Facial expression as an indicator of pain in critically ill intubated adults during endotracheal suctioning

Mamoona Arif Rahu, Mary Jo Grap, Jeffrey F. Cohn, Cindy L. Munro, Debra E. Lyon, Curtis N. Sessler

Research output: Contribution to journalArticle

18 Scopus citations


Background Facial expression is often used to evaluate pain in noncommunicative critically ill patients. Objectives 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 (r = 0.71; P < .001) and with the facial expression component of the scale (r = 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 (r = 0.72; P < .001) and with the facial expression component of that scale (r = 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.

Original languageEnglish (US)
Pages (from-to)412-422
Number of pages11
JournalAmerican Journal of Critical Care
Issue number5
StatePublished - Oct 8 2013
Externally publishedYes


ASJC Scopus subject areas

  • Critical Care

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