Available via license: CC BY-SA
Content may be subject to copyright.
Corresponding author: Samuel Copeland Contact
Information: Samuel.copeland@ttuhsc.edu
DOI: 10.12746/swrccc2016.0416.218
FOCUSED REVIEW
What is the role of music in the intensive care unit?
Phumpattra Chariyawong MD, Samuel Copeland MD, Zachary Mulkey MD
Music has been integral to human
development and advancement with the power to
convey powerful emotions. It is not surprising that
music is played all across the globe and that it has
been found advantageous in the field of medicine.
Music has been shown to help surgeons perform
operations faster and to help in neurologic recovery
following traumatic brain insults.1,2 Music therapy is
also unique in that it is very safe and the cost of
implementation is low. Most hospitals have an easy
listening TV channel that couples peaceful music
and imagery.
The intensive care unit is a unique patient
care experience. It is an extremely busy and loud
place with frequent alarms and flashing lights
where sleep often eludes patients. Unfortunately,
these disturbances in sleep are dramatic and can
lead to multiple co-morbidities, including ICU
delirium which is associated with a 3.2 fold increase
in six month mortality.3,4 We wondered if there is
evidence to support a beneficial effect of music in
the intensive care setting. Specifically, we
wondered whether music therapy could decrease
sedation requirements, improve patients’ anxiety
ratings, and improve hemodynamic parameters.
Most of the literature discusses patients who are
undergoing mechanical ventilation. These patients
are susceptible to multiple stressful factors which
can cause anxiety and in turn increase oxygen
consumption.5
The first question was whether music
therapy improves a patient’s sleep quality in the
ICU over standard care without the addition of
music. Su developed a randomized controlled trial
in which patients were randomized to non-
commercial music for 45 minutes at nocturnal sleep
time or usual care with no music. The music
consisted of sedating piano pieces composed by
the authors of the study. Polysomnography was
recorded for the first two hours of sleep. Results
showed that stage N2 sleep was shorter by 5.2
minutes and stage N3 sleep was longer by 6.5
minutes in the first two hours. Patients in the music
group had significantly lower heart rates and
reported improved sleep quality over the control
group.6
The second question was whether music is
actually beneficial or is it simply the reduction in
background ICU noise that offers benefits. In the
largest music focused clinical trial to date, Chlan
found that there are multiple benefits to music
therapy. Experimental patients in the MICU were
recruited and divided into three groups of either
patient-driven music (PDM), noise-cancelling
headphones (NCH), or control. Patients in the
experimental group had an anxiety score that was
19.5 points lower than the control group. In
addition, patients in the experimental group also
used fewer sedatives, both in intensity and
frequency, than control patients. Both findings were
statistically significant. Their conclusion was that in
patients receiving ventilator support for respiratory
failure, PDM and NCH resulted in greater reduction
in anxiety compared with usual care. Interestingly,
when PDM is compared to NCH, there was no
statistically significant difference in the reduction in
anxiety or sedation intensity in PDM compared with
NCH.7 This study demonstrates that some type of
therapy is preferable to none, but it does not
answer the question of whether music therapy is
driving the lower anxiety scores.
Another study by Chlan evaluated the
effectiveness of music therapy on relaxation and
anxiety in mechanically ventilated patients. Patients
experienced significantly less anxiety assessed by
pretest-posttest state anxiety scores. Physiologic
parameters were also measured. The heart rates
and respiratory rates decreased significantly over
time in patients in the study group compared to the
control group, suggesting relaxation and less
stress-arousal.8 Positive effects of music on anxiety
levels based on patient perception have been
supported by several studies. Wong conducted a
study of music therapy on anxiety in twenty
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Chariyawong P, et al. Role of Music in ICU
ventilator-dependent Chinese patients. The results
suggested that music therapy was more effective in
decreasing state anxiety than an uninterrupted rest
period. Physiologic measures of blood pressure
and respiratory rate were significantly lower by the
end of the 30 minutes of music.9 Almerud evaluated
qualitative and quantitative measures after
mechanically ventilated patients listened to
classical music for 30 minutes. Systolic and
diastolic blood pressures significantly fell during the
music therapy session and rose after the end of the
session.10 One randomized controlled trial of twenty
subjects did not support the conclusion that music
influences physiologic parameters. This study
indicated that listening to music leads to higher
sedation scores but no significant decrease in
blood pressure and heart rate.11 However, this
study collected data from sedated mechanically
ventilated patients whose blood pressures and
heart rates might be lower than patients’ baseline
secondary to sedative drugs. Music may not have
additional effects when added to pharmacological
sedation. In aggregate these studies indicate that
music therapy might improve anxiety using both
psychological and physiological criteria.
