The feasibility of using mouthpiece ventilation in the intensive care unit for post-extubation breathing support after acute tetraplegia.

STUDY DESIGN: A prospective cohort of patients with acute tetraplegia. OBJECTIVES: This study aimed to determine the feasibility of using mouthpiece ventilation (MPV) in the intensive care unit (ICU) for patients who are extubated after suffering an acute cervical spinal cord injury (CSCI). SETTING: ICU, Princess Alexandra Hospital, Brisbane Australia. METHODS: New admissions to ICU in the 14 months between April 2017 and June 2018 with a CSCI who underwent intubation were assessed for inclusion. MPV was provided to consenting participants (who were deemed likely to be able to maintain ventilation on their own) at the time of extubation and was utilised in addition to standard care while participants were awake. MPV settings, usage, and support hours to educate and facilitate MPV were collected. Feedback from participants and clinical staff was gathered throughout the study. Pre- and post-extubation measures of forced vital capacity (FVC), the frequency of endotracheal suction of sputum, and gas exchange using ventilation-perfusion ratios were recorded along with the incidence of reintubation. RESULTS: Fourteen participated in utilising MPV with 16 episodes of extubation. The average time per participant to have MPV titrated and bedside data collected was 178 minutes. Data from 16 episodes of extubation have been included. Three of the 14 participants failed initial extubation. Feedback from participants and clinicians has been positive and constructive, enabling MPV settings to be adapted to the person with acute CSCI during this pilot study. CONCLUSION: MPV is feasible to use post-extubation for people with CSCI in ICU. Pressure control mode MPV was deemed the most suitable for newly extubated acute CSCI patients. Intensive clinical support is required initially to provide education prior to MPV, and at the time of extubation for both patient and treating clinicians. Both report it to be a useful adjunct to ICU treatment.

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study.

BACKGROUND: Critical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. OBJECTIVES: The objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach-style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. METHODS: A new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. RESULTS: The service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. CONCLUSIONS: Critical care outreach-style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

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.

The safety and efficacy of prolonged use of one-way speaking valves.

BACKGROUND: One-way speaking valves were first engineered to improve communication in patients with tracheostomies. More recently, additional indications for one-way speaking valves have been explored, including improving ventilation, weaning, and reducing aspiration; however, safety and adverse events have not been well defined. OBJECTIVES: The aim of this study was to examine the cardiorespiratory changes that occur with prolonged use of a one-way speaking valve in relation to safety and efficacy. METHODS: A prospective observational study of adult patients (n = 20) was carried out in a tertiary level intensive care unit. Continuous monitoring of cardiorespiratory parameters, including heart rate (beats per minutes), respiratory rate (breaths per minute), systolic, diastolic, and mean arterial pressure (mmHg), and oxygen saturations (%), was conducted for 2 h whilst participants used a one-way speaking valve. The participants then continued to use the one-way speaking valve as long as tolerated. Data are reported as median and range (non-normative data) or as mean ± standard deviation (normative data). RESULTS: The time to tracheostomy was 17.5 (range = 7-54) days after the initiation of mechanical ventilation, and the time to first use of the one-way speaking valve was 11.4 days (standard deviation = 5.46) after tracheostomy. The participants tolerated using a one-way speaking valve (for more than 2 h) after a median of 2 (range = 1-8) days from first use. There were no significant changes to any cardiorespiratory parameters over the 2-h period and also no adverse events in this study whilst participants used one-way speaking valves for up to 17 (range = 5.5-17) hours. CONCLUSIONS: The prolonged use of a one-way speaking valve is safe for patients who reached a threshold of 2 h.

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study.

BACKGROUND: Patients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear. OBJECTIVES: The objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events. METHODS: This was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university-affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range]. RESULTS: There were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity. CONCLUSIONS: Low-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.

Improving physical activity after stroke via treadmill training and self management (IMPACT): a protocol for a randomised controlled trial.

