COVID-19: Experts Warn of Psychological Trauma From 'Air Hunger'

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Psychological trauma that may result from feelings of severe breathlessness in COVID-19 patients receiving lung protective ventilation is an "urgent" problem that requires increased awareness and appropriate treatment, say three critical care physicians.

"With the likelihood that hundreds of thousands of short-of-breath patients around the world during this pandemic will require low-tidal-volume mechanical ventilation, we are concerned about the potential for mass psychological trauma among the survivors, induced by untreated air hunger," write the physicians, led by first author Richard Schwartzstein, MD, chief of the Division of Pulmonary, Critical Care and Sleep medicine at Beth Israel Deaconess Medical Center and Harvard Medical School.

"During this crisis, we urge physicians providing critical care to attend to the possibility of extreme air hunger in ventilated COVID-19 patients with ARDS and to consider the known pharmacologic benefits of opiates in their management," they add.

The perspective article was published online June 5 in Annals of the American Thoracic Society.

Severe Shortness of Breath

Recent reports suggest the vast majority of ICU patients with severe COVID-19 have severe shortness of breath prior to intubation and mechanical ventilation. The strategy for ventilating these patients is to constrain their tidal volume (the size of their breaths) because large breaths may damage the lungs.

However, this is also a recipe for 'air hunger' — a term the authors call "the most uncomfortable form of dyspnea" — and may lead to emotional and psychiatric problems, including posttraumatic stress disorder (PTSD) in acute respiratory distress syndrome (ARDS) survivors, Schwartzstein told Medscape Medical News.

"We can't prove that the two things are linked at this point but one wonders about a possible association between the trauma of being incredibly short of breath and not being able to do much about it and developing these problems," he said.

"Anecdotally, in talking to patients who have been in respiratory failure and on mechanical ventilation, many of them recall a 'smothering' sensation, which is frightening and they describe fear," he added.

With the advent of neuromuscular blockade to induce paralysis in mechanically ventilated patients, "we worry even more about this problem because we can't make any evaluation about whether the patient is short of breath or not," Schwartzstein said.

He also said there is a persistent mistaken notion that paralysis reduces dyspnea. "We know now that neuromuscular blockade does not diminish air hunger. Most sedatives also do not relieve shortness of breath," he said.

Yet, the clinicians note, the issue of air hunger is manageable. However, the first step is recognizing it.

"Physicians who are treating ARDS due to COVID-19, some of whom may not be accustomed to treating patients with respiratory failure, must first be aware of the problem and then consider means by which air hunger can be ameliorated," Schwartzstein said in a statement.

As for treatment, opiates are "the most reliable agent for symptomatic relief of air hunger — they seem to act both through depression of ventilatory drive and ascending perceptual pathways, as they do with pain," the authors note.

Several studies have shown that morphine, even at low doses, relieves air hunger. "At our hospital, we give a good, healthy dose of opiates as part of the sedation protocol." Schwartzstein said.

Lessening Psychological Trauma in Survivors

Medscape Medical News reached out to experts in psychiatry and critical care for comment on this topic.

O. Joseph Bienvenu, MD, PhD, associate professor, psychiatry and behavioral sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland said this is an issue that comes up for consultation-liaison psychiatrists.

"Critical illnesses and the treatments needed to keep patients alive are huge stressors and psychiatric morbidity is common after ICU care," he told Medscape Medical News.

Research suggests that about 40% of survivors have clinically significant anxiety symptoms, 30% have clinically significant depressive symptoms, and 20% have clinically significant PTSD symptoms after an ICU stay.

"Remembering feeling short of breath during critical illness is associated with PTSD symptoms in survivors. There are ways to lessen the risk of psychological trauma after an ICU stay, "but the field is still relatively young, so experts don't all agree," Bienvenu said.

Bienvenu is a proponent of ICU diaries written to critically ill patients by clinical staff and family members to help patients understand how ill they were, what procedures and care they had, and why some of their memories may be of things that did not happen — or at least did not happen as remembered.

"These [diaries] address an important issue for critically ill patients in intensive care — delirium, which can be associated with hallucinations, misperceptions/delusions, and awful nightmare-like experiences that still seem quite real for a long time afterward," said Bienvenu.

He also supports post-ICU follow-up programs — either in person or virtual — which address psychological recovery along with physical and cognitive recovery/adaptation and post-ICU support groups for patients and family members.

Balancing Act

Two critical care physicians also weighed in.

Mirna Mohanraj, MD, program director for the Pulmonary & Critical Care Medicine Fellowship at Mount Sinai Morningside Hospital in New York City, said she appreciates the "concepts and concerns" put forth in the perspective piece.

Like Schwartzstein, Mohanraj noted that the heavy sedation and neuromuscular blockade to achieve safe and effective ventilation make it difficult to estimate a patient's sense of air hunger.

She noted that at Mount Sinai Morningside, COVID-19 patients with severe ARDS often had far greater analgesia, sedative, and paralytic requirements than typical ARDS patients.

"We were intrigued to find patients needing remarkably high doses of opiate and benzodiazepine infusions in addition to neuromuscular blockade. The anti-dyspnea effects of opiates are well-described; at the observed high rates, one would presume that the sensation of air hunger would be effectively dampened or eliminated," Mohanraj told Medscape Medical News.

Mohanraj agreed that opiates in COVID-19 ARDS may be beneficial in several ways, including the treatment of air hunger.

However, she added, "caution must be exercised to administer the minimal amount of analgesic, sedative, amnestic, and paralytic treatments necessary to effectively manage symptoms of pain and dyspnea and also achieve safe ventilation to improve survival," she said.

"Excess use of sedatives and analgesics may also negatively contribute to post-ARDS neuromyopathy, ICU delirium, and post-ARDS cognitive dysfunction," said Mohanraj.

She "strongly supports including COVID-19 survivors in formal studies of post-ICU syndrome to better understand if the use of opiates will lead to a lower incidence of PTSD."

Beyond COVID-19

Craig Jabaley, MD, assistant professor of anesthesiology, Emory University School of Medicine, Atlanta, Georgia, and a member of the Society of Critical Care Medicine (SCCM), noted that air hunger is "an important issue for all critically ill patients with severe respiratory failure, be it COVID-19 or any other cause."

"Psychological stress resulting from critical illness of any cause has been associated with adverse long-term effects, and efforts to mitigate this have been a research and clinical focus of the critical care community for several decades.

"As the authors point out, expertise in the care of critically ill adults is important for both the recognition and treatment of any number of clinical challenges associated with critical illness, including air hunger," Jabaley said.

"From the SCCM standpoint, development of, and advocacy for, multidisciplinary tiered staffing models have been central to pandemic preparedness and response efforts to ensure the availability of trained professionals to meet surge demands for critical care," he told Medscape Medical News.

Jabaley said ameliorating air hunger, in particular, involves recognition of the issue by trained professionals; optimization of mechanical ventilation strategies by the multidisciplinary critical care team; and appropriate sedation strategies, such as those outlined in the "SCCM 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU."

The study had no specific funding. Schwartzstein, Bienvenu, Mohanraj and Jabaley have disclosed no relevant financial relationships.

Ann Am Thorac Soc. Published online June 5, 2020. Full text

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