Does mechanical threshold inspiratory muscle training promote recovery and improve outcomes in patients who are ventilator-dependent in the intensive care unit? The IMPROVE randomised trial.

BACKGROUND: In patients who are ventilator-dependent in the intensive care unit, inspiratory muscle training may improve inspiratory muscle strength and accelerate liberation from the ventilator, but optimal training parameters are yet to be established, and little is known about the impact of inspiratory muscle training on quality of life or dyspnoea. Thus, we sought to ascertain whether inspiratory muscle training, commenced while ventilator-dependent, would improve outcomes for patients invasively ventilated for 7 days or longer. METHODS: In this randomised trial with assessor blinding and intention-to-treat analysis, 70 participants (mechanically ventilated ≥7 days) were randomised to receive once-daily supervised high-intensity inspiratory muscle training with a mechanical threshold device in addition to usual care or to receive usual care (control). Primary outcomes were inspiratory muscle strength (maximum inspiratory pressure % predicted) and endurance (fatigue resistance index) at ventilator liberation and 1 week later. Secondary outcomes included quality of life (SF-36v2, EQ-5D), dyspnoea, physical function, duration of ventilation, and in-hospital mortality. RESULTS: Thirty-three participants were randomly allocated to the training group, and 37 to the control group. There were no statistically significant differences in strength (maximum inspiratory pressure) (95% confidence interval [CI]: -7.4 to 14.0) or endurance (fatigue resistance index) (95% CI: -0.003 to 0.436). Quality of life improved significantly more in the training group than in the control group (EQ-5D: 17.2; 95% CI: 1.3-33.0) (SF-36-PCS: 6.97; 95% CI: 1.96-12.00). Only the training group demonstrated significant reductions in dyspnoea (-1.5 at rest, -1.9 during exercise). There were no between-group differences in duration of ventilation or other measures. In-hospital mortality was higher in the control group than in the training group (9 vs 4, 24% vs 12%, p = 0.23). CONCLUSIONS: In patients who are ventilator-dependent, mechanical threshold loading inspiratory muscle training improves quality of life and dyspnoea, even in the absence of strength improvements or acceleration of ventilator liberation.

Inspiratory muscle training in intensive care unit patients: An international cross-sectional survey of physiotherapist practice.

BACKGROUND: Inspiratory muscle training is safe and effective in reversing inspiratory muscle weakness and improving outcomes in patients who have experienced prolonged mechanical ventilation in the intensive care unit (ICU). The degree of worldwide implementation of inspiratory muscle training in such patients has not been investigated. OBJECTIVES: The objectives of this study were to describe the current practice of inspiratory muscle training by intensive care physiotherapists and investigate barriers to implementation in the intensive care context and additionally to determine if any factors are associated with the use of inspiratory muscle training in patients in the ICU and identify preferred methods of future education. METHOD: Online cross-sectional surveys of intensive care physiotherapists were conducted using voluntary sampling. Multivariate logistic regression analysis was used to identify factors associated with inspiratory muscle training use in patients in the ICU. RESULTS: Of 360 participants, 63% (95% confidence interval [CI] = 58 to 68) reported using inspiratory muscle training in patients in the ICU, with 69% (95% CI = 63 to 75) using a threshold device. Only 64% (95% CI = 58 to 70) of participants who used inspiratory muscle training routinely assessed inspiratory muscle strength. The most common barriers to implementing inspiratory muscle training sessions in eligible patients were sedation and delirium. Participants were 4.8 times more likely to use inspiratory muscle training in patients if they did not consider equipment a barrier and were 4.1 times more likely to use inspiratory muscle training if they aware of the evidence for this training in these patients. For education about inspiratory muscle training, 41% of participants preferred online training modules. CONCLUSION: In this first study to describe international practice by intensive care therapists, 63% reported using inspiratory muscle training. Improving access to equipment and enhancing knowledge of inspiratory muscle training techniques could improve the translation of evidence into practice.

Inspiratory muscle training for intensive care patients: A multidisciplinary practical guide for clinicians.

