Eddy Fan

Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.

OBJECTIVESnTo (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients functional mobility, and (3) evaluate effects on length of stay.nnnDESIGNnSeven-month prospective before/after quality improvement project.nnnSETTINGnSixteen-bed medical intensive care unit (MICU) in academic hospital.nnnPARTICIPANTSn57 patients mechanically ventilated 4 days or longer.nnnINTERVENTIONnA multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.nnnMAIN OUTCOME MEASURESnSedation and delirium status, rehabilitation treatments, functional mobility.nnnRESULTSnCompared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15 mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.nnnCONCLUSIONSnUsing a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

Inhaled Corticosteroids in Patients With Stable Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis

CONTEXTnRecent studies of inhaled corticosteroid (ICS) therapy for managing stable chronic obstructive pulmonary disease (COPD) have yielded conflicting results regarding survival and risk of adverse events.nnnOBJECTIVEnTo systematically review and quantitatively synthesize the effects of ICS therapy on mortality and adverse events in patients with stable COPD.nnnDATA SOURCESnSearch of MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PsychInfo through February 9, 2008.nnnSTUDY SELECTIONnEligible studies were double-blind, randomized controlled trials comparing ICS therapy for 6 or more months with nonsteroid inhaled therapy in patients with COPD.nnnDATA EXTRACTIONnTwo authors independently abstracted data including study characteristics, all-cause mortality, pneumonia, and bone fractures. The I(2) statistic was used to assess heterogeneity. Study-level data were pooled using a random-effects model (when I(2) > or = 50%) or a fixed-effects model (when I(2) < 50%). For the primary outcome of all-cause mortality at 1 year, our meta-analysis was powered to detect a 1.0% absolute difference in mortality, assuming a 2-sided alpha of .05 and power of 0.80.nnnRESULTSnEleven eligible randomized controlled trials (14,426 participants) were included. In trials with mortality data, no difference was observed in 1-year all-cause mortality (128 deaths among 4636 patients in the treatment group and 148 deaths among 4597 patients in the control group; relative risk [RR], 0.86; 95% confidence interval [CI], 0.68-1.09; P = .20; I(2) = 0%). In the trials with data on pneumonia, ICS therapy was associated with a significantly higher incidence of pneumonia (777 cases among 5405 patients in the treatment group and 561 cases among 5371 patients in the control group; RR, 1.34; 95% CI, 1.03-1.75; P = .03; I(2) = 72%). Subgroup analyses indicated an increased risk of pneumonia in the following subgroups: highest ICS dose (RR, 1.46; 95% CI, 1.10-1.92; P = .008; I(2) = 78%), shorter duration of ICS use (RR, 2.12; 95% CI, 1.47-3.05; P < .001; I(2) = 0%), lowest baseline forced expiratory volume in the first second of expiration (RR, 1.90; 95% CI, 1.26-2.85; P = .002; I(2) = 0%), and combined ICS and bronchodilator therapy (RR, 1.57; 95% CI, 1.35-1.82; P < .001; I(2) = 24%).nnnCONCLUSIONSnAmong patients with COPD, ICS therapy does not affect 1-year all-cause mortality. ICS therapy is associated with a higher risk of pneumonia. Future studies should determine whether specific subsets of patients with COPD benefit from ICS therapy.

