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Detection of Dyspnea in Mechanically Ventilated Patients in Intensive Care Units and

Assessments of Nurses’ Knowledge

Al-Tamimi Sajeda, RN; Khlouf Qasem, RN; Al-a ‘mar Farah, RN; Amro Samah, RN; & Alhurani Abdullah,

PhD, MSN, MBA, RN.

Abstract

Aims: We investigated to assess nurses’ knowledge about dyspnea among mechanically

ventilated patients and to assess the presence of dyspnea among mechanically ventilated

patients in intensive care units at JUH.

Methods: A cross-sectional study was conducted to assess nurses’ knowledge about dyspnea

among mechanically ventilated patients and to assess the presence of dyspnea among

mechanically ventilated patients in intensive care units at JUH. A sample of adult patients

who were admitted to the intensive care units at JUH as well as intensive care unit nurses.

Results: Of the 20 ventilated patients admitted to the intensive care unit at Jordan University

Hospital and who met the inclusion criteria,70 % (n=14) patients had developed dyspnea. The

patient’s ages ranged from 24 to 81 years with a mean age of 56.9 years (SD=16.05), 35%

(n=7) were female and 65 % (n=13) were male. Regarding the clinical findings of the sample,

the patient’s heart rate ranged from 58 to 140 beats per minute with a mean heart rate of 98.2

beats per minute (SD=20.46), and the patient’s respiratory rate ranged from 14 to 30 breaths

per minute with a mean respiratory rate 22.35 breaths per minute (SD=4.05). Of the 20

intensive care unit nurses who worked at Jordan University Hospital and met the inclusion

criteria, 60% (n=16) were female and 40 % (n=8) were male, 20% (n= 4 ) were practical

nurses, 65% (n= 13) were registered nurses, and 15% (n= 3) were nurses practitioner. The

nurses’ ages ranged from 28 to 43 years with a mean age of 34.8 years (SD=4.56), and the

nurses’ years of experience ranged from 4 to 13 years with mean years of experience of 7.85

years (SD=3.04).
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Conclusion:

Dyspnea assessment should be integrated into ICU nursing practice, to optimize the best-

delivered care possible

Keywords: dyspnea, mechanically ventilated patients, nurses, intensive care unit, Middle

east, knowledge, mechanical ventilator, sedated patients, non-communicative patients.

Reflective Questions:

1. What is the prevalence of dyspnea among mechanically ventilated patients in

intensive care units?

2. What is the nurses’ level of knowledge regarding dyspnea in mechanically

ventilated patients?
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Introduction

Among the objectivity that governs the intensive care unit (ICU) assessment methods,

the ultimate accurate assessment remains elusive; and yet, maximizing patient comfort in the

ICU implies managing numerous sources of discomfort, including dyspnea (Chanques,

Nelson, & Puntillo, 2015). Dyspnea is defined as a disturbing sensation that is common in

patients suffering from respiratory distress. One important goal of a mechanical ventilator

(MV) is to alleviate these symptoms. Conversely, dyspnea can persist, reappear, or worsen

after MV (Schmidt et al., 2011).

One-third of critically ill patients cannot report what they are experiencing from

feelings and symptoms (Nelson et al., 2001). The main reasons are ongoing sedation,

language barrier or sensory deficiency, delirium, and deafness (Persichini et al., 2015). The

fact that patients cannot communicate does not mean that they do not experience dyspnea and

it is clear that these patients are exposed to the almost same risk factors of dyspnea as

communicative patients. Nevertheless, patients’ perception of autonomous breathing is

correlated with extubation success (Demoule et al., 2018; Schmidt et al., 2011). As observed

with pain, it cannot be excluded with sedation; and may give an external appearance of

respiratory comfort, but falsely reassuring (Hofbauer et al., 2004). Furthermore,

noncommunicative patients should rather be considered a vulnerable population at high risk

for misdiagnosis of dyspnea (Raux et al., 2007).

