Development of a clinical practice guideline for physiotherapy management of adults invasively ventilated with community-acquired pneumonia.

BACKGROUND AND SETTING: Patients hospitalised with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit (ICU) for invasive mechanical ventilation and receive treatment by physiotherapists. However, clinical physiotherapy practice is variable for this ICU cohort. OBJECTIVES: To develop a clinical practice guideline for physiotherapy management of adults invasively ventilated with CAP using the best available evidence. METHODS: Guideline development using evidence synthesis according to the GRADE and JBI approaches, incorporating findings from four preceding phases of a mixed-methods research program: systematic review and meta-analysis, national survey of Australian ICU physiotherapy practice, e-Delphi study to determine expert consensus, and multidisciplinary peer-review of the expert consensus statements by senior ICU clinicians to determine validity and applicability of the statements for translation into practice. RESULTS: The guideline comprises 26 recommendations, encompassing physiotherapy assessment, patient selection and prioritisation, and treatment. Physiotherapy treatment covers domains of humidification, patient positioning, hyperinflation techniques, manual chest wall techniques, normal saline instillation, active treatment, and mobilisation. Recommendations are rated as strong or conditional based on JBI criteria, and certainty of evidence according to GRADE. Considerations for practice are provided within the guideline to enhance clarity and practicality, particularly for conditional recommendations where evidence is limited or conflicting. CONCLUSION: This guideline, based on the best available evidence for clinical physiotherapy practice for adults invasively ventilated with CAP, is intended to support clinicians with clinical decision making. Further research is required to evaluate guideline implementation into clinical practice, and incorporate the values and preferences of ICU patients and their families. CONTRIBUTION OF PAPER.

A retrospective study of physiotherapy management for patients with pneumonia requiring invasive ventilation in a single-center Australian ICU.

Background: Pneumonia is a frequent diagnosis for patients admitted to Australian intensive care units (ICUs) for invasive ventilation. Physiotherapists in ICU provide interventions to enhance respiratory function and physical recovery. Objective: This retrospective cohort study aimed to describe physiotherapy management of adults with pneumonia who require invasive mechanical ventilation in a single Level 3 ICU in a quaternary teaching hospital. Methods: All adults admitted with a medical diagnosis of pneumonia requiring invasive mechanical ventilation over a two-year period were included. Demographic and clinical data, including APACHE II score, ventilator-free days (VFDs) to day 28, ICU length of stay (LOS), and type and frequency of physiotherapy episodes of care delivered in ICU, were collected from electronic medical records. Correlations between VFDs to day 28 and the frequency of physiotherapy interventions delivered per subject were examined using Spearman's rho analysis. Results: From 208 records screened, 66 subjects with an ICU admission diagnosis of pneumonia, who required invasive mechanical ventilation, were included. Median (IQR) ICU LOS was 10 (5-17) days, and mortality rate was 15.2% ( n = 10 ). The cohort had a median of 20.5 (IQR 2-25) VFDs to day 28. Community-acquired pneumonia (66.7%, n = 44 ) was the most frequent type of pneumonia diagnosis. There were 1110 episodes of physiotherapy care, with patients receiving a median of 13.5 (IQR 6.8-21.3) episodes during their ICU stay, with a median rate of 1.2 (IQR 1.0-1.6) episodes per day. Over 96.7% of patients with pneumonia received physiotherapy treatment during their ICU stay. Overall, physiotherapy treatments consisting only of respiratory techniques were most commonly provided (55.1%, n = 612 ). Airway suctioning (92.4%, n = 61 ), patient positioning (72.7%, n = 48 ) or positioning advice to nurses (77.3%, n = 51 ), and hyperinflation techniques (63.6%, n = 42 ) were among the respiratory techniques most delivered. Conclusion: This study described the current intensive care physiotherapy management in a single center for adults with pneumonia who required invasive mechanical ventilation, demonstrating that respiratory physiotherapy interventions are often provided for this ICU patient cohort. Further research is warranted to determine the efficacy of respiratory physiotherapy interventions to justify their use for ICU patients with pneumonia receiving invasive mechanical ventilation.

Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness.

Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).

Physiotherapy management for COVID-19 in the acute hospital setting and beyond: an update to clinical practice recommendations.

This document provides an update to the recommendations for physiotherapy management for adults with coronavirus disease 2019 (COVID-19) in the acute hospital setting. It includes: physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the use of physiotherapy treatments and personal protective equipment. New advice and recommendations are provided on: workload management; staff health, including vaccination; providing clinical education; personal protective equipment; interventions, including awake proning, mobilisation and rehabilitation in patients with hypoxaemia. Additionally, recommendations for recovery after COVID-19 have been added, including roles that physiotherapy can offer in the management of post-COVID syndrome. The updated guidelines are intended for use by physiotherapists and other relevant stakeholders caring for adult patients with confirmed or suspected COVID-19 in the acute care setting and beyond.

The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study.

BACKGROUND: There are few reports of new functional impairment following critical illness from COVID-19. We aimed to describe the incidence of death or new disability, functional impairment and changes in health-related quality of life of patients after COVID-19 critical illness at 6 months. METHODS: In a nationally representative, multicenter, prospective cohort study of COVID-19 critical illness, we determined the prevalence of death or new disability at 6 months, the primary outcome. We measured mortality, new disability and return to work with changes in the World Health Organization Disability Assessment Schedule 2.0 12L (WHODAS) and health status with the EQ5D-5LTM. RESULTS: Of 274 eligible patients, 212 were enrolled from 30 hospitals. The median age was 61 (51-70) years, and 124 (58.5%) patients were male. At 6 months, 43/160 (26.9%) patients died and 42/108 (38.9%) responding survivors reported new disability. Compared to pre-illness, the WHODAS percentage score worsened (mean difference (MD), 10.40% [95% CI 7.06-13.77]; p < 0.001). Thirteen (11.4%) survivors had not returned to work due to poor health. There was a decrease in the EQ-5D-5LTM utility score (MD, - 0.19 [- 0.28 to - 0.10]; p < 0.001). At 6 months, 82 of 115 (71.3%) patients reported persistent symptoms. The independent predictors of death or new disability were higher severity of illness and increased frailty. CONCLUSIONS: At six months after COVID-19 critical illness, death and new disability was substantial. Over a third of survivors had new disability, which was widespread across all areas of functioning. Clinical trial registration NCT04401254 May 26, 2020.

Quantification of the negative impact of sedation and inotropic support on achieving early mobility in burn patients in ICU: A single center observational study.

INTRODUCTION: Early rehabilitation for burns survivors in the intensive care unit (ICU) is arguably more challenging than the general population. Early achievement of functional verticality milestones (FVMs) has the potential to ameliorate the detrimental effects of bed rest and immobility observed in ICU patients and reduce healthcare costs. However, the time to achieving FVMs after burn injury is influenced by factors such as sedation practices, cardiovascular stability, mechanical ventilation, acute skin reconstruction and length of stay (LOS) during the acute intensive care period. OBJECTIVES/AIMS: The aims of this study were to identify the association between early achievement of FVMs and factors influencing cessation of bedrest in adult patients with burns receiving ICU care, and to explore barriers to achievement of FVMs as recorded by clinicians. METHODS: A 5-year retrospective observational cohort study was conducted. The digital medical records were reviewed for each case to explore episodes of FVMs and patient factors which may contribute to persistent bed rest, such as use of infused sedative and/or inotropic medication, mechanical ventilation, burn surgery, total body surface area (TBSA), ICU length of stay and pre-ICU practices. Logistic regression was used to examine the association between FVM achievement and treatment and injury factors in ICU survivors. RESULTS: The total sample available for analysis included 64 patients. When sedation/agitation score was within recommended limits, odds of achieving FVMs was 21 times greater than periods outside those limits. When deep sedatives were infused, the odds of achieving FVMs decreased by 87% compared to periods when there was no infusion of these medications. In addition, the odds of achieving FVMs was reduced by 13% for each increase of 1 mL/h in the daily maximum noradrenaline dose. DISCUSSION AND CONCLUSION: Maintaining sedation and agitation scores within the optimal range, and minimising sedative infusion and inotropic support enhances the likelihood of early and frequent mobilization in patients with burns admitted to ICU. Additional barriers identified were mechanical ventilation, burns surgery, pre-ICU practices and ICU length of stay. The challenge for clinicians moving forward is to determine how these factors may be modified to increase early mobilization of burn patients in ICU.

