Effect of combined pulmonary-psychological nursing on posttraumatic stress disorder in patients with acute respiratory distress syndrome

Abstract

BACKGROUND

Survivors of acute respiratory distress syndrome (ARDS) frequently suffer from long-term physical and psychological sequelae, including impaired lung function and posttraumatic stress disorder (PTSD), highlighting the need for comprehensive rehabilitation strategies.

AIM

To evaluate the impact of staged pulmonary rehabilitation nursing combined with cognitive psychological intervention (SPRNCPI) on PTSD in patients with ARDS.

METHODS

A retrospective analysis was conducted on the data of 230 patients with ARDS admitted from April 2020 to April 2024. The patients were divided into two groups: A routine care (RC) group (n = 125) and a SPRNCPI group (n = 105). The SPRNCPI group received mechanical ventilation support, RC, and additional staged pulmonary rehabilitation nursing combines with cognitive psychological interventions including psychological support, emotional management training, and regular follow-ups. Baseline demographic information, respiratory function parameters, oxygenation index, serum cortisol levels, PTSD symptoms, emotional status, and quality of life were assessed.

RESULTS

After nursing, forced expiratory volume in one second (P < 0.001), forced vital capacity (P = 0.009), and PaO₂/FiO₂ (P = 0.005) were significantly higher in the SPRNCPI group than in the RC group. Serum cortisol levels (P = 0.002), Impact of Event Scale-Revised overall score (P < 0.001), Self-Rating Anxiety Scale (P = 0.002), and Self-Rating Depression Scale (P < 0.001) scores were significantly lower in the SPRNCPI group. Physiological field scores (P = 0.033), psychological field scores (P = 0.015), social field scores (P = 0.043), and environmental field scores (P = 0.010) were significantly higher in the SPRNCPI group.

CONCLUSION

SPRNCPI significantly improves respiratory function, reduced PTSD symptoms, lowered anxiety and depression levels, and enhanced overall quality of life in patients with ARDS. This integrated approach offers a promising strategy for enhancing patient outcomes in critical care settings.

Key Words: Acute respiratory distress syndrome; Pulmonary rehabilitation; Cognitive psychological intervention; Posttraumatic stress disorder; Mental health; Nursing

Core Tip: This study demonstrates that a novel, integrated protocol combining staged pulmonary rehabilitation nursing with cognitive psychological intervention offers a holistic approach for survivors of acute respiratory distress syndrome. Unlike routine care, this combined strategy significantly improved not only respiratory function and oxygenation but also mitigated psychological trauma, effectively reducing symptoms of posttraumatic stress disorder, anxiety, and depression. This underscores the critical need to address both physical and mental health in acute respiratory distress syndrome recovery to enhance overall patient outcomes.

INTRODUCTION

Acute respiratory distress syndrome (ARDS) is a life-threatening condition characterized by the acute onset of hypoxemia and bilateral pulmonary infiltrates. Despite advancements in critical care medicine, ARDS remains a challenging condition with high rates of complications and prolonged hospital stay[1]. Patients suffering from ARDS often experience severe physical and psychological distress, including posttraumatic stress disorder (PTSD), which can persist long after the acute phase of illness has resolved[2]. The prevalence of PTSD among ARDS survivors is estimated to be as high as 23.9%, underscoring the need for comprehensive interventions that address physical recovery and mental health[3].

The pathophysiology of ARDS involves complex interactions between inflammatory mediators, endothelial dysfunction, and alveolar damage. While essential for maintaining oxygenation, mechanical ventilation can exacerbate lung injury through mechanisms such as volutrauma and atelectrauma. Protective lung ventilation strategies have been developed to mitigate these risks, but they do not fully address the multifaceted challenges faced by patients with ARDS[4,5]. Moreover, the psychological impact of prolonged intensive care unit (ICU) stays and invasive treatments cannot be overlooked. Anxiety, depression, and PTSD are common comorbidities that significantly affect patients’ quality of life and functional outcomes[6]. Therefore, the importance of integrating psychological support into the care of patients with ARDS is being increasingly recognized.

