Carolina Fu

Very Early Passive Cycling Exercise in Mechanically Ventilated Critically Ill Patients: Physiological and Safety Aspects - A Case Series

Introduction Early mobilization can be performed in critically ill patients and improves outcomes. A daily cycling exercise started from day 5 after ICU admission is feasible and can enhance functional capacity after hospital discharge. In the present study we verified the physiological changes and safety of an earlier cycling intervention (< 72 hrs of mechanical ventilation) in critical ill patients. Methods Nineteen hemodynamically stable and deeply sedated patients within the first 72 hrs of mechanical ventilation were enrolled in a single 20 minute passive leg cycling exercise using an electric cycle ergometer. A minute-by-minute evaluation of hemodynamic, respiratory and metabolic variables was undertaken before, during and after the exercise. Analyzed variables included the following: cardiac output, systemic vascular resistance, central venous blood oxygen saturation, respiratory rate and tidal volume, oxygen consumption, carbon dioxide production and blood lactate levels. Results We enrolled 19 patients (42% male, age 55±17 years, SOFA = 6 ± 3, SAPS3 score = 58 ± 13, PaO2/FIO2 = 223±75). The median time of mechanical ventilation was 1 day (02), and 68% (n=13) of our patients required norepinephrine (maximum concentration = 0.47 µg.kg -1.min-1). There were no clinically relevant changes in any of the analyzed variables during the exercise, and two minor adverse events unrelated to hemodynamic instability were observed. Conclusions In our study, this very early passive cycling exercise in sedated, critically ill, mechanically ventilated patients was considered safe and was not associated with significant alterations in hemodynamic, respiratory or metabolic variables even in those requiring vasoactive agents.

Misalignment of the knees: Does it affect human stance stability

INTRODUCTION Data describing the relationships between postural alignment and stance stability are scarce and controversial. OBJECTIVE The aim of this study was to evaluate the effects of sensory disturbances on knee alignment in upright stance and the effects of knee hyperextension on stance stability. METHOD Kinetic and kinematic data of 23 healthy adult women were collected while quietly standing in four sensory conditions. Kinematic data: knee angle (dependent variables) variations were analyzed across sensory conditions. Kinetic data: as subjects with hyperextended knees showed a clear tendency to flex their knees as balance challenge increased, center of pressure (COP) parameters (dependent variables) were analyzed in each sensory condition among trial sub-groups: Aligned-Trials (knee angle<180°), Hyperextended-Trials (>180°) and Adjusted-Trials (>180° initially, turned <180° under challenging conditions). RESULTS Differences were found in mean velocity of COP in two conditions showing that knee alignment can affect stance stability. CONCLUSION Knee hyperextension is a transient condition changing under postural challenges. Knee hyperextension affected postural control as mean velocity was the highest in the hyperextended group in natural standing sensory condition and lowest with sensory disturbance.

Can quiet standing posture predict compensatory postural adjustment

OBJECTIVE The aim of this study was to analyze whether quiet standing posture is related to compensatory postural adjustment. INTRODUCTION The latest data in clinical practice suggests that static posture may play a significant role in musculoskeletal function, even in dynamic activities. However, no evidence exists regarding whether static posture during quiet standing is related to postural adjustment. METHODS Twenty healthy participants standing on a movable surface underwent unexpected, standardized backward and forward postural perturbations while kinematic data were acquired; ankle, knee, pelvis and trunk positions were then calculated. An initial and a final video frame representing quiet standing posture and the end of the postural perturbation were selected in such a way that postural adjustments had occurred between these frames. The positions of the body segments were calculated in these initial and final frames, together with the displacement of body segments during postural adjustments between the initial and final frames. The relationship between the positions of body segments in the initial and final frames and their displacements over this time period was analyzed using multiple regressions with a significance level of p ≤ 0.05. RESULTS We failed to identify a relationship between the position of the body segments in the initial and final frames and the associated displacement of the body segments. DISCUSSION The motion pattern during compensatory postural adjustment is not related to quiet standing posture or to the final posture of compensatory postural adjustment. This fact should be considered when treating balance disturbances and musculoskeletal abnormalities. CONCLUSION Static posture cannot predict how body segments will behave during compensatory postural adjustment.