BACKGROUND: The level of physical activity undertaken by stroke survivors living in the community is generally low. The main objectives of the IMPACT trial are to determine, in individuals undergoing rehabilitation after stroke, if 8 weeks of high-intensity treadmill training embedded in self-management education (i) results in more physical activity than usual physiotherapy gait training and (ii) is more effective at increasing walking ability, cardiorespiratory fitness, self-efficacy, perception of physical activity, participation, and health-related quality of life as well as decreasing cardiovascular risk, and depression, at 8 and 26 weeks. METHODS: A prospective, two-arm, parallel-group, randomised trial with concealed allocation, blinded measurement and intention-to-treat analysis, will be conducted. 128 stroke survivors undergoing rehabilitation who are able to walk independently will be recruited and randomly allocated to either the experimental or control group, who will both undergo gait training for 30 min, three times a week for 8 weeks under the supervision of a physiotherapist. Outcomes will be measured at baseline (Week 0), on completion of the intervention (Week 8) and beyond the intervention (Week 26). This study has obtained ethical approval from the relevant Human Research Ethics Committees. DISCUSSION: Improving stroke survivors' walking ability and cardiorespiratory fitness is likely to increase their levels of physical activity. Furthermore, if education in self-management results in sustained high levels of physical activity, this should result in improved participation and quality of life. TRIAL REGISTRATION: This trial was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12613000744752 ) on 4th July, 2013.

Exercise training for improving outcomes post-burns: a systematic review and meta-analysis.

OBJECTIVES: To determine the effectiveness of different modalities of exercise and to evaluate the safety of exercise-based interventions post-burns. DATA SOURCES: Six databases were searched from inception to October 2017 using "burn," "exercise" and synonyms as keywords. Relevant authors, key journals and reference lists of included studies were hand-searched. REVIEW METHODS: Articles reporting on exercise interventions in patients post-burn and considering physical, physiological or psychological outcomes were considered. Two authors independently screened 2253 records and selected 19 articles for inclusion. The quality of the evidence was assessed at the study level and at the outcome level. RESULTS: Unbiased effect size estimators (pooled Hedges' g) with 95% confidence intervals (CIs) were calculated if there were two or more trials with homogeneous outcomes. There were no significant differences post-exercise training in VO2peak ( g = 0.99; 95% CI: -0.4 to 2.4: P = 0.18), resting energy expenditure ( g = -0.51; 95% CI: -1.99 to 0.97: P = 0.5) and muscle strength ( g = 0.51; 95% CI: -0.03 to 1.05: P = 0.07) between groups. Evidence suggested exercise had a beneficial effect on body composition ( g = 0.59; 95% CI: 0.05 to 1.14: P = 0.03), need of surgical release of contractures (risk ratio = 0.34; 95% CI: 0.2 to 0.7; P = 0.004) and health-related quality of life. However, a lack of evidence existed regarding the safety of exercise training post-burns. CONCLUSION: Limited evidence suggests that exercise has a beneficial effect on physical and physiological outcomes in patients post-burn. Further trials using high-quality methodology are required, with focus on reporting of adverse events, health-related quality of life and psychological outcomes.

Secretion clearance strategies in Australian and New Zealand Intensive Care Units.

INTRODUCTION/AIMS: To describe the processes of care for secretion clearance in adult, intubated and mechanically ventilated patients in Australian and New Zealand Intensive Care Units (ICUs). METHODS/RESULTS: A prospective, cross-sectional study was conducted through the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) Point Prevalence Program. Forty-seven ICUs collected data from 230 patients intubated and ventilated on the study day. Secretion clearance techniques beyond standard suctioning were used in 84/230 (37%) of patients during the study period. Chest wall vibration 34/84 (40%), manual lung hyperinflation 24/84 (29%), chest wall percussion 20/84 (24%), postural drainage/patient positioning 17/84 (20%) and other techniques including mobilisation 15/84 (18%), were the most common secretion clearance techniques employed. On average (SD), patients received airway suctioning 8.8 (5.0) times during the 24-h study period. Mucus plugging events were infrequent (2.7%). The additional secretion clearance techniques were provided by physiotherapy staff in 24/47 (51%) ICUs and by both nursing and physiotherapy staff in the remaining 23/47 (49%) ICUs. CONCLUSION: One-third of intubated and ventilated patients received additional secretion clearance techniques. Mucus plugging events were infrequent with these additional secretion clearance approaches. Prospective studies must examine additional secretion clearance practices, prevalence of mucus plugging episodes and impact on patient outcomes.

Aquatic Exercise Training is Effective in Maintaining Exercise Performance in Trained Heart Failure Patients: A Randomised Crossover Pilot Trial.

