Beruflich Dokumente
Kultur Dokumente
Critical Care update
Shane Patman
President, International Confederation of Cardiorespiratory Physical Therapists
Associate Professor, School of Physiotherapy
Session outline
• The role of the physiotherapist in the ICU.
• The evidence to support the interventions that physiotherapists
implement with the ICU patient population.
• The evidence regarding which patients benefit, and which patients may
not benefit, from physiotherapy in this setting.
• The evidence regarding the risks of physiotherapy interventions in ICU.
• Best practices for mitigating these risks and safely intervening in this
practice environment.
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Critical care admission = Major life event
Koo, Choong & Fan (2011) Prioritizing rehabilitation strategies in the care of the critically ill. Critical Care Rounds 8(4)
http://www.canadiancriticalcare.org/resources/Pictures/ccroundsv8i4_11.pdf
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Consequences of critical care
Critical care admission = Major life event
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Respiratory physiotherapy in critical care
• Respiratory physiotherapy interventions are generally aimed to facilitate airway clearance,
optimise lung volumes, enhance gas exchange, and reduce work of breathing.
• Techniques may include positioning, manual and ventilator hyperinflation (MHI & VHI),
percussion, vibration, suctioning, respiratory muscle strengthening, breathing exercises and
mobilisation, along with education, weaning from mechanical ventilation and non‐invasive
ventilation.
• Multimodal respiratory physiotherapy treatment as practiced by physiotherapists is considered
safe.
• Insufficient evidence‐based to date to support respiratory physiotherapy as a distinct part of
respiratory care in MV patients
• published studies are all small‐sized, insufficiently powered, conducted in a variety of populations and
utilising different treatments and various clinical endpoints
• not proven to influence relevant ICU outcome parameters
Berney S, Haines K, Denehy L (2012); Spapen HD, De Regt J, Honoré PM (2017)
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Evidence?
• Gosselink, R., Bott, J., Johnson, M., Dean, E., Nava, S., Norrenberg, M., & ... Vincent,
J. L. (2008). Physiotherapy for adult patients with critical illness: recommendations
of the European Respiratory Society and European Society of Intensive Care
Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care
Medicine, 34(7), 1188‐1199. https://doi.org/10.1007/s00134‐008‐1026‐7
• Evidence from randomized controlled trials or meta‐analyses was limited and most of
the recommendations were level C (evidence from uncontrolled or nonrandomized
trials, or from observational studies) and D (expert opinion).
• Stiller, K. (2013). Physiotherapy in intensive care: an updated systematic review.
Chest, 144(3), 825‐847. http://dx.doi.org/10.1378/chest.12‐2930
• The evidence from RCTs evaluating the effectiveness of routine multimodality
respiratory physiotherapy is conflicting
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Respiratory physiotherapy in critical care
• There is reducing focus on the provision of respiratory treatment
unless patients present with atelectasis and/or secretion retention
• May promote better “airway hygiene”
• May provide short term effects on oxygenation and ventilation
• Techniques should not be performed routinely but only if considered
to be appropriate and useful in selected patients.
Berney S, Haines K, Denehy L (2012); Spapen HD, De Regt J, Honoré PM (2017)
Physiotherapy in Critical Care
“Physiotherapy is an important intervention that prevents and mitigates adverse effects of
prolonged bed rest and mechanical ventilation during critical illness.
Rehabilitation delivered by the physiotherapist is tailored to patient needs and depends on
conscious state, psychological status and physical strength.
It incorporates any active and passive therapy that promotes movement and includes
mobilisation.
Early progressive physiotherapy, with a focus on mobility and walking whilst ventilated, is
essential in minimising functional decline.
