PulmonaryA multimodal rehabilitation program for patients with ICU acquired weakness improves ventilator weaning and discharge home☆
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
References (44)
- et al.
Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure
Am J Med Sci
(2011) - et al.
Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project
J Crit Care
(2010) - et al.
Physical training is beneficial to functional status and survival in patients with prolonged mechanical ventilation
J Formos Med Assoc
(2011) - et al.
Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) task force
J Nutr Health Aging
(2009) - et al.
National Association for medical direction of respiratory C: management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference
Chest
(2005) - et al.
Ventilation outcomes study G: Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study
Chest
(2007) - et al.
Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines
Chest
(2007) - et al.
The Chelsea critical care physical assessment tool (CPAx): validation of an innovative new tool to measure physical morbidity in the general adult critical care population; an observational proof-of-concept pilot study
Physiotherapy
(2013) - et al.
Toward an integrated research agenda for critical illness in aging
Am J Respir Crit Care Med
(2010) - et al.
Neuromuscular dysfunction acquired in critical illness: a systematic review
Intensive Care Med
(2007)
Paresis acquired in the intensive care unit: a prospective multicenter study
JAMA
Impact of intensive insulin therapy on neuromuscular complications and ventilator dependency in the medical intensive care unit
Am J Respir Crit Care Med
A framework for diagnosing and classifying intensive care unit-acquired weakness
Crit Care Med
Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study
Intensive Care Med
One-year outcomes in survivors of the acute respiratory distress syndrome
N Engl J Med
Post-ICU symptoms, consequences, and follow-up: an integrative review
Nurs Crit Care
Factors associated with functional recovery among older intensive care unit survivors
Am J Respir Crit Care Med
Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis
Am J Respir Crit Care Med
Does ICU-acquired paresis lengthen weaning from mechanical ventilation?
Intensive Care Med
Groupe de Reflexion et d'Etude des Neuromyopathies en R: Respiratory weakness is associated with limb weakness and delayed weaning in critical illness
Crit Care Med
Groupe de Reflexion et d'Etude des Neuromyopathies En R: Presence and severity of intensive care unit-acquired paresis at time of awakening are associated with increased intensive care unit and hospital mortality
Crit Care Med
Acquired weakness, handgrip strength, and mortality in critically ill patients
Am J Respir Crit Care Med
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Clinicaltrials.gov identifier: NCT3195127.