CHEST Original Research

SLEEP DISORDERS

Medical Hypnosis as a Tool to Acclimatize

Children to Noninvasive Positive
Pressure Ventilation
A Pilot Study
Vincent Delord, MSN; Sonia Khirani, PhD; Adriana Ramirez, MSc;
Erick Louis Joseph, AS; Clotilde Gambier, MSN; Maryse Belson, MSN;
Francis Gajan, MD; and Brigitte Fauroux, MD, PhD

Background: Patient cooperation is crucial for the success of noninvasive positive pressure venti-
lation (NPPV). This study evaluated the efficacy of medical hypnosis to reduce anticipatory anx-
iety and acclimatization time in children who are candidates for long-term NPPV.
Methods: Medical hypnosis was performed by a trained nurse. The acclimatization time and long-
term compliance with NPPV were evaluated.
Results: Hypnosis was performed in nine children aged 2 to 15 years. Seven children had a high
level of anticipatory anxiety because of a tracheotomy since birth (n 5 2), a history of maxillofacial
surgery (n 5 2), severe dyspnea because of lung disease (n 5 2), and morbid obesity and depres-
sion (n 5 1), and two children with obstructive sleep apnea failed standard NPPV initiation. The
hypnosis techniques were based on distraction in the youngest patient and indirect or direct hyp-
notic suggestions in the older children to obtain a progressive psychocorporal relaxation. All
patients accepted the interface and the NPPV after the first hypnosis session. A median of three
sessions was needed for overnight (. 6 h) NPPV acceptance. The 6-month compliance with NPPV
was excellent, with a median use of 7.5 h per night.
Conclusion: Medical hypnosis is an effective, safe, noninvasive, and inexpensive tool for reducing
the anticipatory distress and acclimatization time for NPPV. This therapy is particularly useful in
children with traumatic experiences, such as a tracheotomy or facial surgical procedures.
CHEST 2013; 144(1):87–91

Abbreviations: NPPV 5 noninvasive positive pressure ventilation; OSA 5 obstructive sleep apnea

Agrowing body of evidence indicates that hypnosis

can be a useful adjunct to medical procedures. Hyp-
nosis is a state of highly focused attention, with reduc-
tion in peripheral awareness and a heightened response
Manuscript received September 13, 2012; revision accepted
December 12, 2012.
Affiliations: From the Pediatric Pulmonary Department (Messrs
Delord and Joseph; Dr Khirani; Mss Ramirez, Gambier, and Belson;
and Prof Fauroux), AP-HP, Hôpital Armand Trousseau, Paris; Pain
and Otorhinolaryngology Department (Dr Gajan), CHU Rouen,
Rouen; S2A Santé (Dr Khirani), Ivry sur Seine; ADEP ASSISTANCE
(Ms Ramirez), Suresnes; and IMSERM U 955 (Prof Fauroux),
Pierre et Marie Curie Paris 6 University, Paris, France.
Funding/Support: The research of Prof Fauroux is supported
by the Association Française contre les Myopathies; Vaincre la
Mucoviscidose; Assistance Publique-Hôpitaux de Paris, INSERM,
Université Pierre-et-Marie-Curie-Paris 6, ADEP Assistance,
S2A Santé, and IPSanté.
to social cues. For example, with the guidance of a
health-care professional, hypnosis can help patients to
disregard environmental reality, such as discomfort
associated with medical therapies or procedures. Thus,
children treated with hypnosis are less likely to report
pain or fear in association with medical interventions.1-5
The techniques most often used involve distraction and
indirect or direct hypnotic suggestions coupled with
imagery that provides a substitute focus of attention
Correspondence to: Brigitte Fauroux, MD, PhD, Pediatric
Pulmonary Department, AP-HP, Hôpital Armand Trousseau, 28 Ave
du Docteur Arnold Netter, Paris F-75012, France; e-mail: brigitte.
fauroux@trs.aphp.fr
© 2013 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.12-2259