Pulmonary rehabilitation has emerged as a promising adjunctive therapy for various respiratory conditions, including chronic obstructive pulmonary disease (COPD) and interstitial lung disease[7]. This multidisciplinary approach aims to improve physical function, reduce symptoms, and enhance overall quality of life[8]. However, its application in ARDS is poorly established. Staged pulmonary rehabilitation, tailored to the different phases of ARDS - from the acute phase through recovery - offers a potential pathway to optimize patient outcomes. By incorporating targeted exercises, breathing techniques, and education, staged pulmonary rehabilitation can help restore lung function and promote independence[9]. In addition, cognitive psychological interventions have shown promise in addressing the emotional and psychological toll of critical illness. These interventions include psychological support, emotional management training, and regular follow-ups, which can mitigate the risk of developing PTSD and other mental health issues[10].

Despite the recognized benefits of pulmonary rehabilitation and cognitive psychological interventions, their integration into standard care for ARDS remains limited. Traditional approaches often focus on physiological stabilization and mechanical ventilation optimization, with less emphasis on holistic recovery[11]. This gap highlights the need for additional comprehensive care models that address physical and psychological aspects of recovery. For patients with ARDS, the traumatic experience of dyspnea, dependency on life-support, and the ICU environment itself can be profound psychological stressors. Cognitive psychological interventions, which encompass techniques such as cognitive restructuring, emotional regulation training, and psychological support, are designed to help patients process these traumatic experiences, develop adaptive coping mechanisms, and reduce maladaptive thought patterns. Given the high burden of PTSD and other mental health disorders in ARDS survivors, innovative strategies that combine evidence-based pulmonary rehabilitation with cognitive psychological interventions must be explored. This combined approach has the potential to mitigate the burden of PTSD and improve overall well-being; however, further exploration is necessary to fully understand its impact on ARDS patient care.

MATERIALS AND METHODS

Case selection

This study retrospectively analyzed the medical records of 230 patients with ARDS admitted to Henan Provincial People’s Hospital from April 2020 to April 2024. Collect demographic information of patients through the case system. All executed procedures comply with the ethical standards of the responsible committees for human experiments (institutions and countries) and the 1964 Declaration of Helsinki and subsequent versions. This study was approved by the Institutional Review Board of Henan Provincial People’s Hospital. Informed consent was waived by the Institutional Review Board and Ethics Committee of Henan Provincial People’s Hospital for this retrospective study because of the exclusive use of de-identified patient data, which posed no potential harm or impact on patient care.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Patients over 18 years old; (2) Clinically diagnosed with ARDS[12]; (3) They have received mechanical ventilation greater than 12 hours or noninvasive ventilation greater than 4 hours; and (4) They have complete medical records. The exclusion criteria were as follows: (1) Combined with severe cognitive impairment, unable to cooperate with rehabilitation training and nursing evaluation; (2) Seriou’s chest deformities, spinal deformities, and other diseases that affect respiratory movement; (3) History of chest surgery or trauma within 3 months; (4) Combined with advanced malignant tumors; and (5) Pregnant and lactating of women.

A total of 261 patients with ARDS were initially identified during the study period. After the inclusion and exclusion criteria were applied, 31 patients were excluded: 5 for severe cognitive impairment, 12 for preexisting spinal or chest deformities, 8 with a recent history of chest surgery or trauma, and 6 with advanced malignancies. Finally, 230 patients were enrolled in this study.

Grouping and nursing methods

Grouping criteria: According to the type of care received, the patients were divided into two groups: The routine care (RC) group and the staged pulmonary rehabilitation nursing combined with cognitive psychological intervention (SPRNCPI) group. A total of 125 patients with ARDS who only received routine medical care and standard treatment were included in the RC group, and 105 patients who received SPRNCPI in addition to RC were included in the SPRNCPI group. The disparity in group sizes arose from the retrospective assignment based on the standard care protocols available at different phases of the study period and patient eligibility for the combined intervention, rather than from randomized allocation.

Nursing methods: The patients were first rapidly initiated on mechanical ventilation support: Once ARDS was diagnosed, mechanical ventilation support was immediately initiated to maintain the oxygenation index (PaO₂/FiO₂ ratio) within a safe range. Protective lung ventilation strategies were employed, such as low tidal volume ventilation (6 mL/kg ideal body weight), limiting plateau pressure to no more than 30 cm H₂O, and using positive end-expiratory pressure (PEEP) as needed to optimize gas exchange.

