Ambulating on a vent – Part III

resp 14

In Part III I’ll briefly present the three research studies in the literature regarding ambulation of patients on mechanical ventilation. In Part IV, I’ll address what facilities should consider if they are convinced this is a worthwhile endeavor, and what else is needed in regards to research.

Research Studies

1.  Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L et al.  Early activity is feasible and safe in respiratory failure patients.  Crit Care Med.  2007; 35:139-145.

In this study the researchers wanted to know if early activity in critically ill patients was feasible and safe.  In this prospective cohort study, the participants patients in a RICU (n=103) who had been on a vent for >4 days (only exclusion criteria was <4days).  Pts had to be neurologically responsive to verbal stimulation, meet specific respiratory conditions (FIO2 <0.7, Positive end-expiratory pressure <11cm H2O), and meet circulatory criteria (absence of orthostatic hypotension and catacholamine drips).  Those not meeting all 3 criteria had a trial of activity with close monitoring for adverse events.  The activity plan required a PT, RT, RN, critical care technician, 2x/day. Activity events included sitting EOB, standing, ambulating.  Adverse events were low and did not require extubation, increased cost, or longer stay.  Avg ambulation at d/c was 212’ (69% could ambulate 100′ or more); age not a factor in participation.  Their conclusion was that early activity is feasible and safe in this population, and is a possible therapy to prevent or treat critical illness-related neuromuscular complications.  This study did not have a control group, so they could not say that early activity improves d/c time or long-term outcomes.

2.  Thomsen GE, Snow GL, Rodriguez L, Hopkins RO.  Patients with repiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority.  Crit Care Med.  2008; 36:1119-1124.

At the same location as the Bailey study, the researchers hypothesized that “ambulation of patients with acute respiratory failure would increase with transfer to an intensive care unit where activity is a key component of patient care.”  Their participants (N=104) were patients who were vented >4 days, did not have a neurological disease that prevented activity (e.g. stroke), were not readmitted to the RICU, and were not terminally ill.  Those patients were also required to have been in another hospital ICU for 2 days before being transferred to this unit, and have a stay on their unit of 2 or more days so they could compare activity levels.  To start the activity protocol they had to be able to follow commands, have FiO2 <0.7 and positive end-expiratory pressure <11cm H2O, no catecholemine drips and no sign of orthostatic hypotension.  During ambulation (yes/no, and how far recorded each time) they would monitor O2 sats and BP.  They concluded that transferring a patient who is having acute respiratory failure to their unit significantly improved ambulation, even when taking the underlying pathophysiology into account; that the ICU setting “may contribute unnecessary immobilization throughout the course of acute respiratory failure;” and that sedatives significantly reduce the possibility of ambulation.  They also called for further reserach to determine if ICU immobility affects long-term neuromuscular dysfunction and if early activity in the ICU improves outcomes.

3.  Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L et al.  Early intensive care unit mobility thereapy in the treatment of acute respiratory failure.  Crit Care Med.  2008; 36:2238-2243.

In this study, the researchers wanted to answer if physical therapy in the intensive care unit provides benefit (the theory is sound, but there is no data).  In a medical intensive care unit, patients who were intubated within the past 48 hours and admitted to the MICU within 72 hours were enrolled.  Inclusion criteria was >18 years old and having an ET tube, while exclusion criteria was inability to walk before their ICU illness (use of AD were allowed), cognitive impairment before the illness (defined as “nonverbal”), immuncompromised/on prednisone before admission, having a neuromuscular disease such as myasthenia gravis, Guillan-Barre or ALS which could impair weaning from the vent, acute stroke, BMI >45, hip fracture, unstable c-spine or a pathological fracture, being on a vent >48 hours before being transferred from another facility, >72 hours for current admittance or transferring from another hospital with >72 hour stay, a DNR order upon admission, recent hospitalization (30 days), cancer treatment in last 6 months, and re-admit to ICU during this stay.

Interestingly, “it was determined a priori that only patients who survived to a hospital discharge would be included in the outcome analyses based on results of prestudy data that found few patients who died in the ICU achieved sufficient wakefulness to be considered for [PT] before their death.  Thus, outcome data were compared for patients in the Usual Care Group with patients in the Protocol group who survived to hospital discharge.”

Patients were assigned to the Usual Care group (N=165) or the Protocol group (N=165) with a block design.  The UCG included usual treatment (PROM), whereas the PG received four levels of treatment in the protocol (1 – PROM, 2 – PROM, active resistance, sitting, 3 – same as #2 but now sitting EOB, and 4 – same as #3 but adding active transfers and building to ambulation.  This protocol was implemented 7d/wk with an RN, a CNA, and a PT.  Primary outcomes were the proportion of patients receiving PT in the total number of patients surviving to discharge.  Their conclusion was that early mobility was feasible, safe, did not increase costs, and reduced ICU and hospital length of stays for those receiving the protocol.

Picture credit: resp 14, originally uploaded by roujo.

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2 responses to “Ambulating on a vent – Part III

  1. Can you share an actual orderset or protocol?

    • Hi Deb, sorry for the delay (sold our condo and moved to Minneapolis for a geriatric residency). It has been a long time since I did the literature review – I don’t remember if any of the papers had a protocol or not, but if you look the papers up on pubmed and the author has an email address you can ask them to send you a copy.
      David

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