Anxious Vent patient - looking for alternative therapy

[NextGen]

My patient was put on a vent during a pneumonia episode and has not been able to be weaned off. Now she is on my LTAC. Her O2 levels are always good. She has coughing spells and periods where she feels like she cannot breath. Nursing and respiratory have tried EVERYTHING and have been unable to resolve this or figure out what triggers it - we have tried repositioning vent tubes, anti-anxiety meds, deep breathing exercises, scheduled albuterol etc... Some days/nights she is comfortable and does not have any issues. Anyone have any thoughts on alternative therapies that might work? Thanks in advance!

[MunoRN, RN]

Anxiety is unfortunately a normal physiological response to an endotracheal tube or trach, as well as being on a vent, which is why it's encouraged that people decide ahead of time if this is really something they would want long term.

The body is hard-wired to want to control our airway and respiratory drive, when it senses there is something abnormal related to our airway or respiratory drive the normal response is a fight or flight response, which can also be described as a sense of panic or anxiety.

Benzos can be effective but particularly when used long term are likely to induce delirium, which itself produces a fight or flight response.

Often this anxiety is worsened by coughing and more specifically bronchospasm. The use of levalbuterol rather than albuterol should considered when bronchospasm is an issue since albuterol is strongly associated with paradoxical bronchospasm, likely resulting from the s-albuterol portion of racemic albuterol, levalbuterol only contain the r-albuterol isomer which is less likely to cause bronchospasm.

Generally the alternative therapy that should be considered, and I'm not trying to be harsh, is comfort care.

[blondy2061h, MSN, RN]

What about biofeedback of sorts? Letting her watch her o2 sat and try and practice controlling her respiratory and heart rates?

[KatieMI, BSN, MSN, RN]

Is she on weaning protocol? What vent setting she spends most of the time AND coughs mostly? (these two are different things usually)

Is she still intubated or she is trached? If trached, does she have short neck? ("trache-positional" cough is very common among such patients and very unpleasant)

How often she gets albuterol? This med has anxiety as one of common side effects. Can she be converted to anticholinergics or levalbuterol?

Is she "wet"? Is there any cardiac stuff on board? Basal crackles?

If no s/s of HF and she has a lot of secretions, can she be put on Scop?

How about good 'ol Robitussin? Mucomyst?

If she is getting "sumethin' for pain" anyway and everybody is sure that cough is the problem, can dose be partially converted to codeine HS?

If there is possible CHF, was it worked up and treated? How about CAD?

Is she really here, a, o x 3? Does she sleep ok? Can she sundown?

Can she be given antidepressant with high antianxiety activity like Trazodone? What about sertraline? (worse safety profile, though).

What "alternatives" did you already tried? Music, NO TV after 10 pm to facilitate sleep, no nighttime vitals (while on tele so you know she's alive), blankets from home, family explained that cough is good and doesn't freak out every time it happens?

Overall, cough and anxiety are very common among LTACH patients. They may or may not have to do anything with each other, and may or may not (more commonly, contrary to popular wisdom, they are not) have anything to do with oxygen. You need really think outside of the box to figure it out sometimes. Do not relay on psych consult and benzos - they do a good job treating anxiety per se but little, if something, to treat its cause.