Investigating activity in hospitalized patients with chronic obstructive pulmonary disease: a pilot study

Effect of Nighttime Earplugs and Eye Masks on Sleep Quality in Intensive Care Unit Patients

Purpose

Poor sleep quality in intensive care unit (ICU) can be associated with poor outcome. Excessive noise and lights in ICU are known to disrupt patients’ sleep by causing arousals.

Study design

A prospective randomized controlled study.

Materials and methods

The patients admitted to the medical ICU were prospectively included and randomized to receive earplugs and eye masks or no intervention during their first 5 nights in ICU. Their arousal index and other sleep parameters were measured during the first night by polysomnography. Secondary outcomes including wrist actigraphy profiles and subjective sleep quality were recorded during all study nights.

Results

Seventeen patients were enrolled. Eight patients were randomized to earplugs and eye masks group and nine patients were randomized to control group during their first 5 nights in the ICU. The use of earplugs and eye masks demonstrated the trend toward lower arousal index during the first night (21.15 (14.60) vs 42.10 (18.20) events per hour, p = 0.086) and increased activity index (activity count/hour) (16.12 (7.99) vs 10.84 (10.39) count/hour, p = 0.059) compared to control group. Polysomnography and actigraphy did not demonstrate good agreement.

Conclusion

The use of earplugs and eye masks has a trend toward reduction in arousal index and increased activity in patients admitted to ICU. Limited sample size most likely explained insignificant difference in outcomes. Wrist actigraphy did not accurately measure sleep parameters in ICU patients.

Trial registration

www.clinicaltrials.in.th, TCTR20170727003.

How to cite this article

Arttawejkul P, Reutrakul S, Muntham D, Chirakalwasan N. Effect of Nighttime Earplugs and Eye Masks on Sleep Quality in Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(1):6–10.

How much do hospitalized adults move? A systematic review and meta-analysis

AIM

To quantify the type and duration of physical activity performed by hospitalized adults.

BACKGROUND

Inactivity is pervasive among hospitalized patients and is associated with increased mortality, functional decline, and cognitive impairment. Objective measurement of activity is necessary to examine associations with clinical outcomes and quantify optimal inpatient mobility interventions.

METHODS

We used PRISMA guidelines to search three databases in December 2017 to retrieve original research evaluating activity type and duration among adult acute-care inpatients. We abstracted data on inpatient population, measurement method, monitoring time, activity duration, and study quality.

RESULTS

Thirty-eight articles were included in the review and 7 articles were included in the meta-analysis. Study populations included geriatric (n = 5), surgical (n = 5), medical (n = 12), post-stroke (n = 10), psychiatric (n = 2), and critical care inpatients (n = 4). To measure activity, 29% of studies used human observation and 71% used activity monitors. Among inpatient populations, 87-100% of time was spent sitting or lying in-bed. Among medical inpatients monitored over a continuous 24-hour period (n = 7), 70 min per day was spent standing/walking (95% CI 57-83 min).

CONCLUSIONS

This review provides a baseline assessment and benchmark of inpatient activity, which can be used to compare inpatient mobility practices. While there is substantial heterogeneity in how researchers measure and define how much inpatients move, there is consistent evidence that patients are mostly inactive and in-bed during hospitalization. Future research is needed to establish standardized methods to accurately and consistently measure inpatient mobility over time.

Actigraphy to Measure Physical Activity in the Intensive Care Unit: A Systematic Review

OBJECTIVE

In the intensive care unit (ICU), prolonged inactivity is common, increasing patients' risk for adverse outcomes, including ICU-acquired weakness. Hence, interventions to minimize inactivity are gaining popularity, highlighting actigraphy, a measure of activity involving a wristwatch-like accelerometer, as a method to inform these efforts. Therefore, we performed a systematic review of studies that used actigraphy to measure patient activity in the ICU setting.

DATA SOURCES

We searched PubMed, EMBASE, CINAHL, Cochrane Library, and ProQuest from inception until December 2016.

STUDY SELECTION

Two reviewers independently screened studies for inclusion. A study was eligible for inclusion if it was published in a peer-reviewed journal and used actigraphy to measure activity in ≥5 ICU patients.

DATA EXTRACTION

Two reviewers independently performed data abstraction and risk of bias assessment. Abstracted actigraphy-based activity data included total activity time and activity counts.

RESULTS

Of 16 studies (607 ICU patients) identified, 14 (88%) were observational, 2 (12%) were randomized control trials, and 5 (31%) were published after 2009. Mean patient activity levels per 15 to 60 second epoch ranged from 25 to 37 daytime and 2 to 19 nighttime movements. Actigraphy was evaluated in the context of ICU and post-ICU outcomes in 11 (69%) and 5 (31%) studies, respectively, and demonstrated potential associations between actigraphy-based activity levels and delirium, sedation, pain, anxiety, time to extubation, and length of stay.

CONCLUSION

Actigraphy has demonstrated that patients are profoundly inactive in the ICU with actigraphy-based activity levels potentially associated with important measures, such as delirium, sedation, and length of stay. Larger and more rigorous studies are needed to further evaluate these associations and the overall utility of actigraphy in the ICU setting.

