Abstract

1. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation PohlmanMC, Schwickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical Care Medicine. 2010; 38(11): 2089-2094. • Background/Intro • It is postulated that initiating PT early will decrease mortality rates in ICU patients • There is a recent progression toward early mobilization in patients on mechanical ventilation (MV) • PT should be initiated from the onset of patients being placed on MV due to developing a higher functional level compared to those who do not receive PT • The protocol implemented resulted in improved functional independence upon hospital discharge, more days free of ventilator usage, and reduced confusion related to being in the ICU • Intervention involved all disciplines of care in the ICU and consisted of awakening patients from sedation for PT • Abstract • Objective: Physical and occupational therapy are possible immediatelyafter intubation in mechanically ventilated medicalintensive care unit patients. The objective of this study was todescribe a protocol of daily sedative interruption and early physicaland occupational therapy and to specify details of intensivecare unit-based therapy, including neurocognitive state, potentialbarriers, and adverse events related to this intervention. • Design and Patients: Detailed descriptive study of the interventionarm of a trial of mechanically ventilated patients receivingearly physical and occupational therapy. • Setting: Two tertiary care academic medical centers participatingin a randomized controlled trial. • Intervention: Patients underwent daily sedative interruptionfollowed by physical and occupational therapy every hospital dayuntil achieving independent functional status. Therapy began withactive range of motion and progressed to activities of daily living,sitting, standing, and walking as tolerated. • Measurements and Main Results: Forty-nine mechanically • ventilated patients received early physical and occupational therapyoccurring a median of 1.5 days (range, 1.0 –2.1 days) afterintubation. Therapy was provided on 90% of MICU days duringmechanical ventilation. While endotracheally intubated, subjectssat at the edge of the bed in 69% of all physical and occupationaltherapy sessions, transferred from bed to chair in 33%, stood in33%, and ambulated during 15% (n _ 26 of 168) of all physicaland occupational therapy sessions (median distance of 15 feet;range, 15–20 feet). At least one potential barrier to mobilizationduring mechanical ventilation (acute lung injury, vasoactive medicationadministration, delirium, renal replacement therapy, or body mass index >30 kg/m2) was present in 89% of patient encounters. Therapy was interrupted prematurely in 4% of all sessions, most commonly for patient-ventilator asynchrony andagitation. • Conclusion: Early physical and occupational therapy is feasiblefrom the onset of mechanical ventilation despite high illnessacuity and presence of life support devices. Adverse events areuncommon, even in this high-risk group. • Conclusion • A variety of activities proved to be safe and feasible early in the care of MV patients leading to successful ambulation • PT can be implemented successfully with sedative interruption thus leading an improved functional status • Results • 49 patients underwent early PT/OT • Therapy sessions occurred 498 days of 570 • Reasons for no therapy sessions included marked ventilator dysynchrony, mean arterial pressure <65 mm Hg, and active gastrointestinal blood loss, patient fatigue, and respiratory distress • On the majority of sessions patients were able to perform UE and LE AROM exercises, move actively in bed, sit at the edge of the bed, groom themselves, and simulate eating • Less frequently patients were able to move from bed to chair, stand, or ambulate • It was a rare occurrence for patients to respond negatively to coming out of sedation, exhibit ICU delirium, or be unresponsive to PT during the study • Adverse effects to exercise occurred during 80 out of 498 with the most common causes being ventilator asynchrony or agitation • Patients accomplished a greater percentage of activities and required less assistance as they progressed from MV, to extubated in the ICU, to being on the medical ward • Article 1 and Evidence • Chen S, Su CL, Wu YT, et al. Physical training is beneficial to functional status and survival in patients with prolonged mechanical ventilation. J of the Formosan Medical Association. 2011; 110: 572-579. • The study demonstrated that patients on MV significantly improved their functional status immediately and it continued to improve the following year after receiving physical therapy • The survival rate one year after discharge was significantly higher in the PT group compared to the control group • The study was a prospective, randomized controlled trial indicating a higher level of evidence • Methods and Materials • Inclusion criteria consisted of: age ≥ 18 years-old, MV for < 72 hours with an expected 24 hours of ventilatory support, or baseline functional independence ≥ 70 (from Barthel Index) • Exclusion criteria consisted of: rapidly evolving neuromuscular disease, admission after cardiopulmonary arrest, diagnosis of irreversible condition with 6-month mortality estimated at >50%, elevated intracranial pressure, multiple absent limbs, or enrollment in another trail • Patients were randomly assigned to PT intervention group or standard care • Patients were placed on the protocol to receive daily PT if they did not possess any contraindications to treatment • PT was initiated if the patient exhibited 3 of the 4: opening eyes to a voice, using eyes to follow, squeezing hand on request, or protruding tongue on request, < 3 required PROM exercises to be completed instead of the typical PT intervention • Level of assistance was determined based on each patient’s needs to complete the activity and progression of exercises was patient dependent • Activities consisted of: AROM in the semi-recumbent position, bed mobility, sitting on side of bed, balance exercises, activities of daily living, and transfers • PT was continued until the patient reached functional status or was discharged from the hospital • Number, duration of treatments, vital signs at rest and with activity were recorded • Patients were monitored for adverse events and PT was terminated if any were present • Article 2 and Evidence • Yang PH, Wang CS, Wang YC, et al. Outcome of physical therapy intervention on ventilator weaning and functional status. Kaohsiung J Med Sci. 2010; 26: 366-372. • The study established that PT aided in restoring mobility to MV patients • However, there was no correlation between the amount of time a patient received PT and an increase in mobility • The study was a prospective, non-randomized controlled trial • Discussion • The study focused on daily PT/OT sessions that began from the initiation of MV • The results demonstrate activity is feasible on MV patients immediately after they have been intubated • Adverse effects to exercise were not a common occurrence thus, indicating early PT/OT is safe to perform • It is likely adverse events did not occur because each session was based on a sequential progression depending on each patient’s tolerance • Summary • All three articles demonstrated that PT could safely be initiated without frequently having adverse effects to exercise in the early intervention of patients on MV • The studies demonstrate early PT increases the functional status of patients and improves their ability to ambulate • Therefore, the articles provide evidence for PT to be utilized more frequently in MV patients • Presentation by: Amy M. Bramble, Student Physical Therapist • Bellarmine University • Clinical Significance • The study shows that initiating PT/OT early with MV patients is a safe feasible means to improve functional outcomes at the time of hospital discharge • This study provides insight into the future of PT being utilized more frequently in the ICU setting to aid in preparation of weaning patients off MV • Purpose • To describe an early PT/OT intervention of daily sedative interruption for ICU patients that are on MV