Validation of the Critical Care Pain Observational Tool (CPOT) to Detect Oropharyngeal Pain in Mechanically Ventilated Adults
CCCF ePoster library. Dale C. Nov 8, 2018; 233415; 48
Craig M. Dale
Craig M. Dale
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Introduction: Recent studies identify common oral procedures as underappreciated sources of pain in patients receiving invasive mechanical ventilation1,2However, critically ill patients receiving mechanical ventilation are frequently unable to self-report3Consequences of poor pain control include increased duration of mechanical ventilation, infection, ICU length of stay, 30-day mortality, and treatment costs4-6. Current guidelines recommend use of a behavioral pain tool in non-verbal patients7.

Objective: Our objective was to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT), previously validated for other painful exposures, to detect oropharyngeal pain in intubated and tracheostomised adults during routine oral care procedures8.

Methods: Two trained research team members independently observed patients during two non-painful (rest and gentle touch) and three potentially painful (oral suctioning, tooth brushing, and swabbing with a sponge toothette) procedures. Recruitment was stratified by level of consciousness i.e., (i) Glasgow Coma Score (GCS) of 4-8 (unconscious but able to move); (ii) GCS score of 9-12 (conscious but likely unable to self-report); and (iii) GCS score of 13-15 (conscious and likely able to self-report by non-verbal means). Conscious patients were asked if they experienced pain during each procedure (yes/no) and to rate their pain intensity on a 0 to 10 numeric rating scale (NRS). Bedside nurses performed routine oral care according to unit standards. We calculated mean CPOT and NRS scores across raters for each painful exposure separately and performed Receiver Operating Characteristic (ROC) curve analyses to assess accuracy of the CPOT for detecting pain (score >2) compared to the NRS (score ≥4). We used repeated measures ANOVA to assess change in CPOT scores across painful and non-painful exposures in patients stratified according to the 3 levels of consciousness. Power analysis estimated a minimum sample size of 76 patients.

Results: A total of 98 patients, primarily intubated (92.9%) and male (63.3%) participated. Criterion validation was supported by patient self-report of pain during tooth brushing (AUC=.80; P<0.5) and oral suction (AUC=.72; P<0.3) but not for oral swabbing (AUC=.68; P=0.16). Discriminative validation was demonstrated for all oral care procedures compared to rest (P<.001). Intra-class correlation coefficients between raters ranged from .78 to .91 (P<.001) for total CPOT scores, indicating excellent inter-rater reliability. The proportion of patients with CPOT scores >2 indicating pain presence during oral procedures were: oral suction (42.9%); swabbing with toothette (38.7%); and tooth brushing (29.7%). Level of consciousness did not influence CPOT scores (F=2.75; P=.07), but the interaction between exposure and level of consciousness was statistically significant (F=4.7l P<.001). CPOT scores for the 3 potentially painful exposures were lower in participants with GCS 13-15 compared to the unconscious (GCS 4-8) and altered consciousness groups (GCS 9-12).

Conclusion: The CPOT is reliable and valid for the detection of oropharyngeal pain during oral care procedures indicated as painful by critically ill adults. As pain associated with an endotracheal tube and oral health deterioration may occur during mechanical ventilation, regular oropharyngeal pain assessment and management may improve patient experiences and treatment outcomes.

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