Moreover, dyspnea in mechanically ventilated patients is an underestimated-serious

problem (Schmidt et al., 2014). There is overwhelming evidence that dyspnea is prevalent

and serious in mechanically ventilated ICU patients and is also linked to poor outcomes

(Decavèle, Similowski, & Demoule, 2019; Santos et al., 2016). Hence, dyspnea is strongly

associated with reduced life expectancy and poor patient outcomes (Schmidt et al., 2014).
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However, once dyspnea has been detected, it is essential to have a step-by-step protocol to

identify its cause and manage it at the earliest convenience (Decavèle, Similowski, &

Demoule, 2019).

Detecting dyspnea offers useful information on the patient's clinical circumstance,

enables early intervention, and determines the intervention's effectiveness; Despite that, there

is a scarcity of documenting and assessing dyspnea (Baker, DeSanto-Madeya, & Banzett,

2017).

This study aims to assess nurses’ knowledge about dyspnea among mechanically

ventilated patients and to assess the presence of dyspnea among mechanically ventilated

patients.

Materials and Methods

Study design and participants

This study includes two ideas of interest, first, to detect the prevalence of dyspnea

among mechanically ventilated patients; and second, to assess nurses’ knowledge of dyspnea

among mechanically ventilated patients.

Detection of dyspnea among mechanically ventilated patients

A quantitative, cross-sectional observational study was used to detect dyspnea among

mechanically ventilated patients in Jordan University Hospital (JUH) to gather a specific type

of information using the presented tool and determine how the subject of study can cause the

mentioned phenomena.

A convenience sampling technique has been utilized in this study with a total of 20

participants since it is a pilot study. The inclusion criteria were (1) patients age above 18
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years, and (2) patients on mechanical ventilators, while the exclusion criteria were patients in

the weaning process.

The variable of interest was measured using the Respiratory Distress Observation

Scale (RDOS) this 7-item scale is a reliable, valid instrument that measures respiratory

distress and distinguishes respiratory distress from pain. In addition, it shows promise and

clinical efficacy as an observational dyspnea assessment tool (Campbell., 2007; Zhuang,

Yang, Neo, & Cheung, 2019; Campbell, & Templin, 2015).

Assessing nurse’s knowledge of dyspnea among mechanically ventilated patients

Our second variable of interest is assessing nurse’s knowledge of dyspnea among

mechanically ventilated patients, a quantitative, cross-sectional observational study was used

to assess nurse’s knowledge of dyspnea among mechanically ventilated patients in the ICU of

the JUH.

Since it is a pilot study, a convenience sampling technique has been utilized to

assemble the needed sample which equals 20 ICU nurses. Inclusion criteria were (1) intensive

care unit nurses and (2) with at least one year of clinical experience. The exclusion criteria

were (1) floater nurses and (2) trainee nurses.

The second variable of interest will be collected upon a modified self-report

questionnaire adapted by (Hassen et al., 2023) to assess nurse’s knowledge regarding

mechanically ventilated patients, and contain 16 questions, each question has 4 response

answers, however, 10 questions will be included in our project, and applied to the clinical

area, with a total score of 10. The level of knowledge will be categorized into these

categories; poor (<4), moderate (4-7), and rich knowledge (>7).

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Ethical considerations

Ethical approval will be obtained after this pilot study, from the scientific research

committee and the ethics committee at the School of Nursing at the University of Jordan. In

addition, ethical approvals will be obtained from the institutional review board (IRB) of the

University of Jordan Hospital.

After matching the eligibility, each participant signed the consent form after

explaining the purpose of our project, and they had the entire freedom for participating. For

the patients, the project’s purpose was explained to the patient’s proxy.

Measures

Demographic Characteristics

The demographic characteristic of patients will be collected after reviewing the

literature which will include age, and gender (Appendix I). And the nurse will include age,

gender, year of experience in ICUs, and educational level (Appendix II).