Not only patients in medical intensive care
units, but patients in cardiovascular intensive care
units seem to benefit from music therapy. Two
studies have reported good outcome of music
therapy on cardiovascular disease patients. White
used a three group repeated measures
experimental design in forty-five patients with acute
myocardial infarction. Patients were divided into
three groups: 1. music in quiet, restful environment
(experimental group), 2. quiet, restful environment
without music (attention group), and 3. treatment as
usual (control group). State anxiety was reduced
significantly immediately during the intervention and
for one hour after the intervention in the
experimental group only. Heart rate, respiratory
rate and myocardial oxygen demand were
significantly decreased immediately during the
intervention and for one hour after in the
experimental group compared to the control group
but did not differ significantly differ from the
attention group.12 Barnason studied effects of
music on anxiety in coronary artery bypass graft
patients. Spielberger’s state-trait anxiety inventory,
patient’s verbal ratings of both mood and anxiety by
numeric rating scale, and physiologic parameters
were measured. This study found significant
improvement in mood but not in anxiety scores in
these subjects. Heart rate and systolic and diastolic
blood pressures were significantly decreased by
the intervention, indicating generalized physiologic
relaxation.13 These two studies indicate that music
is not harmful to patients and may help improve
mood, anxiety, and physiologic responses to stress.
However, Elliot did not find any relation between
music therapy and anxiety reduction in a
randomized controlled trial. Both psychologic and
physiologic variables were measured but there was
no significant reduction in anxiety in patients
exposed to music. The author claimed that these
results may be explained by a type II error.14
Most of the studies have focused on non-
invasive measures, such as subjective state anxiety
and physiologic parameters, such as blood
pressure, respiratory rate, and heart rate. The
human body also responds to stress with hormone
release. Cortisol, corticotrophin, epinephrine, and
norepinephrine levels increase when patients are
under stress. Chlan studied the influence of music
on these biomarkers using a 2-group experimental
design with repeated measures study of 10
patients. The levels of cortisol, corticotrophin,
epinephrine and norepinephrine were measured
four times during 60 minutes. However, there were
no significant changes in these four biomarkers in
patients who listened to music and in patients who
rested quietly.15 Chlan also measured 24 hour
urinary free cortisol levels as a stress biomarker in
70 patients; music intervention did not significantly
reduce urinary free cortisol levels.16
Our review of the literature indicates that
there were important differences among trials
studying whether music therapy has physiologic
benefits. Chan took note of these differing results
and proposed that there may be demographic
differences that would make patients more or less
likely to respond to music therapy. In his
randomized trial, he studied Chinese patients
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Chariyawong P, et al. Role of Music in ICU
admitted to an ICU and was able to categorize
patients into two distinct clusters. He found that
older, less educated females had a greater
response to music therapy played over a 30 minute
period with reductions in pulse, blood pressure, and
respiratory rate. Those who were less likely to
respond were younger, male, and more educated,
with only a significant reduction in systolic blood
pressure noted with music therapy.17 This study
suggests that certain population subgroups may be
more influenced by music therapy. The types of
music that were offered in the study were limited to
Chinese classical music, religious Tibetan music,
Western classical, or Jazz. It is universally
understood that there are different preferences in
music. While one person may enjoy classical
music, another person may find the rhythms of
heavy metal to be soothing; this leads us to the
questions of whether patients’ personal preferences
affect their responses. The general
recommendation for music used to relax patients is
soothing music with a sustained melodic quality
and a general absence of strong rhythms,
percussions, and lyrics.
To answer whether a specific type of music
should be used, Chi performed a literature review.
Her analysis concluded that overall results
indicated music selected on the basis of research
yielded better results that music selected simply on
basis of individual preference. The argument was
that music that was selected by an individual could
cause stimulation rather than relaxation.
Specifically, she found that music specially
designed to enhance relaxation was effective in
treating tension and negative moods. This concept
was at least partly refuted by noting that repetitive
exposures to music increased the listener’s comfort
level. This finding led them to ask whether patient
preference should play a role in music selection.
Their review suggested that personal preference,
familiarity, cultural background, and past
experiences should not be ignored. They suggest
that while patient preference should be considered,
the first consideration must always be grounded in
research. Their conclusion was that music chosen
by research generally produces more relaxation,
reduces pain or anxiety, and prevents stress
induced changes in psychological responses.
Patients should be given options for listening, but
each option should be research driven so that it has
the highest chance of achieving the desired
outcome.18
Overall, the evidence suggests that music
therapy should routinely be prescribed for patients
in the intensive care unit. Nurses have a key role in
music implementation. We suggest that music
therapy should be triggered by a nursing
assessment of either elevated CAM ICU scores,
hemodynamic parameters which suggest acute
agitation, or patient reported anxiety.
Demographics should be considered when
implementing music therapy, but demographics
should not prevent offering therapy. The type of
music should be geared towards relaxation, and
patients should be offered music often. Multiple
relaxing selections should be offered so that
patients can choose which one they feel is most
suitable for relaxation and better physiologic
outcomes.
