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Bento H, Fisk E, Johnson E, Goudelock B, Hunter M, Hoekstra D, Noren C, Hatton N, Magel J. Inspiratory Muscle Training While Hospitalized With Acute COVID-19 Respiratory Failure: A Randomized Controlled Trial. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2023; 14:134-142. [PMID: 37389410 PMCID: PMC10289076 DOI: 10.1097/jat.0000000000000217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Although inspiratory muscle training (IMT) has been used in outpatient settings for patients who recovered from COVID-19 respiratory failure, little data exist to support earlier implementation in acute care hospitals. This study aimed to assess the safety and feasibility of IMT during the acute disease phase of COVID-19. Design Setting and Patients Sixty patients presenting with COVID-19 to a single academic medical center were randomized to control or intervention groups using systematic randomization. Measurements Participants in the control group had their maximal inspiratory pressure (MIP) measured at enrollment and hospital discharge. They were also asked for their rating of perceived exertion on the Revised Borg Scale for Grading Severity of Dyspnea and were scored by researchers on the Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks Mobility Scale and the Intensive Care Unit Mobility Scale (IMS). Control group patients otherwise received standard care. Participants in the intervention group, in addition to the measures described previously, received inspiratory threshold trainers with the goal of doing 2 sessions daily with a physical therapist for the duration of their inpatient hospitalization. In these sessions, the patient completed 3 sets of 10 breaths with the trainer. Initial resistance was set at 30% of their MIP, with resistance increasing 1 level for the subsequent session if the patients rated their during-activity rating of perceived exertion as less than 2. Changes in functional outcome measures, amount of supplemental oxygen, hospital length of stay (LOS), discharge location, adverse events, and mortality were assessed in group comparisons. Results Of 60 enrolled patients, 41 (n = 19 in intervention and n = 22 in control) were included in the final data set, which required completion of the study, initial and discharge data points collected, and survival of hospitalization. Final groups were statistically similar. A total of 161 sessions of IMT were completed among the 19 patients in the intervention group. Mortality totaled 2 in the control group and 3 in the intervention group and adverse events during intervention occurred in only 3 (1.8%) sessions, all of which were minor oxygen desaturations. Sessions were unable to be completed for all potential reasons 11% of possible times. Dropout rate in the intervention group was 3 (10%). Both intervention and control groups demonstrated improved MIP, decreased supplemental oxygen requirements, improved function on the AM-PAC, and slightly decreased function on the IMS. Length of stay was shorter in the intervention group, and discharge disposition was similar between groups. Conclusions With a low number of recorded adverse events, similar mortality between groups, and successful completion of 161 exercise sessions, IMT may be a feasible and safe intervention for some hospitalized patients with COVID-19.
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Affiliation(s)
- Haley Bento
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Elizabeth Fisk
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Emma Johnson
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Bruce Goudelock
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Maxwell Hunter
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Deborah Hoekstra
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Christopher Noren
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - Nathan Hatton
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
| | - John Magel
- Acute Therapy Services, University of Utah Health, 520 Wakara Way, Salt Lake City, UT 84108 (USA). . Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- Acute Therapy Services, University of Utah Health, Salt Lake City
- School of Medicine, The University of Utah, Salt Lake City
- Department of Physical Therapy and Athletic Training, The University of Utah, Salt Lake City
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Randelman M, Zholudeva LV, Vinit S, Lane MA. Respiratory Training and Plasticity After Cervical Spinal Cord Injury. Front Cell Neurosci 2021; 15:700821. [PMID: 34621156 PMCID: PMC8490715 DOI: 10.3389/fncel.2021.700821] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/11/2021] [Indexed: 12/30/2022] Open
Abstract
While spinal cord injuries (SCIs) result in a vast array of functional deficits, many of which are life threatening, the majority of SCIs are anatomically incomplete. Spared neural pathways contribute to functional and anatomical neuroplasticity that can occur spontaneously, or can be harnessed using rehabilitative, electrophysiological, or pharmacological strategies. With a focus on respiratory networks that are affected by cervical level SCI, the present review summarizes how non-invasive respiratory treatments can be used to harness this neuroplastic potential and enhance long-term recovery. Specific attention is given to "respiratory training" strategies currently used clinically (e.g., strength training) and those being developed through pre-clinical and early clinical testing [e.g., intermittent chemical stimulation via altering inhaled oxygen (hypoxia) or carbon dioxide stimulation]. Consideration is also given to the effect of training on non-respiratory (e.g., locomotor) networks. This review highlights advances in this area of pre-clinical and translational research, with insight into future directions for enhancing plasticity and improving functional outcomes after SCI.