RC: The patients were assisted in turning over and performing back tapping every 2 hours to promote sputum clearance and prevent atelectasis pneumonia; the oxygen flow rate was adjusted reasonably according to the patient’s condition and medical orders to ensure adequate oxygen supply; the patient’s vital signs, respiratory rate, rhythm, and depth were closely monitored, and abnormalities were promptly identified and reported to the doctor; nebulization inhalation therapy was performed on patients 2-3 times a day as per medical orders.

SPRNCPI: The SPRNCPI included the following: (1) First stage (acute phase, within 48 hours of mechanical ventilation); (2) Second stage (relief phase, from 48 hours of mechanical ventilation up to before weaning); and (3) Third stage (rehabilitation phase, from after weaning until discharge). The cognitive psychological interventions, which were integrated throughout these stages, included the following: (1) Psychological support: Providing counseling services to patients and their families to help them cope with the anxiety and fear brought about by the illness; (2) Emotional management training: Teaching patients’ emotional regulation skills under the guidance of professional psychological consultants to reduce the risk of developing PTSD; and (3) regular follow-ups: Continuously tracking the patient’s recovery status after discharge and providing further psychological support and rehabilitation training when necessary.

Observation indicators

Baseline data collection: For all enrolled patients, baseline demographic information, including severity grading, causes, and length of hospital stay, was collected from the medical record system.

Respiratory function parameters: Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were recorded before nursing care and 1 week after nursing care, and the FEV1/FVC ratio was then calculated. FVC was measured using a spirometer (V508368, Jiangsu Yuanyan Medical Equipment Co., Ltd., China) to record the patient’s thoracic gas volume. FEV1 was measured using a pulmonary function testing device (AS-407, MINATO Medical Science, Japan).

Optimal PEEP: Before and 1 week after nursing care, the “PEEP incremental-decremental method” was used to determine the optimal PEEP. PEEP was incrementally increased from 5 cm H₂O with a gradient of 2 cm H₂O per step (not exceeding 20 cm H₂O). Each adjustment was maintained for 30 minutes of ventilation until respiratory mechanics stabilized, followed by the measurement of arterial blood gases (PaO₂ and PaCO₂), oxygenation index (PaO₂/FiO₂), plateau pressure, and static lung compliance [Cstat, calculated as: Cstat = tidal volume/(plateau pressure-PEEP)]. If plateau pressure exceeded 30 cm H₂O or if circulatory indicators (heart rate, mean arterial pressure) fluctuated more than 15% from baseline values, then the increase was stopped and the decrement phase began. Starting from the highest safe PEEP value, the value was decreased in the same gradient down to 5 cm H₂O, with each gradient also maintained for 30 minutes and the parameters recorded accordingly. The optimal PEEP was determined based on the principle of “optimal oxygenation and minimal risk of lung injury”. Preference was given to the PEEP value where PaO₂/FiO₂ was maximized (≥ 200 mmHg, or ≥ 150 mmHg if FiO₂ ≤ 0.6) and SpO₂ ≥ 92% while also meeting plateau pressure ≤ 30 cm H₂O, Cstat ≥ 30 mL/cm H₂O, and stable circulation (heart rate, mean arterial pressure fluctuation < 15%, no signs of inadequate tissue perfusion).

Oxygenation index: Before and 1 week after nursing care, the oxygenation index was calculated using the relevant lung ventilation parameters displayed on the ventilator as = PaO₂/FiO₂, where PaO₂ is the arterial oxygen partial pressure, and FiO₂ is the fraction of inspired oxygen. A high oxygenation index indicates a good respiratory status.

Serum cortisol: Before nursing care and 1 week after nursing care at 8:00, 6 mL of fasting venous blood was collected from the patient into a tube without anticoagulant and kept completely still until serum separation. Centrifugation was performed to separate the serum by spinning at 4000 rpm for 10 minutes at 4 °C. The supernatant was carefully withdrawn. Enzyme-linked immunosorbent assay, specifically specific serum cortisol assay kit (ab108665, Abcam, MA, United States), was used to detect serum cortisol levels.