If this process does not occur within the critical care environment, there are increased costs of
service provision to the health system, as these patients often require extensive periods of
rehabilitation and follow‐up to meet long‐term disability needs as a result of critical illness.”
http://www.csp.org.uk/publications/physiotherapy‐works‐critical‐care
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Benefits of early rehabilitation in ICU
• There is a growing body of evidence to support programmes of early
mobilisation within ICU
• When utilised, early mobility is associated with reduced ICU and hospital length
of stay and improved functional outcomes.
• evidence to show patients do show a response to exercise and can therefore be trained
• shorter duration of delirium
• improved weaning from MV, with more ventilator‐free days
• reduced muscle atrophy
• improved strength and independence with functional ADLs
• The exact definition of early mobility is still not defined, and actual ability to
mobilise can be limited 11
Denehy, L., Lanphere, J. & Needham, D.M. Ten reasons why ICU patients
should be mobilized early. Intensive Care Med (2017) 43: 86.
https://doi.org/10.1007/s00134‐016‐4513‐2
• Attenuates complications of bed rest
• Addresses sequelae of ICU‐acquired weakness
• Perceived barriers are modifiable
• Implementation is feasible
• Promotes reduction of sedation
• It is safe
• Promotes improved functional outcomes with early start
• May improve delirium
• New technologies expand opportunities
• May reduce overall resource utilization
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What is early rehabilitation?
Passive Techniques Active Techniques
• Passive movements / CPM • Exercise therapy
• Stretching • Cycle ergometry
• Splinting • Interactive video games
• Passive cycling • IMT
• NMES (electrical muscle stimulation) • ADL training
• Tilt tabling / moveo • Out of bed / functional mobilisation
https://youtu.be/woofpnw‐u74
See: Sommers, J., Engelbert, R. H., Dettling‐Ihnenfeldt, D., Gosselink, R., Spronk, P. E., Nollet, F., & van der Schaaf, M. (2015).
Physiotherapy in the intensive care unit: an evidence‐based, expert driven, practical statement and rehabilitation
recommendations. Clinical Rehabilitation, 29(11), 1051‐1063. doi:10.1177/0269215514567156 13
Exercise Prescription for critically ill
• Based on functional capability and ability to tolerate activity
• Progressive phases with guidelines:
• positioning
• exercise type
• transfers
• gait retraining
• education
• FITT, SMART considerations / framework
Source: http://i.ytimg.com/vi/TasqmU4yK8w/maxresdefault.jpg
• MDT effort
See also: https://youtu.be/rAEjjcjob‐Y
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Electrical Muscle Stimulation
• very low to low quality evidence of the beneficial effects of EMS delivered in the ICU for
improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy
• Electrical muscle stimulation appears to preserve muscle mass and strength in long‐stay
participants and in those with less acuity. No such benefits were observed when
commenced prior to 7 days or in patients with high acuity.
• Minimal adverse events reported.
• Optimal training variables and safety of the intervention require further investigation.
Connolly, B., O'Neill, B., Salisbury, L., & Blackwood, B. (2016). Physical rehabilitation interventions for adult patients during critical
illness: an overview of systematic reviews. Thorax, 71(10), 881‐890. https://doi.org/10.1136/THORAXJNL‐2015‐208273
Hermans, G., De Jonghe, B., Bruyninckx, F., & Van den Berghe, G. (2014). Interventions for preventing critical illness polyneuropathy
and critical illness myopathy. The Cochrane Database Of Systematic Reviews, (1),
Edwards, J., McWilliams, D., Thomas, M., & Shah, S. (2014). Electrical Muscle Stimulation in the Intensive Care Unit: An Integrative
Review. Journal of the Intensive Care Society, 15(2): 142‐9. https://doi.org/10.1177/175114371401500212
Parry, S. M., Berney, S., Granger, C. L., Koopman, R., El‐Ansary, D., & Denehy, L. (2013). Electrical muscle stimulation in the intensive
care setting: a systematic review. Critical Care Medicine, 41(10), 2406‐2418. https://doi.org/10.1097/CCM.0b013e3182923642
Cycle Ergometry
Kho, M. E., Molloy, A. J., Clarke, F. J., Ajami, D., McCaughan, M., Obrovac, K., & ... Cook, D. J. (2016). TryCYCLE: A
Prospective Study of the Safety and Feasibility of Early In‐Bed Cycling in Mechanically Ventilated Patients.