Key words—ICU, music therapy, agitation, anxiety
The Southwest Respiratory and Critical Care Chronicles 2016;4(16) 42
Chariyawong P, et al. Role of Music in ICU
Table 1. Summary of Reviewed Studies
Author
Su 6
Chlan 7
Chlan 8
Wong 9
Type of Trial
RCT
RCT
2 group, pretest-posttest
experimental design
Crossover repeated measures
design with random
assignment
Number of patients
28
373
54
20
Main Outcome
Hemodynamics,
polysomnography, VSH sleep
scale
Anxiety and sedative use
Anxiety, heart rate and
respiratory rate
Mean blood pressure,
respiratory rate, Spielberger
State Trait Anxiety Inventory
Results
Music group had shorter
stage N2 sleep and longer
stage N3 sleep, lower heart
rates, and reported better
sleep quality
Experimental groups
experienced decreased
anxiety scores and sedative
exposure compared to the
control group.
Music therapy group
significantly less anxiety and
decrease heart rate and
respiratory rate compared to
control group
Music therapy was more
effective in decreasing
anxiety and decreased blood
pressure and respiratory rate
at the end of the intervention
Conclusion
Soothing music can be used
in the ICU to improve
patients sleep
Patient directed music
resulted in greater reduction
in anxiety compared with
usual care but not noise
cancelling headphones
A single music therapy
session found to be effective
for decreasing anxiety and
promoting relaxation
Music therapy is an effective
intervention in decreasing
anxiety in ventilator
dependent patients
Author
Almerud 10
Dijkstra 11
White 12
Barnason 13
Type of Trial
Quantitative and qualitative
methods
RCT with repeated measures
3 group repeated measures
experimental design
Prospective, repeated
measures, quasi-
experimental, random
assignment
Number of patients
20
20
45
96
Main Outcome
Systolic, diastolic blood
pressure and heart rate
Systolic, diastolic, mean
arterial blood pressure, heart
rate, respiratory rate
Anxiety level, heart rate,
respiratory rate and
myocardial oxygen demand
Anxiety, mood, blood
pressure and heart rate
Results
Significant fall in systolic and
diastolic blood pressure
during music therapy session
and a corresponding rise after
cessation of treatment
Higher sedation scores in
experimental group, no
significant differences in
physiologic parameters
Significant reduction in heart
rate, respiratory rate,
myocardial oxygen demand
in experimental compared to
control group but not in
attention group. Anxiety
reduced in experimental
group only,
Significant mood
improvement but no
significant differences of
anxiety ratings, significant
effects over time on heart
rate, systolic and diastolic
blood pressure
Conclusion
Intensive care nursing staff
can beneficially apply music
therapy as a non-
pharmacological intervention
Music associated with higher
level of sedation in sedated,
mechanically ventilated ICU
patients
Patients recovering from
acute myocardial infarction
may benefit from music
therapy in quiet, restful
environment
The overall response by all
intervention groups
demonstrated relaxation
response. Reduced anxiety
and improved mood within
all three groups.
Author
Elliott 14
Chlan 15
Chlan 16
Chan 17
Type of Trial
RCT
RCT
2 group experimental design
with repeated measures
Repeated measures design
Number of patients
56
70
10
101
Main Outcome
Psychologic and physiologic
variables
Urinary free cortisol
Levels of cortisol,
corticotrophin, epinephrine
and norepinephrine
Demographic characteristics,
physiologic parameters
Results
No significant reduction in
anxiety was achieved for
patients using music or
muscle relaxation
interventions.
No significant differences
among groups in urinary free
cortisol over the course of
ventilator support
Levels of 4 biomarkers did
not differ significantly
between patients who listened
to music and patients who
rested quietly
Cluster analysis yielded 2
clusters. Cluster 1 was
younger educated males and
had less effect from music
therapy. Cluster 2 was older
uneducated females and had
more effect from music
therapy
Conclusion
These results differ from
those of similar studies but
may be related to the high
probability of a type II error.
Music did not significantly
reduce cortisol
Additional research is needed
with larger sample size
Music is more likely to be
effective in patients who have
similar characteristics to
cluster 2.
The Southwest Respiratory and Critical Care Chronicles 2016;4(16) 43
Chariyawong P, et al. Role of Music in ICU
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Details
1. Submitted-11/18/2015
2. Accepted-9/23/2016
3. Reviewer-Steven Urban MD
4. Author affiliations- Phumpattra Chariyawong is a resident
in Internal Medicine at Texas Tech University Health Sciences
Center in Lubbock, TX. Samuel Copeland is a fellow in
Pulmonary and Critical Care Medicine at TTUHSC in
Lubbock, TX. Zachary Mulkey is a faculty member in
Internal Medicine at TTUHSC in Lubbock, TX.
5. Corresponding author- Samuel Copeland at
Samuel.copeland@ttuhsc.edu
6. Conflicts-none
The Southwest Respiratory and Critical Care Chronicles 2016;4(16) 44