Letter to the editor: Failing an automated comprehension test while being able to report on needs: eyetracking in critically ill intubated patients should not be underestimated,Critical Care

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Letter to the editor: Failing an automated comprehension test while being able to report on needs: eyetracking in critically ill intubated patients should not be underestimated
Critical Care ( IF 9.3 ) Pub Date : 2022-12-22 , DOI: 10.1186/s13054-022-04280-x
Christian Waydhas , Robert Gaschler , Christopher Ull , Christina Weckwerth , Oliver Cruciger , Uwe Hamsen

Dear editors

With great interest, we have read the article “Assessing oral comprehension with an eye tracking based innovative device in critically ill patients and healthy volunteers: a cohort study” published by Bodet-Contentin and colleagues in Critical Care.

They studied the ability of healthy volunteers and critically ill patients to answer the questions of the Montreal Toulouse Test to study their oral comprehension by using an eye-tracking device. The test questions were read out loud by a recorded voice, and the test was performed automated without the active involvement of a human being. An answer was classified as “right” when the subject fixated the panel with the described picture for at least 3 s within a time window of 6 s. The authors reported a median rate of correct answers of 93% in healthy volunteers and of 38% critically ill patients. As a take-home message, they conclude that “implementing an oral comprehension test using an innovative eye-tracking-based interface seems feasible in critically ill intubated patients.”

Critical readers may come to another conclusion. They might take home that most critically ill patients who are thought to be able to communicate judiciously (calm and awake as evaluated by the Richmond Agitation and Sedation Scale (RASS) with proper hearing and vision) are not able to do so by using eye-tracking technology. Performance of critically ill patients on the test apparently was very poor. Of the 15 test items used (compare: video provided online as File 2), nine contained four panels (i.e., one target panel and three distractor panels, guessing baseline = 25%). The other 6 contained two panels (guessing baseline = 50%). The average guessing rate across the 15 items thus was 35%. Hence, the performance of critically ill patients was very close to the performance expected under guessing. For critically ill patients older than 60, the authors report an even lower performance (27% median correct rate). One might argue that—instead of exclusively arguing based on guessing rates—one should also consider the time demands and constraints (fixating the correct panel for 3 out of 6 s). Yet, in this case one would still conclude that critically ill patients apparently perform very poorly on the test the way it had been administered. Given that their performance was close to chance baseline, one might even doubt that eyetracking-based assessment is feasible at all in this population.

However, we feel that some technical concerns may have precluded more favorable results, as several other investigators have observed [2,3,4].

Our major concern is that the requirement of gazing at least three seconds at a panel on a monitor in the study by Bodet-Contentin et al. is not possible for many ICU patients. In the study from Duffy et al. [2], a gaze fixation of 0.4 s was used. In another study, it has been observed and reported by patients that even a gaze fixation time of 1 s was too strenuous for many patients [5] and a gaze fixation time of 0.6 s was recommended. This is one reason: We believe that the results from Bodet-Contentin substantially underestimate the ability of their patients to thoughtfully communicate by using the eye-tracking technology.
Another reason lies in the observation that intubated critically ill patients can consistently report on their appraisals of their situation via eye fixations on response panels [6]. For instance, 90% indicate to feel trapped (while other items show lower approval rates). This underlines that patients understand what they are asked and are able to indicate their answer via fixation position. The questions posed in the Montreal–Toulouse test do have little or no context to the extreme situation the patients are experiencing. Accounting for the high level of concentration required by the patients their motivation to give answers might be reduced. Beyond the example just mentioned, in several studies it has been shown that critically ill patients are quite able to give differentiated answers questions concerning their actual situation, requirements, and projections on their future [3,4,5,6].
Thirdly, although automation of tasks will allow the medical personal on an ICU to focus on other duties, in this particular setting, we feel that a personal interaction with a human being would be preferable. One major concern of awake critically ill patients is the lack of communication with nurses or physicians [7]. So, being interrogated by a machine (e.g., automation, recorded voice, lack of individualization) might further reduce patients’ motivation and ability to focus their gaze.

In conclusion, we congratulate the authors that they provided a study on assessment of oral comprehension after previous studies suggested that the eye-tracking technology is feasible in non-verbal critically ill patients. On the other hand, we believe that some of the unfavorable technical circumstances of the study did preclude a better performance of those non-verbal patient. Future studies have to show that the eye-tracking technology can be successfully implemented in the daily routine in an ICU and adds to the well-being of non-verbal patients.

Not applicable.