Plos One, 11(12). https://doi.org/10.1371/journal.pone.0167561
• 30 minutes of in‐bed supine cycling 6 days/week in the ICU
• Cycling termination was infrequent (2.0%, 95% CI: 0.8%‐4.9%) and no device
dislodgements occurred.
• Early cycling within the first 4 days of MV among hemodynamically stable patients is
safe and feasible. Research to evaluate the effect of early cycling on patient
function is warranted.
Kho ME, Molloy AJ, Clarke F, et al. CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry
versus routine physiotherapy in mechanically ventilated patients. BMJ Open 2016;6:e011659.
https://doi.org/10.1136/bmjopen‐2016‐011659
Nickels, M. R., Aitken, L. M., Walsham, J., Barnett, A. G., & McPhail, S. M. (2017). Critical Care Cycling Study
(CYCLIST) trial protocol: a randomised controlled trial of usual care plus additional in‐bed cycling sessions
versus usual care in the critically ill. BMJ Open, 7(10), e017393. https://doi.org/10.1136/bmjopen‐2017‐017393
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Cycle Ergometry
https://www.worldnewsmd.com/Video/Physical%20Therapy/
7News‐‐‐Sleep‐cycle‐helping‐patients
Ambrosino et al Rev Port Pneumol. 2011;17(6):283‐288
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Inspiratory Muscle Training
• Inspiratory muscle training for selected patients in the ICU facilitates weaning,
with potential reductions in length of stay and the duration of non‐invasive
ventilatory support after extubation.
• The heterogeneity among the results suggests that the effects of IMT may
vary; this perhaps depends on factors such as the components of usual care or
the patient's characteristics.
Elkins, M., & Dentice, R. (2015). Inspiratory muscle training facilitates weaning from
mechanical ventilation among patients in the intensive care unit: a systematic review. Journal
of Physiotherapy, 61(3), 125‐134 http://dx.doi.org/10.1016/j.jphys.2015.05.016
Rehabilitation activities
– linking research to practice
Lai, Chih‐Cheng et al (2017). Early mobilization reduces duration of mechanical
ventilation and intensive care unit stay in patients with acute respiratory
failure. Arch Phys Med Rehab 98(5): 931‐939. http://dx.doi.org/10.1016/j.apmr.2016.11.007
• MDT protocol, within 72 hrs of MV & CVS stable
• 4 levels of the protocol: level 1 ‐ passive extremities movement; level 2 ‐active
extremities movement; level 3 ‐ a sitting position on the bed; and level 4 ‐ move from
the bed to a chair beside the bed.
• twice daily, 5 days/wk during family visit, 30 minutes each
• shorter MV durations (4.7d vs 7.5d; P<.001)
• shorter ICU stays (6.9d vs 9.9d; P=.001)
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Lai et al (2017). Arch Phys Med Rehab. 98(5): 931–939
What is the latest evidence saying?
Tipping C et al (2017) The effects of active mobilisation and rehabilitation in ICU
on mortality and function: a systematic review. Intensive Care Med 43:171–183
https://doi.org/10.1007/s00134‐016‐4612‐0
• Active mobilisation and rehabilitation in the ICU has no impact on short‐ and
long‐term mortality, but may improve mobility status, muscle strength and days
alive and out of hospital to 180 days.
• There were no consistent effects on function, QoL, ICU or hospital length of
stay, duration of MV, or discharge destination
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Early Rehabilitation ‐ Safety
Hodgson, C. L., Stiller, K., Needham, D. M., Tipping, C. J., Harrold, M., Baldwin, C.
