ARTICLE IN PRESS

Psychosomatics 2019:&:1 8 © 2019 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.

Case Report

Ventilator-Dependent Patients Successfully

Weaned With Cognitive-Behavioral Therapy:
A Case Series

Jonah N. Cohen, Ph.D., Arun Gopal, M.D., Karsten J. Roberts, M.Sc., R.R.T.,
Eleanor Anderson, M.D., Andrew M. Siegel, M.D.

purpose of this paper is to describe a model of anxiety

Introduction
Approximately one-third of patients in intensive care
units (ICUs) are mechanically ventilated.1 Mechanical
ventilation (MV) is associated with significant levels of
morbidity (e.g., ventilator-associated pneumonia, lung
injury), mortality,2,3 and nearly 40% of all ICU costs.4,5
Forty percent of the time that a patient is receiving MV
is spent trying to wean the patient from the ventilator,6
highlighting the importance of developing treatments to
expedite ventilator weaning.
Reductions in the duration of MV can substan-
tially improve clinical outcomes and reduce financial
cost.7,8 Anxiety is routinely reported as a primary
interfering factor to weaning.9 Anxiolysis in ICUs is
often achieved with benzodiazepines given their rapid
onset of action including delirium, tolerance, and with-
drawal.9,10 However, benzodiazepines have adverse
side effects particularly worrisome for critically ill indi-
viduals.
To our knowledge, there is only a single study11
that has posited an anxiety model for challenge-to-
wean patients. This study, however, examined state
anxiety, a nonspecific anxiety construct, highlighting
the need for models with greater specificity. Further-
more, over decades, only a handful of case studies
have evaluated interventions targeting anxiety for MV
weans. However, these studies have largely consisted
of therapies based on relaxation and hypnosis,12,13
rather than cognitive-behavioral therapy (CBT), con-
sidered the gold standard treatment of anxiety. The
in the ventilator weaning process and to conduct a
study of a cognitive-behavioral interventions for these
concerns.
Model of Anxiety and Treatment
Our psychiatric consultation service is frequently
asked to offer guidance in challenge-to-wean cases in
ICUs. Over time, we have come to speculate that chal-
lenge-to-wean patients often have difficulty weaning
because of anxiety that resembles panic. Panic is charac-
terized by an abrupt onset of intense fear, accompanied
by symptoms including heart racing, shortness of
breath, and chest pain that the patient believes to be
harmful, thereby causing further sympathetic arousal.
Cognitive-behavioral models of panic inform our
speculations. In our clinical observations, challenge-
to-wean patients face the stressors of acute illness and
weaning trials, which lead to apprehension before
weaning. When weaning begins, the apprehensive
patient experiences a variety of physiological sensa-
tions and interprets these sensations as harmful, rather
Received November 26, 2018; revised February 5, 2019; accepted Feb-
ruary 8, 2019. From the Department of Psychiatry (J.N.C.),
Massachusetts General Hospital, Boston, MA; Department of Psychi-
atry (A.G., E.A., A.M.S.), University of Pennsylvania Perelman
School of Medicine, Philadelphia, PA; Department of Respiratory
Care Services (K.J.R.), Hospital of the University of Pennsylvania,
Philadelphia, PA. Send correspondence and reprint requests to Jonah
Cohen, Ph.D., Department of Psychiatry, 6th floor, 1 Bowdoin
Square, Boston, MA 02114; e-mail: jonah.cohen@mgh.harvard.edu
© 2019 Academy of Consultation-Liaison Psychiatry. Published by
Elsevier Inc. All rights reserved.

