- Email: [email protected]
Music Improves Patient Comfort Level During Outpatient Bronchoscopy
Music Improves Patient Comfort Level During Outpatient Bronchoscopy* james M. Dubois, MHA, RRT; Thaddeus Bartter, MD, FCCP; and Melvin R. Pratter, MD, FCCP Study objective: To determine the effect of music during bronchoscopy on patient perception of the procedure. Design: Prospective randomized trial. Setting: University-based bronchoscopy suite. Patients: Twenty-one patients received music (M + ), and 28 patients served as controls (M-). Measurements and results: Physiologic responses, subjective patient perceptions, and administered medications were monitored. After the procedure, the technician and the physician both rated their impression of the patients' comfort levels to see how accurately they correlated with actual patient reports. There was no difference in physiologic responses between theM+ and M- groups. The M+ patients reported significantly
with outpatient procedures, there is a need to make patients as comfortable as possible with as little anesthesia as possible to ensure rapid postprocedure recovery and timely hospital discharge. Several studies have suggested that the use of music may favorably alter patient perception and may increase patient comfort for any given level of pharmacologic sedation. 1-5 We undertook a prospective randomized trial of the use of music in the outpatient bronchoscopy suite. METHODS
Subjects From May 15, 1991, to May 15, 1993, we prospectively enrolled all outpatients coming in for bronchoscopy who understood English well enough to be able to understand choices. Patients were randomized by medical record number; those whose last number was odd were given the option to listen to music, while those whose last digit was even were not. The patients assigned to listen to music listened to new wave music, "Reflections of Passion" by Yanni played through headphones by a portable compact disc player (Sony Walkman). The equipment was inexpensive; the player cost $119, and the compact disc cost $14.99. Music was started before beginning bronchoscopy and stopped after the procedure was over.
Data Collection Physiologic parameters monitored included heart rate, blood pressure, and oxygen saturation before and during bronchoscopy. The amount and type of sedation used was also documented, as *From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cooper Hospital/University Medical Center, UMDNJ / Robert Wood Johnson School of Medicine at Camden, Camcfen, NJ. Manuscript received August 17, 1994; revision accepted October 12.
greater comfort (p=0.02) and less cough (p=0.03) than theM-group, while there was no difference in reported dyspnea P=0.21). Both physicians and technicians were very inaccurate in their assessments of patient level of comfort. Medications given did not differ for the two groups. Conclusion: Music during bronchoscopy is a simple and inexpensive nonpharmacologic way to improve patient comfort. (CHEST 1995; 108:129-30) M+=received music; M-=did not receive music, or control
Key words: bronchoscopy; music; patient comfort
were any complications of the procedure. After the bronchoscopy, the patient was asked to fill out a questionnaire that asked about level of comfort during the procedure. The physician and the technician who assisted with the bronchoscopy filled out separate forms describing their impressions of the worst discomfort experienced by the patient during the procedure. All parties used the Borg scale6 to describe comfort level. Each party was blinded to the others' responses about level of comfort.
Statistical Analysis All data were entered into a computerized database (Statistical Package for Social Sciences [SPSS], version 4.1, Chicago). Data were analyzed using two-tailed Student's t tests and correlation coefficients. RESULTS
Fifty-two subjects were accrued during the study period. Twenty-four patients were randomized by number to receive music. Three refused, leaving 21 patients in the music group (M+). Twenty-eight patients were randomized to the control group (M-). The M + and M- groups had similar mean ages (56 ± 14 years vs 54± 17 years) . There were no significant differences in gender distribution (12 men and 9 women in theM+ group, and 16 men and 12 women in theM- group). There was no significant difference in mean duration of bronchoscopy for the M+ vs the M- group. Physiologic parameters monitored during the procedure (Table 1) and medications given did not differ significantly for the two groups. TheM+ patients received 2.81 ± 1.58 mg of midazolam per procedure, while theM-patients received 3.19±2.12 mg. Two of the subjective parameters monitored were CHEST /108/1 I JULY, 1995
129
Table !-Physiologic Parameters for Music and Control Groups*
Resting oxygen saturation End oxygen saturation Resting heart rate End heart rate Resting systolic pressure Resting diastolic pressure End systolic pressure End diastolic pressure
Music Group
Control Group
95±3 92±5 89±19 104± 19 135±20 81 ±14 154±27 89±13
95±2 93±3 90±16 101 ± 22 133± 17 82±14 152±24 95±24
*p>0.05 (not significant) for all comparisons between groups.
