Laura Jurema dos Santos

Early rehabilitation using a passive cycle ergometer on muscle morphology in mechanically ventilated critically ill patients in the Intensive Care Unit (MoVe-ICU study): study protocol for a randomized controlled trial.

BackgroundPatients in Intensive Care Units (ICU) are often exposed to prolonged immobilization which, in turn, plays an important role in neuromuscular complications. Exercise with a cycle ergometer is a treatment option that can be used to improve the rehabilitation of patients on mechanical ventilation (MV) in order to minimize the harmful effects of immobility.Methods/DesignA single-blind randomized controlled trial (the MoVe ICU study) will be conducted to evaluate and compare the effects of early rehabilitation using a bedside cycle ergometer with conventional physical therapy on the muscle morphology of the knee extensors and diaphragm in critical ill patients receiving MV. A total of 28 adult patients will be recruited for this study from among those admitted to the intensive care department at the Hospital de Clínicas de Porto Alegre. Eligible patients will be treated with MV from a period of 24 to 48xa0h, will have spent maximum of 1xa0week in hospital and will not exhibit any characteristics restricting lower extremity mobility. These subjects will be randomized to receive either conventional physiotherapy or conventional physiotherapy with an additional cycle ergometer intervention. The intervention will be administered passively for 20xa0min, at 20 revolutions per minute (rpm), once per day, 7xa0days a week, throughout the time the patients remain on MV. Outcomes will be cross-sectional quadriceps thickness, length of fascicle, pennation angle of fascicles, thickness of vastus lateralis muscle, diaphragm thickness and excursion of critical ICU patients on MV measured with ultrasound.DiscussionThe MoVe-ICU study will be the first randomized controlled trial to test the hypothesis that early rehabilitation with a passive cycle ergometer can preserve the morphology of knee extensors and diaphragm in critical patients on MV in ICUs.Trial registrationNCT02300662 (25 November 2014).

Use of neuromuscular electrical stimulation to preserve the thickness of abdominal and chest muscles of critically ill patients : a randomized clinical trial

OBJECTIVEnTo evaluate and compare the effects of neuromuscular electrical stimulation combined with conventional physical therapy on muscle thickness in critically ill patients.nnnDESIGNnDouble-blind, randomized controlled trial.nnnPATIENTSnTwenty-five patients participated in the study.nnnMETHODSnPatients on mechanical ventilation for 24-48 h were randomized to an intervention group (neuromuscular electrical stimulationu2009+u2009conventional physical therapy) or a conventional group (sham neuromuscular electrical stimulationu2009+u2009conventional physical therapy). Primary outcome was thickness of the rectus abdominis and chest muscles, determined on cross-sectional ultrasound images before and after the intervention.nnnRESULTSnEleven patients were included in the intervention group and 14 in the conventional group. After neuromuscular electrical stimulation, rectus abdominis muscle thickness and chest muscle thickness were preserved in the intervention group, whereas there was a significant reduction in thickness in the conventional group, with a significant difference between groups. There was a significant difference between groups in length of stay in the intensive care unit, with shorter length of stay in the intervention group.nnnCONCLUSIONnThere was no change in rectus abdominis and chest muscle thickness in the intervention group. A significant decrease was found in these measures in the conventional group.

Cycling-off modes during pressure support ventilation: effects on breathing pattern, patient effort, and comfort.

PURPOSEnExpiratory asynchrony during pressure support ventilation (PSV) has been recognized as a cause of patient discomfort, increased workload, and impaired weaning process. We evaluated breathing pattern, patient comfort, and patient effort during PSV comparing 2 flow termination criteria: fixed at 5% of peak inspiratory flow vs automatic, real-time, breath-by-breath adjustment within the range of 5% to 55%.nnnMATERIALS AND METHODSnRandomized crossover clinical trial. Sixteen awake patients, in the process of weaning, under PSV for more than 24 hours were subjected to 3 phases of PSV, each lasting 1 hour and using 1 of the 2 aforementioned termination criteria.nnnRESULTSnEffective pressure support during automatic adjustment (AA) was 12.5±3.2 cm H2O vs 12.5±3.9 cm H2O (P=.9) with the fixed termination criterion, and external positive end-expiratory pressure was 6.2±1.8 vs 6.8±2 (P<.05). The effective termination criterion was higher during AA (31% [23-39] vs 12% [6-23]; P<.01), but without producing premature breath terminations. Pressure overshoots and alternative cycling-off were also decreased. Throughout the AA period, we observed a higher respiratory rate (24±8 breaths/min vs 19±6 breaths/min; P<.001), lower tidal volume (484 ± 88 mL vs 518±102 mL; P<.001), and shorter inspiratory times (1.0±0.3 seconds vs 1.3±0.3 seconds; P<.001). Automatic adjustment was associated with lower airway occlusion pressure after 0.1 second (P0.1) (1.8±0.9 cm H2O vs 2.4±1 cm H2O; P<.01), lower pressure-time product to trigger the ventilator, and lower subjective discomfort (visual analog scale, 3.7±1.3 vs 4.5±1.2; P<.001).nnnCONCLUSIONSnWhen compared with a fixed termination criterion, the use of a variable, real-time-adjusted termination criterion improved some indices of patient-ventilator synchrony, producing better breathing pattern, less discomfort, and slightly lower patient effort during PSV.

