Functional Outcome of Mechanically Ventilated Patients Recovering - PowerPoint PPT Presentation

Functional Outcome of Mechanically Ventilated Patients Recovering from Acute Respiratory Failure C L I N I C A L P R O B L E M S O L V I N G I B Y O L I V I A S H U C K

Meet Patient “A” — 77 y/o male — Single, 3 Daughters — Additional Co- morbidities: — SNF since May 2013 — Hypertension, Obesity, — Prior Level of Peripheral Edema, Acquired Function Factor VIII, Spinal Stenosis & Depression. — Admitting Diagnosis: — No PT while in ICU/ ¡ Hypothermia and AMS. MRICU — After Admission: ¡ C. Difficile ¡ Hypercapnic Respiratory Failure

Timeline of Hospitalization Day 1: Day 23: Day 30: PT Day 36: PT Admission Acute Care Eval Re-Eval Day 15: Day 25: Day 35: PT Day 37: PT MRICU Attempted Treatment Treatment PT Eval

Acute Respiratory Failure — What is it? — Causes — Who is at risk? — Signs and Symptoms — Diagnosis — Treatment: Mechanical Ventilation — Short-term and long- term effects Chest radiograph of a patient on admission to ICU (Wong 2000)

Initial Examination — Cognition: Safety intact, able to follow 2 step commands, however was not oriented to time. — Sensation: SILT however diminished on dorsal aspect of L foot. — ROM: WFL ¡ Exception: Bilateral shoulder flexion and plantarflexion — MMT: Only 3/5 in elbow flexion/extension Left MMT Right MMT Shoulder flexion 2+/5 2+/5 Grip Strength 2/5 2/5 Hip flexion (ext- 2+/5 2+/5 NT) Knee flexion/ 2+/5 2+/5 extension DF/PF 1/5 1/5

Initial Evaluation Continued — Pain: 0/10 throughout session — Activity tolerance — Functional Mobility: ¡ Maintain sidelying with UE support on bedrail with CGA ¡ Eccentric rolling from sidelying to supine w/o assist ¡ Roll L/R with max A x 2 ¡ Transferred with a maxi mover to bedside chair ¡ Poor static sitting balance ¡ VS: normal and breathing on 2 L nasal cannula

Evaluation Findings — Impairments : Reduced muscle strength, reduced AROM, reduced PROM, loss of sensation in L foot, & decreased static balance — Functional Limitations: Unable to walk, unable to transfer independently, & altered ability to sit — Disability : Unable to return home, unable to work, & unable to be independent with ADLs

Prognosis (+) (-) — Patient no longer — Prior Level of function dependent on — PMH mechanical ventilation — # of Co-morbidities — Family support — Patient’s age — Activity tolerance/ — Fall risk endurance — Long period of — Delirium improving immobilization during ventilation period

Treatment and Goals — Patient Goals: To walk — Treatment Goals: ¡ Will roll L/R with mod A x — Exam Strategy: 2 ¡ Increase the patient’s ¡ Supine-sit with max A x 2 strength, specifically in the LE’s. ¡ Static sitting EOB x 5 min with min A x 2 ¡ Increase ROM of shoulder flexion so patient can do ¡ Sit-stand with max A x 2 some ADL’s (eating, partial dressing, etc). ¡ Discharge to inpatient rehab or to home with 24 assist and HHPT

Intervention — Initial Exercises: — Progressed to: ¡ Scapular retractions ¡ Static sitting EOB with self correction for posture ¡ Shoulder shrugs ¡ Multidirectional weight ¡ Hip adduction/pillow shifting and reaching squeeze ¡ Sitting EOB: AROM LAQ, ¡ Ankle pumps glut sets, hip flexion, ¡ Heel slides dorsiflexion, and ¡ Maintaining sidelying plantarflexion exercises position with UE on bedrail with CGA

Goals Met Before Discharge ¡ MET ÷ Supine-sit with max A x 2 ÷ Static sitting EOB x 5 min with min A x 2 ÷ Sit-stand with max A x 2 ¡ Not met but progressing ÷ Will roll L/R with mod A x 2 ¡ Able to perform more ADLs ¡ Discharge Plans ÷ Inpatient PT

Clinical Question Does early physical therapy intervention influence the amount of functional gain at time of discharge in patients who are recovering from acute respiratory failure?