PTSD symptoms: The Impact of Event Scale-Revised (IES-R) questionnaire was used to measure PTSD symptoms before and 1 week after care. The IES-R encompasses three dimensions: Overall intrusion, overall avoidance, and overall hyperarousal, comprising 22 items in total. It assesses the distress level related to specific difficulties over the past seven days on a scale from “not at all” (item score = 0), “a little bit” (1), “moderately” (2), “quite a bit” (3), to “extremely” (4). The total score is calculated by summing up the scores of all items, ranging from 0 to 88. The Cronbach’s alpha for the IES-R is 0.91[13].

Emotion and hope level evaluation: The patient’s mood and hope level were evaluated before and after patient care using the Self-Rating Scale for Depression (SDS), Self-Rating Anxiety Scale (SAS), and Herth Hope Scale. SDS and SAS both contain 20 questions and are rated on a 4-point scale, with low scores indicating weak depression and anxiety. The Herth Hope Scale consists of 12 questions, with scores of 12-23 being low, 24-35 being moderate, and 36-48 being high; high scores indicate a high level of hope. The Cronbach’s alpha values for SDS and SAS are 0.92 and 0.81, respectively[14,15]. The Cronbach’s alpha for the Herth Hope Scale is 0.88[16].

Survival quality evaluation: The World Health Organization Quality of Life-BREF Scale was used to assess the quality of life before and after patient care. This scale consists of 26 questions, each rated on a 5-point Likert scale (1-5 points), and is divided into four domains: Physical, psychological, social relationships, and environment. The raw scores for the items within each domain are summed and then converted to a standardized score using the formula: Standardized score = [(raw score - minimum possible score)/(maximum possible score - minimum possible score)] × 100, resulting in a score range of 0-100. High scores indicate good quality of life in that domain. The Cronbach’s alpha for the World Health Organization Quality of Life-BREF Scale is 0.90[17].

Statistical analysis

The χ² test or Fisher exact probability method was used for the comparison of classified variables between two groups. t-test or Mann-Whitney U test was used for the analysis of differences in the numerical variables between two groups. SPSS version 20.0 and GraphPad Prism version 5 statistical software were used for data analysis. All P values were bilaterally distributed, and P < 0.05 indicated that the difference was statistically significant.

RESULTS

Analysis of differences in general information of patients

In the comparison of general information between the RC (n = 125) and SPRNCPI (n = 105) groups, no significant differences were observed in age (P = 0.064), gender distribution (P = 0.508), body mass index (P = 0.090), education level (P = 0.534), combined diabetes (P = 0.785), combined hypertension (P = 0.247), combined hyperlipidemia (P = 0.347), smoking status (P = 0.611), or drinking status (P = 0.825; Table 1). These results indicate that the two groups were comparable in terms of baseline demographics.

Table 1 Comparison of general information between two groups, mean ± SD/n (%).

Parameters	RC group (n = 125)	SPRNCPI group (n = 105)	t/χ2	P value
Age (years)	56.74 ± 5.65	58.86 ± 10.44	1.868	0.064
Gender			0.439	0.508
Male	72 (57.60)	65 (61.90)
Female	53 (42.40)	40 (38.10)
BMI (kg/m2)	23.02 ± 3.00	23.73 ± 3.30	1.704	0.090
Education level (years)			1.255	0.534
Primary or below	37 (29.60)	30 (28.57)
Secondary school	44 (35.20)	44 (41.90)
College or above	44 (35.20)	31 (29.52)
Combined diabetes	17 (13.60)	13 (12.38)	0.075	0.785
Combined hypertension	21 (16.80)	12 (11.43)	1.340	0.247
Combined hyperlipidemia	25 (20.00)	16 (15.24)	0.883	0.347
Smoking			0.985	0.611
Never	30 (24.00)	20 (19.05)
Former	19 (15.20)	15 (14.28)
Current	76 (60.80)	70 (66.67)
Drinking			0.384	0.825
Never	27 (21.60)	22 (20.95)
Former	20 (16.00)	14 (13.33)
Current	78 (62.40)	69 (65.72)

BMI: Body mass index; RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention.

