"Non-Pharmacological Interventions to Optimize Sleep and Circadian Health in the ICU" Amy Korwin (03/16/2022)

March 23, 2022

ID7597

To CiteDCA Citation Guide

00:03Great great so we have some people
00:05already joining so good afternoon everyone
00:07and welcome to GAIL some seminar.
00:09So today we're delighted actually to
00:11have again one of our own sleep fellows.
00:13Doctor Amy Corwin is going to be presenting
00:15her work and other work on optimizing sleep
00:18and circadian health in critical care,
00:20and doctors now will be introducing her.
00:22But before I get to that before we
00:24get to that, I have a few reminders.
00:27So first sleep seminar lectures are
00:29available for CME credit and to
00:30receive credit you just need to text
00:32the ID for the lecture to Yale Cloud.
00:34See any.
00:35And if you're not sure how to do that,
00:37the information will show up in the chat.
00:39Secondly, there are recordings of
00:41lectures available within two weeks.
00:43They are not available for credit,
00:44but you're free to view them.
00:46And then finally,
00:47if you do have questions during the talk,
00:49please use the chat feature.
00:51Go ahead and put your questions
00:52in as the talk goes on.
00:53They'll be moderated at the
00:54end and also at the end.
00:56You'll have permission to unmute
00:58yourself if you prefer to do that.
01:00So now I'm going to turn this session
01:01over to Doctor Melissa Cowart.
01:03She's an assistant professor here at Yale.
01:05Our former.
01:06Sleep fellowship director,
01:07and she's also an active researcher on sleep
01:10and circadian rhythms in critical illness.
01:13Thanks excuse me,
01:15thanks Janet.
01:16Good afternoon everyone.
01:17It's really my pleasure today to
01:20introduce Doctor Aidan Corwin.
01:22And really,
01:23I said excuse me as a culmination of
01:25her time here with us at Yale as we
01:28were discussing while we were waiting,
01:29she is getting close to the end
01:30and we wish her all the best and we
01:32wish her all the best again later.
01:33But anyway,
01:34Doctor Korman attended Brown
01:36University where she majored,
01:38majored in neuroscience and graduated
01:40Magna *** laude from Brown.
01:42She matriculated to the University of
01:44Pennsylvania School of Medicine and
01:45then matched at the Hospital of the
01:47University of Pennsylvania Internal Medicine,
01:49where she really had an outstanding resident.
01:52Career and was ultimately selected
01:54as a chief resident there.
01:56We were delighted to recruit her
01:57here to yell for her pulmonary
01:59and critical care fellowship,
02:00and that's where I really got
02:01to work with Amy.
02:02I was really had a wonderful
02:05time mentoring her,
02:06and I'm extraordinarily proud of her work,
02:08implementing and testing the time restricted
02:11intermittent feeding in the medical ICU.
02:13For those of you who have worked
02:15in complicated clinical settings,
02:17really of any type and know what
02:18it is to try to implement change,
02:20you can appreciate what a labor.
02:22Of a meticulous and dedicated work that
02:25would be during this most recent year,
02:27Doctor Coren has joined the Yale
02:28State program as a sleep fellow,
02:29and she's of course done a wonderful job,
02:31and she's been awarded in Aspire
02:33Fellowship from the ATS that
02:34supports both her career development
02:36and her research efforts.
02:38As I've said, it's been a pleasure to
02:39work with her at these last several years,
02:41and I hope you will join me in
02:43welcoming her to the podium for what is
02:45sure to be a great discussion of non
02:47pharmacologic interventions to optimize
02:48sleep and circadian health in the ICU.
02:51Take it away, Amy.
02:52Alright, so thank you so much for
02:54that very nice introduction and
02:56thank you all for joining remotely.
02:58I'm really excited to share with
02:59you all today and what I've learned
03:01along the way about Nonpharmacologic
03:03management of sleep and circadian
03:04health and critically ill patients.
03:08Sorry my slides. OK so this this
03:11course is available for CME credit.
03:13I'm going to leave this up here for
03:15an extra couple of minutes here
03:17or a minute or so, and I know the
03:19code will be posted in the chat.
03:21For those of you who need the CME credit.
03:23Hopefully some people have
03:25had time to take it down.
03:27So I'm going to get into the talk now.
03:29I wanted to give a brief outline.
03:30First time to let you all know
03:32what will be discussing today.
03:33I'm going to start by giving some
03:35background information to help us all
03:37be on the same page and understanding
03:39of the current understanding of
03:40sleep and circadian health and
03:42critically ill patients and why
03:43this is such an important problem.
03:45To acknowledge and to be aware of.
03:47And then we're going to talk a little
03:49bit about what it is that actually
03:51causes and contributes to sleep and
03:53circadian disruption in this population.
03:54And those factors are mainly divided into
03:573 broad categories of patient related.
03:59Factors,
04:00environmental factors and then things
04:02that are related to the acute illness
04:04and critical care treatments themselves.
04:07I'll summarize practice recommendations
04:08that hopefully will be useful to some of
04:11you moving forward to help your patients,
04:13and then I'll touch briefly on future
04:16directions for research in this field.
04:19So just to start with,
04:20you know there have been quite a few
04:23observational studies trying to describe,
04:24quantify and qualify.
04:25What sleep and super Kadian rhythms
04:28look like in critically I'll patients,
04:30and you can imagine and I'll talk
04:31a little bit more about that.
04:33There are very many factors that contribute
04:35to disordered sleep in ICU patients,
04:38some coming from the patient side,
04:39and comes some coming from the medical side,
04:42such as interventions in the ICU environment.
04:45Some of the salient features that
04:47have been identified to describe.
04:48The state of sleep and circadian rhythms
04:51and I see patients are noting that sleep
04:53is often a very insufficient duration.
04:56The sleep that patients are able to
04:58achieve is often highly fragmented
05:00and as abnormal sleep architecture.
05:02And then finally,
05:03this circadian phase has been
05:05demonstrated in multiple critical
05:07populations to be misaligned,
05:08usually in the delayed direction
05:11or sometimes even abolished.
05:13So I'll start by describing the
05:15insufficient sleep duration.
05:16So this was a study.
05:17It was a cross sectional observational
05:19study done by Doctor Canal right
05:20here in our own department and
05:22some colleagues they enrolled 23
05:24patients into 24 hour PSG's on
05:26these patients and what they found
05:28was that overall patients had a
05:30really insufficient sleep duration.
05:32They divided the patients into those who
05:34had typical sleep features on their eggs,
05:36which were 14 of those patients,
05:38and these patients achieved a total
05:40sleep time of just over 6 hours.
05:42Then one striking feature is that
05:44about a third of the sleep time
05:46occurred during daytime hours,
05:47which is very disadvantageous from a
05:50circadian perspective and the remaining
05:529 patients who had atypical sleep on
05:54EEG. They found even worse numbers,
05:56so the total sleep time was under
05:585 hours and again about 1/3 of it
06:01occurring during daytime hours.
06:02And this was a similar study
06:04done by Elliott Group.
06:05This was 57 ICU patients who again
06:08underwent 24 hour PS fees and
06:10this is just a box plot showing
06:12the average duration of sleep
06:13time and you can see that there's
06:16a pretty wide distribution here.
06:17A variable distribution with patient and
06:19kind of some having a longer sleep time,
06:22but on average,
06:23most of the patients had again
06:25well below our recommendation
06:26of 7 to 8 hours of sleep time.
06:29And these are some of the more granular
06:31numbers to drive from that study.
06:33Again, the median sleep time was five hours,
06:35but what I wanted to point out with this
06:37slide is that some really striking numbers,
06:39the duration of sleep without
06:40waking on medium was three minutes.
06:42So patients were able to achieve just
06:44three minutes of sleep before being woken up.
06:47They had on average about 38 sleep periods
06:50throughout the 24 hour recording session,
06:52and 41% of their sleep
06:54occurred during daytime hours.
06:55So all of these numbers to really
06:58highlight just how disruptive
06:59the quality of their sleep.
07:01This is a more visual representation
07:03of the sleep fragmentation that
07:05I was alluding to earlier.
07:06This study was done by Friedman Group.