Recruitment maneuvers for acute lung injury: A systematic review

RATIONALEnThere are conflicting data regarding the safety and efficacy of recruitment maneuvers (RMs) in patients with acute lung injury (ALI).nnnOBJECTIVESnTo summarize the physiologic effects and adverse events in adult patients with ALI receiving RMs.nnnMETHODSnSystematic review of case series, observational studies, and randomized clinical trials with pooling of study-level data.nnnMEASUREMENTS AND MAIN RESULTSnForty studies (1,185 patients) met inclusion criteria. Oxygenation (31 studies; 636 patients) was significantly increased after an RM (PaO2): 106 versus 193 mm Hg, P = 0.001; and PaO2/FiO2 ratio: 139 versus 251 mm Hg, P < 0.001). There were no persistent, clinically significant changes in hemodynamic parameters after an RM. Ventilatory parameters (32 studies; 548 patients) were not significantly altered by an RM, except for higher PEEP post-RM (11 versus 16 cm H2O; P = 0.02). Hypotension (12%) and desaturation (9%) were the most common adverse events (31 studies; 985 patients). Serious adverse events (e.g., barotrauma [1%] and arrhythmias [1%]) were infrequent. Only 10 (1%) patients had their RMs terminated prematurely due to adverse events.nnnCONCLUSIONSnAdult patients with ALI receiving RMs experienced a significant increase in oxygenation, with few serious adverse events. Transient hypotension and desaturation during RMs is common but is self-limited without serious short-term sequelae. Given the uncertain benefit of transient oxygenation improvements in patients with ALI and the lack of information on their influence on clinical outcomes, the routine use of RMs cannot be recommended or discouraged at this time. RMs should be considered for use on an individualized basis in patients with ALI who have life-threatening hypoxemia.

Physical complications in acute lung injury survivors: a two-year longitudinal prospective study.

Objective:Survivors of severe critical illness frequently develop substantial and persistent physical complications, including muscle weakness, impaired physical function, and decreased health-related quality of life. Our objective was to determine the longitudinal epidemiology of muscle weakness, physical function, and health-related quality of life and their associations with critical illness and ICU exposures. Design:A multisite prospective study with longitudinal follow-up at 3, 6, 12, and 24 months after acute lung injury. Setting:Thirteen ICUs from four academic teaching hospitals. Patients:Two hundred twenty-two survivors of acute lung injury. Interventions:None. Measurements and Main Results:At each time point, patients underwent standardized clinical evaluations of extremity, hand grip, and respiratory muscle strength; anthropometrics (height, weight, mid-arm circumference, and triceps skin fold thickness); 6-minute walk distance, and the Medical Outcomes Short-Form 36 health-related quality of life survey. During their hospitalization, survivors also had detailed daily evaluation of critical illness and related treatment variables. Over one third of survivors had objective evidence of muscle weakness at hospital discharge, with most improving within 12 months. This weakness was associated with substantial impairments in physical function and health-related quality of life that persisted at 24 months. The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up. The cumulative dose of systematic corticosteroids and use of neuromuscular blockers in the ICU were not associated with weakness. Conclusions:Muscle weakness is common after acute lung injury, usually recovering within 12 months. This weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months. These results provide valuable prognostic information regarding physical recovery after acute lung injury. Evidence-based methods to reduce the duration of bed rest during critical illness may be important for improving these long-term impairments.

Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials

As the mortality from critical illness has improved in recent years, there has been increasing focus on patient outcomes after hospital discharge. Neuromuscular weakness acquired in the intensive care unit (ICU) is common, persistent, and often severe. Immobility due to prolonged bed rest in the ICU may play an important role in the development of ICU-acquired weakness. Studies in other patient populations have demonstrated that moderate exercise is beneficial in altering the inflammatory milieu associated with immobility, and in improving muscle strength and physical function. Recent studies have demonstrated that early mobility in the ICU is safe and feasible, with a potential reduction in short-term physical impairment. However, early mobility requires a significant change in ICU practice, with reductions in heavy sedation and bed rest. Further research is required to determine whether early mobility in the ICU can improve patients short-term and long-term outcomes.

Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project.

PURPOSEnThe aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation.nnnMATERIALS AND METHODSnProspective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted.nnnRESULTSnOf the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge.nnnCONCLUSIONSnThis pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.

Technology to enhance physical rehabilitation of critically ill patients

Background:Neuromuscular complications after critical illness are common and can be severe and persistent. To ameliorate complications, there is growing interest in starting physical medicine and rehabilitation therapy immediately after physiologic stabilization. The introduction of physical medicine and rehabilitation-related technology into the intensive care unit may help facilitate delivery of this therapy. Discussion:Neuromuscular electrical stimulation therapy creates passive contraction of muscles through low-voltage electrical impulses delivered through skin electrodes placed over target muscles. Although neuromuscular electrical stimulation has not been studied in patients with acute critical illness, published guidelines based on available evidence suggest that neuromuscular electrical stimulation may be considered in intensive care unit patients who are at high risk of developing muscle weakness. Bedside cycle ergometry can provide range of motion and muscle strength training for intensive care unit patients who are either sedated or awake, and may help preserve muscle architecture and improve strength and function. Finally, custom-designed technological aids to assist with ambulating mechanically ventilated patients may reduce the human resource requirements and improve the safety and effectiveness of early mobilization in the intensive care unit. Conclusion:Physical medicine and rehabilitation-related technologies may play an important role in preventing and treating intensive care unit-acquired neuromuscular complications. Future studies are needed to evaluate their efficacy in intensive care unit patients.

