Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study.

BACKGROUND: Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. METHODS: We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. RESULTS: Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. CONCLUSION: TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. TRIAL REGISTRATION: Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.

Effect of prehabilitation on ventilatory efficiency in non-small cell lung cancer patients: A cohort study.

OBJECTIVE: Cardiopulmonary exercise testing (CPET) for patients awaiting lung resection for non-small cell lung cancer (NSCLC) has developed considerably in recent years. Pulmonary rehabilitation before surgery (prehabilitation) improves postoperative risk factors such as forced expiratory volume in 1 second and peak oxygen consumption (VO2peak). Ventilatory inefficiency assessed according to the linear regression of the ratio between the increase in minute ventilation and the expired carbon dioxide flow during CPET (VE/VCO2 slope) >35, is a high-risk factor for postoperative complications. Our objective was to assess the effect of prehabilitation on VE/VCO2 slope, and its relationship with VO2peak. METHODS: This retrospective cohort study was performed between January 1, 2014 and December 31, 2017 at Rouen University Hospital. One hundred fifty-two patients with NSCLC awaiting lung surgery who underwent CPET were screened. A total of 50 patients who underwent CPET before and after prehabilitation were included. RESULTS: VE/VCO2 slope did not change significantly after prehabilitation (median, 37.1 [25th-75th percentile, 33.8-43.4] vs median, 35.4 [25th-75th percentile, 31.1-40.5]; P = .09), whereas VO2peak increased significantly (from a median of 13.2 [25th-75th percentile, 11.9-14.7] to a median of 14.8 [25th-75th percentile, 13.1-16.4] mL/kg/min). The number of patients with a high risk of postoperative complications (ie, VE/VCO2 slope >35) did not change significantly after prehabilitation. Cardiorespiratory parameters improved significantly more in patients who underwent at least 15 sessions of ambulatory prehabilitation. CONCLUSIONS: VE/VCO2 slope, a known predictor of favorable surgical outcomes in patients with NSCLC, did not change with the prehabilitation program used in this study, despite clear improvements in VO2peak and other CPET measures. Larger, prospective studies are needed to confirm the results of this study.

Functional Electrical Stimulation-A New Therapeutic Approach to Enhance Exercise Intensity in Chronic Obstructive Pulmonary Disease Patients: A Randomized, Controlled Crossover Trial.

OBJECTIVE: To evaluate the effect of quadriceps functional electrical stimulation (FES)-cycling on exertional oxygen uptake (V˙o2) compared with placebo FES-cycling in patients with chronic obstructive pulmonary disease (COPD). DESIGN: A randomized, single-blind, placebo-controlled crossover trial. SETTING: Pulmonary rehabilitation department. PARTICIPANTS: Consecutive patients (N=23) with COPD Global Initiative for Chronic Obstructive Lung Disease stage 2, 3, or 4 (mean forced expiratory volume during the first second, 1.4±0.4L [50.3% predicted]) who had recently begun a respiratory rehabilitation program. INTERVENTION: Two consecutive 30-minute sessions were carried out at a constant load with active and placebo FES-cycling. MAIN OUTCOME MEASURES: The primary outcome was mean V˙o2 during the 30-minute exercise session. The secondary outcomes were respiratory gas exchange and hemodynamic parameters averaged over the 30-minute endurance session. Lactate values, dyspnea, and perceived muscle fatigue were evaluated at the end of the sessions. RESULTS: FES-cycling increased the physiological response more than the placebo, with a greater V˙o2 achieved of 36.6mL/min (95% confidence interval [CI], 8.9-64.3mL/min) (P=.01). There was also a greater increase in lactate after FES-cycling (+1.5mmol/L [95% CI, .05-2.9mmol/L]; P=.01). FES-cycling did not change dyspnea or muscle fatigue compared with the placebo condition. CONCLUSIONS: FES-cycling effectively increased exercise intensity in patients with COPD. Further studies should evaluate longer-term FES-cycling rehabilitation programs.

Effects of different early rehabilitation techniques on haemodynamic and metabolic parameters in sedated patients: protocol for a randomised, single-bind, cross-over trial.

INTRODUCTION: Early rehabilitation has become widespread practice for patients in intensive care; however, the prevalence of intensive care unit-acquired weakness remains high and the majority of physiotherapy is carried out in bed. Several inbed rehabilitation methods exist, but we hypothesise that techniques that provoke muscle contractions are more effective than passive techniques. METHODS: A randomised, controlled cross-over study will be carried out to evaluate and compare the effectiveness of early rehabilitation techniques on cardiac output (CO) in sedated patients in intensive care. 20 intubated and sedated patients will undergo 4 10 min rehabilitation sessions. 2 sessions will involve 'passive' techniques based on mobilisations and inbed cycle ergometry and 2 involving electrostimulation of the quadriceps muscle and Functional Electrical Stimulation-cycling (FES-cycling). The primary outcome is CO measured by Doppler ultrasound. The secondary outcomes are right ventricular function, pulmonary systolic arterial pressure, muscle oxygenation and minute ventilation during exercise. RESULTS AND CONCLUSION: Approval has been granted by our Institutional Review Board (Comité de Protection des Personnes Nord-Ouest 3). The results of the trial will be presented at national and international meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02920684.