Comparison of clinical characteristics between the two groups of patients

In the comparison of clinical characteristics between the RC and SPRNCPI groups, no significant differences were observed in lung injury score (P = 0.089), severity grading (P = 0.506), causes of illness (P = 0.813), Acute Physiology and Chronic Health Evaluation II score (P = 0.153), Sequential Organ Failure Assessment score (P = 0.766), length of hospital stay (P = 0.661), length of ICU stay (P = 0.712), ventilation duration (P = 0.634), or duration of respiratory failure (P = 0.220; Table 2). These results indicate that the two groups were comparable in terms of clinical characteristics.

Table 2 Comparison of clinical characteristics between two groups of patients, mean ± SD/n (%).

Parameters	RC group (n = 125)	SPRNCPI group (n = 105)	t/χ2	P value
Lung injury score	2.65 ± 0.35	2.74 ± 0.44	1.708	0.089
Severity grading			0.442	0.506
Moderate	93 (74.40)	74 (70.48)
Severe	32 (25.60)	31 (29.52)
Causes			0.952	0.813
Trauma	30 (24.00)	31 (29.52)
Sepsis	39 (31.20)	31 (29.52)
Pneumonia	44 (35.20)	33 (31.43)
Other or unknown	12 (9.60)	10 (9.52)
APACHE II score	14.47 ± 2.35	14.12 ± 1.26	1.434	0.153
SOFA score	7.25 ± 1.58	7.19 ± 1.63	0.298	0.766
Length of hospital stay (days)	28.53 ± 5.77	28.28 ± 2.72	0.440	0.661
Length of ICU stay (days)	15.02 ± 1.06	14.97 ± 1.08	0.370	0.712
Ventilation duration (days)	9.53 ± 2.68	9.39 ± 1.71	0.477	0.634
Duration of respiratory failure (days)	8.93 ± 1.12	9.11 ± 1.16	1.230	0.220

APACHE II: Acute Physiology and Chronic Health Evaluation II; SOFA: Sequential Organ Failure Assessment; ICU: Intensive care unit; RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention.

Comparison of lung function between the two groups of patients

In the comparison of lung function between the RC and SPRNCPI groups, no significant differences were observed in FEV1 before nursing (P = 0.792), FVC before nursing (P = 0.481), or FEV1/FVC ratio before nursing (P = 0.919; Table 3). After nursing, FEV1 (2.02 ± 0.16 vs 1.92 ± 0.25, t = 3.620, P < 0.001) and FVC (2.41 ± 0.31 vs 2.32 ± 0.25, t = 2.641, P = 0.009) were significantly higher in the SPRNCPI group. Although the FEV1/FVC ratio showed a trend toward improvement in the SPRNCPI group, the difference did not reach statistical significance (P = 0.063).

Table 3 Comparison of lung function between two groups of patients, mean ± SD.

Parameters	RC group (n = 125)	SPRNCPI group (n = 105)	t	P value
FEV1 (L)
Before nursing	1.32 ± 0.24	1.33 ± 0.21	0.264	0.792
After nursing	1.92 ± 0.25	2.02 ± 0.16	3.620	< 0.001
FVC (L)
Before nursing	1.97 ± 0.22	1.99 ± 0.19	0.706	0.481
After nursing	2.32 ± 0.25	2.41 ± 0.31	2.641	0.009
FEV1/FVC (%)
Before nursing	66.14 ± 5.62	66.21 ± 5.49	0.102	0.919
After nursing	82.61 ± 4.91	83.84 ± 5.04	1.867	0.063

FEV1: Forced expiratory volume in 1 second; FVC: Forced vital capacity; RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention.

Comparison of blood gas between the two groups of patients

In the comparison of blood gas parameters between the RC and SPRNCPI groups, no significant differences were observed in optimal PEEP before nursing (P = 0.748), FiO₂ before nursing (P = 0.066), and PaO₂/FiO₂ before nursing (P = 0.232; Table 4). After nursing, significant differences were noted: Optimal PEEP (8.93 ± 1.02 vs 9.26 ± 1.14, t = 2.265, P = 0.024) and FiO₂ (0.45 ± 0.05 vs 0.47 ± 0.06, t = 2.509, P = 0.013) were significantly lower in the SPRNCPI group, whereas PaO₂/FiO₂ was significantly higher in the SPRNCPI group (285.43 ± 24.76 vs 276.67 ± 22.15, t = 2.830, P = 0.005).