Effect of hemodialysis on intra-abdominal pressure

OBJECTIVE To study the effect of hemodialysis on intra-abdominal pressure. METHODS Five patients admitted between July and November of 2003 were evaluated in the intensive care unit. Intra-abdominal pressure was measured before and after hemodialysis, maintaining the ventilatory parameters except for PEEP (positive-end expiratory pressure). RESULTS Intra-abdominal pressure was significantly reduced by hemodialysis in all the 5 patients. CONCLUSION Hemodialysis significantly reduced intra-abdominal pressure in the 5 patients, an effect which could have influence over other organic systems. This reduction is related to the weight variation before and after hemodialysis, as well as to the loss of volume caused by this procedure.

Noninvasive positive-pressure ventilation in clinical practice at a large university-affiliated Brazilian hospital.

OBJECTIVES: To describe noninvasive positive-pressure ventilation use in intensive care unit clinical practice, factors associated with NPPV failure and the associated prognosis. METHODS: A prospective cohort study. RESULTS: Medical disorders (59%) and elective surgery (21%) were the main causes for admission to the intensive care unit. The main indications for the initiation of noninvasive positive-pressure ventilation were the following: post-extubation, acute respiratory failure and use as an adjunctive technique to chest physiotherapy. The noninvasive positive-pressure ventilation failure group was older and had a higher Simplified Acute Physiology Score II score. The noninvasive positive-pressure ventilation failure rate was 35%. The main reasons for intubation were acute respiratory failure (55%) and a decreased level of consciousness (20%). The noninvasive positive-pressure ventilation failure group presented a shorter period of noninvasive positive-pressure ventilation use than the successful group [three (2-5) versus four (3-7) days]; they had lower levels of pH, HCO3 and base excess, and the FiO2 level was higher. These patients also presented lower PaO2:FiO2 ratios; on the last day of support, the inspiratory positive airway pressure and expiratory positive airway pressure were higher. The failure group also had a longer average duration of stay in the intensive care unit [17 (10-26) days vs. 8 (5-14) days], as well as a higher mortality rate (9 vs. 51%). There was an association between failure and mortality, which had an odds ratio (95% CI) of 10.6 (5.93 – 19.07). The multiple logistic regression analysis using noninvasive positive pressure ventilation failure as a dependent variable found that treatment tended to fail in patients with a Simplified Acute Physiology Score II≥34, an inspiratory positive airway pressure level≥15 cmH2O and pH<7.40. CONCLUSION: The indications for noninvasive positive-pressure ventilation were quite varied. The failure group had a longer intensive care unit stay and higher mortality. Simplified Acute Physiology Score II≥34, pH<7.40 and higher inspiratory positive airway pressure levels were associated with failure.

The clinical relevance of timed motor performance in children with Duchenne muscular dystrophy

Abstract Background: The measurement of time and compensatory movements for functional tasks is not frequently used to evaluate children with Duchenne muscular dystrophy (DMD). As muscle weakness progresses, new synergies (compensatory movements) are selected to perform the tasks, demanding higher times. Objectives: The present study aimed to describe the timed motor performance of rising from the floor to standing, sitting down on the floor from standing, climbing up four steps and climbing down four steps 18 and 6 months prior to gait loss and to investigate possible relationships between these timed performances, the compensatory movements and the Vignos Scale (VS) scores. Method: Fourteen children with DMD (mean age: 9.6) were videotaped performing the tasks. Spearman correlation tests investigated the relationships between the times, compensatory movements (scored by FES-DMD) and VS. Results: The timed performance and the compensatory movements for rising from the floor, climbing up and climbing down steps varied broadly and were correlated to each other among patients with DMD at 18 and 6 months prior to gait loss. The relationship was not found for sitting on the floor. The timed performance and compensatory movements for climbing up and down steps also correlated to the VS. Conclusion: Rising from the floor, climbing up, and climbing down steps have some components in common, such as the demand for muscle strength and the recruitment of compensatory muscle synergies, as DMD progresses. To sit down on the floor, some children let themselves fall, resulting in a faster performance, but more compensatory movements.