journal.publications.chestnet.org CHEST / 144 / 1 / JULY 2013 87

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 (eg, floating, attending an amusement park or princess
ball) to allow the child to experience relaxation and,
thus, reduce his or her focus on uncomfortable feel-
ings or sensations. Because children naturally have a
greater capability for imagination than adults, they may
be more receptive to hypnosis than older subjects.6
Numerous reports have shown that medical hypnosis
may provide anxiety and pain relief to children with
medical conditions such as cancer, cystic fibrosis, lung
disease, and surgical interventions.1-4,7-12
Long-term noninvasive positive pressure ventila-
tion (NPPV) is increasingly used in children with severe
obstructive sleep apnea (OSA) and chronic respira-
tory failure as a result of neuromuscular disorders or
lung diseases. The aim of NPPV is to improve breath-
ing and relieve the sensation of dyspnea by means of
ventilatory support administered through a nasal or
facial interface affixed by head gear. Even though this
type of ventilatory support is considered noninvasive
compared with that delivered through an endotra-
cheal tube or a tracheotomy, the application of a mask
to the face may be frightening to a child, especially in
the case of a previous traumatic procedure or respira-
tory distress.13,14 Indeed, most children requiring NPPV
have chronic underlying conditions, which may have
required numerous medical and surgical interventions,
sometimes since the first months of life. Young chil-
dren are also less likely than adults to understand the
rationale for a given intervention.
Patient cooperation is required for the success of
NPPV. Clinical experience shows that the first breaths
with the ventilatory equipment are key. Indeed, in
most children, NPPV provides such a reduction of the
breathing effort that the acclimatization is quite easy
once the child has accepted the first assisted breaths.
However, some children have such an extremely high
level of anticipatory anxiety that the application of
NPPV may be a very challenging procedure.14 Further-
more, research indicates that children remember their
experiences of medical procedures, and this affects
how they respond to ongoing medical therapy.15-18
Alternative tools to decrease the level of anticipa-
tory anxiety are thus warranted for this population.
The aim of the present study is to report our expe-
rience with medical hypnosis in nine children who
require NPPV.
Materials and Methods
Patient Selection
Medical hypnosis was proposed to all consecutive children
aged . 2 years who were referred to our pulmonary department
during 2011 for NPPV and in whom the initiation of NPPV was
expected to be particularly difficult or in whom standard initiation
of NPPV had failed.13 All parents gave written consent for the
report of their child’s medical history. The study was approved by
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the ethical committee of our university (Saint Antoine Hospital,
Comité de Protection des Personnes, Ile de France V, Paris,
France).
Procedure
Hypnotic treatment was administered by a nurse (V. D.) trained
in pediatric hypnoanalgesy at the French Institute of Hypnosis,
Paris, France. During a first contact, the child and parents were
asked a series of open-ended and specific questions regarding ele-
ments of the child’s medical and surgical experience. The aim of this
contact was to determine the patient’s fears and main interests.19
Next, depending on the child’s age, different hypnosis techniques
were used (Table 1). In children aged , 2 to 3 years, the hypnosis
approach was based on distraction with auditory, kinesthetic, and
visual stimulation to bypass the patient’s attention. In older chil-
dren, the hypnosis technique depended mainly on the child’s ability
for imaginary play. When the child expressed his or her imagina-
tion spontaneously, the hypnosis practitioner would accompany
the child in the imaginary experience. On the other hand, when
the child was unable to express his or her imagination spontane-
ously, as may be observed in children with a high level of anxiety
or agitation, the hypnosis state was initiated by the practitioner by
means of direct suggestions. The final aim of these different tech-
niques was to obtain a progressive psychocorporal relaxation,
enabling the child to dissociate from fear and anxiety.
The children were considered as being in a hypnotic state when
they were able to bypass the medical reality while remaining in
continuous (gestural or verbal) connection with the hypnosis prac-
titioner. Each individual hypnosis session lasted 15 to 30 min. Ses-
sions could be repeated at the child’s request during the same or
the next day, and the number of sessions was registered. The par-
ents were free to attend and participate actively in the hypnosis
sessions.
The success of hypnosis was defined by the child accepting the
interface and the NPPV without any resistance together with a
nocturnal use of at least 6 h at hospital discharge. The objective
long-term compliance with NPPV was assessed by analysis of the
memory chips of the home ventilators at 6 months.
Results
Medical hypnosis was performed in nine children
(seven boys) aged 2 to 15 years (median, 7 years)
(Table 2). A 13-year-old boy (patient 1) with France-
schetti syndrome and an 8-year-old boy (patient 2)
with laryngeal paralysis, both with tracheotomy since
Table 1—Hypnosis Techniques Used
Infants (Aged About
, 2-3 y) Older Children (Aged . 2-3 y)
Distraction Indirect suggestions
Visual stimulation The child expresses his or her
Auditory stimulation imagination spontaneously, and
Kinesthetic the hypnosis practitioner accompanies
stimulation the child in the imaginary experience.
Direct suggestions
The child is unable to express his or
her imagination spontaneously, so the
hypnosis practitioner gives the child
direct suggestions to help him or her
enter an imaginary experience.
Original Research
 journal.publications.chestnet.org
Table 2—Patient Characteristics

