Guido Vagheggini

Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients

In critically ill patients, a prolonged hospital stay, due to the initial acute insult and adverse side-effects of drug therapy, may cause severe late complications, such as muscle weakness, prolonged symptoms, mood alterations and poor health-related quality of life. The clinical aims of physical rehabilitation in both medical and surgical intensive care units (ICUs) are focussed on the patient to improve their short- and even long-term care. The purpose of this article is to review the currently available evidence on comprehensive rehabilitation programmes in critically ill patients, and describe the key components and techniques used, particularly in specialised ICUs. Despite the literature suggesting that several techniques have led to beneficial effects and that muscle training is associated with weaning success, scientific evidence is limited. Due to limitations in undertaking comparative studies in ICUs, further studies with solid clinical short- and long-term outcome measures are now welcomed.

A proposal of a new model for long-term weaning: Respiratory intensive care unit and weaning center

BACKGROUND Respiratory intermediate care units (RICU) are hospital locations to treat acute and acute on chronic respiratory failure. Dedicated weaning centers (WC) are facilities for long-term weaning. AIM We propose and describe the initial results of a long-term weaning model consisting of sequential activity of a RICU and a WC. METHODS We retrospectively analysed characteristics and outcome of tracheostomised difficult-to wean patients admitted to a RICU and, when necessary, to a dedicated WC along a 18-month period. RESULTS Since February 2008 to November 2009, 49 tracheostomised difficult-to wean patients were transferred from ICUs to a University-Hospital RICU after a mean ICU length of stay (LOS) of 32.6 +/- 26.6 days. The weaning success rate in RICU was 67.3% with a mean LOS of 16.6 +/- 10.9 days. Five patients (10.2%) died either in the RICU or after being transferred to ICU, 10 (20.4%) failed weaning and were transferred to a dedicated WC where 6 of them (60%) were weaned. One of these patients was discharged from WC needing invasive mechanical ventilation for less than 12h, 2 died in the WC, 1 was transferred to a ICU. The overall weaning success rate of the model was 79.6%, with 16.3% and 4.8% in-hospital and 3-month mortality respectively. The model resulted in an overall 39 845 +/- 22 578 euro mean cost saving per patient compared to ICU. CONCLUSION The sequential activity of a RICU and a WC resulted in additive weaning success rate of difficult-to wean patients. The cost-benefit ratio of the program warrants prospective investigations.

Efficacy of temporary positive expiratory pressure (TPEP) in patients with lung diseases and chronic mucus hypersecretion. The UNIKO® project: a multicentre randomized controlled trial:

Objective: To evaluate whether temporary positive expiratory pressure provides benefit in patients with lung diseases and chronic hypersecretion. Design: Single blind multicentre randomized trial. Setting: Five Italian rehabilitation centres. Participants: Ninety-eight patients with chronic obstructive pulmonary disease and/or chronic bronchitis (n=78), or bronchiectasis (n=20), with a peak cough expiratory flow >150 l/min and sputum production >30 ml/day, randomly included into two treatment groups. Interventions: For 10 consecutive days, the active group performed twice a day 20-minute cycles of manually assisted breathing techniques in sequence with the addition of 15 minutes of temporary positive expiratory pressure, while the control group was treated by manually assisted breathing techniques alone. Measures: Within and between group changes of arterial oxygenation index, lung volumes and respiratory muscles strength were recorded at enrolment and after 3 and 10 treatment sessions. Pre-to-post treatment change of sputum volume and bronchial encumbrance (Δ-visual analog scale), sputum density and purulence were compared daily within the study period. Results: No significant changes were recorded for the oxygenation index, while dynamic lung volumes and respiratory muscle strength significantly (P <0.05) improved in the active group. The group comparison analysis of the pre-to-post change showed that inspiratory capacity was significantly higher in the active than in the control group (+19.5% and +2.2%, P=0.044) at day 10. A greater improvement in Δ-visual analog scale was recorded in the active group at day 3 and 8. Conclusions: These preliminary data suggest that temporary positive expiratory pressure improves lung volumes and speeds up the improvement of bronchial encumbrance in patients with lung diseases and hypersecretion.

Use of the Functional Independence Measure in People for Whom Weaning From Mechanical Ventilation Is Difficult

Background The Functional Independence Measure (FIM) has been proposed as an outcome measure for people receiving pulmonary rehabilitation after an acute exacerbation of chronic obstructive pulmonary disease. Objective The purpose of this study was to examine the clinical utility of the FIM after a weaning program in people for whom weaning from mechanical ventilation is difficult. Design This was a retrospective observational study. Methods People who had had a tracheostomy, for whom weaning from mechanical ventilation was difficult, and who were participating in a weaning program (WP group) were retrospectively evaluated. People receiving pulmonary rehabilitation after an acute exacerbation of chronic obstructive pulmonary disease (PR group) were included as a validated control group. The scores on the FIM questionnaire and the Medical Research Council dyspnea scores were assessed at admission to and at discharge from the programs. Results Admission and discharge data from 56 participants in the WP group and 63 participants in the PR group were compared. At admission, according to the FIM, 5 participants in the WP group (7.7%) were defined as functionally independent, 34 (52.3%) were defined as partially dependent, and 26 (40.0%) were defined as completely dependent. At discharge, the mean FIM global score was significantly improved, from 47.9 (SD=22.8) to 62.6 (SD=30.0). For participants in the WP group, changes in the FIM score were significantly inversely related to the admission Acute Physiology and Chronic Health Evaluation (R=−.286) and Simplified Acute Physiology (R=−.293) scores and directly related to the admission FIM score (R=.355). At admission, 46 participants in the PR group (67.7%) were defined as functionally independent, 19 (27.9%) were defined as partially dependent, and 3 (4.4%) were defined as completely dependent. After pulmonary rehabilitation, the mean FIM global score was significantly improved, from 97.4 (SD=27.5) to 102.5 (SD=25.7). Limitations The study was not randomized and involved a relatively small sample size. Conclusions The FIM can be used as a functional status outcome measure in people for whom weaning from mechanical ventilation is difficult.