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Affiliation(s)
- Margo Randelman
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States.,Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Lyandysha V Zholudeva
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States.,Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, PA, United States.,Gladstone Institutes, San Francisco, CA, United States
| | - Stéphane Vinit
- INSERM, END-ICAP, Université Paris-Saclay, UVSQ, Versailles, France
| | - Michael A Lane
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States.,Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, PA, United States
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Ataya A, Silverman EP, Bagchi A, Sarwal A, Criner GJ, McDonagh DL. Temporary Transvenous Diaphragmatic Neurostimulation in Prolonged Mechanically Ventilated Patients: A Feasibility Trial (RESCUE 1). Crit Care Explor 2020; 2:e0106. [PMID: 32426748 PMCID: PMC7188416 DOI: 10.1097/cce.0000000000000106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Prolonged mechanical ventilation promotes diaphragmatic atrophy and weaning difficulty. The study uses a novel device containing a transvenous phrenic nerve stimulating catheter (Lungpacer IntraVenous Electrode Catheter) to stimulate the diaphragm in ventilated patients. We set out to determine the feasibility of temporary transvenous diaphragmatic neurostimulation using this device. DESIGN Multicenter, prospective open-label single group feasibility study. SETTING ICUs of tertiary care hospitals. PATIENTS Adults on mechanical ventilation for greater than or equal to 7 days that had failed two weaning trials. INTERVENTIONS Stimulation catheter insertion and transvenous diaphragmatic neurostimulation therapy up to tid, along with standard of care. MEASUREMENTS AND MAIN RESULTS Primary outcomes were successful insertion and removal of the catheter and safe application of transvenous diaphragmatic neurostimulation. Change in maximal inspiratory pressure and rapid shallow breathing index were also evaluated. Eleven patients met all entry criteria with a mean mechanical ventilation duration of 19.7 days; nine underwent successful catheter insertion. All nine had successful mapping of one or both phrenic nerves, demonstrated diaphragmatic contractions during therapy, and underwent successful catheter removal. Seven of nine met successful weaning criteria. Mean maximal inspiratory pressure increased by 105% in those successfully weaned (mean change 19.7 ± 17.9 cm H2O; p = 0.03), while mean rapid shallow breathing index improved by 44% (mean change -63.5 ± 64.4; p = 0.04). CONCLUSIONS The transvenous diaphragmatic neurostimulation system is a feasible and safe therapy to stimulate the phrenic nerves and induce diaphragmatic contractions. Randomized clinical trials are underway to compare it to standard-of-care therapy for mechanical ventilation weaning.
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Affiliation(s)
- Ali Ataya
- Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Erin P Silverman
- Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Aranya Bagchi
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Smith BK, Martin AD, Lawson LA, Vernot V, Marcus J, Islam S, Shafi N, Corti M, Collins SW, Byrne BJ. Inspiratory muscle conditioning exercise and diaphragm gene therapy in Pompe disease: Clinical evidence of respiratory plasticity. Exp Neurol 2016; 287:216-224. [PMID: 27453480 DOI: 10.1016/j.expneurol.2016.07.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 06/30/2016] [Accepted: 07/20/2016] [Indexed: 11/30/2022]
Abstract
Pompe disease is an inherited disorder due to a mutation in the gene that encodes acid α-glucosidase (GAA). Children with infantile-onset Pompe disease develop progressive hypotonic weakness and cardiopulmonary insufficiency that may eventually require mechanical ventilation (MV). Our team conducted a first in human trial of diaphragmatic gene therapy (AAV1-CMV-GAA) to treat respiratory neural dysfunction in infantile-onset Pompe. Subjects (aged 2-15years, full-time MV: n=5, partial/no MV: n=4) underwent a period of preoperative inspiratory muscle conditioning exercise. The change in respiratory function after exercise alone was compared to the change in function after intramuscular delivery of AAV1-CMV-GAA to the diaphragm with continued exercise. Since AAV-mediated gene therapy can reach phrenic motoneurons via retrograde transduction, we hypothesized that AAV1-CMV-GAA would improve dynamic respiratory motor function to a greater degree than exercise alone. Dependent measures were maximal inspiratory pressure (MIP), respiratory responses to inspiratory threshold loads (load compensation: LC), and physical evidence of diaphragm activity (descent on MRI, EMG activity). Exercise alone did not change function. After AAV1-CMV-GAA, MIP was unchanged. Flow and volume LC responses increased after dosing (p<0.05 to p<0.005), but only in the subjects with partial/no MV use. Changes in LC tended to occur on or after 180days. At Day 180, the four subjects with MRI evidence of diaphragm descent had greater maximal voluntary ventilation (p<0.05) and tended to be younger, stronger, and use fewer hours of daily MV. In conclusion, combined AAV1-CMV-GAA and exercise training conferred benefits to dynamic motor function of the diaphragm. Children with a higher baseline neuromuscular function may have greater potential for functional gains.
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Affiliation(s)
- Barbara K Smith
- Department of Physical Therapy, P.O. Box 100154, University of Florida, Gainesville, FL 32610, United States; Department of Pediatrics, P.O. Box 100144, University of Florida, Gainesville, FL 32610, United States.
| | - A Daniel Martin
- Department of Physical Therapy, P.O. Box 100154, University of Florida, Gainesville, FL 32610, United States
| | - Lee Ann Lawson
- Department of Pediatrics, P.O. Box 100144, University of Florida, Gainesville, FL 32610, United States
| | - Valerie Vernot
- College of Liberal Arts and Sciences, P.O. Box 117300, University of Florida, Gainesville, FL 32611, United States
| | - Jordan Marcus
- College of Public Health and Health Professions, P.O. Box 100185, University of Florida, Gainesville, FL 21610, United States
| | - Saleem Islam
- Department of Surgery, P.O. Box 100296, University of Florida, Gainesville, FL 32610, United States
| | - Nadeem Shafi
- Department of Pediatrics Critical Care Division, University of Tennessee Health Science Center, 50 N. Dunlap, Memphis, TN 38103, United States
| | - Manuela Corti
- Department of Pediatrics, P.O. Box 100144, University of Florida, Gainesville, FL 32610, United States
| | - Shelley W Collins
- Department of Pediatrics, P.O. Box 100144, University of Florida, Gainesville, FL 32610, United States
| | - Barry J Byrne
- Department of Pediatrics, P.O. Box 100144, University of Florida, Gainesville, FL 32610, United States
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