudden changes
• Simple compositions and soft tones
SETTING and SAMPLE
• 5 medical centers in the Minneapolis-St. Paul urban
area
• 12 ICUs total (medical, medical-surgical)
• Adult critically ill patients receiving acute
mechanical ventilatory support for a primary
pulmonary component
– Pneumonia, COPD, respiratory failure, pulmonary edema, etc.
• Alert and interacting appropriately with nursing staff
• Provide own informed consent
– IRB and intervention requirements
MEASURES
• Anxiety
– 100-mm Visual Analog Scale-Anxiety
– Assessed similar time each study day
• Illness severity (APACHE III)
• Length of time mechanically ventilated
• Length of ICU stay
• All daily medications
• Ventilator settings and weaning trials
• Music Assessment Tool (experimental)
Equipment for Experimental PDM
Subject Characteristics
• N = 373 enrolled; N = 286 considered for final analysis
• Age = 58.5 +14.4; Range 21-88
• 52% female; 86% White, 12% Black, 1%Native American,
1%Asian
• APACHE III 63.2 +21.6; Range 15-123
• 55% respiratory failure, 25% respiratory distress, 5%
pneumonia, 3% COPD, 2% hypoxemia, 10% other
• Median total ICU days = 17 (1-86)
• Median total ventilator days = 10 (0-80)
• 5.7 + 6.4 days on protocol; Range 1-30 days
Participant Characteristics at
Enrollment (N = 373)
Patient-directed Headphones
Music
(n = 122)
(n = 126)
Usual Care
(n = 125)
p-value
Age
60.4(15.4)
59.4(14.3)
57.8(13.5)
.37
Male
58(46%)
66(54%)
56(45%)
.28
APACHE III
63.1(18.7)
62.2(22.3)
65.6(23.5)
.43
VAS-A
51.9 (32.4)
49 (30.1)
52.3 (29.7)
.66
MUSIC PREFERENCES BY
GENRES
• Classical
• Heavy Metal
• Rhythm & Blues
• World Music
• Reggae
• Oldies (1950-1970)
• New Age/Contemporary
• Rock
• Country
• Hip Hop
• Jazz
• Rap
• Sacred/Religious
• Pop Music
• Alternative Rock
• Other
• Big Band
RESULTS
• Baseline anxiety 48.8 +29.3; range 0-100
– Moderate anxiety
– Highly variable and individual symptom
• PDM subjects listened to music 79.8 minutes/day
• Headphones subjects wore them for 34
minutes/day
Analysis of State Anxiety
• Change by assigned group first assessed
using scatterplots
• Mixed-effects models for anxiety analysis
• Included anxiety data on subjects with 3
or more data points to model change over
time (N = 193)
• Not all subjects able to report anxiety
each day
Visual Analog Scale-Anxiety
Final Models
Model 1/Model 2
β(se(β))
p-value
Intercept
40.6(6.8) / 40.9(6.8)
<.001 / <.001
Day
-.54(.28) / -.51(.28)
.052 / .08
Patient-directed music
-26.3(7.1) / -26.9(7.0)
<.001* / <.001*
Headphones only
-12.2(7.1) / -12.5(.08)
.09 / .08
Final models control for APACHE III, sedative medications and interaction
effects between treatment groups and VAS-A baseline; Usual care is
reference group.
24
Mean VAS-Anxiety Controlling
for Sedation Intensity
Discussion of Results
• Participants self-initiated music listening when
desired
– Individual control and management of highly variable symptom
• PDM significantly reduced anxiety during mechanical
ventilatory support
– Anxiety reduced 26 points over time
– Controlled for sedative medications
• Patients report benefit with PDM use
– “It’s the only thing that got me through….”
• Control group did not have reduced anxiety over time
Implications for Practice
and Future Research
• Beneficial, effective adjunctive intervention
– No documented adverse effects
– Integrate into ICU care; translation of findings to practice
• Self-directed and preferred music allows for choice
and control; empowers patients
• Impact of PDM on other outcomes warrant future
research
– Ventilator-free days?
– Weaning trials?
• Influence on post-ICU outcomes is unknown
“There are two means of refuge from
the miseries of life: Music and cats”.
~Albert Schweitzer, 1875-1965
German medical missionary, theologian, musician,
philosopher
Thank you for your attention!