07:08This was 22 Mickey patients and
07:11they underwent 24 or 48 hour PSG's
07:14and concomitant noise measurements
07:15and I'll come back to that aspect
07:17of the study later in the talk
07:18they again demonstrated about 40
07:20sleep periods over 24 hours.
07:23So similar to what Elliot study
07:24demonstrated and each of the bars in the
07:27graph on the left here show an individual
07:29subject and their sleep is plotted.
07:31Over a 24 hour bar and the black spots
07:33represent the sleep in the white
07:35represents week and I've tried to
07:36highlight a sort of a typical nocturnal
07:38sleep period with the red lines and you
07:41can see that for most of these patients,
07:44fair amount of their sleep occurs
07:46outside of that nocturnal period,
07:48and also that their sleep is just
07:50very highly fragmented into these
07:52short pieces around the clock.
07:54In addition to the sleep being of
07:56insufficient duration and being fragmented,
07:58studies have also shown that the
08:00sleep architecture is disrupted.
08:02Some studies have shown that the
08:04proportion of our normal sleep
08:06stages is very off from work.
08:07That should be reproducibly
08:09demonstrated has been a deficit
08:11and slow wave sleep and REM sleep,
08:13and that's what's shown here
08:15from Elliot study again.
08:16Very notably,
08:17they had median of 0 minutes
08:19of each of these sleep stages.
08:21Other studies have shown a bit more
08:23mild findings that reproducibly.
08:25Demonstrated that these sleep stages
08:27are reduced and we know that that's
08:29important because these are thought to
08:31be the most restorative stages of sleep.
08:33Other studies have demonstrated
08:35atypical sleep with EG findings
08:38that are too atypical to even
08:40classify in the normal sleep
08:42staging criteria.
08:43This was an example of a PSG
08:45finding from Friedman study,
08:46which is a representation of a patient
08:48with sepsis and encephalopathy and
08:50what they're showing here is that
08:52there's a background of low amplitude
08:54mixed frequency which we would
08:55normally think of as weak period,
08:57but then mixed in.
08:58With that we see Delta and Theta
09:00waves so abnormal there.
09:03And this was an example of a
09:06similar concept from Coopers Paper.
09:08This was a prospective cohort analysis
09:10looking at 20 ventilated patients
09:12from medical and surgical ICU's and
09:15again evaluated with 24 hour PSG and
09:17this picture is demonstrating the
09:20concept of pathologic wakefulness.
09:22What this shows is that there are
09:24features of sleepy EG that prove
09:26that get involved or get in the
09:29way of behavioral wakefulness.
09:30So this patient is actually
09:32performing biocal's where the two
09:34dark arrows are on the bottom.
09:35And you can see that despite them
09:37being awake enough to perform the
09:39biocal so behavioral wakefulness,
09:40they do have these slow waves in the EG.
09:44And aside from everything I've
09:46mentioned about the disruption
09:47and sleep quality and quantity,
09:49there have also been studies to try
09:51to qualify and quantify the circadian
09:54phase and critically ill patients.
09:56These studies have been done
09:57in various different subsets
09:58of critically I'll patients,
10:00including patients with sepsis
10:02and patients with brain injury and
10:04those studies have been repeatedly
10:06demonstrated that the patients
10:07have a delayed circadian phase,
10:09and this is one example of
10:10a group of 16 ICU patients.
10:13This was.
10:13An observation,
10:14ULL study and subset of the patients
10:16included in the overall study had
10:19this circadian analysis and what
10:20they did was they measured the
10:22urinary 6 sulfate oxy melatonin,
10:25which is a melatonin metabolite every
10:27four hours and they use the trend
10:29in that to determine the circadian
10:31accuracies or the circadian phase
10:33for the patients and the normal
10:35phase is defined by these red lines.
10:37So what you can see is that for
10:38each of these individual subjects,
10:40the majority of them are phase delayed.
10:44So hopefully they have convinced you now
10:47that patients in the ICU often have very
10:50disrupted sleep and circadian rhythms.
10:51But why does this matter? So?
10:53The reason that this is so important is
10:55because we know that these findings are
10:57associated with poor clinical outcomes.
10:58So for patients with atypical
11:00sleep characteristics,
11:01it's been shown that they have a higher
11:03chance of having mechanical ventilation,
11:06meaning failure patients with sleep
11:08deficiency can have inferior immunological
11:10function as well as poor glycemic control.
11:13We know that poor sleep and.
11:14Is the line for Kadian rhythms is
11:16thought to be a probable risk factor
11:18for delirium and certain lack of sleep
11:20features can be associated with increased
11:22ICU length of stay and even mortality,
11:25and I'll describe some of these
11:27findings over the next few slides.
11:29So this was a study done
11:30by Rose Campos Group.
11:31They looked at 27 patients who had
11:34hypercapnic respiratory failure
11:36and were treated with non invasive
11:38ventilation for at least 48 hours.
11:40What they did was a 17 hour PSG
11:42on these patients during somewhere
11:44between days two and four.
11:46After an Ivy initiation so they had
11:48already been requiring some form of
11:50PAP therapy for a couple of days.
11:51At this point I'm and what their aim
11:54was was really to see if there was
11:56any association between PSG features.
11:58So qualities of the sleep.
12:00And then the patient outcomes they
12:02were looking to see if the patients
12:04were able to successfully wean
12:05from NIV or if they had what they
12:07defined as late nivs failure.
12:09And this was a composite endpoint of death,
12:12endotracheal intubation or
12:13persistent need for non invasive
12:15ventilation on day six of the study.
12:17What they found was among the
12:19patients that they studied.
12:20Those who went on to have success in
12:23meeting from non invasive ventilation.
12:25We're less likely to have abnormal sleep,
12:27whereas this is a more common
12:28finding in patients who had late.
12:30Failure.
12:30They also found that a higher night
12:33today total sleep time ratio,
12:35meaning more of the sleep was
12:37occurring during the nocturnal period,
12:38which is circadian,
12:40which is a two circadian advantage
12:42that seemed to predict or be
12:44associated with an Ivy success,
12:46whereas the opposite more of daytime
12:48sleep was associated with late and Ivy
12:51failure and then finally significant
12:53decrease in the proportion of REM was
12:56also associated with late and Ivy failure,
12:58and this is just the graph from
13:00the same paper demonstrating.
13:02That association by sleep staging
13:03so among the group of patients
13:05who went on to have success in
13:07winning from Nid versus those who
13:08had failure and waiting from NIV.
13:10There was no significant difference
13:12in stages and one to N 3 but they did
13:15note that a significant reduction
13:16in the proportion of REM sleep was
13:18associated with an Ivy failure.
13:20So all of these things together to
13:22suggest that perhaps you know the
13:23quality of the sleep that patients
13:25achieve really may be associated
13:26with important clinical outcomes.
13:28In this case related to their ability
13:31to wean from ventilatory support.
13:34This was a study that was done
13:35by Doctor Canal right here
13:37at Yale with some colleagues,
13:38and this is an observation ULL
13:40cohort study that looked to see
13:42what happened in patients who had
13:43loss of end 2 features and how
13:46did that affect their outcomes.
13:47So they looked at 93 making patients
13:49who were undergoing continuous,
13:51EG as part of their plan evaluation in
13:54their Vicky's day and they found that
13:57among patients who had loss of N2 features,
13:59the odds ratio of death was increased.
14:02So in patients who didn't have K complexes,
14:04the odds ratio was.
14:0518.8 and those without sleep
14:07spindles had an odds ratio of 6.3.
14:09It means both reached
14:10statistical significance.
14:11Additionally,
14:12they found that in patients who
14:14had lack of K complex on there,
14:16e.g.,
14:16this was associated with longer
14:18MCU and hospital length of stay.
14:20So these are all really tremendously
14:22important clinical outcomes and
14:23important to acknowledge that
14:25maybe you know the sleep is really
14:26associated or the quality of sleep.
14:28Rather it's really associated
14:30with important clinical outcomes.
14:32So taking a step back now to
14:34frame the problem.
14:34So I've described how sleep and
14:36circadian health in MCU patients
14:38can be very severely disrupted,
14:39and we know now that these
14:41disrupted these disruptions,
14:42rather may be associated
14:44with really adverse outcomes.