Tool (1) Mechanical Ventilator- Respiratory Distress Observation Scale

Is a practical tool for estimating respiratory distress when patients are unable to

provide a dyspnea self-report. The scale to be assessed is the RDOS (Appendix III), a 5-item

used to assess the presence and severity of respiratory distress. Each measure is assigned a

point value, and the points are added together. A numerical score for heart rate, breathing

rate, paradoxical breathing (abdominal muscles moving in with inspiration), accessory

muscle use (observable rise in clavicle during inspiration), and facial expression of fear (eyes

wide open, facial muscles tense, brow furrowed). According to (Decavèle et al., 2019) this

model was simplified into MV-RDOS = 3.3 + (Heart Rate/65) + (Respiratory Rate/50) + (1 X
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Paradox breathing) + (1 X Accessory muscles) + (1 X Fear). The level of dyspnea score will

be categorized as no significant dyspnea (< 2.6), or significant dyspnea (≥ 2.6).

Tool (2) knowledge of the ICU Nurses Related to Mechanical Ventilation

The knowledge survey question was modified and adapted by (Baker et al., 2020) to

assess nurse knowledge regarding mechanically ventilated patients (Appendix IV), and

contain 16 questions, each question has 4 response answer and 8 questions will be included in

our project and applied to the clinical area. The level of knowledge will be categorized

depending on the frequency and percentage of answering the question

Data collection

The study’s purpose and need were explained to unit managers at the selected units.

Participants who agreed to participate in the study were informed about the purpose of the

study. The data then were collected using The Respiratory Distress Observation Scale

(RDOS) in less than 5 minutes for each patient. Also, the assessment of patients has been

done during the daytime from 08:00 to 15:00. The questionnaire regarding nursing

knowledge of dyspnea was in the English language as in the original version. And we were

available to explain and answer all the respondents' questions for the completion of the

nurse’s knowledge regarding the dyspnea questionnaire.

Statistical analysis

Statistical analysis was performed by using SPSS software version 26.0 Descriptive

statistics including frequency distribution and percentage were used to describe sample

characteristics and to display patients' demographic and clinical data among mechanically

ventilated patients in intensive care units at the University of Jordan hospital. The frequencies

and percentages were also used to describe the nurse’s responses regarding the knowledge

assessment survey.
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Results

Of the 20 ventilated patients admitted to the intensive care unit at Jordan University

Hospital and who met the inclusion criteria,70 % (n=14) patients had developed dyspnea. The

patient’s ages ranged from 24 to 81 years with a mean age of 56.9 years (SD=16.05), 35%

(n=7) were female and 65 % (n=13) were male (Table 1). Regarding the clinical findings of

the sample, the patient’s heart rate ranged from 58 to 140 beats per minute with a mean heart

rate of 98.2 beats per minute (SD=20.46), and the patient’s respiratory rate ranged from 14 to

30 breaths per minute with a mean respiratory rate 22.35 breaths per minute (SD=4.05)

(Table 2).

Table (1): Description of demographic variables among ventilated patients (N=20)

Variable N Percentage Mean (SD) Range
Age (Years) 56.9 (16.05) 24-81
Gender
Female 7 35%
Male 13 65%
SD: standard deviation
n: Number of cases
Table (2): Description of clinical variables among mechanically ventilated patients

(N=20)

Clinical Variables Mean (SD) Range

Heart rate (beat/min) 98.2 (20.46) 58 -140
Respiratory rate (breath/ min) 22.35 (4.05) 14-30
SD: standard deviation
n: Number of cases
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Of the 20 intensive care unit nurses who worked at Jordan University Hospital and

met the inclusion criteria, 60% (n=16) were female and 40 % (n=8) were male, 20% (n= 4)

were practical nurses, 65% (n= 13) were registered nurses, and 15% (n= 3) were nurses

practitioner. The nurses’ ages ranged from 28 to 43 years with a mean age of 34.8 years

(SD=4.56), and the nurses’ years of experience ranged from 4 to 13 years with mean years of

experience of 7.85 years (SD=3.04).

