Kathy Stiller

23
CHEST Original Research CRITICAL CARE journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 825 I n most developed countries, physiotherapy is seen as an integral component of the multidisciplinary management of patients in ICUs. The role of physio- therapy in the ICU and the treatment techniques used by physiotherapists in the ICU vary consider- ably between units, depending on factors such as the country in which the ICU is located, local tradition, staffing levels, and expertise. In 2000, Stiller 1 published a literature review investigating the effectiveness of physiotherapy for adult, intubated patients on mechan- ical ventilation in the ICU, covering a broad range of physiotherapy practice. This concluded that there was only limited evidence concerning the effectiveness of physiotherapy in this setting and identified an urgent need for further research to be conducted to justify the role of physiotherapy in the ICU. The review is frequently cited in articles concerning the role of physiotherapy in the ICU. Given that . 10 years have passed since its publication, what new evidence regarding the role of physiotherapy in the ICU has emerged? Does this new evidence confirm the role Background: Although physiotherapy is frequently provided to patients in the ICU, its role has been questioned. The purpose of this systematic literature review, an update of one published in 2000, was to examine the evidence concerning the effectiveness of physiotherapy for adult, intu- bated patients who are mechanically ventilated in the ICU. Methods: The main literature search was undertaken on PubMed, with secondary searches of MEDLINE, CINAHL, Embase, the Cochrane Library, and the Physiotherapy Evidence Database. Only papers published from 1999 were included. No limitations were placed on study design, intervention type, or outcomes of clinical studies; nonsystematic reviews were excluded. Items were checked for relevance and data extracted from included studies. Marked heterogeneity of design precluded statistical pooling of results and led to a descriptive review. Results: Fifty-five clinical and 30 nonclinical studies were reviewed. The evidence from random- ized controlled trials evaluating the effectiveness of routine multimodality respiratory physio- therapy is conflicting. Physiotherapy that comprises early progressive mobilization has been shown to be feasible and safe, with data from randomized controlled trials demonstrating that it can improve function and shorten ICU and hospital length of stay. Conclusions: Available new evidence, published since 1999, suggests that physiotherapy interven- tion that comprises early progressive mobilization is beneficial for adult patients in the ICU in terms of its positive effect on functional ability and its potential to reduce ICU and hospital length of stay. These new findings suggest that early progressive mobilization should be implemented as a matter of priority in all adult ICUs and an area of clinical focus for ICU physiotherapists. CHEST 2013; 144(3):825–847 Abbreviations: IMT 5 inspiratory muscle training; LOS 5 length of stay; MH 5 manual hyperinflation; NMES 5 neuro- muscular electrical stimulation; RCT 5 randomized controlled/comparative trial; VAP 5 ventilator-associated pneumonia; VH 5 ventilator hyperinflation Physiotherapy in Intensive Care An Updated Systematic Review Kathy Stiller, PhD Manuscript received December 5, 2012; revision accepted May 2, 2013. Affiliations: From the Physiotherapy Department, Royal Adelaide Hospital, Adelaide, SA, Australia. Funding/Support: The author has reported to CHEST that no funding was received for this study. Correspondence to: Kathy Stiller, PhD, Royal Adelaide Hospi- tal, Physiotherapy Department, North Terrace, Adelaide, SA, Australia, 5000; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-2930 Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

Transcript of Kathy Stiller

CHEST Original ResearchCRITICAL CARE

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 825

In most developed countries, physiotherapy is seen as an integral component of the multidisciplinary

management of patients in ICUs. The role of physio-therapy in the ICU and the treatment techniques used by physiotherapists in the ICU vary consider-

ably between units, depending on factors such as the country in which the ICU is located, local tradition, staffi ng levels, and expertise. In 2000, Stiller 1 published a literature review investigating the effectiveness of physiotherapy for adult, intubated patients on mechan-ical ventilation in the ICU, covering a broad range of physiotherapy practice. This concluded that there was only limited evidence concerning the effectiveness of physiotherapy in this setting and identifi ed an urgent need for further research to be conducted to justify the role of physiotherapy in the ICU. The review is frequently cited in articles concerning the role of physiotherapy in the ICU. Given that . 10 years have passed since its publication, what new evidence regard ing the role of physiotherapy in the ICU has emerged? Does this new evidence confi rm the role

