Neuromuscular Sequelae in Survivors of Acute Lung Injury

Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome

Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post-intensive care syndrome, functional limitations, and high costs. Early mobility-based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility-based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility-based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation

RATIONALE

Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design.

OBJECTIVES

To stratify patients for post-ICU disability and recovery to 1 year after critical illness.

METHODS

We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling.

MEASUREMENTS AND MAIN RESULTS

The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year.

CONCLUSIONS

ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

Hospital-level factors associated with report of physical activity in patients on mechanical ventilation across Washington State

RATIONALE

Use of physical and/or occupational therapy in the intensive care unit (ICU) is safe, feasible, and demonstrates improvements in functional status with early administration. Access to physical and/or occupational therapy in the ICU is variable, with little known regarding its use in community ICUs.

OBJECTIVES

Determine what proportion of hospitals across Washington State report use of physical activity in mechanically ventilated patients and investigate process of care factors associated with reported activity delivery.

METHODS

Cross-sectional telephone interview survey study of nurse managers in hospitals caring for patients on mechanical ventilation across Washington State in 2013. Survey responses were linked with hospital-level data available in the Washington State Department of Health Comprehensive Hospital Abstract Reporting System database. Chi-square testing was used to explore unadjusted associations between potential process of care factors and report on activity delivery. Two multivariable logistic regression models were developed to explore the association between presence of a mobility protocol and report on delivery of activity.

MEASUREMENTS AND MAIN RESULTS

We identified 54 hospitals caring for patients on mechanical ventilation; 47 participated in the survey (response rate, 85.5%). Nurse managers from 36 (76.6%) hospitals reported use of physical activity in patients on mechanical ventilation, with 22 (46.8%) reporting use of high-level physical activity (transferring to chair, standing or ambulating) and 24 (51.1%) reporting use in high-severity patients (patients requiring mechanical ventilation and/or vasopressors). Presence of a written ICU activity protocol (odds ratio [OR], 5.54; 95% confidence interval [CI], 1.60-19.18; P = 0.006), hospital volume (OR, 5.33; 95% CI, 1.54-18.48; P = 0.008), and academic affiliation (OR, 4.40; 95% CI, 1.23-15.63; P = 0.02) were associated with report of higher level activity. Presence of a written ICU activity protocol (OR, 6.00; 95% CI, 1.69-21.14; P = 0.005) and academic affiliation (OR, 4.50; 95% CI, 1.21-16.46; P = 0.02) were associated with report of delivery of physical activity to high-severity patients.

CONCLUSIONS

Nurse managers at three-fourths (76.6%) of eligible hospitals across Washington State reported use of physical activity in patients on mechanical ventilation. Hospital-level factors including hospital volume, academic affiliation, and presence of a mobility protocol were associated with report of higher level activity and delivery of activity to high-severity patients.

Factors associated with receipt of physical therapy consultation in patients requiring prolonged mechanical ventilation

BACKGROUND/INTRODUCTION

Mobilization of critically ill patients in the intensive care unit is associated with improved function at hospital discharge and reduced duration of mechanical ventilation (MV). Few studies, however, focus on physical therapy (PT) in patients on prolonged mechanical ventilation (PMV) despite their high risk of immobility and poor outcomes.

OBJECTIVE/AIMS

The objective of this study was to identify factors associated with the receipt of PT consultation among patients requiring PMV. We hypothesized that key factors including age, severity of illness, and presence of a tracheostomy are associated with PT consultation.

METHODS

This was a retrospective cohort study of adults on MV for 14 days or longer for acute respiratory failure at an academic medical center. Primary outcome was PT consultation by day 14 of MV. We examined associations between the following key predictors chosen a priori and PT consultation: age, tracheostomy, illness severity, oxygenation status, shock, hemodialysis, and medical service using multivariable logistic regression. Wilcoxon rank sum testing was used to test relationship between sedation and PT.

RESULTS

We identified 175 patients requiring PMV at our institution. Most were middle-aged (mean, 49.7 [SD, 18.5] years old) men (65%) with high illness severity (mean Acute Physiology and Chronic Health Evaluation III score, 86 [SD, 40]). Less than half of all patients requiring PMV (78/175, 45%) received PT consultation in the intensive care unit, and most failed to progress with therapy beyond range-of-motion exercises (85%). Failure to progress was associated with level of sedation (med Ramsay score 4.5 [interquartile range, 3-6] vs 3.5 [interquartile range, 3-5]; P = .01). Presence of a tracheostomy and prehospital nonambulatory status were associated with receipt of PT by day 14 of MV (odds ratio, 6.94 and 3.42, respectively; P ≤ .05).

