Clinicians from Massachusetts General Hospital and Beth Israel Deaconess Medical Center (BIDMC) are working to raise awareness about air hunger, a traumatizing psychological byproduct of mechanical ventilation.
The team, which includes Christopher M. Worsham, MD, from Massachusetts General Hospital and Robert Banzett, PhD, and Richard Schwartzstein, MD, from BIDMC, outlined their concerns and offered a treatment strategy in a recent article in the Annals of the American Thoracic Society.
“With the likelihood that hundreds of thousands of patients will require low tidal mechanical ventilation around the world, we are concerned about the potential for mass psychological trauma in the survivors induced by untreated air hunger during this pandemic,” the authors write.
Here are five things to know:
A key therapeutic strategy for COVID-19 patients with acute respiratory distress syndrome (ARDS) is lung protective ventilation–mechanical breathing support. This approach entails using low tidal volume (lower levels of air to prevent lung injury) and permissive hypercampnia (allowing higher levels of carbon dioxide in the blood than would typically be comfortable for healthy patients in order to reduce strain on the lungs).
Unfortunately, this treatment strategy is also a recipe for “air hunger” — the subjective feeling that you need more air than your body can take in. It’s comparable to the feeling you get by holding your breath for a long period of time, except that you cannot voluntarily end your breath hold and take in new air. Prolonged air hunger evokes such high levels of fear and anxiety that it has been used as an effective form of torture (waterboarding).
It can be challenging to identify symptoms of air hunger in ventilated patients who can’t easily communicate with their care teams. Research has shown that doctors and nurses consistently underestimate levels of respiratory distress compared to patient reports. Neuromuscular blockade—a drug-induced paralysis that is often used during mechanical ventilation so that patients don’t remove their air tubes—does not diminish air hunger and can make identifying it more difficult.
Opiates are the most reliable agent for the symptomatic relief of air hunger as they both depress the ventilatory drive and perceptual pathways that relay information from the lungs to the brain. In opiate-naïve healthy subjects, 5mg of intravenous morphine provided profound relief of experimentally induced air hunger. Low levels of opiates given to patients with clinical cases of respiratory distress also provided similar relief.
Thus the authors “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.”
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