Table 4 Comparison of blood gas between two groups of patients, mean ± SD.

Parameters	RC group (n = 125)	SPRNCPI group (n = 105)	t	P value
Optimal PEEP (cm H2O)
Before nursing	10.25 ± 1.35	10.31 ± 1.27	0.322	0.748
After nursing	9.26 ± 1.14	8.93 ± 1.02	2.265	0.024
FiO2
Before nursing	0.65 ± 0.08	0.64 ± 0.07	1.847	0.066
After nursing	0.47 ± 0.06	0.45 ± 0.05	2.509	0.013
PaO2/FiO2 (mmHg)
Before nursing	152.36 ± 18.74	155.28 ± 17.92	1.199	0.232
After nursing	276.67 ± 22.15	285.43 ± 24.76	2.830	0.005

PEEP: Positive end-expiratory pressure; RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention.

Comparison of serum cortisol between the two groups of patients

In the comparison of serum cortisol levels between the RC and SPRNCPI groups, no significant differences were observed before nursing (P = 0.4809; Figure 1A). After nursing, serum cortisol levels were significantly lower in the SPRNCPI group (20.65 ± 1.04 vs 21.26 ± 1.91, t = 3.064, P < 0.01).

Figure 1 Comparison of two groups of patients. A: Serum cortisol (ng/mL); B: Herth Hope Scale scores; C: Self-Rating Anxiety Scale and Self-Rating Scale for Depression scores. ^aP < 0.01; ^bP < 0.01. RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Scale for Depression.

Comparison of IES-R score between the two groups of patients

In the comparison of IES-R scores between the RC and SPRNCPI groups, no significant differences were observed in overall intrusion before nursing (P = 0.774), overall avoidance before nursing (P = 0.901), overall hyperarousal before nursing (P = 0.698), or IES-R overall score before nursing (P = 0.828; Table 5). After nursing, overall intrusion (5.91 ± 1.42 vs 6.63 ± 2.32, t = 2.896, P = 0.004) and overall avoidance (6.84 ± 0.27 vs 7.15 ± 1.02, t = 3.259, P = 0.001) were significantly lower in the SPRNCPI group. Overall hyperarousal showed a more pronounced decrease in the SPRNCPI group (4.52 ± 0.75 vs 5.14 ± 1.85, t = 4.545, P < 0.001). The IES-R overall score after nursing was significantly lower in the SPRNCPI group (17.27 ± 1.41 vs 18.92 ± 1.91, t = 7.502, P < 0.001).

Table 5 Comparison of Impact of Event Scale-Revised score between two groups of patients, mean ± SD.

Parameters	RC group (n = 125)	SPRNCPI group (n = 105)	t	P value
Overall intrusion (score)
Before nursing	8.43 ± 1.68	8.37 ± 1.71	0.287	0.774
After nursing	6.63 ± 2.32	5.91 ± 1.42	2.896	0.004
Overall avoidance (score)
Before nursing	9.45 ± 2.73	9.42 ± 0.76	0.125	0.901
After nursing	7.15 ± 1.02	6.84 ± 0.27	3.259	0.001
Overall hyperarousal (score)
Before nursing	6.73 ± 2.23	6.66 ± 0.17	0.389	0.698
After nursing	5.14 ± 1.85	4.52 ± 0.75	4.545	< 0.001
IES-R overall (score)
Before nursing	24.61 ± 5.63	24.45 ± 5.53	0.217	0.828
After nursing	18.92 ± 1.91	17.27 ± 1.41	7.502	< 0.001

IES-R: Impact of Event Scale-Revised; RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention.

Comparison of hopes and emotions between the two groups of patients

In the comparison of Herth Hope Scale scores between the RC and SPRNCPI groups, no significant differences were observed before nursing (P = 0.868) or after nursing (P = 0.295; Figure 1B). In the comparison of SAS and SDS scores between the RC and SPRNCPI groups, no significant differences were observed in SAS (P = 0.558) or SDS (P = 0.241) scores before nursing (Figure 1C). After nursing, SAS and SDS scores were significantly lower in the SPRNCPI group (37.79 ± 4.14 vs 39.62 ± 4.62, t = 3.147, P = 0.002; 38.71 ± 3.73 vs 40.43 ± 4.05, t = 3.336, P < 0.001).