Physiologic response to various levels of pressure support and NAVA in prolonged weaning

Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation wherein the delivered assistance is proportional to diaphragm electrical activity (EAdi) throughout inspiration. We assessed the physiologic response to varying levels of NAVA and pressure support ventilation (PSV) in 13 tracheostomised patients with prolonged weaning. Each patient randomly underwent 8 trials, at four levels of assistance either in PSV and NAVA. i - high (no dyspnoea and/or distress); iv - low (associated with dyspnoea and/or distress; ii and iii - at ∼75% and ∼25% of the difference between high and low support respectively. We measured tidal volume (VT), peak EAdi, (EAdipeak) and airway pressure, ineffective efforts and breathing pattern variability. With both NAVA and PSV, decreasing assistance resulted in parallel significant increase in EAdipeak associated with a concomitant reduction in VT and minute ventilation in PSV, but not in NAVA. VT variability significantly increased when reducing ventilatory assistance in PSV only, while remained unchanged varying the NAVA level. The ineffective triggering index was not significantly different between the two modes. In patients with prolonged weaning, with the specific settings adopted, compared to PSV, NAVA reduced the risk of over-assistance and overall improved patient-ventilator interaction, while not significantly affecting patient-ventilator synchrony.

A prospective multicentric study of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease and different clinical phenotypes.

Background: Recently, it has been proposed that different clinical phenotypes can be recognized in patients with chronic obstructive disease (COPD), namely predominant airway disease or parenchymal destructive changes. Objectives: The aim of this prospective multicenter study was to evaluate whether these two phenotypes may influence outcomes following a pulmonary rehabilitation program (PRP). Methods: We have prospectively evaluated 364 consecutive COPD patients (70 ± 8 years, 76.3% males) admitted to a standard hospital-based PRP in 6 Italian centers. According to their phenotype, the study cohort was divided into two groups: patients with airway obstructive (group 1, n = 208) or parenchymal destructive COPD (group 2, n = 156). Before and after PRP, values of 6-min walking distance, perceived breathlessness (Medical Research Council), health-related quality of life (St. Georges Respiratory Questionnaire) and respiratory muscle function (maximal inspiratory and expiratory pressure) were recorded. Results: PRP resulted in significant improvements in all outcome measures without any significant differences between groups. Conclusions: Our study confirms that COPD patients may benefit from pulmonary rehabilitation independent of their clinical phenotype.

Telemedicine in chronic obstructive pulmonary disease

Telemedicine is a medical application of advanced technology to disease management. This modality may provide benefits also to patients with chronic obstructive pulmonary disease (COPD). Different devices and systems are used. The legal problems associated with telemedicine are still controversial. Economic advantages for healthcare systems, though potentially high, are still poorly investigated. A European Respiratory Society Task Force has defined indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of COPD patients including those undergoing home mechanical ventilation. Key points The costs of care assistance in chronic disease patients are dramatically increasing. Telemedicine may be a very useful application of information and communication technologies in high-quality healthcare services. Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients’ needs. The legal problems associated with telemedicine are still controversial. National and European Union governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a “gold standard” of homecare that is very variable among different European countries and within each European country. The efficacy of respiratory disease telemedicine projects is promising (i.e. to tailor therapeutic intervention; to avoid useless hospital and emergency department admissions, and reduce general practitioner and specialist visits; and to involve the patients and their families). Different programmes based on specific and local situations, and on specific diseases and levels of severity with a high level of flexibility should be utilised. A European Respiratory Society Task Force produced a statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues also of telemonitoring of ventilator-dependent chronic obstructive pulmonary disease patients. Much more research is needed before considering telemonitoring a real improvement in the management of these patients. Educational aims To clarify definitions of aspects of telemedicine To describe different tools of telemedicine To provide information on the main clinical results To define recommendations and limitations We need much more evidence before telemedicine can be considered as real progress in the management of COPD patients http://ow.ly/Rko8305tpnJ

Non-invasive ventilation during cycle exercise training in patients with chronic respiratory failure on long-term ventilatory support: A randomized controlled trial

The role of non‐invasive ventilation (NIV) during exercise training (ET) in patients with chronic respiratory failure (CRF) is still unclear. The aim of this study was to test whether NIV during ET had an additional effect in increasing the 6‐min walking distance (6MWD) and cycle endurance time compared with ET alone.

8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – Part 3

This paper summarizes the Part 2 of the proceedings of the 8th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations.This paper (Part 2) includes sections regarding: Promoting Physical Activity across the Spectrum of COPD (Physical activity: definitions, measurements, and significance; Increasing Physical Activity through Pharmacotherapy in COPD); Pulmonary Rehabilitation in Critical Illness (Complex COPD with comorbidities and its impact during acute exacerbation; Collaborative Self-Management in COPD: A Double-Edged Sword?; and Pulmonary Rehabilitation in Critical Illness.

Integrating the care of the complex COPD patient

Proceedings of the European Seminars in Respiratory Medicine course, Long-Term Integrated Care of COPD Patients held in Stresa, Italy, on 16-17 June, 2016.