CONCLUSIONS

In our study, we found that PT for PMV patients occurs infrequently and is generally of low intensity. Level of sedation, presence of a tracheostomy, and prehospital nonambulatory status were associated with receipt of PT consultation by day 14 of MV.

The reality of patients requiring prolonged mechanical ventilation: a multicenter study

OBJECTIVE

The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days).

METHODS

This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality.

RESULTS

There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs.

CONCLUSION

The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation dependency ≥ 21 days) identified patients with a high risk for complications during intensive care unit stay, longer intensive care unit and hospital stays, high death rates, and higher costs.

Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study

Background

Early mobilization (EM) of patients on mechanical ventilation (MV) is shown to improve outcomes after critical illness. Little is known regarding clinician knowledge of EM or multi-disciplinary barriers to use of EM in the intensive care unit (ICU). The goal of this study was to assess clinician knowledge regarding EM and identify barriers to its provision.

Methods

Simultaneous cross-sectional surveys of medical ICU (MICU) nurses (RN)/physical therapists (PT) respondents and physician (MD) respondents in a single MICU at an academic hospital in Seattle, WA in 2010–2011. Responses were indicated on a 5 point Likert scale and reported as proportion of respondents agreeing or disagreeing. Chi-square testing and Fisher’s exact testing was performed to determine whether responses differed by duration of employment or prior EM experience.

Results

A total of 120 clinicians responded to the survey (91 MDs (response rate 82% (91/111)), 17 RNs (response rate 22%, (17/78)), and 12 PTs (response rate 86%, (12/14)), overall response rate 86%). Most clinicians indicated knowledge regarding benefits of EM. More attending physicians reported knowledge of EM benefits, but also that risks of EM outweigh the benefits compared to trainees (p = 0.02 and 0.01). Clinicians across disciplines reported near universal agreement to use of EM for patients on MV, while the minority reported agreement to EM for patients on vasoactive agents. The most frequently reported cross-disciplinary barriers to EM were staffing and time. Risk of self-injury and excess work stress were indicated as barriers by RN and PT respondents.

Conclusions

MICU clinicians, at our institution, reported knowledge of EM in the ICU. Staffing and clinician time were frequently identified cross-disciplinary barriers. Risk of self-injury and excess work stress were frequently reported RN and PT barriers.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2253-14-84) contains supplementary material, which is available to authorized users.

Effects of early rehabilitation therapy on patients with mechanical ventilation

BACKGROUND

For patients in intensive care unit (ICU), mechanical ventilation is an effective treatment to survive from acute illness and improve survival rates. However, long periods of bed rest and restricted physical activity can result in side effects. This study aimed to investigate the feasibility of early rehabilitation therapy in patients with mechanical ventilation.

METHODS

A randomized controlled trial was carried out. Sixty patients, with tracheal intubation or tracheostomy more than 48 hours and less than 72 hours, were admitted to the ICU of the Affiliated Hospital of Medical College, Qingdao University, from May 2010 to May 2012. These patients were randomly divided into a rehabilitation group and a control group. In the rehabilitation group, rehabilitation therapy was performed twice daily, and the training time and intensity were adjusted according to the condition of the patients. Early rehabilitation therapy included heading up actively, transferring from the supine position to sitting position, sitting at the edge of the bed, sitting in chair, transferring from sitting to standing, and ambulating bedside. The patient's body mass index, days to first out of bed, duration of mechanical ventilation, length of ICU stay, APACHE II score, highest FiO2, lowest PaO2/FiO2 and hospital mortality of patients were all compared between the rehabilitation group and the control group. The differences between the two groups were compared using Student's t test.

RESULTS

There was no significant difference in body mass index, APACHE II score, highest FiO2, lowest PaO2/FiO2 and hospital mortality between the rehabilitation group and the control group (P>0.05). Patients in the rehabilitation group had shorter days to first out of bed (3.8±1.2 d vs. 7.3±2.8 d; P=0.00), duration of mechanical ventilation (5.6±2.1 d vs. 12.7±4.1 d; P=0.005) and length of ICU stay (12.7±4.1 d vs. 15.2±4.5 d; P=0.01) compared with the control group.