Comparison of quality of survival scores between the two groups of patients

In the comparison of quality of survival scores between the RC and SPRNCPI groups, no significant differences were observed in physiological field scores, psychological field scores, social field scores, and environmental field scores (all P > 0.05; Table 6). After nursing, physiological field scores (P = 0.033), psychological field scores (P = 0.015), social field scores (P = 0.043), and environmental field scores (P = 0.010) were significantly higher in the SPRNCPI group.

Table 6 Comparison of quality of survival scores between two groups of patients, mean ± SD.

Parameters	RC group (n = 125)	SPRNCPI group (n = 105)	t	P value
Physiological field (score)
Before nursing	42.36 ± 8.25	42.15 ± 8.17	0.193	0.847
After nursing	63.24 ± 9.32	65.83 ± 8.91	2.145	0.033
Psychological field (score)
Before nursing	39.82 ± 7.64	40.05 ± 7.58	0.228	0.820
After nursing	66.26 ± 8.45	68.92 ± 7.83	2.455	0.015
Social field (score)
Before nursing	45.23 ± 8.91	45.17 ± 8.87	0.044	0.965
After nursing	69.95 ± 9.24	72.36 ± 8.65	2.032	0.043
Environmental field (score)
Before nursing	48.75 ± 9.13	48.82 ± 9.05	0.058	0.954
After nursing	72.14 ± 9.57	75.28 ± 8.74	2.583	0.010

RC: Routine care; SPRNCPI: Staged pulmonary rehabilitation nursing combined with cognitive psychological intervention.

DISCUSSION

This study aimed to evaluate the impact of SPRNCPI on patients with ARDS. Results indicate that this integrated approach led to improvements in several key areas, including lung function, oxygenation index, serum cortisol levels, PTSD symptoms, anxiety, depression, and quality of life. Post nursing assessments revealed that FEV1 and FVC were higher in the SPRNCPI group than in the RC group. This finding suggests that the combination of staged pulmonary rehabilitation and cognitive psychological interventions may enhance lung function recovery in patients with ARDS. Pulmonary rehabilitation typically involves targeted exercises, breathing techniques, and education, which can improve muscle strength and endurance, thereby enhancing overall respiratory function[18,19]. Cognitive psychological interventions may reduce stress and anxiety, which are known to exacerbate respiratory symptoms[20]. Lamberton and Mosher[21] and Sohanpal et al[22] showed that pulmonary rehabilitation and cognitive psychological interventions can improve lung function in other chronic respiratory conditions, such as COPD. However, the specific application of these methods in ARDS is less documented, making our findings particularly valuable for future research.

After nursing, the SPRNCPI group demonstrated better oxygenation index, lower FiO₂, and lower levels of optimal PEEP than the RC group. These changes suggest that SPRCPCI can reduce the demand for the “respiratory support intensity” of mechanical ventilation in patients while improving gas exchange efficiency, reducing their dependence on high-concentration oxygen, and lowering the risk of lung injury (such as barotrauma and volutrauma) potentially caused by prolonged high PEEP and the likelihood of complications such as oxygen toxicity and pulmonary fibrosis due to high-concentration oxygen inhalation. This approach aligns closely with the core principles of “protective lung ventilation strategies” in ARDS treatment. From a mechanistic perspective, the staged pulmonary rehabilitation has likely contributed to good lung compliance and ventilation-perfusion matching, while cognitive psychological interventions may have reduced the physiological stress response, leading to stable blood gas parameters[23,24]. Studies on mechanical ventilation strategies highlighted the importance of optimizing PEEP and FiO₂ levels to improve oxygenation without causing additional lung injury[25]. Our findings support the idea that combining these strategies with comprehensive rehabilitation and psychological support can further enhance patient outcomes.

