The Mechanical Ventilation–Respiratory Distress Observation Scale as a surrogate of self-reported dyspnoea in intubated patients

Abstract

Intensive care unit (ICU) patients are exposed to many sources of discomfort, among which dyspnoea is one of the more severely distressing [1]. In invasively mechanically ventilated patients, dyspnoea is frequent (47% of intubated patients report breathing discomfort when they can first communicate with caregivers) and severe (median rating of 5 on a dyspnoea visual analogue scale (D-VAS); association with anxiety and neurovegetative signs of stress) [2]. It is often linked to ventilator settings and seems to be associated with poorer clinical outcomes (e.g. delayed extubation and post-traumatic stress disorders) [2,3]. As in other settings, identifying and quantifying dyspnoea in mechanically ventilated patients is therefore a major clinical issue. This is challenging because self-report and self-assessment, prerequisites for D-VAS assessment [4], are often impossible or very difficult in this setting. Unfortunately, caregivers markedly underestimate dyspnoea in this context [5,6]. The risk of occult respiratory suffering is therefore major in the ICU setting and neglecting it would amount to medical error [7].

Respiratory distress observation scales to predict weaning outcome

“…Firstly, self-reported dyspnea was not measured, and it would have been interesting to confront dyspnea and MV-RDOS performances to predict SBT outcomes. However, MV-RDOS strongly correlates with dyspnea [ 22 ] and contrarily to self-reported dyspnea (unidimensional assessment of dyspnea intensity by numerical rating scales), MV-RDOS integrates the multiple dimensions of respiratory suffering and could be reach in every patient irrespective of their self-report capabilities. Secondly, this study was conducted exclusively in patients who already failed at least one SBT since these patients represented a priori greater clinical challenge.…”

“…MV-RDOS is strictly clinical, standardized, and does not require patient cooperation. In communicative ICU patients, a MV-RDOS of 2.6 predicts a dyspnea visual analog scale > 30 mm with a 57% sensitivity, a 94% specificity, and an AUC of 0.782 (95% CI 0.581–0.982) [ 22 ], noting that a dyspnea visual analog scale (VAS) > 30 mm is considered clinically important [ 24 ], MV-RDOS was only gathered by the investigator for research purpose and not for clinical decision-making. The MV-RDOS was thus presented using its raw values and was also dichotomized around its 2.6 threshold value that corresponds to a high probability of clinically important self-reported dyspnea.…”

“…In addition, dyspnea is multidimensional in essence, a characteristic not captured by the numerical rating scales typically used in the clinical field [ 8 ]. Respiratory distress observation scales (RDOS) were developed to obviate these limitations, in palliative care medicine [ 20 ], upon admission to the intensive care unit (IC-RDOS [ 21 ]) or under mechanical ventilation (MV-RDOS [ 22 ]). These scales rely on assessing a multidimensional ensemble of measurable physical and behavioral manifestations related to respiratory suffering [ 18 ], correlate with dyspnea in communicative patients [ 20 – 22 ] and provided standardized way to infer dyspnea in noncommunicative patients.…”

Exploration and Development of a Simpler Respiratory Distress Observation Scale (modRDOS-4) as a Dyspnea Screening Tool: A Prospective Bedside Study

“…5 Other groups have adapted it for use in the intensive care unit (ICU) setting in patients on mechanical ventilators. 6,7 We had previously validated the RDOS in 122 palliative care patients within a tertiary hospital and found it to be valid and reliable. 8 In addition, as a secondary aim to find out the prevalence of physical signs of dyspnea among this population, we developed a list of 18 physical signs of dyspnea and administered it to this cohort simultaneously with the validation study.…”

Respiratory Suffering in the ICU: Time for Our Next Great Cause

“…Implementing systematic dyspnea assessments in routine clinical care (as for pain) could be useful (14), and such routine assessments seem readily acceptable to nurses (15). Generalizing the use of observational scales (and particularly their simplified ICU versions [7–9]) could also be useful (16). Specific studies should be designed to determine the potential benefits of such approaches.…”