BACKGROUND: Providing flexible models and a variety of exercise options are fundamental to supporting long-term exercise participation for patients with heart failure (HF). The aim of this pilot study was to determine the feasibility and efficacy of aquatic exercise training during a maintenance phase for a clinical heart failure population. METHODS: In this 2 x 2 crossover design trial, individuals who had previously completed HF rehabilitation were randomised into either a land-based or aquatic training program once per week for six weeks, after which time they changed to the alternate exercise training protocol for an additional six weeks. Six-minute walk test (6MWT), grip strength, walk speed, and measures of balance were compared for the two training protocols. RESULTS: Fifty-one participants (43 males, mean age 69.2 yrs) contributed data for the analysis. Both groups maintained function during the follow-up period, however improvements in 6MWT were greater in the land-based training group (95% CI: 0.7, 22.5; p=0.038), by a mean difference of 10.8 metres. No significant difference was observed for other parameters when the two training protocols were compared. CONCLUSION: Attending an aquatic exercise program once per week is feasible for patients with stable HF and may provide a suitable option to maintain functional performance in select patients.

Inspiratory muscle training to enhance recovery from mechanical ventilation: a randomised trial.

BACKGROUND: In patients who have been mechanically ventilated, inspiratory muscles remain weak and fatigable following ventilatory weaning, which may contribute to dyspnoea and limited functional recovery. Inspiratory muscle training may improve inspiratory muscle strength and endurance following weaning, potentially improving dyspnoea and quality of life in this patient group. METHODS: We conducted a randomised trial with assessor-blinding and intention-to-treat analysis. Following 48 hours of successful weaning, 70 participants (mechanically ventilated ≥7 days) were randomised to receive inspiratory muscle training once daily 5 days/week for 2 weeks in addition to usual care, or usual care (control). Primary endpoints were inspiratory muscle strength and fatigue resistance index (FRI) 2 weeks following enrolment. Secondary endpoints included dyspnoea, physical function and quality of life, post-intensive care length of stay and in-hospital mortality. RESULTS: 34 participants were randomly allocated to the training group and 36 to control. The training group demonstrated greater improvements in inspiratory strength (training: 17%, control: 6%, mean difference: 11%, p=0.02). There were no statistically significant differences in FRI (0.03 vs 0.02, p=0.81), physical function (0.25 vs 0.25, p=0.97) or dyspnoea (-0.5 vs 0.2, p=0.22). Improvement in quality of life was greater in the training group (14% vs 2%, mean difference 12%, p=0.03). In-hospital mortality was higher in the training group (4 vs 0, 12% vs 0%, p=0.051). CONCLUSIONS: Inspiratory muscle training following successful weaning increases inspiratory muscle strength and quality of life, but we cannot confidently rule out an associated increased risk of in-hospital mortality. TRIAL REGISTRATION NUMBER: ACTRN12610001089022, results.

Cerebral microcirculation during mild head injury after a contusion and acceleration experimental model in sheep.

BACKGROUND: Cerebral microcirculation after head injury is heterogeneous and temporally variable. Regions at risk of infarction such as peri-contusional areas are vulnerable to anaemia. However, direct quantification of the cerebral microcirculation is clinically not feasible. This study describes a novel experimental head injury model correlating cerebral microcirculation with histopathology analysis. OBJECTIVE: To test the hypothesis that cerebral microcirculation at the ischaemic penumbrae is reduced over time when compared with non-injured regions. METHODS: Merino sheep were instrumented using a transeptal catheter to inject coded microspheres into the left cardiac atrium, ensuring systemic distribution. After a blunt impact over the left parietal region, cytometric analyses quantified cerebral microcirculation and amyloid precursor protein staining identified axonal injury in pre-defined anatomical regions. A mixed effect regression model assessed the hourly blood flow results during 4 hours after injury. RESULTS: Cerebral microcirculation showed temporal reductions with minimal amyloid staining except for the ipsilateral thalamus and medulla. CONCLUSION: The spatial heterogeneity and temporal reduction of cerebral microcirculation in ovine models occur early, even after mild head injury, independent of the intracranial pressure and the level of haemoglobin. Alternate approaches to ensure recovery of regions with reversible injury require a targeted assessment of cerebral microcirculation.

A new marker of sepsis post burn injury?*.

