ARTS & NEUROSCIENCE
Literature Summaries of Music Interventions in ICU
Weaning from Mechanical Ventilation
Discomfort or Pain During Procedures
Effects on Anxiety and Stress in Critically Ill Patients
Effects on Sleep in Critically Ill Patients
Nature Sound Effects on Anxiety in Mechanically Ventilated Patients
Music can be a valuable tool to improve inpatient quality of life. Especially today, as patients are increasingly debilitated and isolated due to COVID-19, we wanted to approach this subject from a scientific evidence-based perspective. The Arts & Neuroscience Networking Group has compiled a collection of summaries of music-based interventional studies in the ICU, detailing several benefits including lower anxiety and quicker weaning off of ventilators. These are written in plain language to be accessible to the general public as well as seasoned researchers and practitioners. We would like to thank Steven Meisler (Arts & Neuroscience NG co-chair), Stephanie Plamondon, MD (Clinical Associate Professor of Physiatry at the University of Calgary), and India Lissak (Research Coordinator at Massachusetts General Hospital) for their work in reviewing the studies!
Music Intervention Studies Investigating Weaning From Mechanical Ventilation
Twiss, E., Seaver, J., & McCaffrey, R. (2006).
The effect of music listening on older adults undergoing cardiovascular surgery.
Nursing in critical care, 11(5), 224-231.
This study of 62 adults undergoing cardiovascular surgery tested the use of continuous music listening throughout surgery and post-operative care versus usual care on anxiety as measured on the Spielberger State Trait Anxiety inventory, and on intubation time. Patients chose music from a selection of 6 pre-recorded CDs of relaxing music provided by the researcher. They found the music group had significantly lower anxiety scores and fewer minutes of intubation post-operatively. This suggests that music listening during and after surgery reduces anxiety and hastens time to removal of breathing tubes after surgery.
Jaber, S., Bahloul, H., Guétin, S., Chanques, G., Sebbane, M., & Eledjam, J. J. (2006, November).
Effects of music therapy in intensive care unit without sedation in weaning patients versus non-ventilated patients.
In Annales francaises d’anesthesie et de reanimation (Vol. 26, No. 1, pp. 30-38). (French language – English Abstract only assessed)
This randomized crossover study of 30 critically ill patients (15 intubated and 15 non-intubated) evaluated the effect of 20 minutes of music listening versus rest, on vital signs, the Richmond-Agitation-Sedation-Scale (RASS), bispectral index score (BIS) and the Numerical rating scale (NRS) for pain. The authors found that a single music intervention session was effective for decreasing anxiety, pain, and promoting relaxation, as indicated by decreases in heart rate, blood pressure, BIS respiratory rate and NRS in intubated patients during weaning.
Hunter, B. C., Oliva, R., Sahler, O. J. Z., Gaisser, D. A., Salipante, D. M., & Arezina, C. H. (2010).
Music therapy as an adjunctive treatment in the management of stress for patients being weaned from mechanical ventilation.
Journal of Music Therapy, 47(3), 198-219.
In this pilot study, the practicality and efficacy of using Music therapy (MT) to assist 61 adult difficult-to-wean patients off of mechanical ventilation was assessed. The authors compared the effects of 45-60 minute live MT sessions 3x/week during weaning trials on vital signs before and after MT sessions, patient and nurse satisfaction, and nursing perceptions of patient anxiety. They found positive physiological effects on heart rate and respiratory rate from the beginning to the end of the MT sessions, high patient and nurse satisfaction and improved patient as well as nursing stress with less need perceived for medical intervention. This suggests that live music therapy is feasible and helpful for weaning patients from mechanical ventilation by reducing stress and anxiety.
Park, J. Y., & Park, S. (2019).
Effects of Two Music Therapy Methods on Agitation and Anxiety among Patients Weaning off Mechanical Ventilation: A Pilot Study.
Journal of Korean Academy of Fundamentals of Nursing, 26(2), 136-143
In this study, the authors employed a crossover design to determine the effects of two music therapy methods on anxiety and agitation in six patients being weaned off of mechanical ventilation. Patient-preferred music, selected for each patient using the Music Assessment Tool (MAT), and classical relaxation music were compared. Richmond Agitations Sedation Scale (RASS) scores were reduced following both types of music, indicating that both preferred music and classical music reduced levels of agitation. Similarly, Visual Analog Scale (VAS) and State-Trait Anxiety-Inventory (STAI) scores were decreased, indicating reduced levels of anxiety following both musical intervention types. There was no significant difference in the degree of reduction of agitation or anxiety between the two musical interventions.
