Exercise in Critical Care

Introduction

Early mobility in hospital settings is receiving more scrutiny and research. This page on walking with a ventilator is divided into four sections: Section 1: Background; Section 2: Case reports; Section 3: Research; and Section 4: Future directions.

Part I: Background

Result of inactivity/ bedrest

• Bed rest: muscles deteriorate[1]
• Contractures start[2]
• Decreased perfusion Increases hemodynamic instability Increases risk of ischemia and injury [3]
• Muscle – shortened sarcomeres, reduced contractility and strength; slow fibers switch to fast fibers [4]
• Inflammatory disorders—can cause diaphragmatic contractile dysfunction
• Unloaded/stationary diaphragm = decreased stamina
• Sensory deprivation – anxiety and depression disrupt sleep (hence medication)
• Feelings of fatigue – leading to self-limitation [5][6]

Critical Illness Neuromyopathy

• Occurs during ICU (compared to Guillain-Barré syndrome or myasthenia gravis).
• Main motor signs – Proximal weakness Severely symmetrical, total score on manual muscle testing with arm abduction elbow flexion wrist extension hip flexion knee extension dorsiflexion 0 = no visible contraction 1 = visible but no movement 2 = active but not against gravity 3 = active Antigravity 4 = Active antigravity and resistance (note: doesn’t say how much resistance there is!) 5 = normal strength <48 – marked weakness; may have sensory Golgi tendon reflex Loss of muscle mass can be diagnosed by electromyography (EMG), EMG Diagram showing action potential reduction and spontaneity Activities happen but noting is not always possible.
• Patients with critical illness neuromuscular disease (CINM) – increased deflation time and longer weaning time [7]

Outcomes of prolonged ventilation

• DVT’s[8], Pneumonia[9]
• Diaphragm dysfunction[10]
• Residual weakness [11] (still significant residual weakness 12 months after admission – 66% NV on 6-minute walk test) [12]
• Sensory deficits (study: emptying >28 days: 59% had motor or sensory deficits 95% had EMG evidence of chronic partial denervation) [13]
• Increased mortality [14][15] (Study: PMV 98-00 – 1 year mortality 58% 22% died in hospital 36% d/c died within 1 year 57% of survivors left the vent)[16 ]
• Discharge site [17] (study: d/c disposition: 17% go home 35% recover 23% to SNF. study: >96 hours vent 45% to SNF median time to go home 7 months 53% 1 time or more readmissions within 12 months [18]
• Cognitive deficits [19] (27% d/c reported cognitive deficits); 49% of survivors returned to work after 1 year. [20]

Part II: Case Reports

1. Burns JR Jones FL. Early mobilization of patients requiring ventilatory assistance. Chest. 1975 Oct 1;68(4):608.

In this letter to the editor, the authors acknowledge the problems with bed rest and ambulatory patients using respirators, and briefly describe their mobility aids and their anecdotal impressions (formed during a 3-year project) to facilitate/ Accelerated weaning and minimized Problems with bed rest. [twenty one]

2. Kirshblum SC Bach JR. Walker modification for ventilator support personnel. case report. American Journal of Physical Medicine and Rehabilitation. 1992 Oct 1;71(5):304-6.

The purpose of this report is to provide a report on the use of a 24-hour non-invasive ventilator to support an ambulatory patient. The patient was a 53-year-old male with Milroy’s disease respiratory failure restrictive lung disease and a history of R middle lobe resection and acute respiratory failure. Before admission, he could walk <200 feet and climb 5 or fewer steps before becoming dyspneic.

He was admitted with pneumonia and underwent bilateral chest tube intubation and was diagnosed with pulmonary fibrosis. He received trach on day 52 and a 4-month ventilatory weaning attempt failed. However, he did switch from intermittent positive pressure ventilation via the trachea to IPPV via the mouth Nose during the day and at night. At 7 months, he was transferred to an all ADL dependent rehab and could only walk a few steps.

The facility began a comprehensive rehabilitation program that included diaphragmatic/glossopharyngeal respiratory biofeedback and general strength/flexibility/endurance. Since pts were unable to maneuver the wheelchair with all the equipment needed, they adapted a walker to help. he was d/c’ed Returned home after 60 days independent in all ADLs and walking >400′ with a walker, his O2 sat at >94% and eventually returned to full time employment. At the time of writing, he is still on IPPV 20 hours/day and his lung capacity has improved (660ml to 1050ml).

Strengths: presents the potential for cathartic-dependent individuals to regain functional capacity and social roles

Limitations: Case study; no criteria for initiation of walking; no details of rehabilitation program or mobility aid modifications [22]

3. Smith T Forrest G Evans G Johnson RK Chandler N. Albany Medical College Ventilator Walker. Archives of Physical Medicine and Rehabilitation. 1996 Dec 1;77(12):1320-1.

The purpose of this report is to describe the design and use of mobility aids that can accommodate ventilators and O2 tanks. After describing the considerations and the construction of the walker, they presented a 69-year-old woman who underwent elective CABG and had difficulty weaning due to Obese hemidiaphragmatic CHF with left lower atelectasis and obstructive airflow secondary to secretions. She underwent trach a month after surgery and started using the walker twice a day two days later. Over the following week, PT reported significant improvements in strength and power Functional mobility. Five months after the initial surgery, she can walk without assistive devices or supplemental oxygen.