Energy expenditure during weaning from mechanical ventilation: Is there any difference between pressure support and T-tube? ☆,☆☆,★,★★

BACKGROUNDnThe objectives of this study were to compare patients energy expenditure (EE) during pressure support (PS) and T-tube (TT) weaning from mechanical ventilation (MV) through indirect calorimetry (IC) and to crosscheck these findings with the results calculated using Harris-Benedict (HB) equation.nnnMETHODSnThis study is a randomized crossover controlled trial. Patients with clinical criteria for weaning from MV were randomized to PS-TT or TT-PS, with EE measurement for 20 minutes in PS and TT through IC. Energy expenditure was estimated through HB equation with and without activity factor. Statistical analysis used the Student t test for paired samples and Pearson correlation coefficient, as well as Bland-Altman method.nnnRESULTSnForty patients were included. The mean age and Acute Physiology and Chronic Health Evaluation II score were 56 ± 16 years and 23 ± 8, respectively, with predominance of male patients (70%). Mean EE of patients in TT (1782 ± 375 kcal/d) was 14.4% higher than in PS (1558 ± 304 kcal/d; P < .001). In relation to the EE obtained with the HB equation, the mean (SD) value calculated was 1455 (210) kcal/d, and when considering the activity factor, it was 1609 (236) kcal/d, all of them presenting correlation with the values from IC in PS (r = 0.647) and TT (r = 0.539). However, the limits of agreement between the measured EE and the estimated EE suggest that the HB equation tends to underestimate the EE.nnnCONCLUSIONnComparison of EE in PS and in TT through IC demonstrated that there is increased EE in the TT mode. The results suggest that the HB equation underestimates the EE of patients in weaning from MV.

TREINAMENTO MUSCULAR INSPIRATÓRIO COM THRESHOLD™ EM PACIENTES INTERNADOS COM PNEUMONIA BACTERIANA

Contextualizacao: A pneumonia e uma doenca inflamatoria das vias aereas e o risco estimado de adquiri-la e cinco vezes superior para os casos hospitalares. Objetivo: Comparar a forca muscular respiratoria e o tempo de permanencia hospitalar de pacientes internados com pneumonia bacteriana submetidos a um programa de treinamento muscular respiratorio com Threshold™. Metodos: Estudo controlado randomizado, no qual participaram 11 pacientes, divididos em grupo intervencao e controle. A avaliacao da forca muscular inspiratoria (PImax) e expiratoria (PEmax) foi realizada em ambos os grupos atraves da manovacuometria no primeiro e quinto dia de tratamento. Para o treinamento muscular inspiratorio, foi utilizado o Threshold™ PEP. Foi utilizado o teste T de Student para amostras independentes e o Mann-Whitney (p≤0,05). Resultados: Estudo realizado entre setembro e novembro de 2009, onde a media de idade dos pacientes foi de 51±15 anos, com predominio do sexo masculino (64%).

Early ambulation using a cycle ergometer on quadriceps muscle morphology in mechanically ventilated critically ILL patients in the intensive care unit: a randomized controlled trial.

Patients in the intensive care unit (ICU) are exposed to prolonged immobility, which leads to loss of muscle mass. One resource that has proved to be of great utility in hospitals is the cycle ergometer, which is a stationary piece of equipment designed to enable cyclical rotations of lower and/or upper extremities and can be used to perform passive, active and resisted exercises.

Use of electrical neuromuscular stimulation to preserve the morphology of abdominal and chest muscles of critical patients: randomized clinical trial

Neuromuscular electrical stimulation (NMES) has been used as an early therapeutic modality at intensive care units (ICUs) to treat patients on invasive mechanical ventilation (IMV) to compensate and/or decrease loss of muscle mass.