Efficacy of Respiratory Physiotherapy Interventions for Intubated and Mechanically Ventilated Adults with Pneumonia: A Systematic Review and Meta-Analysis.

Purpose: A systematic review was conducted to investigate the effect of respiratory physiotherapy on mortality, quality of life, functional recovery, intensive care length of stay, duration of ventilation, oxygenation, secretion clearance, and pulmonary mechanics for invasively ventilated adults with pneumonia. Method: Five databases were searched for randomized trials published between January 1995 and November 2018. Study quality was assessed using a standardized Joanna Briggs Institute critical appraisal tool, and Review Manager software was used to pool the studies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the level of certainty of the evidence. Results: A total of 14 studies of moderate quality included 251 subjects with pneumonia. Eight studies were pooled for meta-analysis. Interventions that increased inspiratory volume appeared to benefit secretion clearance by nearly 2 grams (mean difference [MD] 1.97; 95% CI: 0.80, 3.14; very low GRADE evidence) and increase static lung compliance immediately after treatment by more than 5 millilitres/centimetre H20 (MD 5.40 mL/cm H2O; 95% CI: 2.37, 8.43; very low GRADE evidence) or by more than 6 millilitres/centimetre H2O after a 20- to 30-minute delay (MD 6.86 mL/cm H2O; 95% CI: 2.86, 10.86; very low GRADE evidence). No adverse events were found. Conclusions: Respiratory physiotherapy that increases tidal volume may benefit secretion clearance and lung compliance in invasively ventilated adults with pneumonia, but its impact on other outcomes, including mortality, length of stay, and other patient-centred outcomes, is unclear, and further research is required.

Objectif : analyse systématique pour explorer l'effet de la physiothérapie respiratoire sur la mortalité, la qualité de vie, le rétablissement fonctionnel, la durée de séjour en soins intensifs, la durée de la ventilation, l'oxygénation, la clairance des sécrétions et la mécanique pulmonaire d'adultes atteints de pneumonie sous assistance respiratoire invasive. Méthodologie : recherche dans cinq bases de données pour en extraire les études aléatoires publiées entre janvier 1995 et novembre 2018. Les chercheurs ont évalué la qualité des études à l'aide de l'outil d'évaluation critique standardisé du Joanna Briggs Institute et ont utilisé le logiciel Review Manager pour regrouper les études. Ils ont utilisé la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour évaluer le degré de certitude des données probantes. Résultats : au total, 14 études de qualité modérée incluaient 251 sujets atteints de pneumonie. Les chercheurs ont regroupé huit études en vue de la méta-analyse. Les interventions qui améliorent le volume inspiratoire semblaient accroître la clairance des sécrétions de près de 2 g (différence moyenne [DM] 1,97; IC à 95 % : 0,80, 3,14; données probantes GRADE très basses) et la compliance pulmonaire statique immédiatement après le traitement de plus de 5 millilitres par centimètre d'eau (DM 5,40 mL/cm d'eau; IC à 95 % : 2,37, 8,43; données probantes GRADE très basses) ou de plus de 6 millilitres par centimètre d'eau après une période de 20 à 30 minutes (DM 6,86 mL/cm d'eau; IC à 95 % : 2,86, 10,86; données probantes GRADE très basses). Aucun événement indésirable n'a été trouvé. Conclusion : la physiothérapie respiratoire qui accroît le volume courant peut contribuer à la clairance des sécrétions et à la compliance pulmonaire chez les adultes atteints de pneumonie sous assistance respiratoire invasive, mais ses effets sur d'autres résultats cliniques, comme la mortalité, la durée d'hospitalisation et d'autres résultats axés sur le patient ne sont pas clairement établis. D'autres recherches s'imposent.