Liu, M. H., Zhu, L. H., Peng, J. X., Zhang, X. P., Xiao, Z. H., Liu, Q. J., … & Latour, J. M. (2020).
Effect of Personalized Music Intervention in Mechanically Ventilated Children in the PICU: A Pilot Study.
Pediatric Critical Care Medicine| Society of Critical Care Medicine, 21(1), e8-e14.
This pilot study enrolled 50 children between 1 month and 7 years old who were in the PICU receiving mechanical ventilation. The cohort was split, with half of the patients receiving music therapy, and the other not. Children in the music group listened to their preferred music for 60 minutes three times a day. The control group received routine care without music. Children who received music therapy were more comfortable during their stay compared to the control group, as measured by the COMFORT Behavior Scale. Children in the music group had better physiologic outcome, including a lower heart rate, respiration rate, systolic blood pressure. oxygen saturation, and diastolic blood pressure. Children in the music group had a shorter ventilation time and a shorter length of stay. This speaks to preferred music’s potential to positively influence psychological factors to both better the quality of patients’ experiences as well as decreasing the length of intubations. This is the first publication describing a randomized, controlled nonblinded pilot trial employing music for children receiving mechanical ventilation.
Music Intervention Studies Investigating Discomfort or Pain During Procedures
Cooke, M., Chaboyer, W., Schluter, P., Foster, M., Harris, D., & Teakle, R. (2010).
The effect of music on discomfort experienced by intensive care unit patients during turning: a randomized cross‐over study.
International journal of nursing practice, 16(2), 125-131.
This study of 17 post-operative ICU patients aimed to test the effect of patient-preferred music on discomfort and anxiety experienced during the turning procedure as measured on a numerical rating scale and faces anxiety scale. Music intervention began 15 minutes before and continued throughout the turning procedure and was compared to headphones with no music in the control group. They found no difference in the two groups in discomfort and anxiety in the turning procedure. Some limits to the study were the low baseline ratings of discomfort and anxiety in both groups. This suggests that further research is warranted to determine if music is effective at alleviating moderate to high levels of discomfort and anxiety during turning in critically ill patients.
Yaman Aktaş, Y., & Karabulut, N. (2016).
The effects of music therapy in endotracheal suctioning of mechanically ventilated patients.
Nursing in critical care, 21(1), 44-52.
This study of 66 mechanically ventilated cardiovascular surgery ICU patients tested the effect of researcher chosen instrumental slow tempo flute music compared with usual care on pain, sedation and vital signs during endotracheal suctioning. The music group received 20 minutes of music listening before and 20 minutes after the procedure. The authors found that pain scores were significantly reduced in the music group during endotracheal suctioning. This suggests that music listening can be used to improve pain management during painful ICU procedures.
Music Intervention Studies Investigating Effects on Anxiety and Stress in Critically Ill Patients
Chlan, L. L. (1995).
Psychophysiologic responses of mechanically ventilated patients to music: a pilot study.
American Journal of Critical Care, 4(3), 233-238.
In this randomised study of 20 mechanically ventilated patients divided into 2 groups, the author tested the effect of classical music listening with noise-cancelling headphones for 30 minutes vs. rest with noise-cancelling headphones and no music on heart rate (HR), respiratory rate (RR), blood pressure (BP) and anxiety measured on standard scoring using the Profile of Mood States (POMS). There were decreases in HR, BP and RR found in the music intervention group and improved POM scores. This suggests that music listening improves physiological and subjective patient reports of anxiety and stress.
Chlan, L. L. (1998).
Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance.
Heart & Lung, 27(3), 169-176.
This multi-center study of 54 alert non-sedated mechanically ventilated patients examined the effect of a single session of non-lyrical relaxing music – 60-80 beats per minute, 30 minute dose – compared with rest with no headphones for 30 minutes on heart rate, respiratory rate and a standardized anxiety measure, the Spielberger State Anxiety inventory. The author found a decrease in HR and RR over time in the music group as well as an improvement in anxiety scores. This suggests that a single music session improves physiological stress and patient reported anxiety during mechanical ventilation.