Background: Although physiotherapy is frequently provided to patients in the ICU, its role has been questioned. The purpose of this systematic literature review, an update of one published in 2000, was to examine the evidence concerning the effectiveness of physiotherapy for adult, intu-bated patients who are mechanically ventilated in the ICU. Methods: The main literature search was undertaken on PubMed, with secondary searches of MEDLINE, CINAHL, Embase, the Cochrane Library, and the Physiotherapy Evidence Database. Only papers published from 1999 were included. No limitations were placed on study design, intervention type, or outcomes of clinical studies; nonsystematic reviews were excluded. Items were checked for relevance and data extracted from included studies. Marked heterogeneity of design precluded statistical pooling of results and led to a descriptive review. Results: Fifty-fi ve clinical and 30 nonclinical studies were reviewed. The evidence from random-ized controlled trials evaluating the effectiveness of routine multimodality respiratory physio-therapy is confl icting. Physiotherapy that comprises early progressive mobilization has been shown to be feasible and safe, with data from randomized controlled trials demonstrating that it can improve function and shorten ICU and hospital length of stay. Conclusions: Available new evidence, published since 1999, suggests that physiotherapy interven-tion that comprises early progressive mobilization is benefi cial for adult patients in the ICU in terms of its positive effect on functional ability and its potential to reduce ICU and hospital length of stay. These new fi ndings suggest that early progressive mobilization should be implemented as a matter of priority in all adult ICUs and an area of clinical focus for ICU physiotherapists. CHEST 2013; 144(3):825–847

Abbreviations: IMT 5 inspiratory muscle training; LOS 5 length of stay; MH 5 manual hyperinfl ation; NMES 5 neuro-muscular electrical stimulation; RCT 5 randomized controlled/comparative trial; VAP 5 ventilator-associated pneumonia; VH 5 ventilator hyperinfl ation

Physiotherapy in Intensive Care An Updated Systematic Review

Kathy Stiller , PhD

Manuscript received December 5, 2012; revision accepted May 2, 2013 . Affi liations: From the Physiotherapy Department, Royal Adelaide Hospital, Adelaide, SA, Australia. Funding/Support : The author has reported to CHEST that no funding was received for this study . Correspondence to: Kathy Stiller, PhD, Royal Adelaide Hospi-tal, Physiotherapy Department, North Terrace, Adelaide, SA, Australia, 5000; e-mail: [email protected] © 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.12-2930

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

826 Original Research

did not study the population and/or intervention of interest ( Fig 1 ).

Systematic Reviews

Twelve systematic literature reviews were identi-fi ed. Their characteristics, including a summary of their results and conclusions, are shown in Table 1 . 4-15 In contrast to the current review, which covers a wide range of ICU physiotherapy practices, these reviews focused on specifi c areas of physiotherapy practice in the ICU, with the most frequent topic being the early mobilization and rehabilitation of patients in the ICU. 4-10 Despite only limited data being available, most con-cluded that early mobilization and rehabilitation are safe and effective in the ICU setting, although further research is required to confi rm and extend its role. 4-10

Clinical Trials: Study and Patient Characteristics

The clinical trials reviewed evaluated a variety of physiotherapy interventions, including multimodality respiratory physiotherapy, mobilization, inspiratory muscle training (IMT), and neuromuscular electrical stimulation (NMES). For the sake of clarity, study fi ndings are presented according to the intervention evaluated.

Multimodality Respiratory Physiotherapy: Eighteen clinical trials were identifi ed that evaluated the effec-tiveness of multimodality respiratory physiotherapy, with the interventions studied including various com-binations of positioning, manual hyperinfl ation (MH), ventilator hyperinfl ation (VH), chest wall vibrations, and rib-cage compression. 16-33 The characteristics and main fi ndings of these 18 studies are shown in Table 2 (sorted according to methodological quality and sam-ple size). There were fi ve RCTs, 16-20 nine randomized crossover trials, 21-29 one systematically allocated con-trolled trial, 30 one historical controlled trial, 31 and two observational studies. 32,33