OBJECTIVES: To describe a multidisciplinary approach to inspiratory muscle training (IMT) for patients in the intensive care unit (ICU). BACKGROUND: Inspiratory muscle weakness is a known consequence of prolonged mechanical ventilation, and there is emerging evidence that specific IMT can ameliorate this weakness. However, IMT is not yet standard practice in many ICUs, possibly because of the wide variety of methods reported and a lack of published practical guidelines. While the optimal parameters for IMT are yet to be established, we share our detailed methodology which has been shown to be safe in selected ventilator-dependent patients and is the only approach which has been shown to increase quality of life in ICU patients. METHODS: Patients who have experienced invasive mechanical ventilation for at least 7 days can commence IMT in either the ventilator-dependent phase or when weaned from mechanical ventilation. Intensity should be prescribed based on maximum inspiratory pressure, which is measurable through the tracheostomy or endotracheal tube via the ventilator or a respiratory pressure meter. Using a removable threshold device, we recommend high-intensity training (5 sets of 6 breaths at a minimum of 50% of maximum inspiratory pressure) performed once per day, supervised by the physiotherapist, with intensity increased daily such that patients can only just complete the 6th breath in each set. RESULTS: Using this high-intensity approach, IMT is likely to improve not only inspiratory muscle strength but also quality of life in patients recently weaned from mechanical ventilation of 7 days' duration or longer. Effective IMT requires a multidisciplinary approach to maximise feasibility, with doctors, nurses, and therapists working closely to optimise conditions for successful IMT. CONCLUSIONS: This multidisciplinary approach to implement IMT in ICU patients should assist clinicians in translating best-available evidence into practice, with the potential to enhance patient recovery.

Mobilisation is feasible in intensive care patients receiving vasoactive therapy: An observational study.

BACKGROUND: Mobilisation of intensive care unit (ICU) patients reduces ICU-acquired weakness and is associated with better functional outcomes. However, the prevalence of mobilisation of ICU patients remains low. A known barrier to mobilisation is haemodynamic instability, frequently with patients requiring vasoactive therapy. There is a lack of published data to guide clinicians about the safety and feasibility of mobilising patients receiving vasoactive therapy. OBJECTIVES: To describe our mobilisation practice in ICU patients receiving vasoactive therapy and identify factors associated with mobilisation and adverse events. METHODS: Retrospective cohort study of patients undergoing vasoactive therapy in a 31-bed tertiary ICU (October-December, 2016). Details of vasoactive drug dosage, mobilisation, and adverse events were extracted from databases, including mobilisation intensity (ICU Mobility Scale [IMS]). Two generalised linear mixed models were used: first, to describe factors associated with mobilisation and second, to describe factors associated with adverse events during mobilisation, adjusting for age, gender, and acute physiology and chronic health evaluation II score as co-variates. RESULTS: In 119 patients undergoing vasoactive therapy on 371 cumulative vasoactive days, 195 mobilisation episodes occurred (37.5% of vasoactive days). Low (76.8%) and moderate (13.7%) dose vasoactive therapies were associated with a higher probability of mobilisation relative to high (9.4%) dose therapy (odds ratio = 5.50, 95% confidence interval = 2.23-13.59 and odds ratio = 2.50, 95% confidence interval = 0.95-6.59, respectively). For patients who mobilised on vasoactive therapy (n = 72), maximum mobilisation intensity was low (IMS = 1-2) in 31%, moderate (IMS = 3-5) in 51%, and high (IMS = 6-10) in 18% of vasoactive days. While no serious adverse events occurred, there were 14 occurrences of reversible hypotension requiring transient escalation of vasoactive therapy (7.3%), associated with lower mean arterial pressure (p = 0.001). CONCLUSION: In our ICU, patients mobilised on approximately one-third of vasoactive days. Clinicians should anticipate a higher risk of hypotension during mobilisation in patients receiving vasoactive therapy, which may require transient escalation of vasoactive therapy.

Defining new barriers to mobilisation in a highly active intensive care unit - have we found the ceiling? An observational study.

BACKGROUND: Mobilisation of intensive care (ICU) patients attenuates ICU-acquired weakness, but the prevalence is low (12-54%). Better understanding of barriers and enablers may inform practice. OBJECTIVES: To identify barriers to mobilisation and factors associated with successful mobilisation in our medical /surgical /trauma ICU where mobilisation is well-established. METHODS: 4-week prospective study of frequency and intensity of mobilisation, clinical factors and barriers (extracted from electronic database). Generalized linear mixed models were used to describe associations between demographics, clinical factors and successful mobilisation. RESULTS: 202 patients accounted for 742 patient days. Patients mobilised on 51% of patient days. Most frequent barriers were drowsiness (18%), haemodynamic/respiratory contraindications (17%), and medical orders (14%). Predictors of successful mobilisation included high Glasgow Coma Score (OR = 1.44, 95%CI=[1.29-1.60]), and male sex (OR = 2.29, 95%CI=[1.40-3.75]) but not age (OR = 1.05, 95%CI=[1.01-1.08]). CONCLUSIONS: Our major barriers (drowsiness, haemodynamic/respiratory contraindications) may be unavoidable, indicating an upper limit of feasible mobilisation therapy in ICU.

Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians.