Ventilação não invasiva com pressão positiva pós-extubação: características e desfechos na prática clínica.

Objective To describe postextubation noninvasive positive pressure ventilation use in intensive care unit clinical practice and to identify factors associated with noninvasive positive pressure ventilation failure. Methods This prospective cohort study included patients aged ≥ 18 years consecutively admitted to the intensive care unit who required noninvasive positive pressure ventilation within 48 hours of extubation. The primary outcome was noninvasive positive pressure ventilation failure. Results We included 174 patients in the study. The overall noninvasive positive pressure ventilation use rate was 15%. Among the patients who used noninvasive positive pressure ventilation, 44% used it after extubation. The failure rate of noninvasive positive pressure ventilation was 34%. The overall mean ± SD age was 56 ± 18 years, and 55% of participants were male. Demographics; baseline pH, PaCO2 and HCO3; and type of equipment used were similar between groups. All of the noninvasive positive pressure ventilation final parameters were higher in the noninvasive positive pressure ventilation failure group [inspiratory positive airway pressure: 15.0 versus 13.7cmH2O (p = 0.015), expiratory positive airway pressure: 10.0 versus 8.9cmH2O (p = 0.027), and FiO2: 41 versus 33% (p = 0.014)]. The mean intensive care unit length of stay was longer (24 versus 13 days), p < 0.001, and the intensive care unit mortality rate was higher (55 versus 10%), p < 0.001 in the noninvasive positive pressure ventilation failure group. After fitting, the logistic regression model allowed us to state that patients with inspiratory positive airway pressure ≥ 13.5cmH2O on the last day of noninvasive positive pressure ventilation support are three times more likely to experience noninvasive positive pressure ventilation failure compared with individuals with inspiratory positive airway pressure < 13.5 (OR = 3.02, 95%CI = 1.01 - 10.52, p value = 0.040). Conclusion The noninvasive positive pressure ventilation failure group had a longer intensive care unit length of stay and a higher mortality rate. Logistic regression analysis identified that patients with inspiratory positive airway pressure ≥ 13.5cmH2O on the last day of noninvasive positive pressure ventilation support are three times more likely to experience noninvasive positive pressure ventilation failure.

The effects of recruitment maneuver during noninvasive ventilation after coronary bypass grafting: A randomized trial

Objective: Pulmonary impairment is a common complication after coronary artery bypass graft procedure and may be prevented or treated by noninvasive ventilation. Recruitment maneuvers include sustained airway pressure with high levels of positive end‐expiratory pressure in patients with hypoxemia, favoring homogeneous pulmonary ventilation and oxygenation. This study aimed to evaluate whether noninvasive ventilation with recruitment maneuver could safely improve oxygenation in patients with atelectasis and hypoxemia who underwent a coronary artery bypass grafting procedure. Methods: Thirty‐four patients admitted to our intensive care unit undergoing mechanical ventilation after surgery, with ratio of arterial oxygen partial pressure to fraction of inspired oxygen < 300 and radiologic atelectasis score ≥2, were included. The control group consisted of 16 randomized patients and the recruitment group consisted of 18 patients. After extubation, noninvasive ventilation was applied for 30 minutes 3 times a day with positive end‐expiratory pressure of 8 cm H2O. The recruitment group received recruitment maneuver with positive end‐expiratory pressure of 15 cm H2O and 20 cm H2O for 2 minutes each during noninvasive ventilation. We analyzed the arterial oxygen partial pressure in room air, radiologic atelectasis score, hemodynamic stability, and adverse events from extubation until discharge. Results: Arterial oxygen partial pressure increased 12.6% ± 6.8% in the control group and 23.3% ± 8.5% in the recruitment group (P < .001). The radiologic atelectasis score was completely improved for 94.4% of the recruitment group with no adverse events, whereas 87.5% of the control group presented some atelectasis (P < .001). Conclusions: Noninvasive ventilation with recruitment maneuvers is safe, improves oxygenation, and reduces atelectasis in patients undergoing coronary artery bypass.