Four of the fi ve RCTs were well designed and involved samples of at least 101 patients. 16-19 Study populations comprised patients who were intubated and mechan-ically ventilated after cardiac surgery, 16 mechanically ventilated . 48 h, 17,19 or mechanically ventilated with acquired brain injury. 18 Patients were prospectively randomly allocated to a control group (usually receiving standard medical/nursing care) or a treatment group that received additional multimodality respiratory phys-iotherapy (comprising a combination of techniques such as positioning, MH, with or without chest wall vibrations). Frequency of this additional multimodality respiratory physiotherapy was as clinically indicated in two studies, 16,17 bid, 19 and six times a day. 18 Medium-term clinical outcomes such as duration of intubation, incidence of ventilator-associated pneumonia (VAP),

of physiotherapy in the ICU? Does it highlight areas of clinical practice where physiotherapy is most effective?

The objective of this systematic review was to update a summary of the evidence concerning the effective-ness of physiotherapy in the ICU. In keeping with Stiller, 1 this review only considers the management of adult, intubated patients on mechanical ventilation.

Materials and Methods

Search Strategy and Study Selection

The PICOS (population, intervention, comparison, outcome and study design) criteria used in this study were deliberately broad to capture all relevant articles, requiring only that the popu-lation comprised adult (aged � 18 years), intubated, mechanically ventilated patients being cared for in an ICU setting and that a physiotherapy intervention had been evaluated or discussed. No limitations were placed on study outcomes. All relevant clinical articles were included and systematic literature reviews, expert opinion papers, and surveys were also eligible for inclusion. The primary literature search was conducted using the PubMed data-base for articles published from January 1, 1999, to July 31, 2012, using the following search terms: “intensive care” AND “physio-therapy.” Additional searches were undertaken on PubMed using the terms “critical care” or “intensive care” AND “physical therapy,” “therapeutic exercise,” “functional training,” “exercise,” “exercise therapy,” “mobilisation,” “rehabilitation” or “ambulation.” Sec-ondary searches, using the same time limitations and search terms, were undertaken on MEDLINE, CINAHL, Embase, Cochrane Library, and the Physiotherapy Evidence Database. Titles and abstracts generated by the search strategy were assessed for eligi-bility and full-text copies of articles deemed to be potentially rel-evant were retrieved. Duplicate publications were excluded. If relevant articles could not be accessed via the Internet, authors were contacted directly. Given that this was a nonclinical study, institutional review board approval was not sought.

Methodological Quality and Analysis

The methodological quality of randomized controlled or com-parative trials (RCTs) was appraised with reference to the National Health and Medical Research Council Guidelines 2 and Consoli-dated Standards of Reporting Trials (CONSORT) statement . 3 All data were extracted by the author. Marked heterogeneity of study design and outcome measures precluded statistical pooling of results for meta-analysis, hence a descriptive summary of the fi nd-ings is presented.

Results

Literature Search

The initial PubMed literature search identifi ed 849 items published since 1999, with 50 relevant studies (34 clinical, 16 nonclinical) included in the review. An additional 35 relevant studies (21 clinical, 14 nonclinical) were retrieved in a broader PubMed search or from other databases. Thus, in total, 85 new studies (55 clinical, 30 nonclinical) were reviewed. Articles were most often excluded because they

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journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 827

and length of stay (LOS) in the ICU and hospital were measured. Two of the four RCTs found no signifi cant difference between groups for any outcomes, 16,18 one found that the median time for 50% of patients to become ventilator-free was signifi cantly longer in the treatment group, 17 and the fi nal study favored the treatment group, with signifi cant benefi ts seen in terms of the clinical pulmonary infection score, ventilator weaning and mortality rates. 19 The fi fth RCT was meth-odologically compromised by a small sample size (n 5 17) that was further compromised by division into three treatment groups. 20

The nine randomized crossover trials all had com-paratively small sample sizes (n � 46) and prospectively evaluated the physiologic effects of individual respi-ratory physiotherapy interventions. 21-29 Six of the ran-domized crossover trials evaluated MH. 21,25-29 Three of these compared MH to VH, when added to a treat-ment of positioning and suction, with all fi nding that VH was as effective as MH for outcomes such as spu-tum clearance and respiratory compliance. 21,26,29 Two studies investigated the addition of MH to a treat-ment of positioning and suction, with both fi nding that MH was associated with short-term benefi cial physiologic effects such as improved respiratory com-pliance. 27,28 Hodgson et al 25 compared two different circuits for delivering MH, fi nding that while MH

with a Mapleson C circuit cleared signifi cantly more sputum than MH with a Laerdal circuit, this did not have any consequences in terms of oxygenation or respiratory compliance. Two randomized crossover trials evaluated the effect of expiratory rib-cage com-pression, fi nding that it did not add to the effective-ness of positioning and suction in terms of oxygenation, respiratory compliance, or sputum clearance. 22,23 Finally, Berney et al, 24 investigating 20 patients who were mechanically ventilated, found that the addition of a head-down tilt to MH, rather than fl at side lying, increased the weight of sputum cleared.