Psychosomatics &:&, & 2019 www.psychosomaticsjournal.org 1

 ARTICLE IN PRESS
Case Report

than as a benign aspect of the weaning process. Impor-

tantly, this interpretation further increases sympathetic
arousal. In turn, physiological arousal and the belief in
its harmful nature escalate into panic and ultimately
the patient withdrawing from the weaning trial.
Patients have the subjective experience of respiratory
distress, but it is an artifact of anxiety, not physiologi-
cal limitation. We speculate that the patient associates
weaning with panic and dyspnea, worsening the anxi-
ety response with each wean attempt, creating a
vicious cycle. See Figure 1.
Present Study
In this paper, we present 2 cases. We aimed to help
wean challenge-to-wean patients from the ventilator by
treating their anxiety with CBT. To this end, we
adapted cognitive-behavioral models of panic14 to the
ventilated patient. We hypothesized that CBT would
reduce the severity of respiratory anxiety, panic symp-
toms, generalized anxiety, and depression, thereby facil-
itating successfully weaning from MV.
Materials and Methods
Participants
ICU teams were asked to refer patients experiencing
the greatest difficulty weaning. Inclusion criteria were:
(1) medical clearance to undergo weaning, (2) failure of
3 spontaneous breathing trials, (3) not delirious, and (4)
English proficiency (to ensure that patients would be
able to engage with CBT). Failure of 3 spontaneous
breathing trials constituted a challenge-to-wean status.
Case 1. Mr. A, man in his 70’s with interstitial pul-
monary fibrosis, underwent a single diseased-donor
lung transplant. The post-transplant course was compli-
cated by primary graft dysfunction, severe pharyngeal
dysphagia, deep venous thrombosis, heart failure with
preserved ejection fraction, and cytomegalovirus. Hos-
pitalization occurred in the setting of end-stage renal
disease with a new hemodialysis requirement in addi-
tion to a rhinoviral infection, resulting in ventilator-
dependent respiratory failure.

FIGURE 1. Model of Panic in Mechanical Ventilation Weaning

Perceived Threat
(Wean Trial from
Mechanical
Ventilation/Physical
Senations)

Interpretations of
Body Sensations as
Catastrophic Apprehension

Body Sensations from

Weaning

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 ARTICLE IN PRESS
Mr. A had no history of anxiety or mood disorders.
He had a tracheostomy due to worsening pneumonia
and he became a challenge-to-wean. He described the
sudden onset of panic symptoms within minutes of
weaning from MV, endorsing a pounding heart, smoth-
ering sensations, sweating, shaking, feelings of choking,
chest discomfort, and a fear of dying. These symptoms
would immediately abate upon return to MV. On refer-
ral, his maximum time on a tracheostomy collar (TC)
was 2.5 hours.
Case 2. Mr. B, a man in his 20’s with a medical his-
tory of diffuse cutaneous systemic sclerosis complicated
by restrictive cardiomyopathy and pulmonary hyper-
tension, underwent a combined heart and bilateral lung
transplant; his course was complicated by an acute kid-
ney injury, coagulopathy, and airway ischemia. A tra-
cheostomy was placed 10 days post-transplant
secondary to difficulties weaning from the ventilator.
His psychiatric history was notable for generalized
anxiety symptoms, panic attacks, and demoralization
during the current and prior medical hospitalizations.
His primary psychiatric complaint was anxiety precipi-
tated only during wean trials. Immediately upon being
placed on TC, Mr. B described experiencing several
panic attack symptoms, including a heart racing, dys-
pnea, chills, and a fear of losing control. Mr. B was
referred with a maximum time on TC of less than 1
hour.
Procedure
Our study was conducted in accordance with the
amended Declaration of Helsinki and had Institutional
Review Board approval. Both patients gave written
informed consent. CBT was adjunctive to typical venti-
lator weaning trials in the ICU1. See Figures 2 and 3 for
details about medications administered during the CBT
intervention. No negative events occurred.
Assessments were conducted pre- and post-CBT.
Psychiatry attempted to see each patient 2 3 times per
week with visits lasting between 5 and 30 minutes, con-
tingent on clinical needs and medical status. Patients
received CBT until they were fully weaned (i.e., when
they were off of the ventilator for a minimum of
1
Further detail about the weaning protocols used is available upon
request.
Psychosomatics &:&, & 2019
Cohen et al.
24 hours). Patients filled out baseline questionnaires
before their first session. Patients completed post-treat-
ment measures immediately after being successfully
weaned off. Mr. A completed post-treatment assess-
ment at 22 days. Mr. B completed post-treatment
assessment at 36 days, given a medical setback unre-
lated to the study. A whiteboard facilitated communica-
tion between clinicians and patients.
CBT had 3 principal components: (1) psychoedu-
cation, (2) cognitive restructuring, and (3) exposure. In
this treatment, derived from an empirically-supported
treatment for panic disorder,15 psychoeducation con-
sisted of teaching about the interrelationship between
thoughts, feelings, and physical sensations during
weaning. The cognitive component taught patients
how to challenge their thoughts, with a particular
focus on identifying thoughts that over-estimated the
probability of negative medical events. The behavioral
component consisted of reducing pressure support val-
ues and increasing the length of time on a particular
pressure or TC in a step-wise, graduated, manner. Bio-
feedback was also used as patients had their vital signs
displayed.
Measures
We assessed respiratory-specific anxiety, panic symp-
toms, generalized anxiety, and depression pre- and
post-CBT. We calculated the number of hours tolerated
on TC before and after the intervention.
Respiratory anxiety. The Anxiety Inventory for
Respiratory Disease provides a psychometrically-sound
assessment of anxiety in respiratory patients as other
instruments are confounded by the physical elements of
somatic disease. A score of 14.5 discriminates between
patients with and without anxiety. The measure is reli-
able, valid,16 and sensitive to change.17
Panic symptoms. We assessed whether patients expe-
rienced the panic symptoms listed in the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition,18
when weaning from the ventilator or when anticipating
weaning and, if they endorsed the symptom, asked
patients to rate symptom severity from 1 to 7 (7 being
the worst).
Generalized anxiety. We assessed generalized
anxiety with the Generalized Anxiety Disorder 7-item
Scale (GAD-7). A score of 10 on the Generalized
Anxiety Disorder 7 represents clinically significant
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Case Report