CONCLUSION

Early rehabilitation therapy was feasible and effective in improving the outcomes of patients with mechanical ventilation.

Prediction of chronic critical illness in a general intensive care unit

OBJECTIVE

To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit.

METHODS

This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed.

RESULTS

There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model.

CONCLUSIONS

CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.

Intensive care unit-acquired weakness: clinical phenotypes and molecular mechanisms

Intensive care unit-acquired weakness (ICUAW) begins within hours of mechanical ventilation and may not be completely reversible over time. It represents a major functional morbidity of critical illness and is an important patient-centered outcome with clear implications for quality of life and resumption of prior work and lifestyle. There is heterogeneity in functional outcome related to ICUAW across various patient populations after an episode of critical illness. This state-of-the art review argues that this observed heterogeneity may represent a clinical spectrum of disability in which there are recognizable clinical phenotypes for outcome according to age, burden of comorbid illness, and ICU length of stay. It further argues that these functional outcomes are modified by mood, cognition, and caregiver physical and mental health. This proposed construct of clinical phenotypes will be used as a framework for a review of the current literature on the molecular biology of muscle and nerve injury. This translational approach for the development of models pairing clinical phenotypes for different functional outcomes after critical illness with molecular mechanism of injury may offer unique insights into the diagnosis and treatment of muscle and nerve lesions.

Long-term outcome after acute lung injury

PURPOSE OF REVIEW

As incidence of acute lung injury (ALI) increases and case fatality decreases, long-term care of survivors is of public health importance. Previous studies demonstrate that these survivors are at risk for impairment in physical, cognitive and mental health. In this review, we will discuss recent studies that add to our knowledge of long-term outcomes after ALI and critical illness.

RECENT FINDINGS

New studies show that persisting impairment in physical and cognitive function continues 5 years after recovery from critical illness. Glucose dysregulation may play a role in development of both depression and cognitive impairment. Premorbid impairment appears to be an important risk factor, but critical illness is an independent risk factor of physical and cognitive functional decline. Recent randomized controlled trials emphasize that post-ICU interventions may not be enough to improve health-related quality of life after ALI. Interventions delivered early in critical illness, such as physical and occupational therapy and creation of ICU diaries, may be key in improving late outcomes after ALI.

SUMMARY

Physical, cognitive and mental health impairments after ALI are common, persistent and expensive. Future research is needed to improve prediction, prevention and treatment of these important sequelae.

Functional disability 5 years after acute respiratory distress syndrome

BACKGROUND

There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS).

METHODS

We evaluated 109 survivors of ARDS at 3, 6, and 12 months and at 2, 3, 4, and 5 years after discharge from the intensive care unit. At each visit, patients were interviewed and examined; underwent pulmonary-function tests, the 6-minute walk test, resting and exercise oximetry, chest imaging, and a quality-of-life evaluation; and reported their use of health care services.

RESULTS

At 5 years, the median 6-minute walk distance was 436 m (76% of predicted distance) and the Physical Component Score on the Medical Outcomes Study 36-Item Short-Form Health Survey was 41 (mean norm score matched for age and sex, 50). With respect to this score, younger patients had a greater rate of recovery than older patients, but neither group returned to normal predicted levels of physical function at 5 years. Pulmonary function was normal to near-normal. A constellation of other physical and psychological problems developed or persisted in patients and family caregivers for up to 5 years. Patients with more coexisting illnesses incurred greater 5-year costs.

CONCLUSIONS

Exercise limitation, physical and psychological sequelae, decreased physical quality of life, and increased costs and use of health care services are important legacies of severe lung injury.

Legacy of intensive care unit-acquired weakness

Loss of muscle mass, nerve dysfunction, and resultant weakness and functional disability represent important and lasting morbidities of an episode of critical illness. As investigators increasingly incorporate long-term functional, neuropsychological, and quality-of-life outcomes into their studies, more data are accruing that support the existence of often devastating and irreversible sequelae of severe illness and treatment in an intensive care unit. This review highlights early quality-of-life literature that supports significant physical dysfunction after intensive care unit treatment and more recent longitudinal studies up to 5 yrs after intensive care unit discharge, which clearly implicate nerve and muscle dysfunction as contributors to this reported disability. Additional follow-up work is needed to understand the pathophysiology of this injury, the spectrum of physical disability, and its associated risk factors. These data are crucial to inform risk-stratification and future rehabilitation interventions, both during the intensive care unit admission and after hospital discharge as patients reintegrate within their community and workplace.

