Functional Outcome of Mechanically Ventilated Patients Recovering - - PowerPoint PPT Presentation

C L I N I C A L P R O B L E M S O L V I N G I B Y O L I V I A S H U C K

Functional Outcome of Mechanically Ventilated Patients Recovering from Acute Respiratory Failure

Meet Patient “A”

— 77 y/o male — Single, 3 Daughters — SNF since May 2013 — Prior Level of

Function

— Admitting Diagnosis:

¡ Hypothermia and AMS.

— After Admission:

¡ C. Difficile ¡ Hypercapnic Respiratory

Failure

— Additional Co-

morbidities:

— Hypertension, Obesity,

Peripheral Edema, Acquired Factor VIII, Spinal Stenosis & Depression.

— No PT while in ICU/

MRICU

Timeline of Hospitalization

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

Acute Respiratory Failure

— What is it? — Causes — Who is at risk? — Signs and Symptoms — Diagnosis — Treatment: Mechanical

Ventilation

— Short-term and long-

term effects

Chest radiograph of a patient on admission to ICU (Wong 2000)

Initial Examination

— Cognition: Safety intact, able to follow 2 step commands, however was not

• riented to time.

— Sensation: SILT however diminished on dorsal aspect of L foot. — ROM: WFL

¡ Exception: Bilateral shoulder flexion and plantarflexion

— MMT: Only 3/5 in elbow flexion/extension

Left MMT Right MMT Shoulder flexion 2+/5 2+/5 Grip Strength 2/5 2/5 Hip flexion (ext- NT) 2+/5 2+/5 Knee flexion/ extension 2+/5 2+/5 DF/PF 1/5 1/5

Initial Evaluation Continued

— Pain: 0/10 throughout session — Activity tolerance — Functional Mobility:

¡ Maintain sidelying with UE support on bedrail with CGA ¡ Eccentric rolling from sidelying to supine w/o assist ¡ Roll L/R with max A x 2 ¡ Transferred with a maxi mover to bedside chair ¡ Poor static sitting balance ¡ VS: normal and breathing on 2 L nasal cannula

Evaluation Findings

— Impairments: Reduced muscle strength, reduced

AROM, reduced PROM, loss of sensation in L foot, & decreased static balance

— Functional Limitations: Unable to walk, unable

to transfer independently, & altered ability to sit

— Disability: Unable to return home, unable to work,

& unable to be independent with ADLs

Prognosis

(+)

— Patient no longer

dependent on mechanical ventilation

— Family support — Activity tolerance/

endurance

— Delirium improving

(-)

— Prior Level of function — PMH — # of Co-morbidities — Patient’s age — Fall risk — Long period of

immobilization during ventilation period

Treatment and Goals

— Patient Goals: To walk — Exam Strategy:

¡ Increase the patient’s

strength, specifically in the LE’s.

¡ Increase ROM of shoulder

flexion so patient can do some ADL’s (eating, partial dressing, etc).

¡ Discharge to inpatient

rehab or to home with 24 assist and HHPT

— Treatment Goals:

¡ Will roll L/R with mod A x

2

¡ Supine-sit with max A x 2 ¡ Static sitting EOB x 5 min

with min A x 2

¡ Sit-stand with max A x 2

Intervention

— Initial Exercises:

¡ Scapular retractions ¡ Shoulder shrugs ¡ Hip adduction/pillow

squeeze

¡ Ankle pumps ¡ Heel slides ¡ Maintaining sidelying

position with UE on bedrail with CGA

— Progressed to:

¡ Static sitting EOB with self

correction for posture

¡ Multidirectional weight

shifting and reaching

¡ Sitting EOB: AROM LAQ,

glut sets, hip flexion, dorsiflexion, and plantarflexion exercises

Goals Met Before Discharge

¡ MET

÷ Supine-sit with max A x 2 ÷ Static sitting EOB x 5 min with min A x 2 ÷ Sit-stand with max A x 2

¡ Not met but progressing

÷ Will roll L/R with mod A x 2

¡ Able to perform more ADLs ¡ Discharge Plans

÷ Inpatient PT

Clinical Question

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

Early Activity is Feasible and Safe in Respiratory Failure Patients

— Purpose: To determine whether early physical

activity was feasible and safe in respiratory failure patients.

