title: Facial expression as an indicator of pain in critically ill intubated adults during endotracheal suctioning.
abstract: BACKGROUND
  Facial expression is often used to evaluate pain in noncommunicative critically ill patients.
  
  
  OBJECTIVE
  To describe facial behavior during endotracheal suctioning, determine facial behaviors that characterize the pain response, and describe the effect of patient factors on facial behavior during pain response.
  
  
  METHODS
  Fifty noncommunicative patients receiving mechanical ventilation were video recorded during 2 phases (rest and endotracheal suctioning). Pain ratings were gathered by using the Behavioral Pain Scale. Facial behaviors were coded by using the Facial Action Coding System for 30 seconds for each phase.
  
  
  RESULTS
  Fourteen facial actions were associated more with endotracheal suctioning than with rest (z = 5.78; P < .001). The sum of intensity of the 14 actions correlated with total mean scores on the Behavioral Pain Scale (ρ = 0.71; P < .001) and with the facial expression component of the scale (ρ = 0.67; P < .001) during suctioning. In stepwise multivariate analysis, 5 pain-relevant facial behaviors (brow raiser, brow lower, nose wrinkling, head turned right, and head turned up) accounted for 71% of the variance (adjusted R² = 0.682; P < .001) in pain response. The sum of intensity of the 5 actions correlated with total mean scores on the behavioral scale (ρ = 0.72; P < .001) and with the facial expression component of that scale (ρ = 0.61; P < .001) during suctioning. Patient factors had no association with pain intensity scores.
  
  
  CONCLUSIONS
  Upper facial expressions are most frequently activated during pain response in noncommunicative critically ill patients and might be a valid alternative to self-report ratings.
authors.affiliation: Critical Care, School of Nursing, Virginia Commonwealth University, Richmond, VA, USA. marif@vcu.edu
authors.forename: Mamoona Arif
authors.initials: MA
authors.lastname: Rahu
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Grap
authors.forename: Jeffrey F
authors.initials: JF
authors.lastname: Cohn
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Munro
authors.forename: Debra E
authors.initials: DE
authors.lastname: Lyon
authors.forename: Curtis N
authors.initials: CN
authors.lastname: Sessler
mesh_terms: D000328:Adult; D016638:Critical Illness; D005149:Facial Expression; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010147:Pain Measurement / Q000379:methods*; D011446:Prospective Studies; D012121:Respiration, Artificial; D013396:Suction / Q000009:adverse effects; D014741:Video Recording