ANNALS OF RESPIRATORY MEDICINE
REVIEW ARTICLE
Rehabilitation in Critically Ill Patients Elena Venturelli1,2, Ernesto Crisafulli2, Francesca Degli Antoni2, Ludovico Trianni2 and Enrico M. Clini1,2 1
Affiliations: 1Department of Oncology, Haemathology and Respiratory Diseases, University of Modena-Reggio Emilia, Modena, Italy and 2Ospedale Villa Pineta, Pavullo, Modena, Italy
A B S T R A C T
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Prolonged stay in the hospital and difficult response to pharmacotherapy can often lead to severe complications in critically ill patients for muscle weakness, physical deconditioning, recurrent symptoms, mood alterations, and poor quality of life. Rehabilitation is a treatment able to expand short- and long-term management of chronic patients admitted to intensive care. Recovery of individual’s physical and respiratory functions are both aims of a rehabilitation course in this area. The purpose of this review article is to resume a ‘‘state of art’’ of the currently available evidence for a rehabilitation strategy in critically ill patients, with a description of the main activities and techniques adopted. Despite the use of several activities and techniques that have led to short-term beneficial effects on both pulmonary and physical functions, muscle retraining represents the most important evidence-based aspect of Intensive Care Unit-rehabilitation: indeed, it is associated with weaning success and helps patients to recover at their maximum at discharge. Keywords: Rehabilitation, mechanical ventilation, physiotherapy, weaning
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Correspondence: Prof. Enrico M. Clini, Department of Pulmonary Rehabilitation, University of Modena and Ospedale Villa Pineta, Via Gaiato 127, 41026 Pavullo (MO), Italy. Tel: 39 0536 42039; Fax 39 0536 42039; e-mail:
[email protected]
INTRODUCTION
‘‘physical-therapy,’’ ‘‘bronchial drainage,’’ ‘‘breathing exercise,’’ and ‘‘muscle training.’’ To ensure that the major articles were reviewed, the reference lists of the extracted articles were also checked to identify other potentially relevant articles. No exclusion criteria based on the level of evidence were applied in our review. Thus, 94 paper were extracted: among these, 29 were randomized controlled trials, 12 systematic reviews, 1 meta-analysis, 24 observational prospective studies, and 6 expert opinions.
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The new approaches and medical tools applied to intensive care area have dramatically improved primary outcomes (i e, hospital mortality and morbidity) in critically ill and ventilated patients.13 Notwithstanding, a prolonged stay in hospital and the difficult response to medications can often cause severe complications in these patients for muscle weakness, physical deconditioning, recurrent symptoms, mood alterations, and poor quality of life.4,5
Table 1 summarizes the components of a rehabilitation course in the critically ill patients. Basically, we have split them into two main clinical areas:
OBJECTIVES
Due to the nature of severe critical illness, the prolonged bed rest appears to have a main role in the muscle weakness of ICU patients. In these patients, rehabilitation can have per se a role in recovering the functions lost.10 Recently, great attention has been given to the early physical activity as a feasible and safe intervention following the initial cardiorespiratory and neurological stabilization.11 Thomsen et al,12 found a good ability of ambulation in critically ill patients with respiratory failure, a couple of days after admission in a recovery unit where a step-by-step activity program (sit on the edge of bed without back support, bed-chair transfer,
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Even if the therapist working in an Intensive Care Unit (ICU) setting may have different applications and workloads in different countries,6 rehabilitation is the only treatment choice able to expand short- and even long-term care of these chronic patients once admitted to ICUs.7 Recovery of individual’s physical and respiratory functions, withdrawing of Mechanical Ventilation (MV), and prevention of bed rest effects are the clinical aims of a rehabilitation course in this area.8,9
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1. Approach to whole body muscle weakness and related complications. 2. Approach to bronco-pulmonary problems.
APPROACH TO WHOLE BODY MUSCLE WEAKNESS AND RELATED COMPLICATIONS
The purpose of this article is to resume a ‘‘state of art’’ of the currently available clinical evidences for a comprehensive rehabilitation program in critically ill patients, with a description of the main activities and techniques adopted.
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DATA SOURCE AND SELECTION Research of all papers in the critical care area was performed using the PubMed database following six specific keywords as the inclusion criteria: ‘‘intensive care,’’ ‘‘rehabilitation,’’ www.slm-respiratory.com
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Table 1. Main Components of Rehabilitation in the Critical Care Area Activities
Techniques and Devices
Mobilization
Postures Passive and active limb exercises Continuous rotational therapy Respiratory muscle training Peripheral muscle training Neuromuscular electrical stimulation
Whole body muscle weakness and related complications Muscle training
Bronco-pulmonary problems
Chest physiotherapy for bronchial drainage
Manual hyperinflation Percussion/vibrations In-exsufflator Intrapulmonary percussive ventilation
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and aided ambulation using a walker) was set. Moreover, in a randomized trial, Schweickert et al,13 have shown that early mobilization and muscle training can improve functional outcomes, cognitive and respiratory conditions in particular in critically ill patients at unit discharge.