significantly better for the music group (Table 2). Using the Borg scale, M+ patients rated overall comfort at 2.5 ± 1.3 vs 3.5 ± 2.4 for the M- patients (p=0.02) . The M+ patients rated cough during the procedure at 2.2 ± 1.4 vs 3.4 ± 1.9 for theM- patients (p=0.03). There was no significant difference in ratings for dyspnea during the procedure (M+ , 1.4 ± 1; M-, 1.7 ± 1.3; p=0.21) . Correlation was used to determine whether physicians or technicians were able to assess the degree of discomfort experienced by the patient during the procedure. Correlations were extremely poor, with a correlation coefficient of 0.19 for physicians and 0.09 for technicians. DISCUSSION
This brief study of the application of music to outpatient bronchoscopy yields two major conclusions. First, the use of music was associated with significantly greater comfort and less cough. Second, those performing the procedure were very poor at discerning the patients' actual levels of comfort (and discomfort). There is a small body of literature on the use of music and other modalities such as relaxation techniques as adjuncts to more routine pharmacologic and nonpharmacologic practice. Some7· 9 have found that patients who listened to music had a significant decrease in anxiety but that the same improvements occurred in control groups, consistent with a placebo effect of the music. Effect on physiologic parameters was varied. Two other studies showed significant reductions in anxiety over and above a control group3 or a matched control period. 4 One showed a physioTable 2-Symptoms for Music and Control Groups (Borg Scale Ratings)
Comfort level Worst dyspnea in bronchoscopy Worst cough in bronchoscopy
130
Music Group
Control Group
p Value
2.5± 1.3 1.4±1
3.5±2.4 1.7 ± 1.3
0.02 0.21
2.2 ± 1.4
3.4± 1.9
0.03
logic benefit from music.4 The study most similar to ours, that by Daub and Kirschner-Hermanns 3 looking at music as a means of reducing preoperative anxiety, found not only a significant benefit to music but also paralleled another finding of our study: the investigators' estimations of patient anxiety correlated poorly with anxiety as measured with psychometric testing. In the Daub and Kirschner-Hermanns3 study, the differences were particularly great for patients who received premedication (with thalamonal) as opposed to groups who received nothing or listened to music. That study3 showed that patients receiving preoperative thalamonal actually experienced increases in anxiety during the investigative period. That study and ours underline the concept that we are surprisingly unable to predict patient comfort level; we cannot determine by observation subjective experiences of the patient. We also may forget at times that the procedure is routine for the physician but may be very threatening to a patient. The data reflect the need for establishment of a systematic way to follow up patient comfort level throughout the procedure. Not surprisingly, since physicians were poor at determining patient comfort level, the amount of medication given in our study did not differ for the two groups. Music before and during bronchoscopy is a simple and inexpensive way to improve patient perception of the experience. It increases patient comfort without any negative side effects. This may be particularly important since the physician is not able to judge accurately a patient's level of comfort. REFERENCES 1 Walther-Larsen S, Diemar V, Valentin N. Music during regional anesthesia: areduced need of sedatives. Regional Anesth 1988; 13:69-71 2 Guzzetta CE. Effects of relaxation and music therapy on patients in a coronary care unit with presumptive acute myocardial infarction. Heart Lung 1989; 18:609-16 3 Daub D, Kirschner-Hermanns R. Reduction of preoperative anxiety-music as an alternative to pharmacotherapy. Anaesthesist 1988; 37:594-97 4 Davis-Rollans C, Cunningham SG. Physiologic responses of coronary care patients to selected music. Heart Lung 1987; 16:370-78 5 Slifer KJ, Penn-Jones K, Cataldo MF, et al. Music enhances patients' comfort during MR imaging. Am J Roentgenol1991; 156:403 6 Jones NL. Objective assessment of exercise-related symptoms. In: Jones NL, ed. Clinical exercise testing. Philadelphia: WB Saunders, 1988; 76-8 7 Zimmerman LM, Pierson MA, Marker J. Effects of music on patient anxiety in coronary care units. Heart Lung 1988; 17: 560-66 8 Bolwerk CAL. The effects of relaxing music on state anxiety in myocardial infarction patients. Heart Lung 1987; 16:331 9 Corah NL, Gale EN, Pace LF, et al. Relaxation and musical programming as means of reducing psychological stress during dental procedures. JADA 1981; 103:232-34 Clinical Investigations