A prospective, systematically allocated, controlled trial involving 60 patients who were mechanically ven-tilated was undertaken by Ntoumenopoulos et al. 30 While the incidence of VAP was signifi cantly lower in a group that received multimodality respiratory phys-iotherapy bid compared with a control group, dura-tion of mechanical ventilation, ICU LOS and mortality were not signifi cantly different between groups.

A large historical controlled trial by Malkoç et al 31 (n 5 501) found that a group that received multimo-dality respiratory physiotherapy had a signifi cantly shorter duration of mechanical ventilation and ICU LOS than a historical control group. However, as the treatment group also received mobilization, it is not clear which components of therapy were effective.

Figure 1. Flowchart of selection of eligible studies.

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828 Original Research

Tabl

e 1—

Cha

ract

eris

tics

of

Syst

emat

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atu

re R

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earl

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dler

and

Mal

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Mob

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tion

of c

ritic

ally

ill p

atie

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with

an e

mph

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on

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tiona

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com

es a

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patie

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afet

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limite

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hav

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m

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zatio

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ly il

l pat

ient

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ppor

ts e

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mob

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as a

saf

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inte

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tion

that

can

hav

e a

sign

ifi ca

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pact

on

func

tiona

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A

mid

ei 5

Vari

able

s th

at h

ave

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use

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eva

luat

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onse

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17M

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mob

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tion

of c

ritic

ally

ill p

atie

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ev

alua

ted

card

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func

tion.

Fut

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stud

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eval

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fety

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ef

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mob

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in th

is s

ettin

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ould

mea

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mul

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phy

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fort

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Am

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61M

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defi

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as

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and

freq

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inte

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C

hoi e

t al 7

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prov

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pat

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pro

long

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mec

hani

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10T

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evie

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ther

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33 a

The

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as th

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amat

ical

ly in

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ce r

ecov

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tiona

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able

pat

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gro

up.

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pira

tory

tech

niqu

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Clin

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ino 11

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atio

nale

and

eff

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spe

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inte

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use

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eani

ng p

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r pa

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s in

a r

espi

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r pa

tient

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stu

dies

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g ev

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port

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t-dr

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size

s ar

e ne

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valu

ate

the

effe

ctiv

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s of

mos

t PT

tech

niqu

es in

the

ICU

. (Con

tinu

ed)

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journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 829

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Rev

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xyge

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ever

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eff

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on b

road

er o

utco

mes

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h as

dur

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n of

mec

hani

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entil

atio

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d IC

U L

OS,

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H h

as b

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tly.

App

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ded

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ende

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r ro

utin

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ther

topi

cs

Elli

ott e

t al 13

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bser

vatio

nal a

nd fu

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sses

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rum

ents

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nts

in th

e IC

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post

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osth

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taliz

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ies

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sure

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vors

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uscl

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ife. I

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nera

l, th

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idity

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use

with

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s ha

s no

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tabl

ishe

d.

Han

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l 14

Iden

tify

whi

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be m

easu

red

in

the

adul

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tical

car

e en

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t and

w

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out

com

es P

Ts a

re c

urre

ntly

incl

udin

g in

res

earc

h re

port

s.

35R

esea

rch

that

has

inve

stig

ated

the

effi c

acy

of P

T in

IC

U h

as p

rim

arily

mea

sure

d

phys

iolo

gic

vari

able

s or

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f cur

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pra

ctic

e, w

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t lin

king

thes

e to

bro

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com

es s

uch

as fu

nctio

nal s

tatu

s an

d he

alth

-rel

ated

qu

ality

of l

ife. F

urth

er w

ork

is n

eede

d to

dev

elop

and

refi

ne

patie

nt-c

ente

red

and

econ

omic

mea

sure

men

ts th

at w

ill b

e su

ffi ci

ently

sen

sitiv

e to

be

able

to

mea

sure

the

effe

ct o

f PT

ser

vice

pro

visi

on in

IC

U.