FIGURE 2. Mr. A: Medications and Their Relative Time of Administration Over the Course of CBT
CBT = cognitive-behavioral therapy

levels of generalized anxiety. The instrument has
strong psychometric properties in medically-ill
individuals.19
Depression. We assessed depression with the Patient
Health Questionnaire 2-item (PHQ-2) version. A score
of 3 or higher signifies likely clinical depression. The
measure has high sensitivity and specificity and is sensi-
tive to change.20 We elected to use the PHQ-2 rather
than the 9-item version, given their psychometrically-
comparable status in deression screening and to reduce
patient burden.21
Delirium. The Confusion Assessment Method for
the ICU (CAM-ICU) assessed delirium. Patients who
were found delirious by the CAM-ICU were excluded
from the study. The CAM-ICU was administered daily
by nursing staff. The CAM-ICU is a valid and reliable
method for diagnosing delirium, particularly in
mechanically-ventilated patients.22
Time on TC. Time on TC was assessed from the
beginning of the intervention until the patient was
weaned. Time on TC before the study was calculated by
the maximum time reached on the previous wean.
Results
Overall, CBT reduced respiratory anxiety (Anxiety
Inventory for Respiratory), generalized anxiety (GAD-
7) panic symptoms, depression (PHQ-2), and the time
on the ventilator. See Table 1. No patients were
excluded for delirium (CAM-ICU).

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FIGURE 3. Mr. B: Medications and Their Relative Time of Administration Over the Course of CBT
CBT = cognitive-behavioral therapy

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Case Report

Mr. A time and his symptoms were not harmful, as he avoided

Mr. A failed wean attempts for approximately a
month before CBT. We treated him for 22 days, at
which point he was successfully weaned from the venti-
lator. During CBT, his medical course was notable for
acute respiratory distress syndrome (ARDS), diffuse
alveolar hemorrhage, acute renal failure requiring renal
replacement therapy, and non ST-elevation myocar-
dial infarction. Ganciclovir was increased to 10 mg/kg
twice daily for cytomegalovirus and cefepime was con-
tinued through for treatment of pseudomonas tracheo-
bronchitis. Mr. A was successfully weaned from MV.
Mr. A stated that he felt CBT was helpful in modu-
lating his anxiety. He initially thought that the feelings
in his body during wean trials indicated a catastrophic
event. Furthermore, Mr. A initially wanted to wean
rapidly, which often resulted in him asking to discon-
tinue wean trials due to anxiety. Before CBT, Mr. A
struggled to learn that his anxiety would habituate in
(i.e., asked to discontinue the wean) before habituation
could occur. This premature discontinuation of wean
trials due to anxiety further strengthened his associa-
tions between weaning, anxiety, and avoidance.
Mr. A benefited by identifying his automatic
thoughts and challenging his thoughts regarding possi-
ble medical catastrophes. Further, aligned with core
CBT principals, Mr. A was guided to a more graduated
fashion, allowing his anxiety to habituate with each iter-
ation (i.e., exposure). He had the chance to learn that
his anxiety was not predictive of an adverse medical
event, allowing him to tolerate and thus continue with
wean trials. Overall, Mr. A exhibited less intense respi-
ratory anxiety panic symptoms, generalized anxiety
and depression, and was ultimately weaned from the
ventilator.
Mr. B

Mr. B failed wean attempts for 2 weeks before CBT.