Progressive mobility program and technology to increase the level of physical activity and its benefits in respiratory, muscular system, and functionality of ICU patients: study protocol for a randomized controlled trial

BackgroundEnhanced mobility in the Intensive Care Unit (ICU) could minimize the negative effects of critical illness, such as declines in cognitive, muscular, respiratory, and functional capacity. We aim to compare the functional status at ICU discharge of patients who underwent a progressive mobilization protocol versus patients who received conventional physiotherapy. We also examine the level of physical activity in the ICU, the degree of pulmonary and muscle function, and the length of stay to analyze correlations between these variables.MethodsThis is a protocol for a randomized controlled trial with blind evaluation. Ninety-six ICU patients will be recruited from a single center and randomly assigned to a control group or an intervention group. To determine the level of protocol activity the patient will receive, the patients’ ability to participate actively and their muscle strength will be considered. The protocol consists of five phases, ranging from passive therapies to walking and climbing stairs. The primary outcome will be the functional status at ICU discharge, measured with the Barthel Index and the ICU Mobility Scale (IMS). Measured secondary outcomes will include the level of physical activity, maximal inspiratory and expiratory pressures, forced expiratory volume in 1 second, maximum voluntary ventilation, handgrip strength, surface electromyography of the lower limb muscles, and results of the Timed Up and Go and 2-Minute Walk tests. Evaluations will be made within 2 days of ICU discharge except for the level of activity, which will be evaluated daily. Physiological variables and activity level will be analyzed by chi-square and t tests, according to the intention-to-treat paradigm.DiscussionMobility and exercise in the ICU should be undertaken with intensity, quantity, duration, and frequency adjusted according to the patients’ status. The results of this study may contribute to new knowledge of early mobility in the ICU, activity level, and varying benefits in critical patients, directing new approaches to physiotherapeutic interventions in these patients.Trial registrationRecruitment will begin in February 2017, and the expected completion date is August 2018. Patients are already being recruited.ClinicalTrials.gov, ID: NCT02889146. Registered on 3 March 2016.

Decline in functional status after intensive care unit discharge is associated with ICU readmission: a prospective cohort study

OBJECTIVES To compare the functional status at intensive care unit (ICU) discharge of patients who were later readmitted to the ICU and patients discharged home and to verify whether a decline in functional status is associated with ICU readmission. DESIGN Prospective cohort study. SETTING ICU at a tertiary teaching hospital. PARTICIPANTS Patients admitted to the ICU, ≥18 years old, submitted to invasive mechanical ventilation (IMV), and discharged to the ward. INTERVENTIONS Functional assessment at ICU discharge. Discharge Group (DG) (patients discharged home) and Readmission Group (RG) (patients who returned to the ICU) were compared with Mann-Whitney and Chi-square or Exact Fisher tests. Multiple logistic regression verified association. MAIN OUTCOME MEASURES Barthel Index, key pinch strength, clinical and demographic data. RESULTS Patients in the readmission group presented lower Barthel Index [Median 40 (IQR 20-75) vs 60 (33-83), P=0.033], greater relative variation (pre and post ICU) of the Barthel Index (P=0.04), lower key pinch strength [3.4 (1.8-4.5) vs 4.5 (2.7-6.8)kg·f, P=0.006] and higher APACHE II [18 (12-22) vs 15 (11-20), P=0.027]. Multiple regression found that the relative variation of the Barthel Index was independently associated with ICU readmission (P<0.001), as well as higher APACHE II (P=0.020), shorter IMV duration (P<0.001) and ICU admission without clear diagnosis (P=0.020). The Hosmer-Lemeshow test indicated good adjustment of the model (P=0.99). CONCLUSION Readmitted patients presented poorer functional status and lower pinch strength. Relative variation of the Barthel Index was associated with ICU readmission despite other factors, as was higher APACHE II, shorter IMV duration and admission without clear diagnosis. TRIAL REGISTRATION NUMBER Not applicable.