14:45So the next question then is
14:47what are the causes of sleep and
14:49circadian disruption and McHugh?
14:50How can we intervene to improve
14:53them and hopefully use that
14:55to optimize patient outcomes?
14:57So I'm going to dive now into
14:58the next part of the talk.
14:59We're going to talk about factors
15:01that disrupt sleep and circadian
15:02health in ICU patients,
15:03and I've divided those for the
15:05purposes of this talk into three
15:07major categories and those
15:08are patient related factors,
15:09environmental factors,
15:10and then factors that are
15:12directly related to acute illness
15:14and critical care treatment.
15:16So the patient factors mainly
15:18fall under 3 realms and those
15:20are psychological distress,
15:21pain and discomfort, and sleep history.
15:24So I'll start by talking
15:26about psychological distress.
15:27So I think this is an area that is
15:29often underappreciated or under
15:31attended to by critical care physicians.
15:34And,
15:34you know,
15:34one thing that I found when I was
15:37putting this talk together was that
15:39a qualitative survey reported that
15:41over 50% of ICU patients actually
15:43endorsed psychological distress as
15:45the most significant sleep disruptor,
15:47and think about that and keep that
15:49in mind as I talk about all of the
15:50other things that disrupt their sleep.
15:52So this is really something that,
15:53from a patient perspective,
15:55is really important.
15:56And some of the psychological
15:57issues that patients experience.
15:58As you can imagine,
16:00are significant health,
16:01worry about their prognosis and also
16:03anxiety and distress related to
16:06upcoming procedures or interventions
16:08that are planned for them.
16:10So various techniques have been tried
16:12to try to treat the psychological distress.
16:15These include complementary medicine
16:17techniques such as acupuncture,
16:19various mind body practices,
16:21relaxation techniques,
16:22even including massage therapy.
16:24There was one paper that reported on.
16:26With past prior to them and music therapy,
16:29which I'll come back to,
16:31there was a systematic review that
16:32showed a trend toward benefit.
16:34Overall with these types of interventions,
16:36but you can imagine these were
16:38quite heterogeneous studies in
16:39populations and so a meta analysis
16:41was really unable to be performed.
16:43I think the take away from here is that
16:45you know there's very low quality of
16:46evidence that this may help patients,
16:48but there's also these are generally
16:50low resource and low risk intervention,
16:53so something to think about
16:55in the right patient.
16:57Music therapy among what I just
16:59spoke about is kind of in the most
17:02reproducibly researched part of this.
17:04There was a systematic review that
17:05looked at 11 studies and they found that
17:08research that music therapy rather was
17:10consistently associated with reduced
17:11anxiety and stress levels in ICU patients,
17:14and one study showed that there
17:16was longer duration of N3,
17:18and in the first two hours of sleep,
17:20although there they found no
17:21difference in the total sleep time
17:23or sleep deficiency overall,
17:24and another study showed that music.
17:26Therapy was associated with their greater
17:28reduction in the bispectral index,
17:30Orbis.
17:30This is a scale that aims to kind of
17:33quantify the degree of patient situation.
17:36Most of the MCU people here may be
17:38familiar with using this to try to
17:40make sure that patients receiving
17:42paralytics are adequately sedated
17:43and the correlation between this
17:45level and sleep characteristics
17:47has not been very well defined,
17:49and I like this picture here to the left.
17:50This is from an Iowa transplant center.
17:52You can see the patient is probably
17:55in the post transplant surgical ICU.
17:57And around him are, you know,
17:59several members of probably the faculty
18:01playing music as he's recovering.
18:04Pre COVID so this is another study
18:06that was done by client at all.
18:08This was an RCT looking at 373
18:11eight patients over 12.
18:13I see they were all mechanically ventilated
18:15and they were randomized to receive
18:17either a patient directed music intervention,
18:20noise cancelling headphones or usual care.
18:23What they found was that the patients
18:25who were randomized to the patient
18:27directed music group had a reduction
18:28in anxiety levels as demonstrated
18:30by the plot on the left here,
18:32which is plotting the visual analog scale.
18:34For anxiety over time during the study,
18:37and that trend was not seen and I'm
18:38in the group with noise cancelling
18:40headphones on the middle plot.
18:41Or in those who received usual
18:43care on the far right.
18:45Similarly,
18:45they found that the patients receiving
18:48patient directed music therapy had a
18:50reduction in the sedation intensity
18:51that they required during their stay,
18:53and whereas that trend was not
18:55observed in patients who received noise
18:57cancelling headphones or usual care.
18:58So just another another study to give
19:01us some thought that perhaps this music
19:04therapy may really be effective in
19:07helping patients.
19:08So moving on now to the pain and
19:10discomfort I wanted to start this
19:12section by just acknowledging
19:13that there is a bidirectional
19:15relationship between pain and sleep,
19:17and that's really important to be aware of.
19:19It's intuitive to us all.
19:21I think that patients who are in a
19:22lot of pain or experiencing discomfort
19:24are going to have a more difficult
19:26time achieving sleep onset and being
19:28able to maintain sleep effectively.
19:30However, it's important to
19:31realize that as well,
19:33patients who have poor sleep quality
19:35or or getting insufficient duration
19:37of sleep may also have an increased.
19:40Perception of pain.
19:40And so these things can go hand in hand
19:43and can feed forward on each other.
19:45So for patients who have pain in the ICU,
19:48oftentimes pharmacologic analgesia
19:50may be necessary,
19:52but there are a lot of very readily
19:54accessible non pharmacologic interventions
19:55that we can think of simple ones even
19:58such as adjusting the patients position,
20:00removing pressure from an injury,
20:02for instance,
20:02I'm using ice and heat packs and then again,
20:05thinking about complementary medicine
20:07such as massage and then remember to
20:09assess and address other causes of
20:11discomfort so these can include just
20:12the patient it needs to use the restroom.
20:14Are they hungry?
20:15Are they thirsty?
20:16Are they nauseous?
20:17Not everything that causes
20:19discomfort is pain.
20:20There was a recent review of 12
20:22studies and they showed that hypnosis,
20:24natural sounds and acupuncture actually
20:26did confirm reduce pain intensity.
20:29Again,
20:29the overall evidence for non
20:31pharmacologic management of pain in this
20:33population provides very low quality data,
20:35but I think it's just worth
20:37reminding ourselves that there are
20:38interventions that are available,
20:39again, mostly low resource and low risk,
20:41and so these are things to
20:43consider to help our patients.
20:44Oftentimes,
20:44as I mentioned.
20:45Pharmacologic analgesia is
20:47necessary given the severity of
20:49illness and the the procedures
20:50these patients are going through.
20:52And then in that case it's it's
20:54recommended to just kind of be
20:56mindful of the choice of analgesic
20:57agent and I'll come back to that a
20:59little bit more later in the talk.
21:02So the last patient factor I want to
21:04talk today about is sleep history.
21:06So sleep history is something that
21:09as now a budding sleep doctor
21:11and and I see doctor,
21:12I think I can say I keep the
21:13two worlds pretty separate.
21:15It's really hard to remember to
21:16think about asking our patients
21:18about their sleep history when
21:19we're in the middle of treating
21:21their critical care illness,
21:22but it's something that can really
21:24go a long ways towards making the
21:26patients have a better experience.
21:27So think about asking their patients
21:29about their habitual food preferences,
21:31how many pillows do they sleep on,
21:32what position?
21:33How dark do they like the room,
21:34etc.
21:35If we're able to accommodate any
21:36of these sleep preferences,
21:38it may make a difference for
21:39patients to have a superior sleep
21:42opportunity and then always remember
21:43to ask patients about their sleep
21:45history. So, do patients have
21:48obstructive sleep apnea?
21:49There was one study that showed
21:51that PAT was only given to 5% of
21:53patients who carried this diagnosis,
21:55and you can imagine we spend all of
21:57our time in clinic trying to tell
21:58patients your sleep quality will really
22:00improve if we if we treat the sleep
22:02disorder and if we just leave that
22:04untreated on when they're in the hospital,
22:05then of course this is
22:06going to contribute to.
22:07Poor quality sleep.