OBJECTIVES: To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team. BACKGROUND: Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention. METHODS: A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team. DISCUSSION: These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (<2%). The tools and strategies described are useful not only to guide practical implementation of early mobilization, but also in the creation of a unit culture where ICU staff prioritize early mobilization and collaborate daily to provide the best possible care. CONCLUSION: These practical tools allow ICU clinicians to safely and effectively implement early mobilization in critically ill patients. A genuinely multidisciplinary approach to safe mobilization in ICU is key to its success in the long term.

Reliability and utility of the Acute Care Index of Function in intensive care patients: An observational study.

OBJECTIVES: To establish the inter-rater reliability of the Acute Care Index of Function (ACIF) in intensive care unit (ICU) patients and determine whether ACIF scores have predictive utility beyond ICU discharge. BACKGROUND: Accurate and reliable measures of physical function are required to describe the recovery trajectory of ICU survivors. The clinimetric properties of the ACIF are yet to be established in ICU patients. METHODS: Prospective observational study in a single tertiary ICU. ACIF scores were recorded independently by 2 physiotherapists across a convenience sample of 100 physiotherapy assessments, and at ICU discharge. RESULTS: Inter-rater reliability of total ACIF scores was very strong (ICC = 0.94). ACIF <0.40 at ICU discharge predicted hospital discharge to a destination other than home (area under ROC = 0.79, 95% CI 0.64-0.89) (sensitivity 0.78). CONCLUSION: The ACIF has excellent inter-rater reliability in ICU patients and scores at ICU discharge predict the likelihood of discharge home. TRIAL REGISTRATION: ACTRN12614001008617 (September 18 2014).

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

INTRODUCTION: The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients. METHODS: A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients. RESULTS: Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations. CONCLUSION: Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

What are the barriers to mobilizing intensive care patients?

PURPOSE: Recently there has been increased interest in early mobilization of critically ill patients. Proposed benefits include improvements in respiratory function, muscle wasting, intensive care unit (ICU), and hospital length of stay. We studied the frequency of early mobilization in our intensive care unit in order to identify barriers to early mobilization. METHODS: A 4-week prospective audit of 106 patients admitted to a mixed medical-surgical tertiary ICU (mean age 60 ± 20 years, mean APACHE II score 14.7 ± 7.8) was performed. Outcome measures included number of patient days mobilized, type of mobilization, adverse events, and reasons for inability to mobilize. RESULTS: Patients were mobilized on 176 (54%) of 327 patient days. Adverse events occurred in 2 of 176 mobilization episodes (1.1%). In 71 (47%) of the 151 patient days where mobilization did not occur, potentially avoidable factors were identified, including vascular access devices sited in the femoral region, timing of procedures and agitation or reduced level of consciousness. CONCLUSIONS: Critically ill patients can be safely mobilized for much of their ICU stay. Interventions that may allow more patients to mobilize include: changing the site of vascular catheters, careful scheduling of procedures, and improved sedation management.

Specific inspiratory muscle training is safe in selected patients who are ventilator-dependent: a case series.

BACKGROUND: Mechanical ventilation of intensive care patients results in inspiratory muscle weakness. Inspiratory muscle training may be useful, but no studies have specifically described the physiological response to training. RESEARCH QUESTIONS: Is inspiratory muscle training with a threshold device safe in selected ventilator-dependent patients? Does inspiratory muscle strength increase with high-intensity inspiratory muscle training in ventilator-dependent patients? DESIGN: Prospective cohort study of 10 medically stable ventilator-dependent adult patients. SETTING: Tertiary adult intensive care unit. METHODS: Inspiratory muscle training 5-6 days per week with a threshold device attached to the tracheostomy without supplemental oxygen. OUTCOME MEASURES: Physiological response to training (heart rate, mean arterial pressure, oxygen saturation and respiratory rate), adverse events, training pressures. RESULTS: No adverse events were recorded in 195 sessions studied. For each patient's second training session, no significant changes in heart rate (Mean Difference 1.3 bpm, 95% CI -2.7 to 5.3), mean arterial pressure (Mean Difference -0.9 mmHg, 95% CI -6.4 to 4.6), respiratory rate (Mean Difference 1.2 bpm, 95% CI -1.1 to 3.5 bpm) or oxygen saturation (Mean Difference 1.2%, 95% CI -0.6 to 3.0) were detected Training pressures increased significantly (Mean Difference 18.6 cmH(2)O, 95% CI 11.8-25.3). CONCLUSION: Threshold-based inspiratory muscle training can be delivered safely in selected ventilator-dependent patients without supplemental oxygen. Inspiratory muscle training is associated with increased muscle strength, which may assist ventilatory weaning.