E., ... & Green, M. (2014). Expert consensus and recommendations on safety
criteria for active mobilization of mechanically ventilated critically ill
adults. Critical Care, 18(6), 658. https://doi.org/10.1186/s13054‐014‐0658‐y
http://ccforum.com/content/18/6/658
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Nydahl P et al (2017). Safety of Patient Mobilization and
Rehabilitation in the ICU: Systematic Review with Meta‐Analysis.
Annals ATS 14(5): 766‐777. https://doi.org/10.1513/AnnalsATS.201611‐843SR
• 48 studies of 7546 patients, with 583 potential safety events occurring in 22,351
mobilization/rehabilitation sessions.
• Total of 583 (2.6%) potential safety events, with heterogeneity in the definitions for these
events
• pooled incidences per 1,000 mobilization/rehabilitation sessions (95% CI)
• hemodynamic changes, 3.8 (1.3–11.4)
• desaturation, 1.9 (0.9–4.3)
• Consequences (e.g. needing to increase dose of vasopressor due to mobility‐related hypotension):
• a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions
• Patient mobilization and physical rehabilitation in the ICU appears safe with a low incidence of
potential safety events, and only rare events having any consequences for patient
management.
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Boyd, J., Paratz, J., Tronstad, O., Caruana, L., McCormack, P., & Walsh, J. (2017).
When is it safe to exercise mechanically ventilated patients in the intensive care
unit? An evaluation of consensus recommendations in a cardiothoracic setting.
Heart & Lung: The Journal Of Critical Care, http://dx.doi.org/10.1016/j.hrtlng.2017.11.006
• 91 mechanically ventilated participants; 54 (59.3%) male; mean age of
56.52 (16.3) years; were studied with 809 occasions of service recorded.
• Ten (0.0182%) minor adverse events were recorded, with only one adverse
event occurring when a patient was receiving moderate level of vasoactive
support.
Conclusions: The consensus recommendations are a useful tool in guiding
safe exercise rehabilitation of mechanically ventilated patients. Our findings
suggest that there is further scope to safely commence exercise rehabilitation
in patients receiving vasoactive support.
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Early mobilisation in ICU is far more than just
exercise
• The critical care environment presents many challenges and opportunities in linking
research to practice
• early mobilisation in the ICU is a complex intervention demanding interdisciplinary
coordination and communication.
• much of the physiotherapists’ time goes into preparing patients for physiotherapy
• prevention’s goal is the modest retention of function, rather than ambitious rebuilding
in patients who have already lost some functioning abilities.
But which patients to target? Which prescription? What is success?
Iwashyna, T. J., & Hodgson, C. L. (2016). Early mobilisation in ICU is far more than just exercise. Lancet (London,
England), 388(10052), 1351‐1352. http://dx.doi.org/10.1016/S0140-6736(16)31745-7 27
Interventions for management of ICU‐AW, with
associated levels of evidence.
Source: Hodgson C, Tipping C Physiotherapy management of intensive care unit‐acquired weakness Journal of Physiotherapy, Volume 63, Issue 1, 2017, 4–10
http://dx.doi.org/10.1016/j.jphys.2016.10.011 28
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Bakhru, R. N., McWilliams, D. J., Wiebe, D. J., Spuhler, V. J., & Schweickert, W. D. (2016).
Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An
International Survey.
Annals Of The American Thoracic Society, 13(9), 1527‐1537. https://doi.org/10.1513/AnnalsATS.201601‐078OC
• International ICU structure and practice is quite heterogeneous, and several
factors (multidisciplinary rounds, setting daily goals for patients, presence of a
dedicated physiotherapist, country, and nurse/patient staffing ratio) are
significantly associated with the practice of early mobility.
• Practice and barriers may be far different based upon staffing structure.
• To achieve successful implementation, whether through trials or quality
improvement, ICU staffing and practice patterns must be taken into account.