22:08Restless legs is another
22:10common sleep disorder.
22:12It can often go untreated in the
22:13hospital because a lot of times
22:15medications that patients may be
22:16on as an outpatient in our stopped
22:18and then additionally there are
22:19a lot of factors associated with
22:21critical illness that can unmask or
22:23exacerbate restless leg symptoms.
22:25Those include blood loss,
22:26acute iron deficiency,
22:27anemia that goes along with that immobility,
22:30which I'll talk a little bit
22:31more about later in the talk.
22:33The sleep deprivation that we've
22:35been speaking about already and
22:37then a lot of drugs that can.
22:38Provoke these symptoms as well.
22:41And then finally,
22:42there are very kind of readily
22:44available interventions just
22:46to promote patient comfort.
22:47So there was something that was piloted
22:49at Upenn called the Comfy card and more.
22:51Luckily I'm at Stanford,
22:52called a tuck knee and toolkit.
22:54The the picture below is of the Upenn
22:56comfy cart and you can see these are
22:58not high resource interventions.
22:59It's basically just some comfort
23:01measures so some eye masks offering
23:03the patient a cup of tea before bed.
23:06A nice warm blanket.
23:07These things can help to signal
23:08that it's time to sleep and to
23:10promote a sleep opportunity.
23:11For patients in each of these cases,
23:14the patients reported improved sleep
23:16quality and more restful sleep.
23:20So that wraps up what I wanted to
23:22talk about with regard to patient
23:24related factors, disrupting sleep
23:26in circadian rhythm in the ICU.
23:28So I'm going to move on now to talk about
23:31environmental factors that disturb sleep.
23:33So environmental factors are very
23:35very prevalent in the in the ICU,
23:38and anyone who's been up there can
23:41imagine a million things on the top of
23:43your head that you can use to describe
23:45things that might just that might
23:47disturb people sleep when it comes to
23:49noise and the list is pretty long,
23:50staff and patient conversations
23:52are ongoing around the clock.
23:54There's always alarms and
23:56monitors that are beeping.
23:57The TV is off and on very loud.
23:59Whether the patient is able to actually
24:01engage in watching that or not.
24:03Overhead codes are frequently called
24:05and devices make noise on on and off.
24:08Light levels are also very maladaptive.
24:10In the ICU environment I'll
24:12describe this in more detail later,
24:14but the ambient lighting during the
24:15day is often too low to adequately
24:18stimulate the circadian system
24:19and then at night there are still
24:21ongoing sources of bright lights,
24:23which again are inappropriate
24:24in the nocturnal setting,
24:25and those include overhead lights,
24:28TV's,
24:28lights on monitors and lights from the hall,
24:30and then the list of patient
24:32care interactions.
24:33And interruptions for that
24:34is quite long as well.
24:36Patients often need to have
24:37frequent vitals checked or neuro
24:39checks depending on what their.
24:40Therefore they may need
24:42lab tests or imaging test.
24:43They may need emergent procedures and
24:46then even routine tasks like hygiene,
24:48bedding change, etc.
24:50So talking 1st about noise.
24:52So there are actually nocturnal
24:54sound level recommendations from The
24:57Who that sound at night shouldn't
24:58be higher than 40 decibels.
25:00And various observational studies
25:02have shown that medical ICU's usually
25:05missed this mark by quite a bit.
25:08Picture below I found actually when
25:09I was trying to prepare this talk I
25:11was looking for some kind of image
25:12to illustrate noise in the ICU and
25:14came across this which was very
25:15pertinent as it's from our own institution.
25:17But what you can see is that the
25:20average sound level in the ICU is 54
25:22decibels and peaks as high as 80 decibels,
25:24which is the left bluff city traffic.
25:27And so this is a pretty notable observation.
25:29ULL studies have also demonstrated
25:31that noise is thought to be responsible
25:33for about 20% of nocturnal arousals,
25:35so this is a really important 'cause of.
25:38With fragmentation,
25:39I put this in here.
25:41Just this is some quotations from
25:43a survey study that was done just
25:45to remind us again on kind of
25:47an individual level,
25:48what patients and staff are experiencing,
25:50and you can see a patient at the top
25:52says the noise is tremendous up here
25:54at the alarms going off and beeps
25:56going off and then even clinical
25:58staff descriptions of the environment.
26:00They say it's a pretty loud place noise
26:01outside the room is a big problem.
26:03Thousand alarms and noise
26:04inside the room loud.
26:06It's loud, so kind of repeating.
26:08That that theme.
26:10I'm going through the study
26:12done by Doctor Canard again,
26:13and colleagues here at.
26:15You know this is a prospective
26:16observational study looking at
26:18the sound level in 59 Mickey
26:19Rooms and what they found was
26:21that the overnight sound level,
26:23as I mentioned earlier,
26:24was about a 54 DB on the alienated scale,
26:27about 63 decibels on the C weighted scale,
26:30with frequent high peaks.
26:31The difference between the scales
26:33suggests that perhaps low frequency
26:35sounds actually contribute in a
26:37meaningful way to the noise level in the ICU,
26:39and these sounds might be.
26:40Things like the air exchangers for instance,
26:42or just kind of environmental ambient
26:44sounds from the hospital workings.
26:46I mean,
26:46these things may be unavoidable
26:48to certain extent,
26:49and so that's important to
26:51acknowledge and then the two graphs
26:52here on the bottom show individual
26:54sound profiles of patient rooms,
26:56and they're pretty different.
26:57It's interesting to note that
26:59in the one on the left panel,
27:00see here,
27:01you can see that the average
27:02sound level is still above what we
27:04would consider to be appropriate
27:06for nocturnal sound level,
27:07but more notable,
27:08it also has several high peaks.
27:11Throughout the recording time,
27:12whereas on the right and we see
27:14this room has a relatively more
27:16stable sound level with fewer peaks,
27:18but the sound is at a higher level,
27:20so the profiles range quite a bit.
27:24This isn't this is a PSG clip
27:27from Friedman's observation,
27:28ULL study and I like this clip because
27:30it shows us just an exact demonstration
27:32of what happens with the noise.
27:33So we see that there's a spiking noise,
27:36and sure enough the patient hasn't
27:38arousal correctly after this happens.
27:40On a larger scale,
27:41this study looked to kind of try
27:44to estimate what is that actual
27:46impact of noise on sleep disruption.
27:48This was a study that did 24 hour PSD's
27:51on patients in various conditions
27:52in the data on the slide is from
27:55mechanically ventilated patients.
27:56In the ICU you can see that in
27:58various forms of trying to quantify
28:00the sound related arousals they
28:02were very prominent and overall
28:04they estimated that about 21% of
28:07arousals were related to noise.
28:10So now that I've described noise in the ICU,
28:12I'm going to move on to describe light.
28:14This is a study that looked at light
28:16exposure and making rooms depending on
28:18which direction they were facing and
28:20they were trying to determine whether
28:22the light profile in the room had any
28:24association with patient outcomes.
28:25They weren't able to demonstrate any
28:27association with clinical outcomes,
28:29but I think the observational data
28:31is very striking and interesting.
28:33What they found was that in the rooms
28:35that were facing every direction
28:37except from South, on average,
28:38the amount of lux.
28:39Rooms received was well under 100
28:41lux during the day and in those
28:43in the South facing direction,
28:45about 400 lux and just to put
28:47this into context,
28:48it's thought that about 180 bucks
28:51is the minimum threshold to
28:53achieve a biologic effect.
28:54There is one set of guidelines that
28:57suggested that 500 to 1000 Lux should
28:59be kind of the target goal for daytime
29:01light exposure and ICU patient rooms,
29:04and then putting this into context and
29:06more kind of regular outdoor exposures.
29:091000 lux is about what we would expect to
29:11be exposed to 100 overcast day outside.
29:13Whereas 32,230 Lux represents the
29:16exposure from direct sunlight,
29:18and when we're thinking about
29:20prescribing therapeutic light
29:21exposure for our patients,
29:22this is usually in the range of
29:24around 10,000 bucks.
29:25So to say that these rooms are
29:27experiencing under under 100 lux
29:28through the course of the day is
29:30really very very dim light.