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Figure 1. Different postures adopted in critically ill patients.
specific bronchial drainage techniques in 35 patients with acute lobar atelectasis. Despite these findings, it is still not known whether these pulmonary function improvements were also correlated with the recovery of stronger outcomes (i e, mortality) in these critically ill patients.
Mobilization
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This approach refers to physical activities to elicit acute physiological effects that may enhance ventilation, central and peripheral perfusion, muscle metabolism and alertness, and are countermeasures for venous stasis and deep vein thrombosis.14 Postures, passive or active limb exercises, and continuous rotational therapy (CRT) are considered the principal strategies to mobilize patients.
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Passive and Active Limb Exercise
Postures
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These are considered the most common and easy techniques to prevent bed-lying associated risks (Figure 1). However, despite their physiological rationale,8 these are still of limited use and effectiveness for a wide application in the clinical setting. Prone position, as one example of posture, has been shown to result in short-term gain of oxygenation in 60%90% of patients with ARDS, improving the mismatch between ventilation and perfusion (V/Q) and the residual lung capacity.1517
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In a recent randomized trial in critically ill and respiratory patients,26 Burtin and colleagues compared the additional effect of early active limb training using a bedside ergometer to a standard session of physiotherapy with upper and lower limb passive motion. They found that quadriceps force and functional status were not different between groups at ICU discharge; however, the total walked distance (6-minute walk test), the isometric quadriceps force, and the perceived functional well-being (measured by SF-36, a health questionnaire) were significantly higher in the study group at this time. Thus, authors concluded that an early training session can ease the whole body recovery in these patients.
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Chatte et al,18 investigating 32 patients under MV due to severe acute respiratory failure not caused by left ventricular failure or atelectasis, found that the mean oxygenation ratio (PaO2/FiO2) significantly increased from 103 when supine to 158 and 159 after 1 and 4 hours in the prone position, respectively. Improvements in lung function have been also documented in patients with unilateral disease once positioned in side lying with the affected lung uppermost.19,20 This posture has been shown to improve oxygenation and V/Q matching also in patients with a mono-lateral pulmonary disease (i e, pleural effusion) receiving MV for acute failure.21
Another study in a medical ICU,27 compared muscle mobilization versus usual care only in acute patients requiring MV. The gradual mobility protocol they applied to both upper and lower limbs (PROM-Passive Range of Motion therapy, active exercise, and ambulation) resulted in feasibility, safety, and decreased length of stay in hospital. The only study
Moreover, Stiller et al,22 found that positioning patients in side lying with the affected lung uppermost, enhanced the radiological resolution of atelectasis when added to AoRM 2011; 000:(000). Month 2011
Limb exercises (passive, active assisted, or active resisted) can be performed with the aim of maintaining joint range of motion, improving soft-tissue length and muscle strength, and decreasing the risk of thromboembolism;23 indeed, the associated gravitational stimulation can speed up the recovery in terms of physiologic fluid redistribution, which in turn may affect the patient’s immobility.24 Notwithstanding, only passive limb movement has been shown to improve metabolic capacity (15% in oxygen consumption) and cardiovascular response.25
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performed to test supported arm training in addition to usual physiotherapy28 gave similar conclusions in patients recently weaned from MV and admitted to a respiratory ICU.
Continuous Rotational Therapy (CRT)
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Rarely applied in ICU, this refers to specialized beds used continuously to turn patients along the longitudinal axis up to an angle of 608 onto each side, with preset degree and speed of rotation. This treatment can prevent sequential airways closure and pulmonary atelectasis often caused by infection and prolonged immobility.29 One randomized study investigating the effectiveness of CRT in the management of 120 critically ill patients admitted to ICU, has shown a significantly lower incidence rate of pneumonia in treated versus untreated controls (9% and 22%, respectively).30 Similar significant reductions in the incidence rate of lower respiratory tract infection, pneumonia, and atelectasis were found by other authors in patients treated with CRT and compared with normal positioning in conventional beds.3133 Finally, Fink et al,32 found a significantly lower duration of endotracheal intubation and length of hospital stay in patients nursed on the oscillating beds; moreover, in a crude costbenefit analysis, authors noted that average costs of care for ICU/day were not significantly different in patients treated with CRT or with conventional beds. Notwithstanding, in this and in another study, it has also been demonstrated that CRT may be not well tolerated in all patients, showing agitation during treatment.31,32
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Figure 2. Modes of peripheral and respiratory muscle training.
