Expert consensus on management of pain, agitation and related issues in adult patients with critical respiratory diseases

Abstract

As patients with critical respiratory diseases suffer from the discomfort of disease, frequent medical and nursing procedures, and the noise disturbance of the ICU environment, it is necessary to implement analgesia and sedation to reduce their negative stress and oxygen consumption. Special emphasis will be placed on the clinical practice of analgesia, sedation and rehabilitation in critically ill patients with respiratory diseases, as different pathophysiological features of the respective pulmonary diseases are presented, such as severe asthma and acute exacerbations of chronic obstructive pulmonary disease, as well as the exclusive situations during respiratory therapy, such as recruitment maneuvers, bedside bronchoscopy and operation of extracorporeal membrane oxygenators. To standardize the prevention and management of pain, agitation, delirium, immobility, and sleep disturbance in adult patients with critical respiratory diseases, the Chinese Thoracic Society and Critical Care Medicine Group of Chinese Association of Chest Physicians, Chinese Medical Doctor Association organized pulmonary and critical care experts to discuss 19 important issues and ultimately provided 20 recommendations based on the best available evidence.Assessment, prevention and management of pain should be prioritized before the administration of continuous infused sedatives in all patients with critical respiratory diseases. Bundles that include multiple strategies of non-pharmacological interventions to prevent and manage delirium and sleep disruption are encouraged. For the patients with stable respiratory and hemodynamic status, early mobility and exercise could be safe and beneficial. Respiratory drive control by addressing patient and ventilator factors should be the priority before administration of analog-sedation protocol in the ARDS patients. Deep sedation could be necessary in the early stage of ARDS with high respiratory drive, and during the recruitment maneuver, prone position and measurement of the respiratory mechanics. Maintaining spontaneous breathing with a lower level of sedation is recommended in COPD patients on invasive mechanical ventilation, while a deeper level of sedation, even with a short course of neuromuscular blockade, may be beneficial among severe asthma patients with high peak airway pressure. Pharmacokinetic alterations in patients with critical respiratory diseases during ECMO support are complicated as varied factors are involved, including ECMO circuit factors, drug factors, and patient factors. Therefore, the dosage of analgesics and sedatives should be adjusted according to the target of analog-sedation protocol in the respective disease.