OutcomesMusic and biological stress dampening in mechanically-ventilated patients at the intensive care unit ward—a prospective interventional randomized crossover trial☆,☆☆
Introduction
Music listening is being increasingly widely used for stress release in all areas of medicine, including oncology, geriatrics, gastroenterology, cardiology, anesthesiology, surgery, pediatrics, palliative care, psychiatry, and intensive care [1]. Indeed, there have been historical references of its benefits, with both Kings Saul and George commissioning harp playing to reduce their stress. Music listening is known to influence both frontotemporal cortical areas and the limbic system, and causes psychophysiological responses [2], [3]. It is involved in specific brain functions such as memory and emotional state and thus can bring a state of relaxation, improve temper and increase motivation [4]. More specifically, listening to relaxing or stress-releasing music can also increase the release of endorphins and enkephalins, and decrease circulating catecholamines [4], [5]. Stress-releasing music is often slow-tempo (60 bpm of rhythm) to which heart and respiratory rates can also be synchronized [4]. The potential benefits are a reduction in pain and a lowering of blood pressure, heart rate, oxygen consumption, muscle tension, and activity of sweat glands [1], [4]. Intensive care units (ICU) are a stressful milieu, and mechanical ventilation (MV) is potentially painful and uncomfortable. In this context, an appropriate and titrated pharmacological support is almost always mandatory to provide comfort without oversedation. While sedative medications are cornerstone in this goal, the way the latter should be administered (intermittent vs continuous with daily interruption) remains controversial [6], [7], [8]. In addition, these drugs are expensive, can lengthen the duration of MV, and have potentially lethal side-effects as well as worsen outcome.
Most studies using music in MV patients tended to show a beneficial effect on clinical physiological parameters such as pulse and respiratory rate, anxiety and pain as well as blood pressure [9]. Of note, Conrad et al observed a reduction of sedative drug consumption in a small cohort of MV patients listening to an hour of a Mozart's piano sonata [5]. On a biological standpoint, they also demonstrated that blood interleukin-6 (IL-6), a cytokine involved in early inflammatory processes, as well as dehydroepiandrosterone, an upstream common precursor of steroids, were decreased whereas growth hormone was increased in response to listening to this classical music [1], [5]. Additional evidence that music listening probably affects the hypothalamus-pituitary-adrenal (HPA) axis also stems from the work of Chlan et al who evaluated blood levels of cortisol and corticotrophin in another small cohort of MV patients [10].
However, for the time being, (i) only a limited number of MV-patients have been tested with music listening, (ii) the impact of music has never been evaluated in a crossover design where patients are their own controls, (iii) patients still maintained on mild sedation instead of those with discontinued sedation; have not been thoroughly studied for responsiveness, and (iv) several essential short-releasing biological stress/inflammatory responses have not been explored. In light of these observations, we postulated that slow-tempo music listening during MV in ICU patients can (1) reduce sedative drug consumption and slow down vital signs in not fully alert patients and (2) damper inflammatory and HPA axis hormonal release.
Section snippets
Study design and population
This prospective randomized-controlled crossover trial included patients requiring invasive mechanical ventilation, while taking benefit of patients being their own controls. The trial received the approval of our local ethical review board (Comité d'Éthique de la Recherche en Santé chez l'Humain du CHUS), and a written informed consent was obtained from the patient's relatives with subsequent approval of randomized patients when possible. This trial was registered in the ClinicalTrials.gov
Results
A total of 294 screened patients were deemed eligible during the time frame of this trial, whereas 239 were not enrolled for the following reasons: 141 (exhibiting exclusion or lacking inclusion criteria), 58 (non availability of the staff), 40 (refusal of consent). Of the 55 randomized patients, 6 patients did not complete all of the requirements of the protocol (missing listening sessions, missing blood samples, non completion of the 3-day MV experimental follow-up), and their data were
Discussion
In the present trial, we report that the biological response is more sensitive than the clinical response after music listening in the current setting. As a primary endpoint, a reduction of stress-related VS, initially expected, was not consistently observed with slow-tempo music listening. However, a clinically relevant trend toward a reduction in narcotic consumption was noted in music-listening patients, especially in those “labeled” as biologically responsive by quickly reducing their
Conclusions
There is still much to be accomplished in furthering our knowledge on this relatively new nonpharmacological intervention in MV patients before pursuing any systematic implementation of music listening as a “guideline” for ICU physicians. Slow-tempo music listening has the potential for reducing narcotic consumption of still sedated MV-ICU patients, at least in “biological responders” displaying a rapid impact on the limbic system, or on “imaging responders” activating specific areas during
Acknowledgments
The authors thank Catherine St Pierre (and the Service de Médecine Interne) for the MP3 sets and contribution in study design, and Nathalie Carrier for statistical analyses.
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Conflict of Interest: The authors declare no conflict of interest and they were neither funded to select specific MP3 devices nor to select special music pieces.
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This study was supported by dedicated grants from the CRCEL-CHUS (PAFI) and was partially presented at the Soc de Reanimation de Langue Française 2011.