Strengths: Pedestrian-sized details

Limitations: Case study; no specific criteria for initiation of walking. [twenty three]

4. Perme CS Southard RE Joyce DL Noon GP Loebe M. Early mobilization of LVAD recipients requiring prolonged mechanical ventilation. Journal of the Texas Heart Institute. 2006;33(2):130.

The purpose of this case report is to report our protocol for mobilization with the aid of a portable ventilator in a patient with cardiac cachexia and LVAD implantation. In addition, we describe specific physical therapy interventions used in LVAD patients requiring prolonged mechanical therapy Ventilate the device after implantation.

The authors typically present their physical therapy assessment including ventilator settings or O2 requirements for their PT interventions (positioning reinforcement and breathing exercises bed movement gait and education; frequency 1x/day 6-7 days/week 15 min-1 hr) and standard For terminating a PT session (LVAD flow significantly lower blood pressure signs/severe symptoms/intolerable dyspnea O2 level <90% significant chest pain extreme fatigue and pt stop request).

Case report: 51-year-old man with heart failure secondary to dilated cardiomyopathy and R-inferior lobe nodules. Over the next 5 weeks, the patient’s cardiac function gradually deteriorated and he developed renal insufficiency and respiratory failure, leading to his intubation. he was placed in a LVAD and they removed his lower right lobe which was further complicated by medical issues requiring constant ventilation. PT was ordered on day 7 after the first weaning trial failed. He underwent LE intensive exercises and mobilization (sit EOB stand and bed<>chair) and he is Gait training activities around the ICU were performed on the vent. During his 49 days in the ICU, he was deflated on 48 days and received 25 PT sessions per day (17 LE sessions, 22 EOB sessions, 21 standing sessions, and 18 gait sessions, 4 of which were performed using portable breathing machine). This The patient improved to T-neck walking without the vent support and disengaged from the vent. Six weeks later, he underwent a heart transplant and went home.

Advantage: Provides more details of PT participation

Limitations: Case study; no specific criteria for initiating ambulation other than how many steps could be taken; unclear session length/consistency or ventilation while ambulating. [twenty four]

Part III: Research Studies

1. Bailey P Thomsen GE Spuhler VJ Blair R Jewkes J Bezdjian L Veale K Rodriquez L Hopkins RO. Early mobilization is feasible and safe for patients with respiratory failure. Critical Care Medicine. 2007 Jan 1;35(1):139-45.

In this study, the researchers wanted to know whether early mobilization of critically ill patients was feasible and safe. In this prospective cohort study, participants had patients on a ventilator for more than 4 days in the RICU (n=103) (only exclusion criteria were <4 days). Pts must be neurological Responses to verbal stimuli met specific respiratory conditions (FIO2 <0.7 positive end-expiratory pressure <11 cm H2O) and met circulation criteria (no orthostatic hypotension and catecholamine instillation). Those who did not meet all 3 criteria were tested for activity and monitored closely adverse event. The activity plan calls for PT RT RN Intensive Care Technician 2 times per day. Activity events include sitting on the EOB and standing and walking. Adverse events were low, and extubation did not require increased costs or length of stay. d/c had an average walking distance of 212′ (69% could walk 100′ or more); age was not a factor in participation. They concluded that early mobilization is feasible and safe in this population and a possible therapy for the prevention or treatment of neuromuscular complications associated with critical illness. The study didn’t have a control group, so they can’t say so early Activities improve d/c time or long-term results. [25]

2. Thomsen GE Snow GL Rodriguez L Hopkins RO. Patients with respiratory failure increase walking activity after transfer to an intensive care unit prioritizing early mobilization. Critical Care Medicine. 2008 Apr 1;36(4):1119-24.

At the same site as the Bailey study, the researchers hypothesized that walking in patients with acute respiratory failure would increase with transfer to the intensive care unit, where mobility is a key component of patient care. Their participants (N=104) were patients with emptying >4 Days of neurological disease that did not prevent activity (such as stroke) did not re-enter the RICU and was not terminally ill. These patients also need to spend 2 days in another hospital’s intensive care unit before being transferred to that ward and stay in their ward for 2 days or more days so they can compare activity levels. To start an activity regimen, they must be able to follow instructions, have FiO2 <0.7, positive end-expiratory pressure <11 cm H2O, no catecholamine drips, and no signs of orthostatic hypotension. During the walk (yes/no and distance recorded each time time) they monitor O2 saturation and blood pressure. They concluded that even after accounting for underlying pathophysiology, moving patients with acute respiratory failure to their unit significantly improved ambulation; the ICU setting could lead to unnecessary immobilization throughout acute respiratory failure; and sedation significantly reduces the likelihood of ambulation. They also call for further research to determine whether ICU immobility affects long-term neuromuscular dysfunction, and whether early mobilization of the ICU improves outcomes. [26]

3. Morris PE Goad A Thompson C Taylor K Harry B Passmore L Ross A Anderson L Baker S Sanchez M Penley L. Early intensive care unit mobilization therapy for acute respiratory failure. Critical Care Medicine. 2008 Aug 1;36(8):2238-43.