29:34This was a study that looked at
29:36an environmental or survey of
29:38environmental factors before and after
29:41a quality improvement intervention.
29:43They looked at various conditions at morning,
29:45noon and night, and you can see that
29:47they're kind of many conditions that
29:49are are kind of maladaptive Lee
29:51applied throughout the day and night.
29:53What I wanted to highlight here is
29:55that over 990 I see patient nights.
29:57There were no lights on in the morning.
29:59Almost half of the time,
30:00and this is important to think
30:02about as light in the morning as an
30:04important circadian stimulus.
30:05To help with entrainment
30:06of the central clock,
30:08whereas bright lights were on in over 1/5
30:10of the rooms in the middle of the night,
30:12which is obvious.
30:14Obviously a circadian disadvantage.
30:17And then now I'm moving on
30:19to patient care interactions,
30:20so another common environmental
30:22cause of sleep disruption.
30:24So this was an observation.
30:25ULL study that looked at 147
30:28ICU patient nights and this was
30:30across different kinds of ICU,
30:31so they had patients in medical,
30:33surgical, cardiac and Neuro ICU's.
30:36And what they found as you can see
30:38here on this histogram is that from
30:407:00 PM to 7:00 AM patients had
30:42awakenings all throughout the night.
30:44On average about 43 care interactions
30:46during the nocturnal.
30:47Time and they reported that of
30:50the nights they observed,
30:51only 6% of them provided patients with
30:54two to three hours of uninterrupted sleep,
30:57so that's pretty pretty horrible to imagine.
31:02I put this graphic here just
31:03to demonstrate that of course,
31:04when we think about taking care
31:05of our critically ill patients,
31:07we think about all the time sensitive tasks.
31:09But plenty of these interruptions are
31:10for tasks that are not time sensitive.
31:13These are episodes of our percentages
31:15rather of patients being bathed overnight,
31:18and you can see that there is a
31:19spike in patients being beings
31:21at four or five and 6:00 AM,
31:22which you can imagine it would be very
31:24disruptive to their sleep opportunity.
31:26I suspect,
31:27although this is based on no data,
31:29that this is probably related to the
31:31nighttime nurses trying to make sure that.
31:33They kind of accomplish this task
31:34before the date time nurses come on.
31:36Have a an often very busy docket of
31:38task to complete for the patient and
31:40so I see why this would make sense
31:42from a nursing workflow standpoint.
31:44But again, for the patient,
31:45sleep opportunities can be very disruptive.
31:48So now that we understand about
31:50some of the object,
31:51the environmental components that lead
31:53to sleep and circadian disruption,
31:56the noise, the light and the patient care,
31:58interruptions.
31:58All of these things together lend
32:01themselves to multicomponent sleep
32:03improvement interventions and these
32:04quiet time protocols have major aims
32:06of trying to reduce or mitigate all
32:08of the factors that I just mentioned.
32:11So they try to focus on educating
32:13people to reduce visitor and
32:15staff talking and to cut down on
32:17overhead announcements during.
32:18The sleep time they aim to
32:20minimize equipment beeps and
32:22nuisance alarms to focus on closing
32:24patient room doors so that hallway
32:26noises and light are not spilling in.
32:28I'm having the lights out when
32:29it's a dedicated sleep time and
32:31then clustering patient care,
32:32so of course they're going to be
32:34time sensitive and urgent tasks that
32:35occur in critically ill patients.
32:37But for those non urgent tasks
32:39they should be scheduled outside of
32:40the protected sleep time and for
32:42tasks that are more time sensitive.
32:44If possible, to consolidate these
32:45together so that there are fewer
32:47interruptions for the patients.
32:48Date. So this is a slide.
32:52This is a figure out are from one of
32:54Doctor Kinards paper for nap time
32:56protocol and these are just various
32:57elements and I put this up here.
32:59I'm not because I'm gonna read
33:01you every bullet point,
33:01but just to demonstrate that often
33:03these protocols can be very well
33:05thought out and involved quite a bit
33:07of different elements and those can
33:09range from the institutional level all
33:10the way down to the direct bedside care.
33:14So this is going back to
33:16that Altman paper again.
33:17The quality improvement intervention and
33:19they did show that on their environmental
33:21survey there was a significant change
33:23in conditions before and answer their
33:26quality improvement intervention.
33:27So what the graphs are showing here is
33:29conditions in the morning in the yellow bars,
33:31noon in the orange bars and
33:33at night in the blue bars.
33:34The conditions that baseline are
33:36represented by the solid bars and
33:38those after the intervention are
33:40represented by the strike bars.
33:41One thing they found was that with
33:43their quality improvement intervention.
33:45A higher proportion of patients
33:46had no lights on at night,
33:48which is a beneficial outcome,
33:50and then similarly they found that doors
33:52and windows shades were more likely to
33:55be open during the daytime at noon,
33:56and more likely to be closed
33:58and protect patients from extra
33:59light pouring in at night.
34:01So these things all kind of show
34:03that a quality improvement or
34:04multicomponent intervention can
34:06really help to promote a more
34:09favorable environment for patients to
34:11achieve a better sleep opportunity.
34:14And this was another study done by
34:16Doctor Canard and colleagues here.
34:18This was a study looking at 56 MCU
34:20patients and they tried to dedicate
34:23from midnight to 4:00 AM as a a rest
34:25time or a nap time for patients,
34:27during which, as I mentioned earlier,
34:29the focus was on keeping the
34:31environment more favorable for sleep.
34:33So again, routine care, medications,
34:36diagnostic tests should be scheduled before,
34:37after and time sensitive test clustered.
34:40What these pictures are showing.
34:42And I apologize for the letters
34:43being out of order.
34:43They're sliced from different figures.
34:46But on the left side of each
34:48is baseline conditions.
34:49The squares are the people who
34:51were randomized to usual care and
34:53the circles are those who are
34:55randomized to receive the naptime
34:57intervention and the closed boxes
35:00are before the intervention.
35:01The open boxes are after the intervention.
35:04What they found was that with the
35:06with the intervention,
35:07they were able to achieve a better.
35:12Reduction in minutes of activity.
35:14I'm sorry in their room per hour
35:17and they also were able to achieve
35:19increased rest time for the
35:20patients as well as the reduction
35:22in the main level and moving.
35:26So multicomponent sleep
35:28improvement interventions have been
35:30investigated by various groups.
35:33Overall, they have been mostly
35:35shown to be effective in reducing
35:38environmental disturbances.
35:40They've been described to show
35:42a decrease in noise levels
35:44as well as in some studies.
35:46Reduction in sound and
35:47light levels overnight,
35:48with one study reporting and increased
35:51likelihood of patients sleep and that
35:53was as described by nursing observations.
35:55And then again in Doctor Kennard study,
35:58they reduced in room activity by 9
36:00minutes per hour and increased rest
36:02time between care from 26 to 46 minutes.
36:05However, these protocols are
36:06not always effective,
36:07and some of the studies looking at
36:09these have failed to show benefit.
36:13One thing in particular that's
36:15been difficult is to demonstrate
36:17improvement in sleep specific outcomes.
36:20So there was a multi multi component
36:23protocol recently that looked at
36:25environmental control and air plugs.
36:27They found increased
36:28delirium and coma free days,
36:30but were unable to demonstrate sleep changes.
36:33Similarly, a multicomponent intervention
36:35in surgical ICU's showed a significant
36:37reduction in the proportion of
36:39days with delirium, but again,
36:41no change in patient reported perceived.
36:43Like quality?
36:46So within the multicomponent interventions,
36:49I wanted to focus a little bit more
36:52specifically on noise and light mitigation.
36:54So earplugs and noise cancelling
36:56headphones are generally thought to
36:58be feasible and well tolerated and
37:00provide patients with an average
37:02sound abatement of about 10 decibels.
37:04There's this one study which I
37:05thought was kind of creative.
37:07They tried to see what effect noise
37:09cancelling headphones would have,
37:10and they use 3 polystyrene head models that
37:13they put on a shelf next to each other,
37:15and what they found they did one where
37:18they just monitored the sound one where
37:20they put on the headphones but didn't
37:22actually turn them on, and then one.
37:24But they had the headphones applied
37:26and turn them on.