Wong, H. L. C., Lopez-Nahas, V., & Molassiotis, A. (2001).
Effects of music therapy on anxiety in ventilator-dependent patients.
Heart & Lung, 30(5), 376-387.
This study of 20 ventilator dependent patients in ICU tested 30 minutes of a choice of relaxing Chinese or Western music delivered via headphones compared with 30 minutes of uninterrupted rest on vital signs, and a standardized measure of anxiety. They found music listening was more effective than rest in decreasing anxiety on the Spielberger State Trait Anxiety Inventory and improving blood pressure and respiratory rates by the end of the intervention. This suggests that relaxing music improves physiological and subjective measures of anxiety in mechanically ventilated patients.
Chlan, L., Tracy, M. F., Nelson, B., & Walker, J. (2001).
Feasibility of a music intervention protocol for patients receiving mechanical ventilatory support.
Alternative therapies in health and medicine, 7(6), 80.
This study of 5 alert mechanically ventilated patients tested the feasibility of patients requesting and choosing preferred relaxing music over a 3 day period and explored barriers to the protocol for patients and nursing staff. The authors found that patients were able to independently request music and listened for over 1 hour on average, at a time. Nurses were also cooperative in offering the intervention. This suggests that patient initiated music interventions are feasible in the ICU setting for mechanically ventilated patients.
Almerud, S., & Petersson, K. (2003).
Music therapy—a complementary treatment for mechanically ventilated intensive care patients.
Intensive and Critical Care Nursing, 19(1), 21-30.
In this study of 20 consecutive ICU patients on mechanical ventilation, the authors tested the effects of 30 minutes classical music applied with headphones during night sleep on blood pressure and heart rate when compared with a control group resting under similar circumstances. There was a statistically significant drop in blood pressure during the intervention, and trend towards a drop in heart rate. None of the subjects recalled listening to music while ventilated. This suggests that during the time the music intervention was applied it had a relaxing effect on patients being mechanically ventilated.
Lee, O. K. A., Chung, Y. F. L., Chan, M. F., & Chan, W. M. (2005).
Music and its effect on the physiological responses and anxiety levels of patients receiving mechanical ventilation: a pilot study.
Journal of clinical nursing, 14(5), 609-620.
This randomized study of 64 mechanically ventilated patients tested the effects of 30 minutes of relaxing music listening versus headphones with no music on vital signs, observed behaviors, anxiety measured on a standardized scale, and patient satisfaction. They found significant improvements in heart rate, respiratory rate, and blood pressure in the music group, and an increase in observed comfortable behavior. This suggests music can provide a simple, safe and effective method of reducing potentially harmful physiological anxiety responses in mechanically ventilated patients.
Stubbs, T. (2005).
Experiences and perceptions of music therapy in critical illness.
Nursing times, 101(45), 34.
This qualitative study of 5 critically ill patients and 4 nurses assessed their perceptions of benefit of 2 sessions of 30 minutes of relaxing music listening with unstructured interviews. They found the nurses reported there were no disadvantages to the music intervention, and felt it was a positive experience for patients. Patients did not recall listening to music in the ICU, but recognized the songs when cued and reported pain perception being altered, sleep relaxation and music dreams. This study suggests that nurses perceive music intervention has positive benefits in critical illness without adverse effects.
Conrad, C., Niess, H., Jauch, K. W., Bruns, C. J., Hartl, W. H., & Welker, L. (2007).
Overture for growth hormone: requiem for interleukin-6?.
Critical care medicine, 35(12), 2709-2713.
This randomized controlled study of 10 post-operative critically ill patients tested the effects of one hour of Mozart piano sonatas versus rest with headphones and no music on vital signs, brain electrical activity, serum levels of stress biomarkers, level of sedation and use of sedative drugs. They found the music intervention reduced the amount of sedative drugs needed to achieve a comparable level of sedation, lower blood pressure and heart rate, increased growth hormone and reduced stress biomarkers such as epinephrine and inflammatory cytokine levels. This suggests music may exert its relaxing effects through the brain via hormone release and immune system changes.
Chlan, L. L., Engeland, W. C., Anthony, A., & Guttormson, J. (2007).