with outpatient procedures, there is a need to make patients as comfortable as possible with as little anesthesia as possible to ensure rapid postprocedure recovery and timely hospital discharge. Several studies have suggested that the use of music may favorably alter patient perception and may increase patient comfort for any given level of pharmacologic sedation. 1-5 We undertook a prospective randomized trial of the use of music in the outpatient bronchoscopy suite. METHODS
Subjects From May 15, 1991, to May 15, 1993, we prospectively enrolled all outpatients coming in for bronchoscopy who understood English well enough to be able to understand choices. Patients were randomized by medical record number; those whose last number was odd were given the option to listen to music, while those whose last digit was even were not. The patients assigned to listen to music listened to new wave music, "Reflections of Passion" by Yanni played through headphones by a portable compact disc player (Sony Walkman). The equipment was inexpensive; the player cost $119, and the compact disc cost $14.99. Music was started before beginning bronchoscopy and stopped after the procedure was over.
Data Collection Physiologic parameters monitored included heart rate, blood pressure, and oxygen saturation before and during bronchoscopy. The amount and type of sedation used was also documented, as *From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cooper Hospital/University Medical Center, UMDNJ / Robert Wood Johnson School of Medicine at Camden, Camcfen, NJ. Manuscript received August 17, 1994; revision accepted October 12.
greater comfort (p=0.02) and less cough (p=0.03) than theM-group, while there was no difference in reported dyspnea P=0.21). Both physicians and technicians were very inaccurate in their assessments of patient level of comfort. Medications given did not differ for the two groups. Conclusion: Music during bronchoscopy is a simple and inexpensive nonpharmacologic way to improve patient comfort. (CHEST 1995; 108:129-30) M+=received music; M-=did not receive music, or control
Key words: bronchoscopy; music; patient comfort
were any complications of the procedure. After the bronchoscopy, the patient was asked to fill out a questionnaire that asked about level of comfort during the procedure. The physician and the technician who assisted with the bronchoscopy filled out separate forms describing their impressions of the worst discomfort experienced by the patient during the procedure. All parties used the Borg scale6 to describe comfort level. Each party was blinded to the others' responses about level of comfort.
Statistical Analysis All data were entered into a computerized database (Statistical Package for Social Sciences [SPSS], version 4.1, Chicago). Data were analyzed using two-tailed Student's t tests and correlation coefficients. RESULTS
Fifty-two subjects were accrued during the study period. Twenty-four patients were randomized by number to receive music. Three refused, leaving 21 patients in the music group (M+). Twenty-eight patients were randomized to the control group (M-). The M + and M- groups had similar mean ages (56 ± 14 years vs 54± 17 years) . There were no significant differences in gender distribution (12 men and 9 women in theM+ group, and 16 men and 12 women in theM- group). There was no significant difference in mean duration of bronchoscopy for the M+ vs the M- group. Physiologic parameters monitored during the procedure (Table 1) and medications given did not differ significantly for the two groups. TheM+ patients received 2.81 ± 1.58 mg of midazolam per procedure, while theM-patients received 3.19±2.12 mg. Two of the subjective parameters monitored were CHEST /108/1 I JULY, 1995
129
Table !-Physiologic Parameters for Music and Control Groups*
Resting oxygen saturation End oxygen saturation Resting heart rate End heart rate Resting systolic pressure Resting diastolic pressure End systolic pressure End diastolic pressure
Music Group
Control Group
95±3 92±5 89±19 104± 19 135±20 81 ±14 154±27 89±13
95±2 93±3 90±16 101 ± 22 133± 17 82±14 152±24 95±24
*p>0.05 (not significant) for all comparisons between groups.