H

ellw

eg 15

E

ffec

tiven

ess

of P

T a

nd O

T fo

r pa

tient

s in

the

IC

U w

ith tr

aum

atic

bra

in in

jury

.34

a D

ata

conc

erni

ng th

e ef

fect

iven

ess

of P

T a

nd O

T fo

r pa

tient

s in

the

ICU

with

trau

mat

ic b

rain

inju

ry a

re v

ery

limite

d, m

akin

g it

impo

ssib

le to

off

er c

lear

, ev

iden

ce-b

ased

rec

omm

enda

tions

. Res

pira

tory

PT

has

not

bee

n sh

own

to b

e ef

fect

ive

for

the

prev

entio

n or

Rx

of V

AP.

The

effi

cacy

of o

ther

PT

and

OT

in

terv

entio

ns m

ust s

till b

e de

mon

stra

ted.

LO

S 5

leng

th o

f sta

y; M

H 5

man

ual h

yper

infl a

tion;

OT

5 o

ccup

atio

nal t

hera

py; P

T 5

phy

siot

hera

py o

r ph

ysic

al th

erap

y; R

x 5 tr

eatm

ent;

VAP

5 ve

ntila

tor-

asso

ciat

ed p

neum

onia

. a I

ndic

ates

the

num

ber

of a

rtic

les

in th

e re

fere

nce

list (

num

ber

of s

tudi

es in

clud

ed in

rev

iew

not

spe

cifi c

ally

sta

ted)

.

Tabl

e 1—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

830 Original Research

Tabl

e 2—

Cha

ract

eris

tics

of

Stu

dies

Eva

luat

ing

Mu

ltim

odal

ity

Res

pira

tory

Phy

siot

hera

py

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

Pros

pect

ive,

rand

omiz

ed,

co

ntro

lled/

com

para

tive

tria

ls

Patm

an e

t al 16

21

0, in

tuba

ted,

m

echa

nica

lly

vent

ilate

d,

post

-car

diac

su

rger

y.

Con

trol

: sta

ndar

d m

edic

al/n

ursi

ng c

are.

Dur

atio

n of

intu

batio

n,

ICU

and

hos

pita

l LO

S,

inci

denc

e of

pos

tope

rativ

e pu

lmon

ary

com

plic

atio

ns.

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n gr

oups

for

any

outc

ome.

For

rou

tine,

unc

ompl

icat

ed c

ardi

ac

surg

ery

subj

ects

, the

pro

visi

on o

f PT

in

terv

entio

ns d

urin

g th

e po

stop

erat

ive

intu

batio

n pe

riod

did

not

impr

ove

outc

omes

.

Rx:

as

for

cont

rol p

lus

PT

as in

dica

ted,

incl

udin

g po

sitio

ning

, MH

, suc

tion.

Te

mpl

eton

and

Pal

azzo

17

180,

intu

bate

d,

mec

hani

cally

ve

ntila

ted

. 4

8 h.

Con

trol

: sta

ndar

d m

edic

al/n

ursi

ng c

are.

Tim

e to

bec

ome

vent

ilato

r-fr

ee,

ICU

and

hos

pita

l mor

talit

y,

ICU

LO

S.

Med

ian

time

for

50%

to b

ecom

e ve

ntila

tor-

free

sig

nifi c

antly

long

er

in R

x gr

oup.

No

sign

ifi ca

nt

diff

eren

ce b

etw

een

grou

ps fo

r an

y ot

her

outc

ome.

Stan

dard

car

e is

at l

east

as

effe

ctiv

e as

ch

est P

T in

pat

ient

s re

quir

ing

mec

hani

cal v

entil

atio

n .

48

h.R

x: a

s fo

r co

ntro

l plu

s re

spir

ator

y PT

as

indi

cate

d,

incl

udin

g po

sitio

ning

, MH

, ch

est w

all v

ibra

tions

, suc

tion.