Influence of music on the stress response in patients receiving mechanical ventilatory support: a pilot study.
American Journal of Critical Care, 16(2), 141-145.
This study of 10 mechanically ventilated patients tested the effect of patient selected music listening for 60 minutes compared to rest for 60 minutes with no headphones on biochemical stress markers in the blood over time, and heart rate. No significant differences were found in levels of biomarkers between groups, but levels of corticotrophin and cortisol decreased over time in the music listening group. The trend to decreased levels was not statistically significant. This suggests that a further study is needed in larger numbers of patients with controlled conditions to determine if the trend of a reduction in biochemical stress markers is actually significant.
Chan, M. F., Chung, Y. F. L., Chung, S. W. A., & Lee, O. K. A. (2009).
Investigating the physiological responses of patients listening to music in the intensive care unit.
Journal of clinical nursing, 18(9), 1250-1257.
This quasi-experimental study of 101 alert critically ill ICU patients assessed the effects of 30 minutes of relaxing music delivered via headphones on vital signs to determine if there was a patient profile for high responders to the music intervention. Researchers provided 4 choices of low pitch 60-80BPM tempo relaxing familiar music to patients. They found that female, older age and those on ventilators were more likely to respond positively with larger effects on heart rate, respiratory rate and blood pressure measures. This suggests that music should be offered to patients if they accept it for relaxation in ICU and music should be based on patient preference.
Han, L., Li, J. P., Sit, J. W., Chung, L., Jiao, Z. Y., & Ma, W. G. (2010).
Effects of music intervention on physiological stress response and anxiety level of mechanically ventilated patients in China: a randomised controlled trial.
Journal of clinical nursing, 19(7‐8), 978-987.
This 3 group randomized controlled study of 137 mechanically ventilated patients tested the effects of a single session of 30 minutes of patient preferred relaxing music compared with headphones with no music or quiet rest groups. Standardized anxiety scores on the Spielberger State-trait anxiety scale were measured before and after the intervention and vital signs were measured before, throughout and after the intervention in all 3 groups. They found improved heart rate, blood pressure, and respiratory rates in the music group while vital signs worsened over time in the quiet rest control group. Reduced anxiety scores occurred in the music and headphones groups. This suggests that preferred music listening improves physiological stress measures and anxiety in mechanically ventilated Chinese patients. Noise and the soundscape in ICU in general may be contributing to stress and may be improved with noise cancelling headphones.
Dijkstra, B. M., Gamel, C., Van Der Bijl, J. J., Bots, M. L., & Kesecioglu, J. (2010).
The effects of music on physiological responses and sedation scores in sedated, mechanically ventilated patients.
Journal of clinical nursing, 19(7‐8), 1030-1039.
This randomized controlled study of 20 sedated mechanically ventilated patients evaluated the effects of 3 doses of 30 minutes of a choice of classical or easy listening music vs. same dose rest periods on vital signs, and sedation scores measured on the Ramsay Sedation Scale. They found no difference in vital signs between groups but subjects in the music group had higher sedations scores. This suggests that music leads to a deeper level of sedation.
Korhan, E. A., Khorshid, L., & Uyar, M. (2011).
The effect of music therapy on physiological signs of anxiety in patients receiving mechanical ventilatory support.
Journal of clinical nursing, 20(7‐8), 1026-1034.
This randomized study of 60 mechanically ventilated patients evaluated the effect of 60 minutes of classical music listening on vital signs before, during and after the intervention. They found the music group had significantly lower mean respiratory rates and blood pressures than the control group and that these measures progressively improved at 30, 60 and 90 minutes. This suggests music listening is beneficial for reducing physiological measures of anxiety and that there is a cumulative dose effect: 60 minutes showed more benefit than 30 minutes of music listening.
Chlan, L. L., Engeland, W. C., & Savik, K. (2013).
Does music influence stress in mechanically ventilated patients?
Intensive and Critical Care Nursing, 29(3), 121-127.
This randomized controlled study of 65 mechanically ventilated patients examined the effects of patient directed and preferred music tailored by a music therapist compared with patient initiated use of noise cancelling headphones or usual care (3 groups) on 24 hour urinary free cortisol (UFC) collected daily. The authors did not find a significant difference in UFC between the 3 groups and there was high variability in levels at entry to the study. There were limitations to the study that may have impacted results such as medication effects on UFC or other medical conditions that were not controlled for.