— Prospective Cohort Study — N = 103 — Inclusion: Respiratory Failure, Mechanical

Ventilation > 4 days

— Exclusion: Mechanical Ventilation 4 days or less

Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139-145. — Methods

¡ Mechanically ventilated patients ¡ Early activity protocol ¡ Goal: Ambulate >100 feet before RICU discharge ¡ Three Activity events: sit EOB w/o support, sit in a chair

after transfer from bed-chair and ambulate with or w/o support from staff.

¡ Six activity-related adverse events ¡ Twice daily sessions

Results

Activity Level in Survivors on the Last Full Day of RICU Admission

Activity Total Group (n = 85) Age <65 yrs (n=49) Age ≥65 yrs (n = 36) No activity 2 2 Sit on bed 4 2 2 Sit in chair 13 5 8 Ambulate ≤100 feet 7 6 1 Ambulate >1oo feet 59 36 23

Results Continued

2 4 6 8 10 12 14 16 18 1 2 3 4 5 6

Number of Comorbidities

Initial ICU Admission to Ambulation (days)

Strengths and Weaknesses

— Strengths:

¡ High rates of activity

participation

¡ Goals for study met:

Number of patients ambulating >100 feet before RICU discharge

— Weaknesses

¡ Lack of objective data (e.g.

muscle strength).

¡ Lack of knowledge

regarding longitudinal effects of early PT intervention.

¡ No control group

Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit

— Purpose: Whether physical activity and mobility

initiated during ICU treatment were maintained after patients were transferred from the ICU to a ward

— Prospective Cohort Study — N= 72 — Inclusion: Respiratory Failure, RICU stay >2

days, transfer to a ward and ward stay >2 days.

— Exclusion: open abdomen, neurologic disease (stroke

• r paralysis) and terminal illness

Hopkins RO, Miller RR, Rodriguez L, et al. Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit. PHYS THER. 2012; 92:1518-1523.

— Methods:

¡ 300 consecutive

mechanically ventilated patients

¡ Early physical activity and

mobility

¡ Goal: Ambulate >100 feet ¡ Activity events: AROM,

PROM, sitting EOB w/o support, transferring from bed-chair and ambulation

¡ Twice daily sessions

300 Patients screened 72 patients in Study Cohort 228 Patients not eligible

Results

5 10 15 20 25 30 35 40 45 Decreased Same Increased

Change in Activity Level from Last RICU Day to First Ward Day

Number of Patients

Results Continued

2 4 6 8 10 12 14 16 18 20 No ambulation Ambulate <100 feet Ambulate >100 feet

No consultation Nursing Assistance with Ambulation PT Consultation

Number of Patients

Activity Level

Conclusion of Study

— Decrease in activity upon transfer – Why?

¡ Fatigue ¡ Patient refusal ¡ Patient to staff ratio ¡ Communication ¡ ICU vs ward staff ¡ Patient load

— Possible Solution

Strength and Weaknesses

— Limitations:

¡ Lack of data

regarding activity

¡ Lack of

longitudinal follow-up

¡ Lack of controls

— Strengths:

¡ Comparing

patients to themselves

Conclusion

— Early activity in patients with Respiratory Failure

appears to be safe but is it beneficial?

— Patient “A” — In the future..

¡ Longitudinal studies ¡ Studies with control groups

Questions?

References

— Bailey P, Thomsen GE, Spuhler VJ, et al. Early

activity is feasible and safe in respiratory failure

• patients. Crit Care Med. 2007;35:139-145.

— Hopkins RO, Miller RR, Rodriguez L, et al.

Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care

• Unit. PHYS THER. 2012; 92:1518-1523.

— Wong WP. Physical Therapy for a Patient in Acute

Respiratory Failure. PHYS THER. 2000; 80:662-670.