37:27And as we would expect,
37:29they did find that compared to control
37:31circumstances and the noise cancelling
37:33headphones on were able to significantly
37:35reduce the sound level and again,
37:37keep in mind that 40 decibels is the goal.
37:39So we're still kind of over that goal.
37:43And they've also been randomized
37:45controlled trials looking at ear
37:46plugs and eye masks together.
37:48What they have found is an increase in M3
37:50and decrease in prolonged weight means
37:52when the earplugs actually remained in place.
37:54Although about 30% of patients
37:56did decline to use the earplugs.
37:58They also noted that earplugs,
38:00andorai,
38:01masks were associated with increased
38:03end two and three and REM stage sleep,
38:05so these are favorable outcomes and
38:08there have also been meta analysis to
38:10suggest that ear plugs and eye masks
38:12may be associated with increased
38:14total sleep time and reduce delirium.
38:16And this is just again a meta analysis
38:19looking at 13 studies and they found
38:21a sleep quality was in fact improved
38:23with use of earplugs or IMAX.
38:28So now I'm going to move on to
38:30talk a little bit about light
38:32interventions in a circadian sense.
38:33So I mentioned earlier that the
38:35light environment in the ICU,
38:36the ambient blaze,
38:37often quite low during the day and this
38:40can lead to lack of circadian entrainment.
38:42What we like to see is that the people
38:45should have kind of exposure to bright
38:47light with a high focus on the blue
38:49light spectrum early in the morning,
38:51and that helps to stimulate melanopsin,
38:53which then entrains this the
38:55suprachiasmatic nucleus which.
38:57Is where the central peripheral,
38:58the central circadian clock lives.
39:01But in order to get an infected light
39:04exposure and light intervention,
39:05we need to be mindful of many aspects
39:07of the light exposure itself,
39:09and that includes the duration,
39:10the intensity,
39:11the spectral composition
39:13of the light exposure.
39:15So again,
39:15what these light interventions are aiming
39:17to do is kind of mimic the normal,
39:19diurnal, bright daytime light exposure.
39:23And so they found a couple of
39:25studies have looked at such
39:27types of cycle lighting or bright
39:29daytime light interventions.
39:30They found overall patient satisfaction
39:33is improved with a superior sleep quality.
39:37A couple of small groups of
39:40patients demonstrated earlier
39:41postoperative mobility as well as
39:44reduced postoperative delirium.
39:45There was one pilot randomized
39:47controlled trial looking at times
39:49like intervention and critically ill
39:51adults with delayed circadian phase.
39:53What they found was that in the
39:55intervention group at Study day three,
39:57there was a 3.6 hour correction
39:59of that delay,
40:00so they had been able to use their
40:02light intervention to advance the
40:04circadian phase by almost 4 hours,
40:06whereas in the control group
40:07at the same period of time,
40:09the patients who are not exposed to the
40:11bright light continued to experience
40:13circadian delay by an additional 2.4 hours.
40:15Over those three study days.
40:17So this is a pretty robust
40:19and impressive response.
40:20Other studies of light interventions,
40:22however,
40:22have failed to show benefit.
40:24Some of the reasons why it's hard to know.
40:26Is it because the intervention
40:28itself is unsuccessful?
40:29Or is it because the intervention
40:31design was such that it didn't
40:33have a possibility of affecting the
40:35outcome that was being measured?
40:37So some of the things that have been
40:39cited are concerned that perhaps
40:41the control groups experienced
40:42the highlight exposure and that
40:44precluded inability to appreciate
40:45the effect of the intervention.
40:46Or perhaps the light that was applied
40:50was had an ineffective duration or
40:52timing the intensity wasn't appropriate,
40:54or the Spectra of light exposure wasn't
40:56appropriate to stimulate the melanopsin.
41:00So put this up as a teaser.
41:02This is called a Phillips vital sky.
41:04It's sort of us around ceiling and
41:08front wall light that can kind of
41:11provide ambient lighting can provide
41:13different spectrum of light along
41:14different angles of gays and this
41:16is something that doctor Canard
41:18is looking into trying to get as
41:19part of her future circadian study.
41:21So this may be coming to a Mickey
41:24room near you soon.
41:25Alright, so that wraps up my section
41:28on environmental disturbances of
41:29sleep in circadian rhythm in the ICU.
41:31So now I'm going to move on to
41:33our final category of sleep.
41:34Disruptors, switches,
41:35factors that are directly attributable to
41:38acute illness and critical care treatment.
41:41So as you, as you all know,
41:43anyone who's critically ill has a
41:45tremendous amount of physiologic change.
41:47And often these changes can directly
41:49impact sleep and circadian health.
41:51Oftentimes,
41:51these patients are on life
41:54sustaining therapy,
41:54and often these are quite invasive.
41:57These may involve mechanical ventilation,
41:59invasive monitoring, such as arterial lines,
42:02and various medical support devices.
42:04Sedation is often a common
42:06thing seen in patients,
42:07and I'll talk more about that as well as
42:09continuous enteral nutrition and immobility,
42:11all of which are disadvantageous.
42:13For sleep and circadian health.
42:16So mechanical ventilation.
42:17The relationship between that
42:19and sleep is quite complex.
42:21I'm just gonna touch on it briefly.
42:22For purposes of this talk today.
42:25But basically there's a very complex
42:28interplay between respiratory Physiology,
42:30work of breathing,
42:31the patient ventilator interface,
42:32and all of these things lining up
42:34to actually improve a patient sleep
42:36opportunity rather than detract from it.
42:38There have been studies to suggest
42:40that ventilator support may actually
42:42improve sleep via improving work
42:43of breeding in certain populations,
42:46and those specifically our patients with
42:48acute on chronic respiratory failure.
42:49For those who are undergoing
42:51prolonged ventilator weaning,
42:52and in these patient populations those
42:55who receive mechanical ventilation tended
42:57to have an increased sleep efficiency
42:59and as a longer total sleep time.
43:01However,
43:02as you can imagine,
43:03ventilator desynchrony or alarms can
43:05obviously be disruptive to sleep opportunity.
43:09So I really like this figure
43:10on this came out of the paper
43:12cited on the bottom corner here.
43:14This basically kind of illustrates
43:15the fact that we're really looking
43:17for the sweet spot on when we when
43:19it comes to optimizing ventilator
43:21settings for these patients,
43:22and so you can imagine a patient
43:24who has a serious respiratory or
43:26neuromuscular disease if we provide
43:28under assistance on the ventilator,
43:30they're going to have increased
43:31work of reading.
43:31Their vent is going to be
43:32alarming all the time.
43:33That's clearly going to disrupt
43:35their sleep opportunity.
43:36However we can swing too far
43:38in the opposite direction.
43:39And if we provide over assistance,
43:41then what can happen?
43:42Is the patient actually has hyperventilation.
43:44They become hypercapnic and this can
43:46lead to central apneas or periodic
43:48breathing patterns that can also be
43:50disruptive to sleep opportunity.
43:52So really what we're looking
43:53for is to try to
43:55improve the pet patient ventilator
43:57interface as much as possible,
43:58and you know there are many more kind of
44:00more detailed discussions about this,
44:02but I'm going to leave our
44:04discussion at that for now.
44:06So moving on to sedation.
44:08So sedating medications are often required
44:11or implemented in caring for ICU patients.
44:14I'm various papers have have
44:17investigated the effect of sedating
44:19medications on sleep architecture,
44:21and there's good evidence to support
44:23the fact that narcotics and benzo
44:25suppress REM and stage N 3 sleep on
44:27both there which are thought to be
44:29the most restorative aspects of sleep.
44:31Propofol is also known to suppress REM,
44:34whereas on the flipside,
44:36Dexmedetomidine.
44:37Press it X actually has been shown
44:39to increase sleep efficiency
44:40and reduce fragmentation,
44:41so this might be something to consider.
44:44We also know that benzos and opiates
44:46can increase the risk of delirium
44:47and so just be mindful and thinking
44:49about which sedating medications to
44:51choose for patients and when possible,
44:53always try to minimize the dosage and
44:56use intermittent dosing over continuous
44:58drips if that's a possibility.
45:00This is just the top half of the
45:02picture from the the ICU delirium trial.