Beaulieu-Boire, G., Bourque, S., Chagnon, F., Chouinard, L., Gallo-Payet, N., & Lesur, O. (2013).
Music and biological stress dampening in mechanically-ventilated patients at the intensive care unit ward—a prospective interventional randomized crossover trial.
Journal of critical care, 28(4), 442-450.
In this randomized crossover study of 49 mechanically ventilated patients the authors evaluated the impact of slow tempo music listening for one hour 2x/day on vital signs, sedative drug consumption and blood stress biomarkers compared to a control condition of rest and headphones with no music. The patients acted as their own control group. They found a trend towards a decrease in fentanyl use, and that blood cortisol and prolactin levels decreased in the intervention group. There was no significant change in vital signs observed. This suggests that slow tempo music quickly reduces stress hormone levels and may reduce narcotic use in mechanically ventilated patients in ICU.
Chlan, L. L., Weinert, C. R., Heiderscheit, A., Tracy, M. F., Skaar, D. J., Guttormson, J. L., & Savik, K. (2013).
Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial.
Jama, 309(22), 2335-2344.
In this multi-center study of 373 critically ill patients the authors evaluated whether listening to patient preferred and initiated music reduces anxiety and the use of sedatives during ventilator support. They found a reduction in daily anxiety as measured by visual analog scale scores compared with usual care and reductions in doses of sedatives by the 5th study day. This suggests that patient-directed and preferred music reduces anxiety and the use of sedative drugs in mechanically ventilated patients.
TABLE 4
Summary of ICU Norse Comments and Observations Concerning Study Protocol
| Randomized Group | Written Nurse Comments and Observations |
| Patient-Directed Music | Patient’s wife says he listens to the music all of the time and it has been working well. Patient was sleeping with headphones on with his wife sleeping next to him in a chair. |
| Patient looks very peaceful and states she likes the music. | |
| Patient was tapping fingers to some of te music provided to him by the music therapist | |
| Patient listened to music most of yesterday (about 10 hours). Tends to be anxious and her blood pressure is lower when she is listening to music. | |
| Patient likes music and always nods head “yes” to have headphones in place when asked. | |
| After putting headphones on, patient appears less anxious. | |
| Patient wears headphones very often and rests well with them in place. Always nods “yes” to wearing headphones. | |
| Patient has been tapping feet to the music and listens for a couple of hours each night; seems happy with it! | |
| After putting headphones on, patient appears less anxious. | |
| Able to decrease propofol slightly | |
| Evening was quieter. Patient put headset on which seemed to help a lot. | |
| Family visited for 1 hour. Patient had diffculty sleeping; tried reading and quiet time before using headphones. | |
| Patient calm and resting on headphones. | |
| Patient was relaxing with music on for 3 hours. | |
| Patient slept well, headphones for 3 hours | |
| Music was on entire night (8 hour shift) | |
| Headphones Only | Patient really benefited from headphones! |
| Patient relaxed with headphones | |
| I’m glad he’s participating. I think the headphones will help him rest. | |
| The headphones would help her get more rest (due to the commotion on the other side of the curtain with roomate). | |
| The patient wanted to wear the headphones most of the day yesterday and communicated that they helped her rest. | |
| Patient put headphones on without prompting | |
| Headphones helped patient sleep during dialysis. | |
| Patient wanted to wear headphones all night. | |
| Patient had earphones on about 1 hour early in the night, then declined to use them rest of night. | |
| Headphones decreased nerves per patient and patient’s wife. | |
| Patient appeared calmer with headphones on. |
Chlan, L. L., Heiderscheit, A., Skaar, D. J., & Neidecker, M. V. (2018).
Economic evaluation of a patient-directed music intervention for ICU patients receiving mechanical ventilatory support.
Critical care medicine, 46(9), 1430.
This study is a secondary analysis of the randomized controlled study of 373 mechanically ventilated patients testing the effects of patient directed and initiated music listening on anxiety and sedative exposure compared with noise-cancelling headphones or usual care. The authors found that the music group had a decreased length of ICU stay and the music is a cost-effective intervention to reduce anxiety.