He reached 24+ hours off of the ventilator on day 36.
TABLE 1. Pre- and Postlevels of Symptoms and Time Off the He experienced a medical setback unrelated to the study
Ventilator
that suspended weaning trials for approximately a
Patient A Patient B
week. His medical course during CBT was complex.
Variable Pre Post Pre Post Due to poor gastric motility and inability to tolerate
Maximum time off ventilator 2.5 h 24+ h <1 h 24+ h oral feeding, a gastro-jejunal tube was placed and a
CAM-ICU 0 0 0 0 computerized tomography scan revealed a large right-
AIR 14 2 30 12
GAD-7 15 7 22 11
sided pleural effusion requiring thoracentesis. Further,
PHQ-2 2 2 7 3 a transbronchial biopsy of the transplanted lung
Total panic severity 35 7 24 15 revealed antibody-mediated rejection. He underwent
Palpitations 5 0 7 4
treatment including plasmapheresis, rituximab, intrave-
Shortness of breath 5 4 7 4
Sweating 5 0 0 2 nous immune-globulin, and a steroid pulse. A respira-
Trembling/shaking 5 0 0 2 tory viral panel was positive for adenovirus, and he was
Feelings of choking 5 0 0 0 subsequently treated with an appropriate course of anti-
Chest Pain/discomfort 5 0 0 3
Nausea/stomach distress 0 0 0 0 viral therapy. He required intermittent blood transfu-
Dizziness 0 0 0 0 sions and had metabolic acidosis requiring bicarbonate
Chills/hot flushes 0 0 2 0 administration in the setting of an acute kidney injury.
Numbing sensations 0 0 0 0
Derealization 0 0 1 0
Diuresis was held, and the kidney injury improved.
Fear of going crazy/losing control 0 3 7 0 Increased respiratory secretions led to a sputum culture
Fear of dying 5 0 0 0 positive for klebsiella and thus necessitated a change in
antibiotic therapy.
Note: AIR = Anxiety Inventory for Respiratory Disease;
CAM-ICU = Confusion Assessment Inventory for the Intensive
Initially, Mr. B would discontinue weans within the
Care Unit. GAD-7 = Generalized Anxiety Disorder 7-item. PHQ- first few minutes, citing a belief that his lungs were fail-
2 = Patient Health Questionnaire 2-item. Panic Symptom Screen ing. Psychoeducation was helpful in elucidating the
italicized to denote overall assessment, with specific symptoms
vicious cycle between Mr. B's thoughts, the anxiety that
listed thereafter.
his thoughts would cause, and his behavior (i.e., avoid-
ance of wean trials) that followed his anxiety. Cognitive

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restructuring was helpful in reducing Mr. B's anxiety.
For example, Mr. B learned that his thoughts about
feelings in his body being indicative of catastrophic dan-
ger were untrue. In turn, he used the phrase "although I
may experience changes in my body, that does not
mean something is wrong; I am under the care of
experts" to combat his anxiety. This cognitive restruc-
turing facilitated Mr. B's engagement in the behavioral
work of reducing pressure support and increasing TC
time. He ultimately reached 24+ hours on TC and
exhibited reductions in respiratory anxiety, panic symp-
toms, generalized anxiety, and depression.
Discussion
This study sought to evaluate whether CBT for the
mechanically-ventilated patient facilitated weaning and
reduced symptoms of respiratory anxiety, panic, gener-
alized anxiety, and depression. CBT reduced respiratory
anxiety, generalized anxiety, panic symptoms, and
depression (in one patient), and facilitated weaning
from the ventilator.
At baseline, both patients had clinically significant
or near clinically significant levels of respiratory anxiety
(Mr. A had a pre-treatment score of 14, and 14.5 is the
cutoff) and at post-treatment both patients had subclini-
cal levels of respiratory anxiety. Furthermore, both
patients had clinically significant levels of generalized
anxiety at pre-treatment and at post-treatment both
patients had subclinical levels or near sub-clinical levels
(Mr. B had a GAD-7 score of 11, and 10 is the cutoff).
Both patients also endorsed significant decreases in
severity of panic symptoms. Mr. B experienced a reduc-
tion in depression from clinical to sub-clinical levels.
Both patients increased time on TC by over 800% and
both were ultimately weaned from the ventilator.
Although both patients exhibited notable decreases in
severity of overall panic symptoms, they also exhibited a
small increase in severity on a handful of specific panic
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Several limitations of this case series should be
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CBT for the ventilated patient may have significant
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dissemination and implementation.
Funding: No funding support.
Declarations of Interest: None.
Disclosure: There are no disclosures. This research
did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Acknowledgments: We would like to extend our
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versity of Pennsylvania. In addition, a sincere thank you
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