I started the Intensive care follow-up clinic to try to make sense of my work with critical patients and get feedback from their physical recovery. Over time, I verified that the patients presented not only physical effects, but that they maintained psychological and cognitive changes. They also suffered from post-traumatic stress disorder (PTSD), as survivors of war or other catastrophes would, which may last for years because of their near death experience.
Army soldiers used to call the day of their injury in battle “the alive day”, because it is almost a rebirth: after surviving a severe injury you have to learn again to do the simple daily things like eating, walking, writing and connecting with family and friends. Our patients are the same; after discharge from the ICU they have a long journey to reach their previous health condition.
Post-Intensive Care Syndrome (PICS) has been studied and is defined as new or worsening impairment in physical, psychological or neurocognitive status arising after critical illness and persisting beyond the acute care hospitalization. Advanced age is a risk factor for neurocognitive impairments, but younger age is associated with an increased risk of psychological dysfunction (anxiety, depression or PTSD). In my clinical practice, I often observe PTSD and anxiety disorders in younger patients with near fatal asthma, and depression/anxiety symptoms in severe COPD exacerbations in older patients.
The near death experience is not the only factor associated with PTSD; some studies connect the reduced time under sedation or mechanical ventilation with the decrease in PTSD symptoms and anxiety. The subjective and objective aspects of the ICU experience are associated with PTSD, like the unpleasant memories of being in the ICU, which can be delusional because of the severity of critical illness, hypoxia and effects of analgesics and sedatives. Poor ICU sleep has been identified in some studies as a risk factor for ICU delirium and there is evidence that sleep deprivation is also associated with immunodepressive effects which may be clinically relevant.
Patients with respiratory failure who have been exposed to prolonged mechanical ventilation are more likely to experience changes in their quality of life (QOL) after discharge. They can have decreased lung function, ICU-acquired weakness, permanent tracheostomy or even develop chronic respiratory failure ventilator-dependence. Severe acute respiratory distress syndrome (ARDS) survivors who require prolonged mechanical ventilation have poorer QOL.
During the ICU stay we can control the modifiable risk factors by maintaining euglycemia, controlling pain, minimizing use of sedation (avoid benzodiazepines) and neuromuscular blockers, and with judicious use of corticoides. Our daily approach is to implement measures like time and space orientation of the patients, noise reduction and sleep promotion at night, physical activity and early mobilization, and mental stimulation with occupational therapy, including cognitive training and music.
In my opinion, respiratory doctors (Intensivists or not) have an important role in post-intensive care recovery: to assess the sleep quality of patients and carry out sleep studies; to implement the pulmonary rehabilitation program, which is essential; and to evaluate patient dyspnoea, accessing the lung function with respiratory tests and the weakness with the six-minute walk test. We also have the tools to evaluate the psychological changes and neurocognitive impairments of our patients. We know how they were before the exacerbation and they trust us to talk about their fears and limitations.
In conclusion I think that the holistic approach to these patients is fundamental, but for me as a clinician I always feel the need to monitor their ' life cycle '. We are always learning from them.
####About the author
Ligia Pires is a Pulmonologist/Consultant and is dedicated to intensive care and obstructive lung diseases.
She was the Chair of the Asthma Commission of the Portuguese Society of Pulmonology, organising meetings on severe asthma.
Currently, Ligia works in the Intensive Care Unit of the Algarve University Hospital.
She is responsible for the Intensive Care Follow-up Clinic for ICU survivors, the severe asthma clinic and is the ICU coordinator of bronchoscopy and pleural techniques.
She was elected as an ERS officer in 2017 and is the Secretary of the Acute Critical Care Group.
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