OBJECTIVES: Accurate diagnosis of sepsis is difficult in patients post burn due to the large inflammatory response produced by the major insult. We aimed to estimate the values of serum N-terminal pro-B-type natriuretic peptide and procalcitonin and the changes in hemodynamic variables as markers of sepsis in critically ill burn patients. DESIGN: Prospective, observational study. SETTING: A quaternary-level university-affiliated ICU. PATIENTS: Fifty-four patients with burns to total body surface area of greater than or equal to 15%, intubated with no previous cardiovascular comorbidities, were enrolled. INTERVENTIONS: At admission, a FloTrac/Vigileo system was attached and daily blood samples taken from the arterial catheter. Infection surveillance was carried out daily with patients classified as septic/nonseptic according to American Burns Consensus criteria. MEASUREMENTS AND MAIN RESULTS: N-terminal pro-B-type natriuretic peptide, procalcitonin, and waveform analysis of changes in stroke volume index and systemic vascular resistance index were measured within the first 24 hours after burn and daily thereafter for the length of the ICU stay or until their first episode of sepsis. Prevalences of stroke volume variation less than 12% (normovolemia) with hypotension (systolic blood pressure < 90 mm Hg) were recorded. Patients with sepsis differed significantly from "no sepsis" for N-terminal pro-B-type natriuretic peptide, systemic vascular resistance index, and stroke volume index on days 3-7. Procalcitonin did not differ between sepsis and "no sepsis" except for day 3. Area under the receiver operating characteristic curves showed excellent discriminative power for B-type natriuretic peptide (p = 0.001; 95% CI, 0.99-1.00), systemic vascular resistance index (p < 0.001; 95% CI, 0.97-0.99), and stroke volume index (p < 0.01; 95% CI, 0.96-0.99) in predicting sepsis but not for procalcitonin (not significant; 95% CI, 0.29-0.46). A chi-square crosstab found that there was no relationship between hypotension with normovolemia (stroke volume variation < 12%) and sepsis. CONCLUSIONS: Serum N-terminal pro-B-type natriuretic peptide levels and certain hemodynamic changes can be used as an early indicator of sepsis in patients with burn injury. Procalcitonin did not assist in the early diagnosis of sepsis.

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.

Nimodipine prophylaxis in aneurysmal subarachnoid hemorrhage, a question of tradition or evidence: A scoping review.

BACKGROUND: The prophylactic use of nimodipine following subarachnoid hemorrhage is a practice established four decades ago when clinical management differed from current and the concept of Delayed Cerebral Ischemia (DCI) was not established. The applicability of the original studies is limited by the fact of not reflecting current practice; by utilising a dichotomised outcome measure such as good neurological outcome versus death and vegetative state; by applying variable dosing regimens and including all causes of poor neurological outcome different than DCI. This study aims to review the available evidence to discuss the ongoing role of nimodipine in contemporaneous clinical practice. METHODS: PRISMA guidelines based review, evaluated the evidence on the prophylactic use of nimodipine. The following search engines: Medline, Embase, Cochrane, Web of Science and PubMed, identified Randomized Control Trials (RCTs) with neurological benefit as outcome measure and the impact of fixed versus weight-based nimodipine dosing regimens. RESULTS: Eight RCT were selected. Three of those trials with a total of 349 patients, showed a reduction on death and vegetative state (pooled RR: 0.62; 95 % confidence interval-CI: 0.45, 0.86) related to DCI. Amongst all studies, all cause death (pooled RR = 0.73, [95 % CI: 0.56, 0.97]) favoured a fixed-dose regimen (pooled RR: 0.60; [95 % CI: 0.43, 0.85]). CONCLUSION: Available evidence demonstrates that nimodipine only reduces the risk for DCI-related death or vegetative state and that fixed-dose regimens favour all cause infarct and death independent of DCI. Contemporaneous studies assessing the benefit of nimodipine beyond death or vegetative states and applying individualized dosing are warranted.

Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review was to review the evidence base for exercise in critically ill patients. DATA SOURCES AND STUDY SELECTION: Using keywords critical care and physical therapy and related synonyms, randomized controlled trials, meta-analyses, and systematic reviews were identified through electronic database searches and citation tracking. Clinical trials with outcomes of mortality, length of hospital and ICU stay, physical function and quality of life, muscle strength, and ventilator-free days were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers abstracted data and assessed quality independently. Effect sizes and 95% confidence intervals were calculated. From 3,126 screened abstracts, 10 randomized controlled trials and five reviews were found. The mean Physiotherapy Evidence Database score was 5.4. Overall there was a significant positive effect favoring physical therapy for the critically ill to improve the quality of life (g = 0.40, 95% confidence interval 0.08, 0.71), physical function (g = 0.46, 95% confidence interval 0.13, 0.78), peripheral muscle strength (g = 0.27, 95% confidence interval 0.02, 0.52), and respiratory muscle strength (g = 0.51, 95% confidence interval 0.12, 0.89). Length of hospital (g = -0.34, 95% confidence interval -0.53, -0.15) and ICU stay (g = -0.34, 95% confidence interval -0.51, -0.18) significantly decreased and ventilator-free days increased (g = 0.38, 95% confidence interval 0.16, 0.59) following physical therapy in the ICU. There was no effect on mortality. CONCLUSION: Physical therapy in the ICU appears to confer significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay. However, further controlled trials of better quality and larger sample sizes are required to verify the strength of these tentative associations.

