Music Intervention for Symptom
Management
Presentation Overview
• Scientific basis of music for anxiety reduction
• Importance of music preference assessment for music listening
interventions
• Music intervention research for symptom management in
critically ill patients receiving mechanical ventilatory support
– Exemplar of a program of research testing an integrative
therapy
– Multidisciplinary team
What are Symptoms?
• Departure from normal function or feeling which is noticed by a
patient, potentially indicating the presence of disease or
abnormality; acute, chronic, wax/wane, resolve
• Subjective & observed by the patient; self-reported
• Can be specific (pain) or non-specific symptoms
• Can be acute or chronic, associated with medical conditions,
whether physical or mental, and may be either a primary or
secondary symptom
– Fatigue
– Anxiety
– Pain
BACKGROUND
•Approximately 5 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, etc.
Patient Symptom Reports
• 10-item checklist physical and psychological symptoms (pain, tired,
short of breath, restless, anxious, sad, hungry, scared, thirsty,
confused)
• Presence (yes/no), intensity (1/mild, 2/moderate, 3/severe),
distress (1/not very distressing, 2/moderate, 3/very distressing)
• 34% mechanically ventilated in two ICUs
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Anxiety, thirsty, tired reported by 50-75% of assessments
No difference in intensity or distress if MV, except anxiety
Pain: mild-moderate intensity; mod-severe distress
Dyspnea was most distressing
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.
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: a heightened state of arousal
– Fear
– Feel miserable
– Inability to speak; cannot convey needs, feelings, etc.
Anxiety Ratings in Mechanically
Ventilated Patients
• Common bothersome symptom
• Cross-sectional ratings; importance of descriptive research
• 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.
Individual Anxiety Plots
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.
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
• Sedative agents are warranted at times yet induce significant
and numerous adverse effects
• Safe and scientifically sound interventions are needed
• Does not induce adverse effects
• Can a non-pharmacologic, adjunctive intervention (music)
reduce anxiety and sedative exposure over the course of
mechanical ventilatory support?
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Why Music?
Scientific Basis of Music to Reduce
Stress
Music perceived as familiar and soothing occupies the brain
Interrupts the stress response
– facilitates relaxation
Focuses attention on pleasing stimuli of music
– reduces anxiety
Music can be a powerful distractor
Reduces amount of sedative medications during medical
procedures (colonoscopy, ambulatory surgery)
Scientific Basis of Music to
Reduce Stress: SR Interruption
• Reception of music produces neural impulses that dampen the
arousability of the CNS through inhibitory neurotransmitters
• Withdrawal of sympathetic activity through diminished
norepinephrine release
• Induces relaxation
– Diminished SNS activity
– Increased PNS activity
What is Relaxing Music?
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Tempo at or below resting heart rate (< 80 bpm)
Predictable dynamics
Fluid, melodic movement
Pleasing harmonies
Regular rhythm without sudden changes
Soft tones
– Strings, flute, piano, or specially synthesized
Anxiety Reduction Through Music
Intervention
• Steady, slow, repetitive rhythms exert a “hypnotic” effect
• Cognitive quieting
• Altered states of consciousness alter perceived anxiety and
facilitate more relaxed states
• Music perceived as pleasant and relaxing reduces tension as
relaxation is incompatible with anxiety
Music for Distraction
• Preferred 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
Psychophysiologic responses of mechanically
ventilated patients to music: A pilot study
Chlan L. Am Jl Crit Care 1995; 4: 233-238
• Randomized n = 20 mechanically ventilated patients
– 30 min. music listening or resting quietly with headphones
– Pre-post design with repeated measures
• Music intervention consisted of MusicRx choices (Dr. Helen
Bonny); all classical music
• Generalized relaxation response
– Decreased HR, RR; BP trended downward
• Reduced distress associated with illness
Effectiveness of music therapy intervention on
relaxation and anxiety for patients receiving ventilatory
assistance.