Serum cortisol levels were reduced in the SPRNCPI group after nursing. Cortisol is a biomarker of stress, and its decrease in this context could indicate a weakened stress response[26]. This finding indicates that the integrated intervention can effectively alleviate the stress response of patients with ARDS. These individuals often face dual stress from severe illness and invasive treatment, which leads to the hyperactivation of the hypothalamic-pituitary-adrenal axis and elevated cortisol levels[27]. The cognitive psychological intervention in SPRNCPI may break this cycle: Psychological support helps patients rationalize their understanding of the disease and reduce fear of the unknown, and emotional management training teaches patients practical coping skills, enabling them to actively regulate their emotional state. These measures reduce the psychological stress source of patients, thereby reducing their cortisol secretion. Persistently high cortisol levels can inhibit immune function and aggravate anxiety and depression, forming a vicious circle. Thomas et al[28] found that cortisol levels were closely related to the severity of respiratory distress, and our results further suggest that reducing cortisol through comprehensive intervention may be a potential way to promote respiratory recovery.

After nursing, overall intrusion, avoidance, hyperarousal, and IES-R scores were lower in the SPRNCPI group than in the RC group. This finding indicates that the integrated approach effectively reduced PTSD symptoms in ARDS survivors. Cognitive psychological interventions, including psychological support and emotional management training, may have directly mitigated the psychological burden by providing structured coping strategies and reducing stress levels. These interventions can help patients process traumatic experiences and develop resilience, thereby decreasing intrusive thoughts and avoidance behaviors[29,30]. Our findings suggest that the integrated approach of staged pulmonary rehabilitation and cognitive psychological interventions addresses the immediate psychological needs and fosters a comprehensive recovery process. The combination of physical rehabilitation and psychological support offers a holistic approach to address the multifaceted challenges faced by ARDS survivors.

After nursing, anxiety and depression scores were lower in the SPRNCPI group than in the RC group, indicating that the integrated approach also has positive effects on mental health. Psychological distress is a significant issue among patients with ARDS, often persisting long after hospital discharge. The reduction in anxiety and depression scores suggests that the staged pulmonary rehabilitation and cognitive psychological interventions improve physical function and provides substantial psychological benefits. The inclusion of regular follow-ups and emotional management training might have played a critical role in achieving these improvements[31,32]. While the intervention significantly reduced anxiety and depression scores, no significant improvement was observed in the Herth Hope Scale. A possible explanation is that hope is a stable and multidimensional construct, influenced by factors beyond the scope of our short-term psychological intervention, such as personal resilience, social support, and long-term outlook. As directly responsive to emotional regulation and coping strategies, anxiety and depression may have been immediately alleviated by the cognitive psychological components.

After nursing, physiological, psychological, social, and environmental field scores were higher in the SPRNCPI group than in the RC group. This finding indicates that the integrated approach positively impacts multiple dimensions of quality of life. Comprehensive rehabilitation programs that address physical and psychological needs are essential for improving long-term outcomes in patients with ARDS[30]. Our findings suggest that the combined approach of staged pulmonary rehabilitation and cognitive psychological interventions can provide a holistic framework for improving the overall quality of life of ARDS survivors.

Despite the promising results, this study has several limitations. The nonrandomized, retrospective design is a principal limitation. Group allocation was determined by the care modality received, which may have introduced selection bias and confounded the observed outcomes. Although baseline characteristics were comparable between the groups, unmeasured factors could have influenced the assignment to the intervention group and the prognosis. The retrospective design limits the ability to establish causality between the intervention and the observed outcomes. Prospective randomized controlled trials are needed to validate these findings. The study population was relatively homogeneous, potentially limiting the generalizability of the results to other populations. Future research should aim to include diverse patient groups to assess the broad applicability of the integrated approach. Psychological outcomes such as PTSD, anxiety, and depression were assessed only 1 week after the intervention. Given that PTSD often develops or persists over a longer period, the absence of long-term follow-up (e.g., at 3 months, 6 months, or 12 months) limits the ability to fully capture the trajectory of psychological recovery. Future studies should include extended follow-ups to further evaluate the sustainability of the intervention effects.

CONCLUSION

The integration of SPRNCPI demonstrated substantial benefits for patients with ARDS. This approach improved lung function, oxygenation, serum cortisol levels, PTSD symptoms, anxiety, depression, and overall quality of life. By addressing physical and psychological dimensions of recovery, SPRNCPI offers a holistic strategy that enhances patient outcomes beyond traditional care methods. Further prospective studies are needed to validate these findings and explore their broad applications in diverse patient populations.