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Bear, D. E., Parry, S. M., & Puthucheary, Z. A. (2017). Can the critically ill patient
generate sufficient energy to facilitate exercise in the ICU?. Current Opinion In
Clinical Nutrition And Metabolic Care, https://doi.org/10.1097/MCO.0000000000000446
• The metabolic demands of exercise are poorly understood in the ICU setting.
• Recent research has highlighted that there is significant heterogeneity in energy
requirements between critically ill individuals undertaking the same functional
activities, such as sit‐to‐stand.
• Nutrition in the critically ill is currently thought of in terms of carbohydrates, fat
and protein. It may be that we need to consider nutrition in a more contextual
manner such as energy generation or management of protein homeostasis.
• Current nutritional support practices in critically ill patients do not lead to
improvements in physical and functional outcomes, and it may be that alternative
methods of delivery or substrates are needed
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Roberson, A. R., Starkweather, A., Grossman, C., Acevedo, E., & Salyer, J.
(2018). Influence of muscle strength on early mobility in critically ill adult
patients: Systematic literature review. Heart & Lung: The Journal Of
Critical Care, 47(1), 1‐9. https://doi.org/10.1016/j.hrtlng.2017.10.003
Physical Function Assessment Tools
• ICU Mobility Scale (IMS)
• Chelsea Critical Care Physical Assessment tool (CPAx)
• Physical Function ICU Test (Scored) (PFIT‐s)
• Functional Status Score for the Intensive Care Unit (FSS‐ICU)
• de Morton Mobility Index (DEMMI)
• Perme ICU Mobility Score
• Surgical Intensive Care Unit Optimal Mobilization Score (SOMS)
• Acute Care Index of Function (ACIF)
• Short Physical Performance Battery (SPPB) Summary information about many of these
• Functional Capacity Scale (FCS) instruments (including how to access and use
them) is available:
• Early Functional Abilities Scale (EFA) http://www.improvelto.com/
• Functional Independence Measure (FIM) and/or Parry et al. Critical Care (2017) 21:249
• Barthel Index https://doi.org/10.1186/s13054‐017‐1827‐6 32
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Crit Care (2017); 21:249 http://dx.doi.org/10.1186/s13054‐017‐1827‐6
• The evaluation of physical functioning is valuable in the ICU to help inform patient
recovery after critical illness, to identify patients who may require rehabilitation
interventions, and to monitor responsiveness to such interventions.
• This viewpoint article discusses:
1. the concept of physical functioning with reference to the WHO International
Classification of Functioning, Disability and Health;
2. the importance of measuring physical functioning in the ICU; and
3. methods for evaluating physical functioning in the ICU.
• Recommendations for clinical practice and research are made, along with discussion
of future directions.
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Recommendations
• Screening for mental capacity should commence from ICU admission and include
assessments of pain, sedation, and delirium status.
• Regular screening for muscle weakness using the Medical Research Council sum‐
score recommend .
• Identification of patients who need evaluation of physical functioning in the ICU
is largely reliant on clinical judgment regarding many potential risk factors.
• Once the patient can follow commands, at a minimum, use of one of four
physical functioning tools is recommended:
1. Physical Functional in ICU Test‐scored;
2. Chelsea Critical Care Physical Assessment Tool;
3. Functional Status Score for the ICU; and
4. ICU Mobility scale.
Parry, Huang & Needham 2017 34
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ICU Mobility Scale (IMS)
Heart & Lung 43 (2014) 19e24
Classification Definition https://doi.org/10.1016/j.hrtlng.2013.11.003
0 Nothing (lying in bed) Passively rolled or passively exercised by staff, but not actively moving
Any activity in bed, including rolling, bridging, active exercises, cycle ergometry and active assisted
1 Sitting in bed, exercises in bed
exercises; not moving out of bed or over the edge of the bed
2 Passively moved to chair (no standing) Hoist, passive lift or slide transfer to the chair, with no standing or sitting on the edge of the bed
3 Sitting over edge of bed May be assisted by staff, but involves actively sitting over the side of the bed with some trunk control
Weight bearing through the feet in the standing position, with or without assistance. This may include
4 Standing
use of a standing lifter device or tilt table.