Table (3): Description of demographic variables among ICU nurses (N=20)

Variable N Percentage Mean (SD) Range

Age (Years) 34.8(4.56) 28-43
Gender
Female 16 60%
Male 8 40%
Education
Diploma degree 4 20%
Bachelor’s degree 13 65%
Master’s degree 3 15%
Clinical experience (Years) 7.85 (3.04) 4-13
ICU: intensive care unit
n: Number of cases

Descriptive statistics were used to analyze the nurses’ responses to the knowledge

assessment survey which consists of eight questions as shown in Table (4).

Table (4): Description of the nurses’ responses to the knowledge assessment survey

among the sample (N=20)

Survey questions N Percentage

Q1: How important is it to use a uniform

tool to assess for dyspnea
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Very important 4 20 %
Important 7 35 %
Moderately important 7 35 %
Of little importance 2 10 %
Not important 0 0%
Q2: How important is it to track
dyspnea every shift
Very important 8 40 %
Important 8 40 %
Moderately important 3 15 %
Of little importance 1 5%
Not important 0 0%
Q3:How important is the
addition of routine
dyspnea assessment in improving
patient-centered care
Very important 8 40 %
Important 7 35 %
Moderately important 5 25 %
Of little importance 0 0%
Not important 0 0%

Survey questions n Percentage

Q4: How important is the addition

of routine dyspnea assessment in
predicting adverse patient outcomes
Very important 4 20%
Important 13 65 %
Moderately important 3 15%
Of little importance 0 0%
Not important 0 0%
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Q5: How easy or difficult is it to administer

the dyspnea assessment
Very difficult 2 10%
Difficult 6 30 %
Easy 12 60%
very Easy 0 0%
Q6: In your opinion, would it be
useful to have an algorithm with specific
options for the treatment of dyspnea
Yes 17 85 %
No 3 15 %
Q7: Would it be helpful to have
a pictorial scale to help communicate
with patients who have difficulty using a
number scale Yes 17 85 %
No 3 15 %
Q8: Do you find it helpful to have
standard words alongside the number
scale to help communicate with patients
who have difficulty using a number scale
Yes 13 65 %
No 7 35 %
n: Number of cases
Discussion

Although it is a single-center-pilot study, it disclosed that dyspnea is present and

significant among non-communicative mechanically ventilated patients. No matter which, the

importance of the issue was assessed among the critical care nursing staff and they show the

well to participate in raising the subject. Nurses play an important role in the care of patients

on mechanical ventilation. Without a doubt, nurses must have considerable knowledge of

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science and demonstrate evidence-based practice while caring for mechanically ventilated

patients (Hassen et al., 2023).

Delivering outstanding, patient-centered care is essential in the ICU, a highly

specialized and organized medical setting for critically sick patients who need ongoing

monitoring and support (Vieira et al., 2021).

Our study focused on these two ideas as follows;

Part 1: Discussion of Socio-Demographic Characteristics of nurse’s knowledge of

essential care of mechanical ventilation.

Our results show that the majority of ICU nurses consider it essential to constantly

assess and document dyspnea. 60 % of the nurses who participated in our study said that the

scale was easy to use and did not interfere with their work. This finding is consistent with the

findings of (Baker et al., 2020), who conducted an anonymous online survey randomly

distributed to nurses representing all intensive care units and discovered that the majority of

the subjects (67%) with the majority of them (19%) were between the ages of 20 and 30.

Part 2: Discussion of the prevalence of dyspnea among mechanically ventilated patients

Detecting dyspnea -in the first place- is important to recognize and evaluate the

presented phenomenon (Decavèle et al, 2019). In our pilot study, ICU-mechanically

ventilated patients were significantly vulnerable to experiencing dyspnea although it is an

underestimated issue and not routinely assessed; with a ratio of 70% which is similar to the

authors’ (Demoule et al., 2022) results in their study. Dyspnea prevalence in mechanically

ventilated patients is estimated to range from 30% to 90% -which is a range that matches our

study results- depending on the patient population and disease history and the accompanying

health status (Decavèle et al, 2019).