In this study, the researchers wanted to answer whether physical therapy in the ICU was beneficial (the theory is plausible, but there are no data). Medical intensive care unit patients who had been intubated within the past 48 hours and admitted to the MICU within 72 hours were included. Inclusion criteria were >18 years of age with ET tube, while exclusion criteria were inability to walk before ICU illness (AD allowed) premorbid cognitive impairment (defined as non-verbal) immunocompromised/prednisone preadmission with neurologic muscle Illnesses such as myasthenia gravis Guillain-Barre or ALS may affect weaning off the vent Acute stroke BMI >45 hip fracture Unstable c-type spine or pathological fracture >48 hours on the vent from another Institutional Transfer >72 Hours Admission or Transfer From another hospital, > 72 hours of hospitalization Obtained a DNR order on admission Recent hospitalization (30 days) Received cancer treatment within the past 6 months and was readmitted to ICU during this hospitalization.

Interestingly, only patients who survived to hospital discharge were pre-determined to be included in the outcome analysis based on results from pre-study data which found that patients who died in the ICU were rarely awake enough to be considered for [PT]. Therefore Outcome data for patients in the usual care group were compared with patients in the protocol group who survived to hospital discharge.

Patients were assigned to either the usual treatment group (N=165) or the protocol group (N=165) using a block design. UCG included conventional treatment (PROM) while PG received four levels of treatment in the protocol (1 – PROM 2 – PROM active resistance sitting 3 – same as #2 but now sitting EOB and 4 – Same as #3, but adds active transfer and build moves. The protocol is administered 7 days a week by a RN, a CNA, and a PT. The primary outcome was the proportion of patients who received PT out of the total number of patients who survived to hospital discharge. They concluded that early mobility was Feasible safety measures do not increase costs nor reduce ICU and hospital stays for patients receiving this regimen. [27]

4. Moodie L Reeve J Elkins M. Inspiratory muscle training increases inspiratory muscle strength in mechanically ventilated patients: a systematic review. Journal of Physical Therapy. 2011 Jan 1;57(4):213-21.

In this study, researchers wanted to answer whether inspiratory muscle training would improve inspiratory muscle strength in adults receiving mechanical ventilation. The study involved 394 participants. Heterogeneity was high in some meta-analyses. A random-effects meta-analysis showed that Training significantly improved maximal inspiratory pressure (MD 7 cmH2O 95% CI 5 to 9), rapid shallow breathing index (MD 15 breaths/min/liter 95% CI 8 to 23), and weaning success (RR 1.34 95% CI 1.02 to 1.76) ).

Although only evaluated in individual studies, duration of noninvasive ventilation after weaning (MD 16 hours 95% CI 13 to 18), length of intensive care unit stay (MD 4.5 days 95% CI 3.6 to 5.4) and hospitalization were also reported. time (MD 4.4 days 95% CI 3.4 to 5.5). Time to weaning was reduced in a subgroup of patients with known weaning difficulties. Other outcomes were not significantly affected or measured.

They concluded that ICU patients who received inspiratory muscle training had shorter postextubation hospital stays and noninvasive ventilatory support. [28]

Part IV: Future Directions

We know that immobility has a negative impact on patients, and being on a ventilator has an even greater negative impact.

Studies have shown that it is feasible and safe to perform PT and ambulation on patients using a ventilator [29][30][31].

So where do we go from here?

[32]

Address barriers to mobility

• Safety concerns
• Dislodging lines or tubes
• Decrease already low oxygenation and hemodynamic parameters (Note: Stiller reference and Gosselink reference include a good flowchart to start with)
• Sedation (which reduces mentation)
• Cost
• Number of workers needed
• Walking aids are needed (do we need to build our own?)
• Obesity
• Time[33][34][35]

Changing a culture

Given the cost of the patient being immobilized and ventilated, is addressing the barrier beneficial? Even then, a cultural change may be required — in the workplace and in the hospital. So what to do? Those who have walked it (Hopkins et al.) have paved a path that they believe will help With this culture change:

Stage 1

• establish a sense of urgency
• Watch pts at d/c; understand the limitations they have and face

Stage 2

• create a powerful guiding coalition
• nurse chief physician director and several influencers working for change

Stage 3

• Create a vision
• For your work, what can you do as part of the nursing process? [36]

Stage 4

• Communicate the vision
• Educate other ICUs about the importance of early ambulation [29]

Stage 5

• Empower others to act
• Being able to share a small part of your work – the d/ca line or flushing the pipeline – to learn how to work with each other and what each other does[37]

Stage 6

• Plan and create short-term wins,
• For example, as RICU admissions increase, FTE increases

Stage 7

• Consolidate improvements and make more changes
• Report compliance with required actions

Stage 8

• Institutionalize new approaches
• within the team (how this is done) and externally (respect and desire to follow the new approach)[38]

Practical assessment and treatment of cervicogenic headaches