Clinical validation of expert consensus statements for respiratory physiotherapy management of invasively ventilated adults with community-acquired pneumonia: A qualitative study.

OBJECTIVES: To conduct multidisciplinary peer-review of expert consensus statements for respiratory physiotherapy for invasively ventilated adults with community-acquired pneumonia, to determine clinical acceptability for development into a clinical practice guideline. RESEARCH METHODOLOGY: A qualitative study was undertaken using focus groups (n = 3) conducted with clinician representatives from five Australian states. Participants were senior intensive care physiotherapists, nurses and consultants. Thematic analysis was used, with a deductive approach to confirm clinical validity, and inductive analysis to identify new themes relevant to the application of the 38 statements into practice. SETTING: Adult intensive care. FINDINGS: Senior intensive care clinicians from physiotherapy (n = 16), medicine (n = 6) and nursing (n = 4) participated. All concurred that the consensus statements added valuable guidance to practice; twenty-nine (76%) were deemed relevant and applicable for the intensive care setting without amendment, with modifications suggested for remaining nine statements to enhance utility. Overarching themes of patient safety, teamwork and communication and culture were identified as factors influencing clinical application. Cultural differences in practice, particularly related to patient positioning, was evident between jurisdictions. Participants raised practicality and safety concerns for two statements related to the use of head-down patient positioning. CONCLUSION: Multidisciplinary peer-review established clinical validity of expert consensus statements for implementation with invasively ventilated adults with community-acquired pneumonia.

Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations.

This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.

Expert consensus for respiratory physiotherapy management of mechanically ventilated adults with community-acquired pneumonia: A Delphi study.

RATIONALE AND AIMS: Patients with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit. Physiotherapy may be provided to optimize respiratory function; however, there is significant variability in clinical practice and limited research directing best practice for this cohort. This study aimed to determine expert consensus for best physiotherapy practice for invasively ventilated adults with CAP. METHOD: A modified Delphi technique involved an international expert panel completing three rounds of an online questionnaire. The initial 35-statement questionnaire, based on a systematic literature review and survey of current clinical practice, covered physiotherapy assessment and treatment of intubated patients with CAP. Quantitative data using Likert scales determined level of agreement, with qualitative data collected through open-ended responses. Consensus threshold was set a priori at 70%. Items not achieving consensus were modified and new items added based on themes from qualitative data. Quantitative data were analysed descriptively, with thematic analysis used on qualitative data. RESULTS: The panel comprised 29 international clinical and academic experts in critical care physiotherapy. Response rate was more than 95% for each round. Outcome achieved was 38 consensus statements covering assessment and treatment, with 28 statements (74%) providing consensus on recommended clinical practice, two consensus disagreement statements (7%) for what practice is not recommended, and eight statements (21%) indicating which treatments may be beneficial. CONCLUSION: Expert consensus regarding physiotherapy for intubated adults with CAP patients provides an evidence-based approach to guide clinical practice. The consensus statements can also be used to guide research evaluating physiotherapy interventions for patients with CAP.

After-hours respiratory physiotherapy for intubated and mechanically ventilated patients with community-acquired pneumonia: An Australian perspective.

