Elsevier

Journal of Critical Care

Volume 47, October 2018, Pages 204-210
Journal of Critical Care

Pulmonary
A multimodal rehabilitation program for patients with ICU acquired weakness improves ventilator weaning and discharge home

https://doi.org/10.1016/j.jcrc.2018.07.006Get rights and content

Highlights

  • A multimodal rehabilitation program for ICU survivors is feasible and well tolerated.

  • Adding a multimodal rehabilitation program to usual care results in improved clinical outcomes.

  • Improvements in mobility are associated with successful weaning and discharge home.

Abstract

Purpose

To compare the effects of adding a progressive multimodal rehabilitation program to usual care (MRP + UC) versus UC alone on 1) functional mobility, strength, endurance and 2) ventilator weaning and discharge status of patients with ICU-acquired weakness (ICUAW) receiving prolonged mechanical ventilation (PMV).

Methods

Randomized pilot trial of an individualized MRP + UC versus UC in middle-aged and older ICU survivors with ICUAW receiving PMV. Outcomes compare changes in strength, mobility, weaning success and discharge home from a long-term acute care hospital (LTACH) between the groups.

Results

Eighteen males and 14 females (age 60.3 ± 11.9 years) who received PMV for ≥14 days were enrolled. Despite no significant differences between groups in the changes in handgrip, gait speed, short physical performance battery or 6-min walk distance after treatment, the MRP + UC group had greater weaning success (87% vs. 41%, p < 0.01), and more patients discharged home than UC (53 vs. 12%, p = 0.05). Post hoc analyses, combining patients based on successful weaning or discharge home, demonstrated significant improvements in strength, ambulation and mobility.

Conclusion

The addition of an MRP that improves strength, physical function and mobility to usual physical therapy in LTACH patients with ICUAW is associated with greater weaning success and discharge home than UC alone.

Section snippets

Background

Approximately half of the patients admitted to intensive care units (ICUs) are over the age of 65 years [1] and develop some degree of muscle weakness [2]. This ICU - acquired weakness (ICUAW) is attributed to the inflammation, prolonged bed rest, medical/surgical interventions and therapeutics [[3], [4], [5]] associated with critical illness, and results in the loss of functional independence [6,7] and reduced quality of life [8]. These patients' weakness is associated with greater disability [

Patient characteristics

This single center, prospective pilot study was conducted in patients with ICUAW, aged ≥50 years receiving PMV on admission to an LTACH for continued medical care, rehabilitation and ventilator weaning. Those who met eligibility criteria (Table E1, Supplementary Materials) and provided informed consent underwent baseline functional assessments and were randomized to receive either UC or MRP + UC. Patients received serial functional assessments (identical to baseline testing) every 2 weeks that

Baseline demographics, functional measures and physical therapy

Eighteen male and 15 female patients 60.3 ± 11.9 years of age with comparable mean baseline characteristics were enrolled from August 2013 to March 2015 (Table 1). One patient withdrew shortly after signing consent (Fig. 1). All patients met 4 of 5 necessary criteria for ICUAW as defined by Stevens (Table E1, Appendix). At baseline, patients in both groups were similarly weak, except that women assigned the MRP had greater quadriceps strength than women assigned to UC (Table 3). The MRP + UC

Discussion

This study provides preliminary evidence that that the addition of a progressive, disability- targeted MRP to usual physical therapy is associated with higher rates of weaning success from PMV and discharge home in select middle-aged and older patients with ICUAW. Those who participated in the MRP demonstrated almost 3-fold greater improvements in handgrip strength, and 2-fold improvements in gait speed and 6MWD compared to the UC group, findings all of which trended toward statistical

Conclusion

These findings suggest that the addition of an MRP, which combines strength, endurance, and mobility training, to usual rehabilitation programs for middle-aged and older survivors of critical illness with ICUAW in the LTACH setting is feasible, and improves weaning success from PMV and discharge to home compared to usual care. Thus, a larger, Phase II investigation of this intervention seems warranted to fine tune the intervention by identifying intermediate and long-term outcomes toward which

Funding information

Dr. Verceles was supported by an NIH/NIA GEMSSTAR award (R03AG045100), a Pepper Scholar Award from the University of Maryland Claude D. Pepper Older Americans Independence Center (NIH/NIA P30AG028747), a GRECC Special Fellowship in Geriatrics and a T. Franklin Williams Scholar Award, with funding provided by: Atlantic Philanthropies, Inc., the John A. Hartford Foundation, the Alliance for Academic Internal Medicine-Association of Specialty Professors and the American Thoracic Society Foundation

Conflicts of interest

The authors report no conflicts of interest.

Authors' contributions

Literature search: AV; Study concept and design: AV, MT, AG; Data acquisition or interpretation of data: AV, CW, JB, TJ, MT, JS; Drafting of the manuscript: AV, CW, AG; Critical revision of manuscript: All authors; Statistical analysis: AV, JS; Study supervision: AV, AG.

Drs. Verceles and Goldberg had full access to the data and take responsibility for its integrity and the accuracy of its analysis.

None of the authors had any conflicts of interest to report relevant to this study.

List of abbreviations

    ICU

    intensive care unit

    ICUAW

    ICU acquired weakness

    LTACH

    long term acute care hospital

    MRP

    multimodal rehabilitation program

    PMV

    prolonged mechanical ventilation

    SPPB

    short physical performance battery

    UC

    usual care

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