significantly better for the music group (Table 2). Using the Borg scale, M+ patients rated overall comfort at 2.5 ± 1.3 vs 3.5 ± 2.4 for the M- patients (p=0.02) . The M+ patients rated cough during the procedure at 2.2 ± 1.4 vs 3.4 ± 1.9 for theM- patients (p=0.03). There was no significant difference in ratings for dyspnea during the procedure (M+ , 1.4 ± 1; M-, 1.7 ± 1.3; p=0.21) . Correlation was used to determine whether physicians or technicians were able to assess the degree of discomfort experienced by the patient during the procedure. Correlations were extremely poor, with a correlation coefficient of 0.19 for physicians and 0.09 for technicians. DISCUSSION
This brief study of the application of music to outpatient bronchoscopy yields two major conclusions. First, the use of music was associated with significantly greater comfort and less cough. Second, those performing the procedure were very poor at discerning the patients' actual levels of comfort (and discomfort). There is a small body of literature on the use of music and other modalities such as relaxation techniques as adjuncts to more routine pharmacologic and nonpharmacologic practice. Some7· 9 have found that patients who listened to music had a significant decrease in anxiety but that the same improvements occurred in control groups, consistent with a placebo effect of the music. Effect on physiologic parameters was varied. Two other studies showed significant reductions in anxiety over and above a control group3 or a matched control period. 4 One showed a physioTable 2-Symptoms for Music and Control Groups (Borg Scale Ratings)
Comfort level Worst dyspnea in bronchoscopy Worst cough in bronchoscopy
130
Music Group
Control Group
p Value
2.5± 1.3 1.4±1
3.5±2.4 1.7 ± 1.3
0.02 0.21
2.2 ± 1.4
3.4± 1.9
0.03
logic benefit from music.4 The study most similar to ours, that by Daub and Kirschner-Hermanns 3 looking at music as a means of reducing preoperative anxiety, found not only a significant benefit to music but also paralleled another finding of our study: the investigators' estimations of patient anxiety correlated poorly with anxiety as measured with psychometric testing. In the Daub and Kirschner-Hermanns3 study, the differences were particularly great for patients who received premedication (with thalamonal) as opposed to groups who received nothing or listened to music. That study3 showed that patients receiving preoperative thalamonal actually experienced increases in anxiety during the investigative period. That study and ours underline the concept that we are surprisingly unable to predict patient comfort level; we cannot determine by observation subjective experiences of the patient. We also may forget at times that the procedure is routine for the physician but may be very threatening to a patient. The data reflect the need for establishment of a systematic way to follow up patient comfort level throughout the procedure. Not surprisingly, since physicians were poor at determining patient comfort level, the amount of medication given in our study did not differ for the two groups. Music before and during bronchoscopy is a simple and inexpensive way to improve patient perception of the experience. It increases patient comfort without any negative side effects. This may be particularly important since the physician is not able to judge accurately a patient's level of comfort. REFERENCES 1 Walther-Larsen S, Diemar V, Valentin N. Music during regional anesthesia: areduced need of sedatives. Regional Anesth 1988; 13:69-71 2 Guzzetta CE. Effects of relaxation and music therapy on patients in a coronary care unit with presumptive acute myocardial infarction. Heart Lung 1989; 18:609-16 3 Daub D, Kirschner-Hermanns R. Reduction of preoperative anxiety-music as an alternative to pharmacotherapy. Anaesthesist 1988; 37:594-97 4 Davis-Rollans C, Cunningham SG. Physiologic responses of coronary care patients to selected music. Heart Lung 1987; 16:370-78 5 Slifer KJ, Penn-Jones K, Cataldo MF, et al. Music enhances patients' comfort during MR imaging. Am J Roentgenol1991; 156:403 6 Jones NL. Objective assessment of exercise-related symptoms. In: Jones NL, ed. Clinical exercise testing. Philadelphia: WB Saunders, 1988; 76-8 7 Zimmerman LM, Pierson MA, Marker J. Effects of music on patient anxiety in coronary care units. Heart Lung 1988; 17: 560-66 8 Bolwerk CAL. The effects of relaxing music on state anxiety in myocardial infarction patients. Heart Lung 1987; 16:331 9 Corah NL, Gale EN, Pace LF, et al. Relaxation and musical programming as means of reducing psychological stress during dental procedures. JADA 1981; 103:232-34 Clinical Investigations