Lee, C. H., Lee, C. Y., Hsu, M. Y., Lai, C. L., Sung, Y. H., Lin, C. Y., & Lin, L. Y. (2017).
Effects of music intervention on state anxiety and physiological indices in patients undergoing mechanical ventilation in the intensive care unit: a randomized controlled trial.
Biological research for nursing, 19(2), 137-144.
This randomized study of 85 mechanically ventilated patients evaluated the effect of 30 minutes of relaxing patient preferred music vs. headphones with no music on two standardized measures of anxiety, heart rate, blood pressure and serum cortisol levels. They found the music group had statistically significant better values in all post intervention measures except diastolic blood pressure. This suggests that relaxing preferred music improves anxiety in mechanically ventilated patients.
Khan, S. H., Xu, C., Purpura, R., Durrani, S., Lindroth, H., Wang, S., … & Khan, B. A. (2020).
Decreasing delirium through music: A randomized pilot trial.
American Journal of Critical Care, 29(2), e31-e38.
This paper describes a randomized clinical trial in which 52 adults undergoing mechanical ventilation in the ICU were recruited to undergo one of three different audio-based treatment modalities: personalized music, nonpersonalized relaxing music, and audiobooks. While several outcome measures did not significantly differ between the three groups, including severity of delirium, patients adhered to the music interventions much more than they did the audiobook method.
Music Intervention Studies Investigating Effects on Sleep in Critically Ill Patients
Su, C. P., Lai, H. L., Chang, E. T., Yiin, L. M., Perng, S. J., & Chen, P. W. (2013).
A randomized controlled trial of the effects of listening to non‐commercial music on quality of nocturnal sleep and relaxation indices in patients in medical intensive care unit.
Journal of advanced nursing, 69(6), 1377-1389.
This study of 28 medical intensive care patients (APACHE II score <=25) tested the effects of 45 minutes of non-commercial sedating piano music vs. headphones with no music on vital signs, subjective and objective sleep parameters at nocturnal sleep time. They found the music group had improved subjective sleep quality and objective sleep profiles as well as lower heart rate, blood pressure and respiratory rates, and the music dose was cumulative. This suggests that 30 minutes or more of soothing music improves sleep quality and relaxation in medical ICU patients.
Nature Sound Intervention Studies Investigating the Effects on Anxiety in Mechanically Ventilated Patients
Saadatmand, V., Rejeh, N., Heravi-Karimooi, M., Tadrisi, S. D., Zayeri, F., Vaismoradi, M., & Jasper, M. (2013).
Effect of nature-based sounds’ intervention on agitation, anxiety, and stress in patients under mechanical ventilator support: A randomised controlled trial.
International Journal of Nursing Studies, 50(7), 895-904.
This study of 60 adult mechanically ventilated patients evaluated the effect of 30-90 minutes of listening to nature-based sounds vs. 30 minutes of rest with headphones and no music on standardized measures of anxiety and agitation as well as vital signs. They found the nature sounds group had significantly lower blood pressures, anxiety and agitation levels than the control group as measured by the FACES anxiety and Richmond Agitation scales after the intervention. They also found the improvements progressed over time. This suggests listening to nature sounds improves anxiety, and agitation in mechanically ventilated patients and longer listening sessions have even more benefit.
Thenmozhi, P., & Indumathy, S. (2019).
Nature Based Sound Therapy on Pain and Anxiety during Extubation of Mechanical Ventilation.
Journal of Medical Music Therapy, 12(1), 16-23.
The authors sought to evaluate the effectiveness of nature-based sound therapy on reduction of pain and anxiety levels during extubation from mechanical ventilation. Of the 30 patient participants, half (n=15) were assigned to an experimental group where they listened to nature-based music therapy 30 minutes prior to extubation. The remaining half of participants (n = 15) served as a control group receiving only the standard of care. The nature-based sound therapy comprised of birds chirping, ocean sounds, rain as well as river and jungle sounds. Pain and anxiety levels were assessed using the numerical pain scale and State-Anxiety Train-Inventory scale. The experimental group demonstrated significantly lower levels of anxiety in comparison to the control group. These findings suggest that nature-based sound therapy may serve as an effective, accessible and cost-effective tool for reducing pain and anxiety during extubation from mechanical ventilation.
