The present research provides (1) an insightful description of the communication difficulties related to MV experienced by both caregivers and patients, and (2) a previously unexplored perspective by comparing the use of two technologically opposed AAC interfaces, thereby covering a notable gap in the literature about the most appropriate AAC strategy in the ICU (3,23). The results confirmed that MV constitutes a major problem in patient-caregiver communication (1,26,30) and suggest that eye tracking technology may improve the communication of mechanically ventilated patients beyond the communication board, regarding the quantity of messages transmitted, the success rate of transmissions, the satisfaction of patient and the communication content despite the difficulties of use encountered.
Beside the communication difficulties experienced with intubated and tracheotomized patients, the fear of not being able to understand patients also seems to lead caregivers to avoid communication exchanges. The AAC systems seemed to be perceived positively by the caregivers, particularly regarding the help that AAC systems could provide and the interest in learning to use these systems in the ICU. The inability of patients to get understood and to ask questions about their health status or care appeared to be the leading cause of communication difficulties. Moreover, the difficulty to communicate with relatives seemed to be more present than the difficulty to communicate with doctors and nurses.
The existing literature associates AAC interfaces use with an improvement of communication through increasing the communication interactions and satisfaction for patients as well as caregivers (31–33). Through the results of the present study, such improvement of communication was more important when using the eye tracking device given that the quantity of transmitted messages, the success rate and the level of patient satisfaction were significantly higher than with the communication board. Furthermore, previous studies revealed that communication with a high-tech AAC interface covered more fundamental needs than basic communication without AAC support (34,35). The fundamental needs seemed, through this study, to be covered by the low- and high-tech interfaces but the latter also extends beyond the dimension of the fundamental needs to the critical care environment. Indeed, the results highlighted 8 common themes between the communication board and the eye tracking device covering fundamental needs (i.e., breathing, pain, nutrition-hydration, installation, psychological state, hygiene, rest, thermoregulation), but also a theme exclusively covered by the eye tracking device (i.e., interaction with the environment). Although AAC interfaces are intended to support communication, difficulties of use can also be encountered. As highlighted in a recent scoping review, barriers to AAC use may be related to caregivers' communication skills, environmental context of critical care and material resources available (36). The barriers considered in the literature concern the implementation of AAC communication in healthcare settings, whereas this study provided a description of specific difficulties in using two AAC interfaces technologies. The difficulties of use involved 2 common categories for both interfaces (i.e., the difficulty to understand the utilization and to select the items) and 2 specific categories for the communication board or the eye tracking device (i.e., difficulty to visualize items and insufficient items for the communication board, difficulty to detect eye gaze and difficulty to install the device for the eye tracking). However, the difficulties of use for the high-tech AAC interface were not systematically encountered and did not hinder the transmission of the messages, unlike the difficulties encountered with the low-tech AAC interface. The principal difficulties in using the communication board and the eye tracking device were, respectively, the selection of the items and the detection of eye gaze. The gestural deprivation inherent to muscle wasting and ICU acquired weakness could explain the difficulty to select the items manually (8,9) and the fluctuating arousal state in ICU patients could explain the difficulty to detect eye gaze (and by extension, the difficulty to select the items through the gaze) by notably limiting eyelid opening (9).
The implementation of AAC strategies in clinical settings requires training of caregivers as well as availability of equipment (15,37,38). As previously explained, most of the caregivers involved were interested in learning to use the eye tracking device. Several training sessions were therefore provided by the investigator during the study, reaching more than half of the ICUs staff. The AAC interfaces should also be available at all bedsides, but the accessibility may depend on the level of technology (15). Indeed, the communication board seems to be more accessible than the eye tracking device, notably because of the reduced cost of a printed paper interface compared to the costs of the different components of the technological interface. Assisted techniques currently dominate in ICUs, so patients completely depend on the assistance of caregivers to communicate (15,37,38). However, the eye tracking device enable the patient to communicate independently but the interface must beforehand be installed and calibrated by caregivers (15,38,39).
Although the results seem very promising, this study presents some limitations to consider. The study involved a sample of 44 patients, thus potentially limiting generalization to the general population. However, the patient sample recruited in this study turns out to be larger than the patient samples of previous, basically pilot, studies evaluating high-tech interfaces in ICUs (34,40,41). The number of patients recruited over a relatively long period of 10 months also suggests a limited target population. The perspectives of caregivers and relatives were not represented, although this information would have been interesting and very relevant to enhance the contribution of the present study in the search for the most effective AAC interface in ICU. The qualitative method may have induced a subjective dimension in the data processing through thematization and categorization. Nevertheless, the sequential procedure structuring the qualitative analysis and the evaluation of the methodological quality through the MMAT permitted to control this potential subjectivity. The monocentric setting may also limit the transferability of the results to other ICU environments. And finally, the communication exchanges were evaluated by an investigator, but any subjectivity and interpretation were prevented by clearly defined judgement criteria specified in the protocol. Future comparative studies should therefore examine the perspectives of caregivers as well as relatives regarding the use of AAC strategies in ICUs and also consider a multicenter setting.