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muscle training. Data obtained in spontaneously breathing chronic respiratory patients suggested that the impaired contractile effect of the diaphragm is due to the altered geometric shape of the dome rather than to the muscle atrophy. Indeed, the diaphragm of patients with COPD is as good as that of normals in generating pressure at comparable lung volumes,38 showing an adaptive change toward the slow-to-fast characteristics (resistance to fatigue) of the muscle fibers.39
Muscle Training
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It’s known so far that muscle mass and its ability to perform aerobic exercise invariably declines during inactivity; the loss of strength, indeed, has been found to decline by 40% after the first week.34 In critically complex patients, skeletal muscle training (see Figure 2) aims at improving strength, which in turn may increase the patient’s ability to perform basic activities of daily life (BADL; e g, washing or dressing) and primary functions (e g, walking without aid). In these patients, the application of a tailored training program seems to be very effective in recovering functions, such as weaning, and in improving hospital survival.35 Furthermore, this rehabilitation approach has also a positive effect on the hospital-stay associated risks, in particular in those individuals confined to bed.10
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From a clinical point of view, recent literature agrees in considering the potential role of inspiratory muscle training as a component of pulmonary rehabilitation in severely disabled COPD and in neuromuscular patients,40,41 aimed at improving their strength and at reducing the respiratory system load perception.42 Studies on ICU ventilatorydependent COPD patients also showed that respiratory muscles training is somewhere associated with a favorable weaning outcome.4346
Peripheral Muscles Training Prolonged inactivity is more likely to cause skeletal muscle dysfunction and atrophy in antigravity muscles (such as femoral quadriceps and latissimus dorsi muscle), with a selective damage of type-2 fibers leading to a reduced capacity to perform aerobic exercise.34,47 In severely disabled patients, muscle re-training (both passive and active training lifting weights or pushing against a resistance with the limbs), produces specific gain of strength and recovery of BADLs* walking ability in particular.
Respiratory Muscle Training
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As for the skeletal muscles, pulmonary ventilation may be profoundly altered by the effects of bed-resting. Respiratory muscle weakness, imbalance between muscle strength and load of the respiratory system, and cardiovascular impairment are major determinants of weaning failure in ventilated patients. In ICU patients this factors and the excessive use of controlled MV may lead to the development of rapid diaphragmatic atrophy and dysfunction.36,37 Nevertheless, the rationale of respiratory muscle training in ICU is still controversial since no physio-pathological information is yet available to support the specific use of respiratory www.slm-respiratory.com
Only two controlled studies, however, report findings on the effects of peripheral muscle re-training in COPD patients after an episode of acute respiratory failure.28,48 As the first, Nava48 demonstrated that incremental aerobic 3
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retraining program was associated with a greater improvement in patient’s exercise capacity and symptoms score as compared to controls. Porta and coworkers28 have then found that selective arm training enhanced the benefits (exercise tolerance and perception of dyspnea) that follow usual physiotherapy.
Neuromuscular Electrical Stimulation (NMES)
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Passive NMES (a simple and noninvasive low-intensity stimulation targeted at inducing muscle contraction) is able to induce positive change in muscle performance without any form of ventilatory stress4951 in severe patients unable to perform any activity. However, no clinical studies have yet completely demonstrated the additional effect of NMES on exercise tolerance when compared with conventional training. From a practical point of view, NMES can be used easily in the critical care setting, applied to lower limb muscles of patients laying in bed, being COPD50,5254 patients and those with congestive heart failure55,56 who are more likely to benefit.
Figure 3. Techniques of chest physiotherapy commonly applied to enhance bronchial hygiene in critically ill patients.
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In these severely ill patients, NMES has proved to have positive effects in terms of strength and aerobic capacity of the treated muscles,53,55,56 reduction of days needed to transfer the patient from bed to chair, and improvement in the overall perceived quality of life.52,55 Due to the experimental demonstration of a beneficial effect in oxygen consumption and in the reperfusion of lower arms,57 NMES has been also considered as a means to prevent the ICU polyneuromyopathy, a frequent complication in the critically ill patients.
Manual Hyperinflation (MH)
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This respiratory technique is aimed at preventing pulmonary collapse (or re-expanding collapsed alveoli), improving oxygenation and lung compliance, and facilitating the movement of secretions toward the central airways.58 Four elements need to be considered by professionals to effectively apply this technique: adequate tidal volume, slow inspiratory flow rate, inspiratory pause, and assessment of intra-bronchial pressure.5963 The fast release of pressure during expiration can finally develop a rapid airflow simulating the cough effect.64
APPROACH TO BRONCO-PULMONARY PROBLEMS
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Airway mucus excess, pulmonary atelectasis, and postoperative or weaning-linked complications frequently worsen the clinical course of patients admitted to ICUs. In particular, an increase of bronchial secretions (ie, due to mucociliary dysfunction or to muscular weakness) affects the respiratory flows thus increasing the risk of nosocomial pneumonia in these patients.6,8 Therefore, scope of chest physiotherapy is to prevent such complications by improving local and/or overall ventilation and gas exchange, and by reducing airway resistance and work of breathing.7 Moreover, other diagnosis-related pulmonary problems can be frequently associated with patient’s difficulties in resuming spontaneous breathing after institution of acute care and MV. Thus, the application of the weaning process may help and speed this recovery.