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Study limitations

It is considered a pilot study, so it needs a larger sample size according to

generalizability terms, whatsoever, the study was conducted in a single centre, due to the

short time span.

Conclusion

Dyspnea assessment should be integrated into ICU nursing practice, to optimize the

best-delivered care possible. Using the RDOS tool to assess dyspnea in patients who cannot

self-report may result in better patient care, patient and family satisfaction, and the betterment

of caregivers and medical staff in the meant units. This study opens the doors for further

research especially in the middle east toward dyspnea among mechanically ventilated

patients, it also seeks further education for ICU nurses toward the presented phenomenon.
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References:

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assessment and documentation: Nurses’ experience yields wide acceptance. BMC

nursing, 16, 1-11.

Baker, K. M., Vragovic, N. S., & Banzett, R. B. (2020). Intensive Care Nurses’

Perceptions of Routine Dyspnea Assessment. American Journal of Critical Care, 2, 132–139.

https://doi.org/10.4037/ajcc2020711

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should evaluate every day. Intensive care medicine, 41, 1347-1350.

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dyspnea in mechanically ventilated patients. Current opinion in critical care, 25(1), 86-94.

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Similowski, T. (2017). Observation scales to suspect dyspnea in non-communicative

intensive care unit patients. Intensive Care Medicine, 1, 118–120.

Hassen, K. A., Nemera, M. A., Aniley, A. W., Olani, A. B., & Bedane, S. G. (2023).

Knowledge Regarding Mechanical Ventilation and Practice of Ventilatory Care among

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https://doi.org/10.1155/2023/4977612

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& Similowski, T. (2015). Diagnostic accuracy of respiratory distress observation scales as

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Appendices

Appendix I: Patients’ demographic data

O Age in years ( )

O Gender: ( ) Male ( ) Female

Appendix II: Nurses’ demographic data

O Age in years ( )

O Gender: ( ) Male ( ) Female

O Years of experience in ICU ( ) years

O Education level : ( ) Bachelor ( ) Master

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Appendix III: MV-Respiratory Distress Observation Scale

Variable Score

0 3.3

Heart rate (beats/min) (Heart rate /65)

Use of neck muscle during inspiration

1- Absent -1
2- Present
+1

Use Abdominal paradox during inspiration

1- Absent -1
2- Present
+1

The facial expression of fear :

1- Absent -1
2- Present
+1

Respiratory rate (cycle/min) + (RR/50)

Total score + 3.3

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Appendix IV: Nurses’ knowledge toward dyspnea among mechanically ventilated

patients

Dyspnea Question

How important is it to use a uniform tool O Very Important

to assess for dyspnea? O Important
O Moderately important
O Little Important
O Not important

How important is it to track dyspnea O Very Important

every shift? O Important
O Moderately important
O Little Important
O Not important

How important is the addition of routine O Very Important

dyspnea assessment in improving patient- O Important
centered care?
O Moderately important
O Little Important
O Not important

How important is the addition of routine O Very Important

dyspnea assessment in predicting adverse O Important
patient outcomes?
O Moderately important
O Little Important
O Not important

How easy or difficult is it to administer O Very difficult

the dyspnea assessment? O Difficult
O Easy
O Very Easy
In your opinion, would it be useful to O Yes
have an algorithm with specific options O No
for the treatment of dyspnea?
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Would it be helpful to have a pictorial O Yes

scale to help communicate with patients O No
who have difficulty using a number scale?

Do you find it helpful to have standard O Yes

words (none, mild, moderate, severe, O No
unbearable) alongside the number scale
to help communicate with patients who
have difficulty using a number scale?