Feasibility of Continuous Actigraphy in Patients in a Medical Intensive Care Unit

BACKGROUND

Poor sleep and immobility are common in patients in the medical intensive care unit (MICU) and are associated with adverse outcomes. Interventions to promote sleep and mobilization in the MICU are gaining popularity, but feasible instruments to measure their effectiveness are lacking. Actigraphy may be useful for large-scale, continuous measurement of sleep and activity, but its feasibility in MICU patients has not been rigorously evaluated.

OBJECTIVE

To evaluate the feasibility of continuous actigraphy measurement in consecutive MICU patients.

METHODS

Wrist and ankle actigraphy data were collected for 48 hours in consenting MICU patients. Actigraphy-based measures of estimated sleep and activity were summarized by using descriptive statistics. Agreement between wrist and ankle measurements was evaluated using Cohen κ statistics (for sleep quantity) and intraclass correlation coefficients (for activity).

RESULTS

Overall, 35 of 48 (73%) eligible patients were enrolled, including 10 requiring mechanical ventilation. Of these patients, 34 (97%) completed the 48-hour actigraphy period; 20 (57%) found the devices comfortable. Wrist devices logged a mean (SD) of 33.4 (8.8) hours of estimated sleep (72% [19%] of recording period) and 19.6 (17.2) movements per 30-second epoch. Ankle devices recorded 43.2 (4.1) hours of estimated sleep (93% [7%] of recording period) and 5.1 (6.0) movements per 30 seconds.

CONCLUSIONS

Uninterrupted actigraphy is feasible and generally well tolerated by MICU patients and may be considered for future large-scale studies. Wrist and ankle actigraphy measurements of sleep and activity in this setting agree poorly and cannot be used interchangeably.

Effectiveness of new sedation and rehabilitation methods for critically ill patients receiving mechanical ventilation

[Purpose] The purpose of this study was to investigate the effects of new sedation management methods and cooperation between nurses and physical therapists on the duration of mechanical ventilation and hospitalization. [Subjects and Methods] Patients who had been treated at the study hospital 2 years before and after the implementation of the new methods were analyzed retrospectively and classified into a “control group” and an “intervention group”, respectively. Both groups were analyzed and subsequently compared regarding the effects of the new sedation and cooperative rehabilitation. [Results] A total of 70 patients met the inclusion criteria and were divided evenly into the two groups. No significant differences were found between the groups in age, APACHE II score, or duration of stay in hospital. On the other hand, significant decreases were seen in the duration of sedation and intubation, mechanical ventilation, and stay in the emergency ward, as well as time until standing. In addition, after intervention, three patients undergoing ventilator treatment were able to be ambulated. [Conclusion] These results suggest that the new sedation and cooperative rehabilitation methods for critically ill patients were effective in the early stage of treatment and shortened the duration of stay in the ward.

Use of Accelerometry to Monitor Physical Activity in Critically Ill Subjects: A Systematic Review

Medical management of critically ill patients often incorporates prolonged bed rest, which, in combination with the underlying illness, results in global muscle weakness and atrophy. Recent evidence has demonstrated improvements in clinical and functional outcomes when exercise and physical activity are incorporated early in the management of ICU patients. Accurate monitoring of ICU patients' physical activity is essential for proper prescription and escalation of activity levels. Accelerometry is a technique used to measure physical activity and has been validated in several ambulatory populations. However, its use in critically ill, hospitalized patients with poor functional mobility is limited. In this review, we focus on the few studies assessing the use of accelerometry to measure physical activity in the care of mechanically ventilated adult ICU patients. The selected literature demonstrates that accelerometry correlates well with direct observation in reporting frequency and duration of various types of physical activity (rolling, sitting up, transferring, walking), but cannot differentiate various intensities of activity or whether movements are voluntary or involuntary with respect to effort. Thus, although accelerometry may serve as a useful adjunct in reporting temporality of physical activity in critically ill patients, other objective information may be needed to accurately record frequency, duration, and intensity of activity in this population.

Physiological responses to passive exercise in adults receiving mechanical ventilation

BACKGROUND

Critical illness may weaken muscles, with long-term consequences.

OBJECTIVE

To assess physiological responses to an early standardized passive exercise protocol to prevent muscle weakness in adults receiving mechanical ventilation.

METHODS

A quasi-experimental within-subjects repeated-measures design was used. Within 72 hours of intubation, 30 patients had 20 minutes of bilateral passive leg movement delivered by continuous-passive-motion machines at a standardized rate and flexion-extension. Heart rate, mean blood pressure, oxygen saturation, and cytokine levels were measured before, during, and after the intervention. The Behavioral Pain Scale was used to measure patients' comfort. Repeated-measures analysis of variance was used to analyze the effect of the exercise on independent variables.