Other studies with MH demonstrated a positive effect on lung compliance and alveolar recruitment,70,71 pulmonary expansion in compressed or unventilated regions,69,72 and reduced rate of hospital pneumonia.73
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Percussion and Vibrations
Chest Physiotherapy for Bronchial Drainage
Manual percussion and vibrations (clapping selected area and then compressing chest during the expiratory phase) are commonly used to increase airway clearance and are often associated with postural drainage. Currently, in critical ventilated patients with a normal cough competence, increase of mucus clearance is described without a significant change of blood gases and lung compliance.74,75
Several manually assisted techniques (manual hyperinflation, percussions/vibrations) and mechanical devices (in-exsufflator) are often applied to facilitate removal of mucus excess (see Figure 3). Basically, these techniques are used in sequence, whereas choice mainly depends upon the patient’s preference and compliance. AoRM 2011; 000:(000). Month 2011
From a technical point of view, the application of MH does not have a standard practice; variability of delivered air volume or flow rates might produce some hemodynamic side effects or barotraumas due to the high pressure developed in the airways or to the large lung volumes applied, especially in those patients under MV.6567 Increase in air volume during MH can be obtained both manually or with assisted MV, each producing similar benefit in clearing excessive mucus.68,69
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Even if Ntoumenopoulos and colleagues73 have demonstrated a direct relationship between chest percussion and vibrations and a 31% incidence rate reduction of ventilatorassociated pneumonia, other studies are unlikely to find similar benefits and also underline frequent association with side effects such as pain attach, atelectasis, and increase of oxygen consumption.70,76,77 For this reason, the use of percussion and vibration in the critical care setting is below the area of a clear and convincing evidence.
including rehabilitation is promoted to speed up the patients’ functional recovery and to prevent prolonged bed laying. This is particularly useful in those patients still needing ventilatory dependence or difficult weaning upon admission. To manage the multiple and complex problems of these patients, integrated programs dealing with both whole body physicaltherapy and pulmonary care are needed.95 Notwithstanding, due to the high variability of patient’s characteristics in ICU and to the lack of a firm long-term outcome measure to set, there is still a limited evidence to support such a comprehensive approach to all the patients admitted and cared for in a critical care area.
In-Exsufflation Born as an aid for noninvasively ventilated neuromuscular patients,7880 the mechanical in-exsufflator promotes removal of excessive mucus by inflating the airways with a large air volume that rapidly is exsufflated by a negative pressure, thus simulating the physiological mechanism of cough.81,82 In mechanically ventilated ICU patients, there are only a few trials showing the efficacy of this cough-assist. An Italian study by Vianello and colleagues,83 demonstrated the safety and the clinical advantage (avoidance of tracheostomy and/or endotracheal intubation) of this device when compared with conventional chest physiotherapy in neuromuscular patients with recent upper respiratory tract infection causing admission. In tracheostomized head/spinal cord injured patients with retained secretions due to the alteration of their cough reflex, Branson84 have also shown that the intermittent use of mechanical in-exsufflation is useful in the management of mucus production.
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As recently reported by the European Task Force of both the Respiratory and the Intensive Care Medicine Societies, Gosselink et al,7 shows there is a lack of systematic reviews, meta-analysis, and randomized clinical trials to support or reject physiotherapy interventions in the critical care area, thus most grades of recommendation are still at level C or D. Notwithstanding, literature has suggested that several activities and techniques have led to some short-term beneficial effects on pulmonary and physical functions. Muscle retraining represents the most important and evidence-based aspect of ICU-rehabilitation: indeed, it is associated with higher rate of weaning success and helps patients to recover their maximal functions at discharge. These effects are best increased by the earliest application of this process.
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Intrapulmonary Percussive Ventilation
Disclosure: The authors declare no conflict of interest.
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Few studies have been published on the physiological and therapeutic role of IPV when applied in chronically ventilated patients. A recent randomized multicenter trial in 46 tracheostomized patients recently weaned from MV demonstrated that the addition of 15-day IPV treatment to usual chest physiotherapy is associated with an improvement of oxygenation (PaO2/FiO2) and expiratory muscle performance also leading to a substantial risk reduction of pneumonia in the month following the end of therapy.93
CONCLUSION
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