How to use an article about quality improvement

Quality improvement (QI) attempts to change clinician behavior and, through those changes, lead to improved patient outcomes. The methodological quality of studies evaluating the effectiveness of QI interventions is frequently low. Clinicians and others evaluating QI studies should be aware of the risk of bias, should consider whether the investigators measured appropriate outcomes, should be concerned if there has been no replication of the findings, and should consider the likelihood of success of the QI intervention in their practice setting and the costs and possibility of unintended effects of its implementation. This article complements and enhances existing Users Guides that address the effects of interventions--Therapy, Harm, Clinical Decision Support Systems, and Summarizing the Evidence guides--with an emphasis on issues specific to QI studies. Given the potential for widespread implementation of QI interventions, there is a need for robust study methods in QI research.

Inter-rater reliability of manual muscle strength testing in ICU survivors and simulated patients

ObjectiveThe goal of the paper is to determine inter-rater reliability of trained examiners performing standardized strength assessments using manual muscle testing (MMT).Design, subjects, and settingThe authors report on 19 trainees undergoing quality assurance within a multi-site prospective cohort study.InterventionInter-rater reliability for specially trained evaluators (“trainees”) and a reference rater, performing MMT using both simulated and actual patients recovering from critical illness was evaluated.Measurements and resultsAcross 26 muscle groups tested by 19 trainee-reference rater pairs, the median (interquartile range) percent agreement and intraclass correlation coefficient (ICC; 95% CI) were: 96% (91, 98%) and 0.98 (0.95, 1.00), respectively. Across all 19 pairs, the ICC (95% CI) for the overall composite MMT score was 0.99 (0.98–1.00). When limited to actual patients, the ICC was 1.00 (95% CI 0.99–1.00). The agreement (kappa; 95% CI) in detecting clinically significant weakness was 0.88 (0.44–1.00).ConclusionsMMT has excellent inter-rater reliability in trained examiners and is a reliable method of comprehensively assessing muscle strength.

Oxygenation Response to Positive End-Expiratory Pressure Predicts Mortality in Acute Respiratory Distress Syndrome. A Secondary Analysis of the LOVS and ExPress Trials

RATIONALEnPrevious trials of higher positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) failed to demonstrate mortality benefit, possibly because of differences in lung recruitability among patients with ARDS.nnnOBJECTIVESnTo determine whether the physiological response to increased PEEP is associated with mortality.nnnMETHODSnIn a secondary analysis of the Lung Open Ventilation Study (LOVS, n = 983), we examined the relationship between the initial response to changes in PEEP after randomization and mortality. We sought to corroborate our findings using data from a different trial of higher PEEP (ExPress, n = 749).nnnMEASUREMENTS AND MAIN RESULTSnThe oxygenation response (change in ratio of arterial partial pressure of oxygen to fraction of inspired oxygen: P/F) after the initial change in PEEP after randomization varied widely (median, 9.5 mm Hg; interquartile range, -16 to 47) and was only weakly related to baseline P/F or the magnitude of PEEP change. Among patients in whom PEEP was increased after randomization, an increase in P/F was associated with reduced mortality (multivariable logistic regression; adjusted odds ratio, 0.80 [95% confidence interval, 0.72-0.89] per 25-mm Hg increase in P/F), particularly in patients with severe disease (baseline P/F [less-than-or-equal-to] 150 mm Hg). Changes in compliance and dead space were not associated with mortality. These findings were confirmed by a similar analysis of data from the ExPress trial.nnnCONCLUSIONSnPatients with ARDS who respond to increased PEEP by improved oxygenation have a lower risk of death. The oxygenation response to PEEP might be used to predict whether patients will benefit from higher versus lower PEEP.