Chlan L. Heart Lung1998; 27: 169-76
• Randomized n = 56 mechanically ventilated patients
– 30 min. music listening or resting quietly
– Pre-post design with repeated measures
• Music intervention consisted of variety of instrumental music;
choice
• Significant state anxiety reduction after music
– Decreased HR & RR
• Participants desired to listen to music throughout the time in the
ICU; asking for names of music choices
Investigating the feasibility of a music intervention
protocol with patients receiving mechanical ventilatory
support.
Chlan L. Alt Therapies Health Med 2001; 7: 80-83
• N = 6 mechanically ventilated patients (feasibility)
• Aim was to determine if ventilated patients can and will initiate
music listening (descriptive research)
• Music intervention consisted of a wide variety of music genres
guided by assessment
• Patients did initiate music listening; equipment
• Requires wide variety of music and knowledge of music to
accommodate personal preferences
Influence of music on the stress response in patients
receiving mechanical ventilatory support: A pilot study.
Chlan L. Am Jl Crit Care 2007; 16: 139-143
• N = 10 mechanically ventilated patients
– Randomized to 60 min. of relaxing music or resting quietly
• Aim was to determine if music could alter select indicators of
the stress response (SR)
– E, NE, ACTH, cortisol
• Interruptions during protocol
• Serum is problematic to obtain; sampling, stability
• Trends toward decreased ACTH & cortisol in music subjects;
slight increase in rest group
Reducing Sedative Exposure in
Ventilated ICU Patients
• Primary Aims: To determine if patient-directed music (PDM)
reduces anxiety and sedative exposure 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; tailored music collection
• Assessment of music preferences daily by music
therapist
• Allows choice, control, and self-management of anxiety
– 2) Noise-canceling headphones (active control)
– 3) Usual care (control)
– No formal sedation protocols in place
Sedative Exposure
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Daily Sedation Intensity Score
Daily Sedation Frequency
Accounts for sedative medications from disparate drug classes
Aggregate data from all patients on 8 commonly received
medications
Weinert C, Calvin A. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in
a medical and surgical intensive care unit. Crit Care Med. 2007; 35(2):393-401.
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
• Illness severity (APACHE III)
• Length of time mechanically ventilated
• Length of ICU stay
• All daily medications
• Music Assessment Tool (experimental)
Patient Characteristics
N = 373 enrolled; 52% female
Age = 58.5 +14.4; Range 21-88
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)
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RESULTS
• Baseline anxiety 48.8 + 29.3; range 0-100
• Moderate anxiety
• Highly variable and individual symptom
• PDM patients listened to music 79.8 minutes/day
– Wide variety of preferred music
• Headphones patients wore them for 34 minutes/day
• 5.7 + 6.4 days on protocol; Range 1-30 days
Primary Analysis
• Change by assigned group first assessed using
scatterplots
• Mixed-effects models
• Change over time & deals with missing data
• Series of best fitting models accounting for covariates
of interest (illness severity, age, gender, time,
baseline anxiety, sedative exposure)
• Included data on subjects with 2 or more data points
to model change over time
RESULTS
• Please refer to the original publication for detailed model parameters
and results (Chlan L., et al., JAMA June 2013)
Discussion of Results
• Participants self-initiated music listening when desired
• Individual control and management of highly variable symptom
• PDM significantly reduced anxiety and sedative exposure during
mechanical ventilatory support; compared to usual care
• No difference between HPs and usual care
• PDM patients had symptom reduction along with reduced sedative
exposure
• Anxiety -19.5 points; reduced 36.5% by 5th study day
• Sedation intensity reduced 36% by 5th study day
• Sedation frequency reduced 38% by 5th study day
– Significantly less than HPs and Usual care
Implications for Practice and
Future Research
• Beneficial, effective adjunctive intervention for anxiety
• No documented adverse effects
• Integrate appropriately into ICU care
• Self-directed and preferred music allows for choice and control;
empowers patients
• Impact of PDM on other outcomes warrant future research
• Ventilator-free days?
• Cost?
• Influence on post-ICU outcomes is unknown