Hypnotic Treatment

6-Mo Objective
Compliance With
Patient Age, y Sex Pathology Medical History Imagery No. Hypnotic Sessions NPPV, h/Night
1 13 M Franceschetti syndrome Tracheotomy since birth Floating in the sea 3 7
2 8 M Laryngeal paralysis Tracheotomy since birth Surfing in the sea while listening 3 (1 1) 8
to his favorite music
3 7 M Apert syndrome Seven neurosurgical and Space tour in a fighter craft 3 7
maxillofacial interventions
4 4 M Cherubinism Repeated mandibular surgery Tour in the pirate boat with 3 6
with tumor enucleations, orbital Peter Pan followed by a space
decompression, and nasal tour in a rocketship
airway calibration
5 2 M Bronchopulmonary dysplasia Severe lung disease, repeated Game with soap bubbles and songs 1 12
hospitalizations with his mother
6 13 F Cystic fibrosis End-stage lung disease with Tour in a shopping center 3 4

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severe dyspnea
7 15 M Morbid obesity with OSA Severe depression Attendance at a rock concert 1 …
8 5 M Obesity with OSA None Attendance at his favorite 1 10
amusement park
9 6 F OSA None Attendance of a princess ball 3 8.5
F 5 female; M 5 male; NPPV 5 noninvasive positive pressure ventilation; OSA 5 obstructive sleep apnea.