Able to step or shuffle through standing to the chair. This involves actively transferring weight from
one leg to another to move to the chair. If the patient has been stood with the assistance of a
5 Transferring bed to chair
medical device, they must step to the chair (not included if the patient is wheeled in a standing lifter
device.)
Able to walk on the spot by lifting alternate feet (must be able to step at least 4 times, twice on each
6 Marching on spot (at bedside)
foot), with or without assistance
7 Walking with assistance of 2 or more people Walking away from the bed/chair by at least 5 metres (5 yards) assisted by 2 or more people
8 Walking with assistance of 1 person Walking away from the bed/chair by at least 5 metres (5 yards) assisted by 1 person
Walking away from the bed/chair by at least 5 metres (5 yards) with a gait aid, but no assistance
9 Walking independently with a gait aid from another person. In a wheelchair bound person, this activity level includes wheeling the chair
independently 5 metres (5 years) away from the bed/chair
Walking away from the bed/chair by at least 5 metres (5 yards) without a gait aid or assistance from
10 Walking independently without a gait aid 35
another person.
Corner E et al (2014) Critical Care. 18:R55
https://doi.org/10.1186/cc13801
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Chelsea Critical Care Physical Assessment tool (CPAx)
Chelsea Critical Care Physical Assessment tool (CPAx)
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Physical Function ICU Test (Scored) (PFIT‐s)
(Sit to stand)
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Functional Status Score for the Intensive Care Unit
(FSS‐ICU)
• Specifically designed for use in ICU, FSS‐ICU uses a scoring system based on the validated
Functional Independence Measurement (FIM)
• This scoring system rates a functional activity between 1 (total assist) and 7 (complete
independence).
Zanni JM, Korupolu R, Fan E, et al: Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project.
J Crit Care. 2010;25(2):254‐262 http://dx.doi.org/10.1016/j.jcrc.2009.10.010
• Patients receiving therapy at a long‐term acute care hospital demonstrate significant
improvements from admission to discharge using the FSS‐ICU. This outcome tool
discriminates between discharge settings and successfully documents functional
improvements of patients in an LTACH setting.
Thrush A, Rozek M, Dekerlegand JL. (2012). The Clinical Utility of the Functional Status Score for the Intensive Care Unit (FSS‐ICU)
at a Long‐Term Acute Care Hospital: A Prospective Cohort Study Physical Therapy, 92(12), 1536‐1545. https://doi.org/10.2522/ptj.20110412 40
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FSS‐ICU
The FSS‐ICU consists of five categories:
• rolling 0 = unable to perform
• supine to sit transfers 1 = total assistance
• unsupported sitting 2 = maximum assistance
• sit to stand transfers 3 = moderate assistance
• ambulation
4 = minimal assistance
Each category was rated from zero to
5 = supervision
seven with a maximum cumulative FSS‐
ICU score of 35. 6 = moderate independence
7 = complete independence
However,… Point prevalence data
Australia & New Zealand USA (across 2 days; acute resp failure)
• 18% of patients walked • 32% mobility (PT/OT provided)
• 23% of pts in ICU for ≥7 days ‐ not • Non‐MV 48% vs MV 26%
SOEOB or walked • 16% on MV achieved out of bed
Jolley et al 2017
• 30% of patients with 02 therapy walked
Berney et al 2013
Switzerland (45% all ICUs)
Germany
• 33% on MV were actively mobilized
• 24% of patients mobilised out of bed
• 2% on MV walked
• 8% on MV were mobilised • 20% potential safety events (nsd passive vs.