45:05This just goes to show that guidelines.
45:07Do recommend doing Protocolized
45:10spontaneous awakening trials.
45:11In this table.
45:12They're kind of combining spontaneous
45:14awakening trials and spontaneous
45:16breathing trials,
45:16which I'm not going to discuss today,
45:19but I wanted to just briefly mention
45:21that spontaneous awakening trials
45:22should only happen in patients
45:24and whom it's safe to do so.
45:26So of course we want to do
45:27the safety screen first.
45:28Make sure the patient is not on.
45:29Paralytics, for instance,
45:31are undergoing alcohol withdrawal
45:32and then they have their their
45:35sedation interrupted and then we
45:36monitor them very closely for any
45:39signs of clinical deterioration.
45:40If they do fail their spontaneous awakening,
45:42trial recommendations are to
45:44research sedatives at half the dose,
45:46so there's still kind of a built-in
45:48assessment to try to really make sure
45:50that patients are were reducing the sedation.
45:52So we kind of achieve just the minimum
45:55that they need to be comfortable and safe.
45:59So moving on now to continue
46:01his enteral nutrition.
46:02I'm sure a lot of you have heard
46:04me talk about this before.
46:06We know that nutrition schedule
46:07can be very influential,
46:09as at Gabor for peripheral clocks
46:11and what that means is that the
46:13scheduling which nutrients are
46:14provided can actually help to entrain
46:16the peripheral circadian clocks,
46:18particularly in the gut and liver.
46:21And you can imagine that continuous
46:23feeding over 24 hours is not very
46:25advantageous from a circadian perspective.
46:27It's not how most of us normally would.
46:29And this can lead to internal
46:31circadian desynchrony,
46:32which is a misalignment between the
46:34central and peripheral circadian clocks.
46:36So there was an icy pilot
46:38done by Van ****** group.
46:39They looked at a 12 hour enteral
46:42nutrition interruption to try
46:43to do some macronutrient fast,
46:45and they found that this did
46:47result in arresting or sorry in
46:49a metabolic faxing response.
46:50Our own IC pilot that we did here at
46:52Yale did show that I'm restricted
46:55and intermittent and grill nutrition
46:57pilot was safe and feasible.
46:59And we do have an ongoing randomized
47:01control trial at Yale in SRC trying
47:03to evaluate the safety and efficacy
47:06of this project and this protocol
47:08and also the circadian effects.
47:09So just as far as a further
47:12definition of the feeding schedule,
47:14continuous feeding is constant rate of
47:17enteral nutrition over 24 hours per day.
47:19Cyclic feeding is a constant rate
47:21for less than 24 hours per day
47:23and then intermittent bolus feeds
47:25involved in providing the feeds
47:27over a shorter duration of time.
47:29And there's thought that that may
47:30be advantageous from a metabolic in
47:32neurohormonal perspective and then
47:33the time restriction is providing
47:35a prolonged period of fasting,
47:37ideally to be aligned with the
47:39nocturnal time period.
47:40And that's not to be the most
47:41important piece in helping to
47:43promote circadian alignment.
47:44And so our protocol tries
47:45to combine aspects of both.
47:49So shifting gears now to discuss
47:51immobility so anyone who's cared for ICU
47:54patients knows that it's very common for
47:57them to have multifactorial immobility.
47:59They're severely ill.
48:00I'm often times this may be complicated
48:03by critical care myopathy or other
48:06neuromuscular disease, and in addition,
48:08there are many physical barriers
48:09imposed by the support devices,
48:11so lines, tubes, etc.
48:12There were studies to show
48:14that even in healthy subjects,
48:16being on bed rest in a period of.
48:18In mobility,
48:19and especially if they were in hypoxia,
48:22hypoxic conditions could cause
48:24respiratory instability during sleep and
48:26a higher proportion of stage one sleep,
48:29which is light and less restorative sleep.
48:31So you can imagine if this was
48:33seen in healthy subjects.
48:34It's probably even more profound
48:36of an effect in ICU patients.
48:38We also know that daytime exercise
48:41maintains circadian alignment
48:42and increases nocturnal sleep,
48:44and so these things together leads in
48:46part to the push for early mobility.
48:49And there was an A trial looking
48:51at early mobility along with the
48:53Sleep Promotion Bundle and they
48:55found reduced incidence of delirium
48:57and continuous sedation needs.
48:58However,
48:59no change was detected in patient
49:02perception of sleep quality.
49:04And I put the slide up just
49:05to kind of show how,
49:07how related sleep and circadian health
49:09is to other aspects of the ABCDEF bundle,
49:12which is thought to be a kind of
49:14a standard of care and a really
49:15great way to practice medicine.
49:17To promote good patient outcomes in the ICU.
49:20So for a we've already talked
49:22about managing patients pain,
49:23we've talked about spontaneous
49:25awakening trials and being
49:26mindful for choices of sedation.
49:28Delirium has been tide into outcomes
49:30for a lot of the studies I've spoken
49:32about and is thought to be highly
49:33related to sleep and circadian health.
49:35And then early mobility
49:36we're talking about now.
49:37And I like this picture too,
49:38because this shows this woman
49:40who she's clearly I'm still
49:42very much requiring support.
49:43She has a tracheostomy and event later,
49:45she has an Ng tube.
49:46She has various forms of Ivs and a Foley,
49:49and she's still able to get
49:50out of bed and walk around.
49:51And this is something that I think we
49:53should be striving towards more in our ICU.
49:58So I hope with that you all have
49:59a better understanding of patient
50:01environmental and acute illness and
50:03treatment related factors that can
50:05disrupt sleep and circadian health and
50:07our patients and have some ideas of how
50:10we can optimize this moving forward.
50:13Just to summarize,
50:14some of the practice recommendations
50:15we can think about paying attention to
50:17psychological distress and pain and
50:19discomfort and using non pharmacologic
50:21methods to manage these as best as we can.
50:23We can make sure that we attend to
50:25underlying sleep disorders and habitual
50:27sleep preferences as part of our.
50:29Care for our patients?
50:30Be on the lookout for multicomponent
50:33sleep promotion bundles which aim to
50:35reduce stimuli as well as perception of
50:37environmental disturbances such as noise,
50:40light and interruptions for patient care.
50:42And then another exciting area.
50:44Future research is finding out more
50:46about how chronotropic bright light or
50:48time restricted and your own nutrition
50:50protocols may be able to help promote
50:53circadian alignment in our patients.
50:54And then finally when we think about aspects
50:57of the patient care that are at regeneca.
51:00Make sure to optimize the
51:01patient ventilator interface,
51:02avoiding over support as well
51:04as under support.
51:06Minimize sedation and be mindful
51:07of the choice of sedation that you
51:10pick for the patient and then have
51:12protocolized spontaneous awakening
51:13trials to try to minimize that
51:15regularly and then promoting early
51:17mobility may be really helpful too.
51:20I and ending this talk.
51:22I just wanted to touch briefly on future
51:24directions for research in this field.
51:26I'm so you may have noticed as I went
51:28through the talk and presented a lot
51:30of different studies that there's sort
51:33of one one really central lacking feature,
51:35which is a precise definition of what
51:37actually is sleep deficiency or circadian
51:40misalignment among these ICU patients.
51:42And I think it's really important
51:44that we work together to define
51:46a reliable and feasible metric
51:48to define sleep and circadian.
51:50Outcomes and this is going to be really
51:52important for testing these sleep
51:54promotion and circadian alignment
51:56interventions moving forward so that
51:58they can be validated and tested
51:59in or reproducible way.
52:01This is likely to involve
52:03subjective measures,
52:04so patient reported symptom scales,
52:06for instance,
52:06to get a sense of patient perception
52:08of sleep and then also objective
52:10sleep and circadian parameters in
52:12the past from a sneak side of things,
52:14these have involved a lot of PSG,
52:17which has been pretty bulky and
52:18that can have a pretty big.
52:20Barrier for both patient and staff
52:22involvement and there are kind of
52:24new creative thinking about how to
52:26perhaps involve smaller or easier to
52:28apply EEG leads to to get a better
52:30sense and an easier way of what sleep
52:33might look like in these patients.
