Ambulation on a vent – Part II

2 Broken Ribs

In Part II, I will cover the four case reports I found in a search of PubMed.  Believe it or not, there are two reports in the literature many years ago – 1972 (Phys Ther – which I can’t access), and 1975 (Chest).  In Part III, I will look at the three research studies in the literature.

 

Case Reports

1.  Burns JR, Jones FL.  Early ambulation of patients requiring ventilatory assistance.  Chest.  1975; 68:608.

In this letter to the editor, the authors acknowledge the problems of bedrest and the problems of ambulating a patient on a respirator, and give a brief description of their walker, and their antecdotal impression (developed over 3 years of the program) of facilitated/hastened weaning and minimizing problems of bedrest.

2.  Kirshblum SC, Bach JR.  Walker modification for ventilator-assisted individuals: case report.  Am J Phys Med Rehabil.  1992; 71:304-306.

The purpose of this report was to give a report on ambulating a patient using 24-hr non-invasive ventilator support.  The patient was a 53 y.o. male with Milroy’s disease, respiratory faulure, restrictive pulmonary disease, and a history of R mid-lobe pneumonectomy and acute respiratory failure.  Before being admitted he could walk <200′ and climb 5 or fewer steps before experiencing dyspnea.

He was admitted and intubated, given bilateral chest tubes, treated for pneumonia, and diagnosed with pulmonary fibrosis.  He was given a trach at day 52, and 4 months of attempted vent weaning failed.  However he did convert from Intermittent Positive Pressure Ventilation via the trach to IPPV via mouth during the day and nose at night.  At 7 months he was transferred to rehab, dependent in all ADL’s and only able to take a few steps.

The facility commenced a comprehensive rehab program consisting of diaphragmatic/ glossopharyngeal breathing, biofeedback, and general strength/ mobility/ endurance.  As the pt was not able to manuever a wheelchair with all the equipment required, they modified a walker to assist.  He was d/c’ed home after 60 days independent in all ADL’s and ambulated >400′ with the walker with his O2 sats >94%, and eventually returned to work full-time.  At the time of the writing he was still on IPPV for 20 hrs/day with an improved vital capacity (660ml to 1050ml).

Strengths: Presents possibility of vent-dependent individual regaining functional ability and social roles

Limitations: case study; no criteria for beginning ambulation; no specifics of rehab program or walker modifications

3.  Smith T, Forrest G, Evans G, Johnson RK, Chandler N.  The Albany Medical College ventilator walker.  Arch Phys Med Rehabil.  1996; 77:1320-1321.

The purpose of this report was to describe the design and use of a walker that could accomodate a ventilator and O2 tank.  After describing considerations and the construction of the walker, they presented a 69 y.o. female admitted for an elective CABG, complicated by a difficult vent weaning due to obesity, hemi-diaphram paralysis, CHF, left lower lung atelectasis, and obstructive air flow secondary to secretions.  She received a trach one month after the surgery, and two days later started using the walker two times a day.  Over the next week the PT reported significant improvement in strength and functional mobility.  Five months after the initial surgery she could walk without an assistive device or supplemental O2.

Strengths: specifics for walker dimensions

Limitations: case study; no specific criteria for beginning ambulation.

4.  Perme CS, Southard RE, Joyce DL, Noon GP, Loebe M.  Early mobilization of LVAD recipients who require prolonged mechanical ventilation.  Tex Heart Inst J.  2006; 33:130-133.

 The purpose of this case report was to “report our regimen of mobilization with the aid of a prortable ventilator, in patients with cardiac cachexia and LVAD implantation.  Further, we describe the specific physical therapy interventions used in an LVAD patient who required prolonged mechanical ventilation after device implantation.”

The authors generally present their physical therapy evaluation which includes ventilator settings or O2 requirements, their PT interventions (positioning, strengthening and breathing exercises, bed mobility, transfers, gait, and education; with frequency 1x/day 6-7days/wk, 15 minutes – 1 hr), and criteria for termination of PT session (significant drop in LVAD flow, hypotension signs/symptoms, severe/ intolerable dyspnea, O2 level <90%, significant chest pain, extreme fatigue, and request of pt to stop).

Case report: 51 y.o. male with heart failure secondary to dilated cardiomyopathy, and a R lower lobe nodule.  Over next 5 weeks pt became progressively worse in his cardiac function, developed renal insufficiency and repiratory failure which resulted in him being intubated.  He was placed on an LVAD and they resected his right lower lobe, which was further complicated by medical problems requiring continued ventilation.  PT was ordered on Day 7 after he failed the first weaning trial.  He was given LE strengthening exercises and mobilization (sit EOB, stand, and bed<>chair), and he was progressed to gait training activities around the ICU while on a vent.  In his 49 day ICU stay he was vented 48 days and received 25 daily PT sessions (17 LE exercise sessions, 22 EOB sessions, 21 standing sessions, and 18 gait training sessions, 4 of which they used a portable ventilator).  The patient improved to a T-collar, ambuation without vent support, and was weaned from the vent.  After 6 weeks he had a heart transplant and d/c’ed home.

Strengths:  Gave more specifics of PT involvement

Limitations:  case study; no specific criteria for beginning ambulation other than that they can take a few steps; unclear as to session length/ consistency or ventilation while ambulating.

Picture credit: 2 Broken Ribs, originally uploaded by bricolage.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s