• 4% stood, marched or walked active)
Nydahl et al 2014 Sibilla et al 2017
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Connolly, B. A., Mortimore, J. L., Douiri, A., Rose, J. W., Hart, N., & Berney,
S. C. (2017). Low Levels of Physical Activity During Critical Illness and
Weaning: The Evidence‐Reality Gap. Journal Of Intensive Care Medicine,
https://doi.org/10.1177/0885066617716377
• between 08:30am – 08:00pm, ICU patients spent a median (IQR) of 100% (96%‐
100%) of the day (10.5 [10.0‐10.5] hours) located in bed, with minimal/no
activity for 99% (96%‐100%) of the day.
• spent approximately two‐thirds of the day alone
• all physical activities occurred during physical rehabilitation sessions
• highlight the need for targeted strategies to improve levels beyond therapeutic
rehabilitation and support for a culture shift toward providing patients with, and
engaging them in, a multidisciplinary, multiprofessional environment that
optimizes overall physical activity.
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Parry, S. M., Knight, L. D., Connolly, B., Baldwin, C., Puthucheary, Z., Morris, P.,
& ... Granger, C. L. (2017). Factors influencing physical activity and
rehabilitation in survivors of critical illness: a systematic review of quantitative
and qualitative studies. Intensive Care Medicine, 43(4), 531‐542.
• The main barriers identified were patient physical and psychological capability
to perform physical activity, safety concerns, lack of leadership and ICU culture
of mobility, lack of interprofessional communication, expertise and knowledge,
and lack of staffing/equipment and funding to provide rehabilitation programs.
• Barriers and enablers are multidimensional and span diverse factors. The
majority of these barriers are modifiable and can be targeted in future clinical
practice.
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Journal of Critical Care (2015); 30:242‐9
http://dx.doi.org/10.1016/j.jcrc.2014.10.017
Need for continuity of care throughout continuum
• Informational needs change at different time points: Be specific
• Fear and worry persists when families do not know what to expect: more work is needed
from Phase 3
• Care givers need support to facilitate patient transition from dependence to
independence: up to 2 years after survival. Continued follow up – structured rehab
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Azoulay, E., Vincent, J., Angus, D. C., Arabi, Y. M., Brochard, L., Brett, S. J., &
... Herridge, M. (2017). Recovery after critical illness: putting the puzzle
together‐a consensus of 29. Critical Care (London, England), 21(1), 296.
https://doi.org/10.1186/s13054‐017‐1887‐7
• highlights how critical illness and critical care affect longer‐term outcomes,
• underlines the contribution of ICU delirium to cognitive dysfunction several
months after ICU discharge,
• gives new insights into ICU acquired weakness,
• emphasizes the importance of value‐based healthcare, and
• delineates the elements of family‐centered care.
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Physiotherapy in Critical Care update
Take‐home messages:
• Routine or prophylactic respiratory physiotherapy unsupported by literature
• Rehabilitation must be commenced within 3 days of ICU admission
• early mobility in patients diagnosed with sepsis may be an exception to this
• IMT during MV has benefit
• Early mobilisation in ICU is far more than just exercise
• Choice of Physical Function Assessment Tool important
• need to consider psychometric properties, utility of measure across continuum of care, & feasibility
throughout all phases of recovery (based on your casemix)
• Expertise, multidisciplinary teamwork, leadership and workplace culture are key
considerations
• There are many unanswered questions and therefore opportunities for collaborative
research efforts
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Conclusion
• Physiotherapy should be considered
a cornerstone in the comprehensive
management of critical ill patients
and, when applied early, may
benefit patients and prevent some
ICU complications.
• Modalities and devices for each
patient depend on disease severity,
comorbidities, and patient
cooperation.
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Questions?
• Presenter contact details:
Shane Patman
Associate Professor, School of Physiotherapy
The University of Notre Dame Australia
19 Mouat Street (PO Box 1225)
Fremantle WA 6959
Australia
shane.patman@nd.edu.au
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