52:34And then circadian parameter is
52:36historically the gold standard for
52:38that was measurements of melatonin or
52:41a surrogate urinary melatonin metabolite.
52:43But in order to get us the definition
52:44of a circadian phase,
52:46these measurements have to be taken.
52:48You know, every hour,
52:49ideally or very frequently,
52:50and that can be.
52:51Labor intensive as well,
52:53and so one thing that's kind of up
52:55and coming that our lab talks about a lot,
52:57is the advent of genomics,
52:59metabolomics and other omics that
53:01may help to kind of have one or
53:03two lab tests that can give the
53:05circadian profile for patients.
53:07And so these are still being
53:09validated but may again make
53:10things a little bit less resource
53:12intensive or more accessible and
53:15then important to always remember
53:16thinking about our critical care
53:17patient outcomes that we want to
53:19know how these interventions actually
53:20affect the overall patient outcomes.
53:22With things like delirium,
53:23length of stay,
53:24mortality and then an interesting
53:25thing to think about is that as
53:28implementation science advances,
53:30this may lead to better ability to
53:32create and sustain multicomponent
53:34interventions,
53:35which I think is going to be
53:36an important future direction
53:37for this part of the field.
53:41So just in summary, we've talked a
53:43lot about how sleep and circadian
53:45health is disrupted in ICU patients
53:47due to the factors that we discussed.
53:50I mentioned that these are important
53:51to think about because they're
53:53associated with poor clinical
53:55outcomes and poor patient experience,
53:57and there are a lot of non pharmacologic
53:59interventions to think about that
54:00can be useful to optimize sleep and
54:02circadian health and our patients.
54:04And we talked about how future research
54:06in this field will change moving forward,
54:08hopefully with better definitions
54:10of outcomes.
54:11And advances in implementation science.
54:14So with that I will open up to questions
54:17I wanted to say thank you so much to
54:20my lab members and I work closely with
54:23Taylor and Darren Veronica salmon.
54:25They're both postdocs or postgrads,
54:27rather and then Doctor Canaller,
54:30who's been an amazing mentor in
54:32both personally and professionally
54:33for me over the past few years,
54:35and I'm so lucky to have had the
54:37chance to work with all of you.
54:42Thank you Amy. That was a turtle forest
54:45and really interesting to listen to.
54:49As Janet noted, you all can put questions
54:51in the chat or you can at this point,
54:53unmute yourself and ask questions directly.
54:56I think as folks get ready to do that all
55:00ask you know you highlighted a lot of the
55:03complexity of what's going on in the field,
55:04and I know you and I have talked
55:06about this now for three years,
55:08but if folks are gonna walk away
55:09today with one like one thing they
55:11could do for sleep in the ICU,
55:13what would you tell him to do?
55:15That's a great question. I think.
55:17I think the most important thing to
55:19do is to just a lot of this is is.
55:22Easily accessible with common sense and
55:24I think just keep sleeping circadian
55:26health on your radar when you're
55:28taking care of ICU patients because
55:30there is so much that's really minimal
55:32interventions that are easy things
55:33to pick off and help patients with.
55:35If you're walking by the room at night
55:37and you see the TV is on or the hall
55:39door is open and the lights are on,
55:40these are all little adjustments
55:42that you can make to help promote
55:44this patient sleep opportunity
55:45or have more favorable circadian
55:46environment for the patients.
55:48I think on an individual level to
55:51think about implementing a unit.
55:53Wide naptime protocol that's going to be
55:55something that's more resource intensive,
55:57but for all of us,
55:58there are very readily accessible
56:00interventions that we can do
56:02ourselves to help the patients
56:03have a superior sleep opportunity.
56:05And I think as a critical care doctor and
56:08a sleep doctor looking at all of this,
56:10I've really become a lot more introspective
56:12of my own practices and thinking about
56:14what are all these awful things that I,
56:15you know,
56:16that I that I do to patients that
56:18are not necessary that really
56:19disrupted their opportunity for
56:21sleep overnight and how necessary is.
56:23That blood draw at,
56:24you know,
56:244:00 AM,
56:25and sometimes it is really necessary and
56:26we really have to get the procedures
56:28done and get the testing done.
56:30And you know that's important.
56:32But there are plenty of times
56:33where they're easy changes that
56:34we can make if we just are mindful
56:36of the fact that our patients are
56:37humans who like to sleep too.
56:44Thank you and then Janet has a.
56:47A question in the chat.
56:50Also interesting idea are
56:51there are ways that we can be
56:53systematic in optimizing sleep?
56:54For example protocols and epic, etc.
56:58Yeah, so that's a very
57:00that is very interesting.
57:01I think that's something and doctor Karen.
57:02I don't know if you want
57:03to speak more to this.
57:04I don't mean to put words in your mouth,
57:05but I think that's something that Doctor
57:07Kennard has thought about in particular,
57:09like with ordering practices and defaults.
57:11So there are meds that are ordered Q 8
57:13that don't really or Q6 for instance,
57:15that the timing of administration just
57:17goes right from when you enter the
57:19medication instead of defaulting to
57:21a schedule and that for instance may
57:23result in the patient being disrupted
57:25at odd hours just to get a medication
57:27that may not necessarily have.
57:28Can be given at a time sensitive interval
57:32or at a specific time around the clock,
57:35so I think that's one area that I
57:37thought was a really interesting idea
57:39to try to leverage Epic and just make
57:42the defaults more more kind of mindful
57:44of sleep and circadian considerations.
57:45And then I wonder from an environmental,
57:48you know management perspective,
57:50would there be a way that you know
57:52the unit lights or the patient room
57:54lights could kind of default to
57:55turning off at like a certain time
57:57and the IT would have to be kind of
57:58an opt in to turn them on instead of.
58:00Just leaving them on until someone
58:02flips the switch and I think things
58:04like that would be interesting.
58:05I'm sure there's a really long
58:06list of you know others would sit
58:07down and think about it too.
58:13Very nice talk Amy. Thank you.
58:14I'm just going to talk instead
58:16of putting in this chat.
58:19You know the question for you
58:20guys who do this kind of work is
58:23it? Is it the duration of
58:25rest time that's important?
58:26Is it actually sleep?
58:28And what is sleep in ICU? And.
58:31Yeah, you can address that.
58:33Yeah, that's a great question.
58:34Last 60 seconds that yeah, yeah,
58:36so doctor allowed me to invite me
58:39to participate with an ATS workshop
58:41that was focused on some of these
58:43areas and one it was a privilege
58:45for me to get to hear all of these.
58:46Like very senior experienced people
58:48talk about these questions and the
58:50question you asked came up quite
58:51a bit like what actually is the
58:53definition of sleep in ICU patients.
58:54It's actually an interesting
58:56question because you know,
58:57typically we don't think of really being
59:00able to apply those same ichd criteria.
59:02The patients who are critically ill for
59:03some of the reasons that I alluded to,
59:05so there are a lot of kind of background
59:07EEG changes that these patients may
59:09experience in the setting of their
59:11critical illness and self allopathy etc.
59:13So I think that's one of the areas
59:15that's kind of actively on the
59:17docket for further clarification
59:19is getting a better definition of
59:21what actually sleep in ICU should
59:22be defined as and what that entails,
59:24so I don't have a great answer except
59:26to say that I think a lot of great
59:28minds are wondering the same thing as you.
59:29And then you know what is the the important
59:32factor here, whether it's through.
59:34Restoration of sleep.
59:35I think these are all questions that
59:37are difficult to actually answer
59:38until we kind of clarify what the
59:41definition of sleep actually is.
59:42But these are all some of the the
59:44questions that I think are going to
59:46be important to clarify with this
59:47research moving forward and how do we
59:49actually determine you know what is
59:51beneficial and what the outcomes are,
59:52and I think the research in this
59:55area has struggled a little bit to
59:57define those outcomes measures and
59:59that's 11 area that the workshop group
01:00:01identified as an important focus for future.
01:00:08All right, thank you everyone for coming.
01:00:09Thank you Amy for a great talk.
01:00:12It was just a pleasure to hear
01:00:13all this take care. Everyone.
01:00:15Thank you. Thanks everyone.
01:00:17Thanks Amy. Triple talk.