CHEST / 144 / 1 / JULY 2013

89
 birth, experienced severe anticipatory anxiety when
they were proposed to change their tracheotomy to
nocturnal NPPV. Patients 3 and 4 had a history of
traumatic or painful medical procedures involving the
maxillofacial area. Two children had severe respira-
tory insufficiency because of bronchopulmonary dys-
plasia (patient 5) and end-stage cystic fibrosis lung
disease (patient 6). Finally, a 15-year-old boy (patient 7)
with severe OSA because of morbid obesity experi-
enced insomnia and severe depression. Hypnosis was
started in all patients as a first-line acclimatization pro-
cedure because of their medical history. Patients 8
and 9 required NPPV for severe OSA but had no spe-
cific medical history or traumatic experience. In these
two patients, medical hypnosis was started after fail-
ure of the standard procedure.
Depending on the patient, different hypnosis tech-
niques were used (Table 1). The youngest patient was
a 2-year-old with bronchopulmonary dysplasia who
spent nearly his whole life in the hospital. In this child,
a distraction technique using three complementary
auditory (a song sung by his mother), kinesthetic (play-
ing finger puppets with the nurse), and visual stimu-
lations (soap bubbles) were immediately effective in
his subsequent acceptance of the interface and NPPV.
In patients 4, 8, and 9, the interface and NPPV were
used as a tool to access their imaginations. In practice,
the nurse entered the room with two pieces of NPPV
equipment, enabling the children to enter their imag-
inations (eg, flying a rocketship) by mimicking the
nurse putting on the interface and the ventilator.
Patient 4 required three different consecutive hyp-
notic induction techniques during the same afternoon
because of his high level of anxiety and agitation. This
patient had a stressful history of three mandibular sur-
gical interventions with tumor enucleations, orbital
decompression, and nasal airway calibration. Medical
hypnosis was also effective in patient 6 who had respi-
ratory failure because of advanced cystic fibrosis lung
disease. She initially refused the interface and NPPV
because she feared worsening of her respiratory dis-
tress. With the help of hypnosis, she was able to dis-
sociate herself from fear and to accept the interface
and NPPV. After the first breaths with NPPV, she
perceived the relief of her respiratory effort and totally
adhered to the NPPV treatment.
The median duration of the first session was 15 min
(range, 10-30 min). All patients accepted the inter-
face and NPPV at the first session, but a median of
three sessions was needed for an overnight NPPV
acceptance (ie, NPPV use for . 6 h/night). All patients
slept at least 4 h with the ventilator during the first
night and at least 6 h with NPPV after the third night,
allowing hospital discharge. The parents of patient 9
asked to be trained to practice hypnosis on their child.
After three training sessions, they could successfully
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perform the hypnosis at home. None of the other
children required hypnosis at home.
Long-term use of NPPV was excellent, with a median
objective compliance of 7.5 h per night in eight of the
nine patients at 6 months. Mean long-term compli-
ance was slightly lower in patient 6 compared with
the other patients because of a difficult social environ-
ment. Because patient 7 underwent bariatric surgery
shortly after the initiation of NPPV, long-term appli-
cation of this therapy was not necessary.
Discussion
This study shows that medical hypnosis is an effec-
tive tool to facilitate the acclimatization of children
with anticipatory anxiety to NPPV. Because of its effi-
cacy, safety, and noninvasiveness, medical hypnosis
is recommended as a first-line procedure in these
patients. Indeed, the intense focus in hypnosis helps
children to dissociate their attention from their imme-
diate physical surroundings and experiences, helping
them to relax instead of focusing on their anxiety or
discomfort associated with application of NPPV.
Medical hypnosis has been shown to be a useful tool
to reduce pain and anxiety in various conditions in
children, but its use for NPPV acclimatization in this
age group has rarely been reported.20 NPPV can be
perceived as stressful for children, particularly for those
who have undergone previous neurosurgical or max-
illofacial interventions, such as patients 3 and 4. The
switch of tracheotomy to NPPV may also represent a
difficult and long-lasting procedure in some patients.14
A tracheotomy is an invasive procedure associated
with recurrent traumatic maneuvers, such as aspira-
tion and tube removal and change, and, as a conse-
quence, hospital visits and hospitalizations. Most of
these children had severe and often multiple medical
disorders, which contribute to anxiety, pain, and psy-
chologic stress for both the child and the family. For
this reason, some children would refrain from any
procedure involving the face or the upper airway.
In one of our previous studies, acclimatization to the
nasal mask without medical hypnosis took . 1 week
in more than one-half of the children with a trache-
otomy, which is twice as long as our experience with
children who did not have a prior tracheotomy.14
With hypnosis, the two patients with a tracheotomy
(patients 1 and 2) accepted the interface after the
first session.
Of interest, hypnosis of the child was associated
with reduced anxiety in the parents, which contrib-
utes to the acceptance and success of NPPV. Parental
behavior influences children’s reactions to medical
procedures,16 and parental involvement in the hypno-
sis intervention seemed to counter the distress and
anxiety that comes from observing their children’s
Original Research
 discomfort and resistance to efforts of medical staff
to complete the procedure.
In conclusion, this pilot study highlights the role of
medical hypnosis as an effective, safe, and noninva-
sive first-line technique to facilitate NPPV acceptance
in children with anticipatory anxiety. The beneficial
effect of medical hypnosis for acceptance of NPPV in
children should be validated by prospective random-
ized controlled trials.
Acknowledgments
Author contributions: Dr Fauroux had full access to all of the
data in the study and takes responsibility for the integrity of the
data and the accuracy of the data analysis.
Mr Delord: performed the hypnosis sessions, recruited the patients,
and contributed to the redaction of the manuscript.
Dr Khirani: contributed to the recruitment of the patients, the
successive hypnosis sessions, and the redaction of the manuscript.
Ms Ramirez: contributed to the recruitment of the patients, the
successive hypnosis sessions, and the redaction of the manuscript.
Mr Joseph: contributed to the recruitment of the patients, the
successive hypnosis sessions, and the redaction of the manuscript.
Ms Gambier: contributed to the recruitment of the patients, the
successive hypnosis sessions, and the redaction of the manuscript.
Ms Belson: contributed to the recruitment of the patients, the suc-
cessive hypnosis sessions, and the redaction of the manuscript.
Dr Gajan: contributed as Mr Delord’s teacher, assisted as an expert
with the hypnosis sessions, and contributed to redaction of the
manuscript.
Prof Fauroux: contributed as principal investigator and to the
study concept and design, analysis of the patient cases, and redac-
tion of the manuscript.
Financial/nonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.
Role of sponsors: The sponsors had no role in the design of the
study, the collection and analysis of the data, or in the preparation
of the manuscript.
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