Early Activity is Feasible and Safe in Respiratory Failure Patients — Purpose: To determine whether early physical activity was feasible and safe in respiratory failure patients. — Prospective Cohort Study — N = 103 — Inclusion: Respiratory Failure, Mechanical Ventilation > 4 days — Exclusion: Mechanical Ventilation 4 days or less

Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139-145. — Methods ¡ Mechanically ventilated patients ¡ Early activity protocol ¡ Goal: Ambulate >100 feet before RICU discharge ¡ Three Activity events: sit EOB w/o support, sit in a chair after transfer from bed-chair and ambulate with or w/o support from staff. ¡ Six activity-related adverse events ¡ Twice daily sessions

Results Activity Level in Survivors on the Last Full Day of RICU Admission Activity Total Group Age <65 yrs Age ≥ 65 yrs (n = 85) (n=49) (n = 36) No activity 2 0 2 Sit on bed 4 2 2 Sit in chair 13 5 8 Ambulate ≤ 100 7 6 1 feet Ambulate >1oo 59 36 23 feet

Results Continued Number of Comorbidities 18 Initial ICU Admission to 16 14 Ambulation (days) 12 10 8 6 4 2 0 0 1 2 3 4 5 6

Strengths and Weaknesses — Strengths: — Weaknesses ¡ High rates of activity ¡ Lack of objective data (e.g. participation muscle strength). ¡ Goals for study met: ¡ Lack of knowledge Number of patients regarding longitudinal ambulating >100 feet effects of early PT before RICU discharge intervention. ¡ No control group

Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit — Purpose: Whether physical activity and mobility initiated during ICU treatment were maintained after patients were transferred from the ICU to a ward — Prospective Cohort Study — N= 72 — Inclusion: Respiratory Failure, RICU stay >2 days, transfer to a ward and ward stay >2 days . — Exclusion: open abdomen, neurologic disease (stroke or paralysis) and terminal illness

Hopkins RO, Miller RR, Rodriguez L, et al. Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit. PHYS THER. 2012; 92:1518-1523. — Methods: ¡ 300 consecutive mechanically ventilated patients 300 Patients ¡ Early physical activity and screened mobility ¡ Goal: Ambulate >100 feet ¡ Activity events: AROM, 72 patients 228 Patients PROM, sitting EOB w/o in Study not eligible support, transferring from Cohort bed-chair and ambulation ¡ Twice daily sessions

Results Change in Activity Level from Last RICU Day to First Ward Day 45 Number of Patients 40 35 30 25 20 15 10 5 0 Decreased Same Increased

Results Continued Activity Level Number of Patients 20 18 16 No consultation 14 12 10 Nursing Assistance with 8 Ambulation 6 4 PT Consultation 2 0 No ambulation Ambulate <100 Ambulate >100 feet feet

Conclusion of Study — Decrease in activity upon transfer – Why? ¡ Fatigue ¡ Patient refusal ¡ Patient to staff ratio ¡ Communication ¡ ICU vs ward staff ¡ Patient load — Possible Solution

Strength and Weaknesses — Limitations: — Strengths: ¡ Lack of data ¡ Comparing regarding activity patients to themselves ¡ Lack of longitudinal follow-up ¡ Lack of controls

Conclusion — Early activity in patients with Respiratory Failure appears to be safe but is it beneficial? — Patient “A” — In the future.. ¡ Longitudinal studies ¡ Studies with control groups

Questions?

References — Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139-145. — Hopkins RO, Miller RR, Rodriguez L, et al. Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit. PHYS THER. 2012; 92:1518-1523. — Wong WP. Physical Therapy for a Patient in Acute Respiratory Failure. PHYS THER . 2000; 80:662-670.