RESULTS

Patients were mostly white men with a mean age of 56.5 years (SD, 16.9) with moderate mortality risk and illness severity. Heart rate, mean blood pressure, and oxygen saturation did not differ from baseline at any time measured. Pain scores were significantly reduced (F(2.43,70.42) = 4.08; P = .02) 5 and 10 minutes after exercise started and remained reduced at the end of exercise and 1 hour later. Interleukin 6 levels were significantly reduced (F(1.60,43.1) = 4.35; P = .03) at the end of exercise but not after the final rest period. Interleukin 10 levels did not differ significantly. Ratios of interleukin 6 to interleukin 10 decreased significantly (F(1.61,43.38) = 3.42; P = .05) at the end of exercise and again after 60 minutes' rest.

CONCLUSION

The exercise was well tolerated, and comfort improved during and after the intervention. Cytokine levels provided physiological rationale for benefits of early exercise.

The study of activity in older ICU patients: an integrative review

The purpose of this study was to review relevant literature on activity of older critically ill patients, including activity interventions conducted in this population, with a focus on activity measurement and technology. Literature published between 1996 and 2012 was reviewed using keywords older adults, inactivity, mobility, progressive mobility, rehabilitation, ambulation, early mobilization, ICU (intensive care unit), and accelerometry using CINAHL, MEDLINE, and the Cochrane Database of Systematic Reviews. Previous relevant research is discussed and includes intervention and nonintervention studies. Although studies have demonstrated the benefits of early mobilization in the ICU setting, this research has not focused on the high-risk older adult ICU population, nor has it addressed how best to quantify these clinical activities. Current technologies, such as accelerometry, may assist in measuring patient activity and in mobilizing high-risk patients during acute, critical illness.

Active mobilization for mechanically ventilated patients: a systematic review

OBJECTIVE

To investigate the effectiveness and safety of active mobilization on improving physical function and hospital outcomes in patients undergoing mechanical ventilation for more than 24 hours.

DATA SOURCES

PubMed, Embase, CINAHL, CENTRAL, Physiotherapy Evidence Database, SinoMed, and ISI Web of Knowledge were searched for randomized controlled trials (RCTs), quasi-RCTs, other comparative studies, and case series with 10 or more consecutive cases. Additional studies were identified through references, citation tracking, and by contacting the authors of eligible studies.

STUDY SELECTION

Two reviewers independently selected potential studies according to the inclusion criteria.

DATA EXTRACTION

Two reviewers independently extracted data and assessed the methodologic quality.

DATA SYNTHESIS

A narrative form was used to summarize study characteristics and outcomes, because the substantial heterogeneity between the individual studies precluded formal meta-analyses. Among the 17 eligible studies, 7 RCTs, 1 quasi-RCT, 1 prospective cohort study, and 1 history controlled study were used to examine the effectiveness; and 2 RCTs, 1 prospective cohort study, and 7 case series were used to examine the safety of active mobilization in patients receiving mechanical ventilation for more than 24 hours. We found that active mobilization may improve muscle strength, functional independence, and the ability to wean from ventilation and may decrease the length of stay in the intensive care unit (ICU) and hospital. However, only 1 study reported that active mobilization reduced the 1-year mortality rate. No serious adverse events were reported among included studies.

CONCLUSIONS

Active mobilization appears to have a positive effect on physical function and hospital outcomes in mechanical ventilation patients. Early active mobilization protocols may be initiated safely in the ICU setting and continued in post-ICU settings. However, the current available studies have great heterogeneity and limited methodologic quality. Further research is needed to provide more robust evidence to support the effectiveness and safety of active mobilization.

Measurement of physiologic responses to mobilisation in critically ill adults

OBJECTIVE

To identify physiologic variables that could be measured in response to mobilisation interventions in critically ill adults.

BACKGROUND

Physical activity may mitigate muscle damage from critical illness, but critically ill patients may have limited activity tolerance. Physiologic measures may be most useful in identifying safety and efficacy of mobilisation in this population.

METHODS

A comprehensive literature search of electronic databases was conducted from 1990 to present, including CINAHL, MEDLINE the Cochrane Database of Systematic Reviews and PubMed. Search terms used were mobilisation, exercise, activity and critical illness. Seventeen articles were identified for review. Physiologic measurement approaches were reviewed for precision and accuracy.

RESULTS

Cardiopulmonary measures comprised the majority of physiologic variables identified, and multiple measures were used. Physiologic measures were primarily used as indicators of safety, although several efficacy measures were identified. Only one standardised tool was found that could be suitable as a safety measure, the Borg Rating of Perceived Exertion. The Medical Research Council Muscle Strength Grading Scale could be used as a physiologic outcome measure. Inflammatory biomarkers may be used as a novel measure of physiologic response. Descriptions of approaches to assure precision and accuracy of physiologic response measures were extremely limited.

CONCLUSIONS

Multiple physiologic variables should be measured when considering response to mobilisation in critically ill patients. Attention should be paid to procedures to assure accuracy and precision in measurement. Future studies including physiologic measures should include inflammatory biomarkers, and other measures of physiologic function, such as pain assessment.