Surviving acute respiratory distress syndrome is like surviving a war, except the battle zone is inside one's chest. It should come as no surprise that many of these patients suffer persistent psychological aftereffects years after discharge, like war veterans. Even so, researchers in Munich were not prepared for what they found.

These investigators selected 80 patients who had severe ARDS and were admitted to a tertiary care university hospital between 1985 and 1995. Many of them had been on extracorporeal membrane oxygenation. Researchers interviewed them an average of four years afterward. They asked them whether they had any traumatic recall of dyspnea, pain, anxiety or nightmares and screened them for post-traumatic stress disorder (PTSD).

Fully a quarter of these patients met the criteria for PTSD. To put that figure in context, only 1.3 percent of United Nations peacekeeping soldiers who had served one year on the Thai-Cambodian border meet the same criteria, according to the researchers.¹

"That was very striking to me to think that my care of an ARDS patient was more traumatic for that patient than sending him to live for a year on the Thai-Cambodian border trying to keep the Khmer Rouge at bay," observed Derek C. Angus, MBCHb. "I thought I was a nicer guy than Pol Pot, but maybe not."

Acknowledging "a lot of miserableness going on in our survivors," the intensivist from the University of Pittsburgh Medical Center suggested, "This could be an astounding opportunity to improve care."

RECOGNIZING PTSD

People who were diagnosed with a life-threatening illness or have undergone invasive medical procedures are among those listed at risk for developing PTSD, according to the PTSD Alliance, a group of professional and advocacy organizations dedicated to increasing awareness and promoting better understanding of the condition. Other listed risk factors include rape, domestic violence and catastrophic events, such as plane crashes and terrorist acts.

The group estimates that 5 percent of all Americans (more than 13 million people) have PTSD at any time. About 8 percent of all adults, or one in 13 people, will develop the disorder during their lifetime.

Rachel Yehuda, PhD, director of the PTSD program at the Bronx Veterans Administration Medical Center in New York, described the condition as a "wiring of the brain that doesn't permit the normal recovery process." People suffering from PTSD "cannot get rid of the memory of the event or the emotional response" that triggered the disorder. They relive the event through flashbacks and recurring nightmares. They avoid reminders of it and constantly feel hyper-aroused. This obsession prevents them from sleeping well and soon takes a toll on their self-esteem and personal relationships.

Dr. Yehuda distinguished between a disorder and a syndrome, noting that people suffering from post-traumatic stress syndrome will process their memories over time, while those with the disorder present with clinically significant symptoms that erode their ability to live functional lives. Recommended treatment for people who present with PTSD symptoms include psychotherapy and antidepressant medication.

The critical care risk factor could be reduced if clinicians assessed patients for PTSD and taught them how to monitor themselves, Dr. Yehuda suggested. Members of the PTSD Alliance recently prepared a booklet to help caregivers recognize patients who present with symptoms.

ADDING EMOTIONAL SUPPORT

Dr. Angus acknowledged that "many of us don't systematically follow ICU survivors in follow-up clinics, and maybe we should." He suggested adding emotional support from psychiatrists and rehab programs as strategies for helping patients recover from their ICU experience.

Tony Liscott, RRT, a team leader in the cardiothoracic ICU at the University of Pittsburgh who works with Dr. Angus, recalled times when long-term acute patients have shown signs of psychosis and even dementia, especially those who don't have a room with a window. "Patients don't know whether it is night or day," he explained.

Staff members try to move patients to a window room when they notice a patient showing signs of distress, and Liscott noted the psychosis resolves quickly. He also recalled the benefits of an excursion for a lung transplant patient who had been in the ICU several months. A nurse and a therapist took the young woman to a glass-covered bridge linking two hospitals where she could see a section of the city complete with traffic and pedestrians.

"Her whole attitude improved," Liscott said. "There was no medical intervention, just stimulation."

Liscott expects the coming and going of different caregivers also proves disorienting to patients. "It has to be traumatic, having different people take care of you every day," he said. "Everyone has different personalities."

Fixing such problems to provide a more user-friendly care system challenges members of the ICU staff, where they carry a heavy patient load due to chronic understaffing. Therapists in the cardiothoracic unit may have as many as 10 patients under their care, making it difficult to leave the unit to accompany a patient to other areas of the hospital.

While Liscott acknowledged that excursions for ICU patients should occur more often, he explained, "Time constraints don't allow it."

REFERENCE

1. Schelling G, Stoll C, Haller M, et al. Health-related quality of life and post-traumatic stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med. 1998;26:651-59.

Editor's Note: Post-tramautic Stress Disorder: A Guide for the Frontline is available from the PTSD Alliance at 1-877-507-PTSD or www.PTSDAlliance.org.