Pa

tman

et a

l 18

144,

intu

bate

d,

mec

hani

cally

ve

ntila

ted

. 2

4 h,

acq

uire

d br

ain

inju

ry.

Con

trol

: sta

ndar

d m

edic

al/n

ursi

ng c

are.

Inci

denc

e of

VA

P, d

urat

ion

of m

echa

nica

l ven

tilat

ion,

IC

U a

nd h

ospi

tal L

OS,

C

PIS

scor

es, P

a o 2 /F

io 2 .

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n gr

oups

for

any

outc

ome.

A r

egul

ar r

espi

rato

ry P

T r

egim

en in

ad

ditio

n to

rou

tine

med

ical

/nur

sing

ca

re d

id n

ot s

igni

fi can

tly d

ecre

ase

the

inci

denc

e of

VA

P, d

urat

ion

of

mec

hani

cal v

entil

atio

n or

IC

U L

OS

in a

dults

with

acq

uire

d br

ain

inju

ry.

Rx:

as

for

cont

rol p

lus

resp

irat

ory

PT, i

nclu

ding

po

sitio

ning

, MH

, suc

tion,

6

times

/d.

Pa

ttans

hetty

and

Gau

de 19

101

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted

. 4

8 h.

Con

trol

: MH

and

suc

tion

bid.

CPI

S sc

ore,

mor

talit

y,

wea

ning

suc

cess

, dur

atio

n of

intu

batio

n, I

CU

LO

S.

Red

uctio

n in

CPI

S sc

ore

sign

ifi ca

ntly

gr

eate

r in

Rx

grou

p. W

eani

ng s

ucce

ss

sign

ifi ca

ntly

hig

her

in R

x gr

oup.

M

orta

lity

sign

ifi ca

ntly

low

er in

Rx

grou

p. N

o si

gnifi

cant

diff

eren

ce

betw

een

grou

ps fo

r du

ratio

n of

in

tuba

tion

or I

CU

LO

S.

Mul

timod

ality

res

pira

tory

PT

bid

de

crea

sed

CPI

S sc

ores

, sug

gest

ing

a de

crea

se in

VA

P an

d m

orta

lity

rate

s.R

x: a

s fo

r co

ntro

l plu

s po

sitio

ning

, che

st w

all

vibr

atio

ns.

B

arke

r an

d A

dam

s 20

17, i

ntub

ated

, m

echa

nica

lly

vent

ilate

d, A

LI.

Gro

up 1

: sup

ine

30°

head

-up,

3-

min

pre

oxyg

enat

ion

(F io

2 5 1

), su

ctio

n.

Pa o

2 , Pa

co 2 ,

dyna

mic

re

spir

ator

y co

mpl

ianc

e,

peak

air

way

pre

ssur

e,

HR

, BP,

S vo

2 bef

ore

and

10-,

30-,

and

60-m

in

post

-Rx.

Sign

ifi ca

nt c

hang

es o

bser

ved

in P

a co

2 an

d co

mpl

ianc

e ov

er ti

me

for

all t

hree

gr

oups

(Pa c

o 2 i

ncre

ased

, com

plia

nce

decr

ease

d 10

-min

pos

t-R

x). P

a o 2 /F

io 2

and

S vo

2 did

not

sig

nifi c

antly

cha

nge

in a

ny g

roup

. S vo

2 was

sig

nifi c

antly

lo

wer

in g

roup

2. H

R a

nd B

P sh

owed

si

gnifi

cant

, but

not

clin

ical

ly im

port

ant,

chan

ges

over

tim

e.

Dis

conn

ectio

n of

pat

ient

s w

ith A

LI

from

m

echa

nica

l ven

tilat

ion

for

PT R

x ca

n re

sult

in s

igni

fi can

t der

ecru

itmen

t of t

he

lung

s an

d al

tere

d ph

ysio

logy

. The

use

of

MH

doe

s no

t app

ear

to o

verr

ide

the

loss

of P

EE

P an

d th

e de

recr

uitm

ent

effe

cts.

Gro

up 2

: as

for

grou

p 1,

then

po

sitio

ned

(L a

nd R

fl at

si

de ly

ing)

, suc

tion.

Gro

up 3

: as

for

grou

p 2,

pl

us M

H.