INTRODUCTION: Community acquired pneumonia (CAP) is a common reason for admission to an intensive care unit for intubation and mechanical ventilation, and results in high morbidity and mortality. The primary aim of the study was to investigate availability and provision of respiratory physiotherapy, outside of normal business hours, for intubated and mechanically ventilated adults with CAP in Australian hospitals. MATERIALS AND METHODS: A cross-sectional, mixed methods online survey was conducted. Participants were senior intensive care unit physiotherapists from 88 public and private hospitals. Main outcome measures included presence and nature of an after-hours physiotherapy service and factors perceived to influence the need for after-hours respiratory physiotherapy intervention, when the service was available, for intubated adult patients with CAP. Data were also collected regarding respiratory intervention provided after-hours by other ICU professionals. RESULTS: Response rate was 72% (n=75). An after-hours physiotherapy service was provided by n=31 (46%) hospitals and onsite after-hours physiotherapy presence was limited (22%), with a combination of onsite and on-call service reported by 19%. Treatment response (83%) was the most frequent factor for referring patients with CAP for after-hours physiotherapy intervention by the treating day-time physiotherapist. Nurses performing respiratory intervention (77%) was significantly associated with no available after-hours physiotherapy service (p=0.04). DISCUSSION: Physiotherapy after-hours service in Australia is limited, therefore it is common for intubated patients with CAP not to receive any respiratory physiotherapy intervention outside of normal business hours. In the absence of an after-hours physiotherapist, nurses were most likely to perform after-hours respiratory intervention to intubated patients with CAP. CONCLUSION: Further research is required to determine whether the frequency of respiratory physiotherapy intervention, including after-hours provision of treatment, influences outcomes for ICU patients intubated with pneumonia.

Efficacy of a respiratory physiotherapy intervention for intubated and mechanically ventilated adults with community acquired pneumonia: a systematic review protocol.

REVIEW OBJECTIVES: The objective of the review is to map evidence on the efficacy of a respiratory physiotherapy intervention for intubated and mechanically ventilated adults with community acquired pneumonia (CAP). Specifically, the review seeks to investigate if respiratory physiotherapy interventions can achieve the following for intubated and mechanically ventilated adults with CAP.

A survey of clinicians regarding respiratory physiotherapy intervention for intubated and mechanically ventilated patients with community-acquired pneumonia. What is current practice in Australian ICUs?

RATIONALE, AIMS, AND OBJECTIVES: Community-acquired pneumonia (CAP) is a common cause for intensive care unit (ICU) admission resulting in high morbidity and mortality. There is a paucity of evidence regarding respiratory physiotherapy for intubated and mechanically ventilated patients with CAP, and anecdotally clinical practice is variable in this cohort. The aims of this study were to identify the degree of variability in physiotherapy practice for intubated adult patients with CAP and to explore ICU physiotherapist perceptions of current practice for this cohort and factors that influence physiotherapy treatment mode, duration, and frequency. METHOD: A survey was developed based on common aspects of assessment, clinical rationale, and intervention for intubated and mechanically ventilated patients. Senior ICU physiotherapists across 88 Australian public and private hospitals were recruited. RESULTS: The response rate was 72%. Respondents (n = 75) stated their main rationale for providing a respiratory intervention were improved airway clearance (98%, n = 60/61), alveolar recruitment (74%, n = 45/61), and gas exchange (33%, n = 20/61). Respondents estimated that average intervention lasted between 16 and 30 minutes (70% of respondents, n = 41/59) and would be delivered once (44%) or twice (44%) daily. Results indicated large variability in reported practice; however, trends existed regarding positioning in alternate side-lying (81%, n = 52/64) or affected lung uppermost (83%, n = 53/64) and use of hyperinflation techniques (81%, 52/64). Decisions regarding duration were reported to be based on sputum volume (95%), viscosity (93%) and purulence (88%), cough effectiveness (95%), chest X-ray (87%), and auscultation (84%). Sixty percent reported that workload and staffing affected intervention duration and frequency. Intervention time was more likely increased when there was greater staffing (P = .03). CONCLUSION: Respiratory physiotherapy treatment varies for intubated patients with CAP. Further research is required to determine what is considered best practice for this patient population.