Ventilator hyperinflation - what settings generate an expiratory flow rate bias?

OBJECTIVES: To determine which mechanical ventilation settings influence the attainment of expiratory flow rate characteristics that may promote secretion mobilisation during ventilator hyperinflation (VHI). DESIGN: Prospective, single centre study. SETTING: Intensive care unit, tertiary metropolitan hospital. PARTICIPANTS: Twenty-four patients receiving mechanical ventilation. INTERVENTIONS: Patients were recruited to either a low PEEP or high PEEP group (5-9 cmH2O or 10-15 cmH2O PEEP respectively). Each group had three hyperinflation protocols applied. MAIN OUTCOME MEASURES: Peak inspiratory flow rates (PIFR) and peak expiratory flow rates (PEFR) were measured and reported as PIFR/PEFR of less than or equal to 0.9; a PEFR-PIFR greater than or equal to 33 L/min; and PEFR greater than or equal to 40 L/min. RESULTS: In both the low and high PEEP groups, VHI protocols using volume-controlled ventilation were significantly better at generating expiratory flow rate bias compared to pressure-controlled or Pressure Support ventilation. An expiratory flow rate bias was also achieved when VHI was performed in volume-controlled ventilation with either a peak inspiratory pressure target of 35 cmH2O or a driving pressure of 20 cmH2O. Median heart rate and blood pressure values did not change during VHI, but transient reductions in blood pressure were present in six participants (25%). CONCLUSIONS: VHI performed using volume-controlled ventilation was more effective than pressure-controlled or Pressure Support ventilation to generate an expiratory flow rate bias. CONTRIBUTION OF THE PAPER: Mechanical ventilator settings can be altered to perform hyperinflation and achieve expiratory flow rate properties that may increase the mobilisation of airway secretions. The results demonstrate that to achieve these properties.

A six-week physical therapy exercise program delivered via home-based telerehabilitation is comparable to in-person programs for patients with burn injuries: A randomized, controlled, non-inferiority clinical pilot trial.

BACKGROUND: Exercise programmes are essential for burn rehabilitation, however patients often have barriers accessing these services. Home-based telerehabilitation (HBT) may be an alternative. This study aimed to determine if exercise programs delivered via HBT were as effective as in-person (IP) programs with respect to clinical outcomes and participant and therapist satisfaction. METHODS: A single center, randomized, controlled, non-inferiority pilot trial with blinded assessment was undertaken. Forty-five adults with ≤ 25% total body surface area (TBSA) burns were randomized to receive a 6-week exercise program delivered either by HBT or IP. The primary outcome was burn-specific quality of life (Burn Specific Health Scale - Brief). Secondary outcomes included health-related quality of life, burn scar-specific outcomes, exercise self-efficacy, pain severity, muscle strength and range of motion (ROM). Participant and therapist satisfaction, technical disruptions and adverse events were also recorded. RESULTS: We found no significant within- or between-group differences for any outcome measures except ROM. Achievement of full ROM was significantly different between groups at Week 12 (IP=100% vs HBT=70%, p = 0.005). Non-inferiority was inconclusive. Participant satisfaction was high (median ≥ 9.8/10), with no significant between-group differences. Therapist satisfaction was high (median ≥ 8.9/10), major technical disruptions low (8%) and no adverse events reported. CONCLUSION: HBT is a safe, effective option to deliver exercise programs for patients with burn injuries ≤ 25% TBSA with comparable clinical outcomes to in-person programmes. Ongoing research is required to further analyze ROM and investigate the effectiveness of HBT for patients with larger burns.

Physiotherapy practices when treating patients with COVID-19 during a pandemic: A survey study.