Intensive care unit-acquired neuromyopathy and corticosteroids in survivors of persistent ARDS

OBJECTIVES

To determine the incidence and outcomes of intensive care unit-acquired neuromyopathy and to investigate the role of methylprednisolone in survivors of persistent acute lung injury.

DESIGN

Secondary analysis of completed randomized placebo-controlled trial.

SETTING

Twenty-five hospitals in the NHLBI ARDS Network.

PATIENTS AND PARTICIPANTS

Patients enrolled in the ARDS Network study of methylprednisolone versus placebo for persistent ARDS who survived 60 days or to hospital discharge.

MEASUREMENTS AND RESULTS

One hundred and twenty-eight study patients survived 60 days. Forty-three (34%) of these patients had evidence by chart review of ICU-acquired neuromyopathy, which was associated with prolonged mechanical ventilation, return to mechanical ventilation, and delayed return to home after critical illness. Treatment with methylprednisolone was not significantly associated with an increase in risk of neuromyopathy (OR 1.5; 95% CI 0.7-3.2).

CONCLUSIONS

ICU-acquired-neuromyopathy is common among survivors of persistent ARDS and is associated with poorer clinical outcomes. We did not find a significant association between methylprednisolone treatment and neuromyopathy. Limitations of this study preclude definitive conclusions about the causal relationship between corticosteroids and ICU-acquired neuromuscular dysfunction.

Review of a large clinical series: sedation and analgesia usage with airway pressure release and assist-control ventilation for acute lung injury

BACKGROUND

Our objective was to compare sedative and analgesic doses, agents, and sedation status in patients with airway pressure release ventilation (APRV) versus assist-control (AC) ventilation on the first day after acute lung injury diagnosis.

METHODS

Observational study at 3 teaching hospitals.

RESULTS

Of 240 patients, 165 received APRV or AC ventilation on day 1 (17 APRV, 148 AC). The median Acute Physiology and Chronic Health Evaluation II score was lower in the APRV versus AC group [17 (14-20) vs. 25 (21-32), P < .001]. Median total doses of sedatives and analgesics were lower in APRV versus AC (29 vs. 98 mg of midazolam-equivalents, P < .001) and (1200 vs. 2400 mcg of fentanyl equivalents, P = .006). APRV patients were less sedated versus AC (median Richmond Agitation-Sedation Scale -2 vs. -4, P < .002).

CONCLUSIONS

APRV may be associated with decreased sedation and analgesia medications and improved sedation status. Differences in the patients receiving APRV versus AC ventilation may have contributed to this conclusion. Further investigation is needed.

The role of future longitudinal studies in ICU survivors: understanding determinants and pathophysiology of weakness and neuromuscular dysfunction

PURPOSE OF REVIEW

The goals of this review are to discuss the pathophysiology and determinants of muscle weakness and neuromuscular dysfunction after critical illness, and to offer thoughts regarding the role of future longitudinal studies in this area.

RECENT FINDINGS

While recent studies support the finding that neuromuscular dysfunction is common and important after critical illness, reversible risk factors and approaches to prevention and treatment remain unproven. Pathophysiologic studies implicate disease and treatment associated factors in the development of nerve and muscle damage during critical illness; these factors may provide targets for future studies.

SUMMARY

Additional studies with improved methodology that address epidemiology and that test interventions are needed to understand and to improve neuromuscular function after critical illness.

Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients)

OBJECTIVES

The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition.

METHODS

Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score > or =2 points and another injury (Abbreviated Injury Scale score > or =2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications).

OUTCOMES

: Incidence of acute lung injuries.

RESULTS

Ten European Centers, 165 patients, mean age 32.7 +/- 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05.

CONCLUSION

Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.

Perioperative care of patients with neuromuscular disease and dysfunction

A variety of different pathologies result in disease phenotypes that are summarized as neuromuscular diseases because they share commonalty in their clinical consequences for the patient: a progressive weakening of the skeletal muscles. Distinct caution and appropriate changes to the anesthetic plan are advised when care is provided during the perioperative period. The choice of anesthetic technique, anesthetic drugs, and neuromuscular blockade always depends on the type of neuromuscular disease and the surgical procedure planned. A clear diagnosis of the underlying disease and sufficient knowledge and understanding of the pathophysiology are of paramount importance to the practitioner and guide optimal perioperative management of affected patients.