ICU:: Intensive Care Unit
RASS:: Richmond Agitation and Sedation Scale

Bodet-Contentin L, Messet-Charrière H, Gissot V, et al. Assessing oral comprehension with an eye tracking based innovative device in critically ill patients and healthy volunteers: a cohort study. Crit Care. 2022;26:288. https://doi.org/10.1186/s13054-022-04137-3.
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This work was supported by the “Junior Clinician Scientist Program” of the Ruhr-University Bochum, Germany (Grant Number K129-19). The funding bodies did not influence the study’s design, the collection, analysis, and interpretation of data, nor in writing the manuscript.

Authors and Affiliations

Department of Trauma Surgery, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
Christian Waydhas
Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
Christian Waydhas, Christopher Ull, Oliver Cruciger & Uwe Hamsen
Department of Psychology, FernUniversität Hagen, Universitätsstraße 33, 58084, Hagen, Germany
Robert Gaschler & Christina Weckwerth

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Contributions

CW and RG drafted the first version of the letter. CU, UH, OC, and CWe provided additional input. All authors read and approved the final manuscript.

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Correspondence to Robert Gaschler.

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Waydhas, C., Gaschler, R., Ull, C. et al. Letter to the editor: Failing an automated comprehension test while being able to report on needs: eyetracking in critically ill intubated patients should not be underestimated. Crit Care 26, 400 (2022). https://doi.org/10.1186/s13054-022-04280-x

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Received: 05 December 2022
Accepted: 14 December 2022
Published: 22 December 2022
DOI: https://doi.org/10.1186/s13054-022-04280-x

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中文翻译：

致编辑的信：在能够报告需求的同时未能通过自动理解测试：不应低估危重插管患者的眼动追踪

尊敬的编辑

我们怀着极大的兴趣阅读了 Bodet-Contentin 及其同事在Critical Care发表的文章“使用基于眼动追踪的创新设备评估重症患者和健康志愿者的口语理解能力：一项队列研究” 。

他们研究了健康志愿者和危重病人回答蒙特利尔图卢兹测试问题的能力，通过使用眼动仪研究他们的口语理解能力。测试问题由录制的声音大声朗读，测试是自动进行的，没有人的积极参与。当受试者在 6 秒的时间窗口内用描述的图片注视面板至少 3 秒时，答案被归类为“正确”。作者报告说，健康志愿者的正确答案中位数为 93%，重症患者为 38%。作为重要信息，他们得出结论：“使用创新的基于眼动追踪的界面实施口语理解测试对于危重插管患者来说似乎是可行的。”

挑剔的读者可能会得出另一个结论。他们可能会带回家，大多数被认为能够明智地交流的危重病人（根据里士满激越和镇静量表 (RASS) 评估的平静和清醒，具有适当的听力和视力）不能通过使用眼睛来做到这一点——跟踪技术。危重病人在测试中的表现显然很差。在使用的 15 个测试项目中（比较：作为文件 2 在线提供的视频），九个包含四个面板（即一个目标面板和三个干扰面板，猜测基线 = 25%）。其他 6 个包含两个面板（猜测基线 = 50%）。因此，这 15 个项目的平均猜测率为 35%。因此，重症患者的表现与猜测下的预期表现非常接近。对于60岁以上的重症患者，作者报告了更低的性能（27% 的中位正确率）。有人可能会争辩说——与其完全根据猜测率争论——还应该考虑时间要求和限制（6 秒中有 3 秒固定正确的面板）。然而，在这种情况下，人们仍然会得出这样的结论，即危重病人在测试中的表现显然很差，因为它已经被执行了。鉴于他们的表现接近机会基线，人们甚至可能怀疑基于眼动追踪的评估在这一人群中是否可行。在这种情况下，人们仍然会得出这样的结论，即危重病人显然在测试中的表现很差，就像测试的执行方式一样。鉴于他们的表现接近机会基线，人们甚至可能怀疑基于眼动追踪的评估在这一人群中是否可行。在这种情况下，人们仍然会得出这样的结论，即危重病人显然在测试中的表现很差，就像测试的执行方式一样。鉴于他们的表现接近机会基线，人们甚至可能怀疑基于眼动追踪的评估在这一人群中是否可行。