Background Specific details pertaining to the clinical and other challenges faced by physiotherapists managing patients with COVID-19 during the pandemic are still largely unknown. Objectives To determine how physiotherapists clinically managed patients with COVID-19 in a hospital-based setting during the pandemic and to identify the personal and professional effects of working as a physiotherapist at this time. Methods Self-administered electronic cross-sectional survey. Participants included physiotherapists from around the world involved in the clinical management of patients with COVID-19. Results Of the 204 participants who returned the questionnaire, 39% worked as senior physiotherapists, 29% as consultant or specialist physiotherapists, 23% as general physiotherapists and 4% as graduate physiotherapists. Seventy-two percent of participants worked in the intensive care unit. The largest barrier to treating patients with COVID-19 was a lack of intensive care trained physiotherapists (70%). Eighty-three percent of participants reported performing activities outside of their typical work duties, including proning patients (55%), tutoring and advising other staff in the intensive care unit (55%) and adjusting or changing ventilator settings (52%). Almost all participants (90%) reported being aware of physiotherapy specific guidelines for treating patients with COVID-19, yet most participants performed techniques that were not recommended. Conclusions The experience of the pandemic highlighted the need for specialist training and availability of experienced cardiorespiratory physiotherapists to manage patients with COVID-19, specifically in intensive care. Furthermore, clear guidelines on the management of patients with COVID-19 should be established to ensure optimal management of patients and ensure the safety of physiotherapy staff.

Cardiovascular mortality post burn injury.

BACKGROUND: Burn injury is responsible for both acute and ongoing inflammation, resulting in systematic changes impacting the cardiovascular, hepatobiliary, endocrine, and metabolic systems, but there is minimal investigation into long-term clinical outcomes. This study aimed to investigate mortality due to cardiovascular related long-term postburn injury. METHODS: This was a retrospective cohort study linking a burns unit database with mortality outcomes from a Registry of Births, Deaths and Marriages. Data were extracted from the Australian Institute of Health and Welfare and stratified into three age groups: 15 to 44 years, 45 to 64 years, and 65+ years. Mortality rate ratios (MRRs) and 95% confidence interval (CI) were calculated to compare the burns cohort mortality incidence rates with the national mortality incidence rates for each of the three age groups. Logistic regression was used to identify demographic and clinical factors associated with cardiovascular mortality. RESULTS: A total of 4,134 individuals in the database were analyzed according to demographic and clinical variables. The 20-year age-standardized cardiovascular mortality rate for the burns cohort was significantly higher compared with the Australian population (250.6 per 100,000 person-years vs. 207.9 per 100,000 person-years) (MRR, 1.21; 95% CI, 1.001-1.45). Cardiovascular mortality was significantly higher in males aged 15-44 and 45-64 years had a cardiovascular mortality rate significantly higher than the Australian population (MRR = 10.06, 95% CI 3.49-16.63), and (MRR = 2.40, 95% CI 1.42-3.38) respectively. Those who died of cardiovascular disease were more frequently intubated postburn injury ( p = 0.01), admitted to intensive care ( p < 0.0001), and had preexisting comorbid physical conditions (60.9% vs. 15.0%, p < 0.0001). CONCLUSION: Survivors from burn injury, especially young males, are at increased long-term risk of death from cardiovascular disease. Increased screening and counseling pertaining to lifestyle factors should be standard management postburn injury. Longitudinal observation of physiological changes, investigation of mechanistic factors, and investigation of interventional strategies should be instituted. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Therapeutic drug monitoring of beta-lactam antibiotics in burns patients--a one-year prospective study.

BACKGROUND: Beta-lactams are first-line antibiotics for the management of superficial infections due to burn injury. There is sparse data available on therapeutic drug monitoring (TDM) in patients with burns in a ward setting. This study was conducted to evaluate the utility of a beta-lactam TDM program in a cohort of burn injury patients in a ward environment. METHODS: Steady-state blood samples were collected immediately before a scheduled dose. The therapeutic concentration targets assessed were (1) free antibiotic concentrations exceeding the minimum inhibitory concentration (MIC; fT > MIC) and (2) free concentrations ≥4× MIC of the known or suspected pathogen (fT > 4× MIC). The duration of therapy was also assessed. RESULTS: A total of 50 patients were included for TDM over a 12-month period. The mean (±SD) age was 49 ± 16 years. The mean percent total body surface area burn was 17 ± 13%. The mean serum creatinine concentration was 86 ± 20 µmole/L. Sixty percent of the patients did not achieve fT > MIC, and only 18% achieved the higher target of fT > 4× MIC. Although all the patients achieved a positive clinical outcome, the duration of antibiotic treatment was shorter in patients who achieved fT > MIC compared with those who did not (4.2 ± 1.1 versus 5.3 ± 2.3 days; P = 0.03). CONCLUSIONS: We found TDM to be a reliable intervention for burn injury patients in a ward environment. This study supports pharmacokinetic data that burns patients may be at risk of subtherapeutic dosing, which may prolong the duration of antibiotic therapy.