然而，正如其他几位研究者所观察到的那样，我们认为一些技术问题可能已经排除了更有利的结果 [2,3,4]。

我们主要担心的是，在 Bodet-Contentin 等人的研究中，凝视显示器面板至少三秒钟的要求。对于许多 ICU 患者来说是不可能的。在 Duffy 等人的研究中。[2]，使用了 0.4 秒的注视时间。在另一项研究中，根据患者的观察和报告，即使是 1 秒的注视时间对许多患者来说都过于费力 [5]，因此建议注视时间为 0.6 秒。这是一个原因：我们认为 Bodet-Contentin 的结果大大低估了患者使用眼动追踪技术进行深思熟虑的交流的能力。
另一个原因在于观察到插管的危重病人可以通过眼睛注视反应面板 [6] 来始终如一地报告他们对自己情况的评估。例如，90% 的人表示感到被困（而其他项目的支持率较低）。这强调了患者了解他们被问到的内容，并且能够通过注视位置表明他们的回答。蒙特利尔-图卢兹测试中提出的问题与患者正在经历的极端情况几乎没有关联。考虑到患者需要高度集中注意力，他们给出答案的动机可能会降低。除了刚刚提到的例子，多项研究表明，重症患者能够就他们的实际情况、要求、
第三，虽然任务自动化将使 ICU 的医务人员能够专注于其他职责，但在这种特殊情况下，我们认为与人进行个人互动会更好。清醒的危重病人的一个主要问题是缺乏与护士或医生的沟通 [7]。因此，被机器询问（例如，自动化、录音、缺乏个性化）可能会进一步降低患者的积极性和集中注意力的能力。

总之，我们祝贺作者在之前的研究表明眼动追踪技术在非语言危重患者中是可行的之后，他们提供了一项关于口语理解评估的研究。另一方面，我们认为该研究的一些不利技术环境确实阻碍了那些非语言患者的更好表现。未来的研究必须表明，眼动追踪技术可以在 ICU 的日常工作中成功实施，并增加非语言患者的健康。

不适用。

加护病房：: 重症监护室
拉斯：: 里士满激越和镇静量表

Bodet-Contentin L、Messet-Charrière H、Gissot V 等。在重症患者和健康志愿者中使用基于眼动追踪的创新设备评估口语理解能力：一项队列研究。暴击护理。2022；26：288。https://doi.org/10.1186/s13054-022-04137-3。
谷歌学术文章
Duffy EI、Garry J、Talbot L、Pasternak D、Flinn A、Minardi C 等。一项通过眼动追踪设备、点头和通讯板评估机械通气外科重症监护病房患者的精神、情感、身体/环境和生理需求的初步研究。Trauma Surg 急性护理开放。2018;3(1):e000180。https://doi.org/10.1136/tsaco-2018-000180。
谷歌学术文章
Maringelli F, Brienza N, Scorrano F, Grasso F, Gregoretti C. 重症监护病房中的凝视控制、计算机辅助交流：“通过眼睛说话。” 矿工麻醉剂。2013；79(2)：165–75。
CAS 谷歌学术
Garry J、Casey K、Cole TK、Regensburg A、McElroy C、Schneider E 等。重症监护中眼动追踪设备的初步研究。外科手术。2016 年；159(3)：938–44。https://doi.org/10.1016/j.surg.2015.08.012。
谷歌学术文章
Ull C、Weckwerth C、Schildhauer TA、Hamsen U、Gaschler R、Waydhas C 等。使用眼动追踪技术与重症监护病房中机械通气患者进行交流的首次体验。残疾康复辅助技术。2020. https://doi.org/10.1080/17483107.2020.1821106。
谷歌学术文章
Ull C、Hamsen U、Weckwerth C、Schildhauer TA、Gaschler R、Jansen O 等。使用预定义的量表和分数与眼动追踪设备识别危重非语言患者的症状。J Trauma Acute Care Surg。2022；92：640–7。https://doi.org/10.1097/TA.0000000000003494。
文章 CAS 谷歌学术
Danielis M、Povoli A、Mattiussi E、Palese A。了解患者在重症监护病房接受机械通气的经历：综合综合和综合总结的结果。J 临床护士。2020；29（13-14）：2107-24。https://doi.org/10.1111/jocn.15259。
谷歌学术文章

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这项工作得到了德国波鸿鲁尔大学“初级临床科学家计划”的支持（授权号 K129-19）。资助机构不影响研究的设计、数据的收集、分析和解释，也不影响手稿的撰写。

作者和隶属关系

埃森大学医院创伤外科，Hufelandstraße 55, 45147, Essen, Germany
克里斯蒂安·瓦达斯
BG 大学医院 Bergmannsheil 普外科和创伤外科，Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
Christian Waydhas、Christopher Ull、Oliver Cruciger 和 Uwe Hamsen
FernUniversität Hagen 心理学系，Universitätsstraße 33, 58084, Hagen, Germany
罗伯特·加施勒和克里斯蒂娜·韦克沃斯

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