(Con

tinu

ed)

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 831

Tabl

e 2—

Con

tinu

ed

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

Pros

pect

ive,

rand

omiz

ed,

cros

sove

r tr

ials

D

enni

s et

al 21

46

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted,

at

elec

tasi

s or

co

nsol

idat

ion

on C

XR

.

Con

trol

: pos

ition

ing,

VH

, ch

est-

wal

l vib

ratio

ns,

suct

ion.

Sput

um w

eigh

t, V t

, HR

, M

AP,

dyn

amic

res

pira

tory

co

mpl

ianc

e, a

irw

ay

pres

sure

, Pa o

2 /F io

2 bef

ore,

im

med

iate

ly a

nd 3

0-m

in

post

-Rx.

Sign

ifi ca

ntly

hig

her

airw

ay p

ress

ure

with

MH

than

VH

. No

sign

ifi ca

nt

diff

eren

ce b

etw

een

Rxs

for

othe

r ou

tcom

es.

VH

was

as

safe

and

eff

ectiv

e du

ring

re

spir

ator

y PT

Rx

as M

H, w

hen

appl

ied

with

the

sam

e pa

ram

eter

s and

pre

caut

ions

. V

H h

as p

oten

tial a

dvan

tage

s ov

er M

H,

the

bigg

est b

eing

that

no

vent

ilato

r circ

uit

disc

onne

ctio

n is

requ

ired.

Rx:

as

for

cont

rol e

xcep

t MH

no

t VH

.

U

noki

et a

l 22

31, i

ntub

ated

, lik

ely

to

requ

ire

mec

hani

cal

vent

ilatio

n .

48

h.

Con

trol

: pos

ition

ing,

suc

tion.

Pa o

2 /F io

2 , Pa

co 2 ,

dyna

mic

re

spir

ator

y co

mpl

ianc

e,

sput

um w

eigh

t bef

ore

and

25-m

in p

ost-

Rx.

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n R

xs fo

r an

y ou

tcom

e. N

o si

gnifi

cant

di

ffer

ence

see

n fr

om p

re- t

o po

st-R

x fo

r an

y ou

tcom

e.

The

rou

tine

use

of r

ib-c

age

com

pres

sion

is

not

rec

omm

ende

d in

a g

ener

al

popu

latio

n of

mec

hani

cally

ven

tilat

ed

patie

nts.

Rx:

as

for

cont

rol p

lus

5-m

in e

xpir

ator

y ri

b-ca

ge

com

pres

sion

pre

suct

ion.

G

enc

et a

l 23

22, i

ntub

ated

, m

echa

nica

lly

vent

ilate

d.

Con

trol

: pos

ition

ing,

5-m

in

MH

, suc

tion.

Pa o

2 /F io

2 , Pa

co 2 ,

stat

ic

resp

irat

ory

com

plia

nce,

sp

utum

wei

ght,

V t , H

R,

MA

P be

fore

and

5- a

nd

20-m

in p

ost-

Rx.

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n R

xs

for

any

outc

ome.

Com

plia

nce

and

V t s

igni

fi can

tly in

crea

sed

from

pr

e- to

pos

t-R

x. N

o si

gnifi

cant

ch

ange

in o

ther

out

com

es.

The

rou

tine

use

of r

ib-c

age

com

pres

sion

du

ring

MH

is n

ot r

ecom

men

ded

in

a ge

nera

l pop

ulat

ion

of m

echa

nica

lly

vent

ilate

d pa

tient

s.R

x: a

s fo

r co

ntro

l plu

s ex

pira

tory

rib

-cag

e co

mpr

essi

on d

urin

g M

H.

B

erne

y et

al 24

20

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted.

Con

trol

: sid

e ly

ing

fl at,

MH

, su

ctio

n.Sp

utum

wei

ght,

PEF

R

duri

ng M

H, s

tatic

re

spir

ator

y co

mpl

ianc

e be

fore

and

imm

edia

tely

po

st-R

x.

Sign

ifi ca

ntly

mor

e sp

utum

and

hig

her

PEF

R d

urin

g R

x w

ith h

ead-

dow

n til

t. C

ompl

ianc

e si

gnifi

cant

ly

impr

oved

ove

r tim

e, n

o si

gnifi

cant

di

ffer

ence

bet

wee

n R

xs.

The

hea

d-do

wn

tilt p

ositi

on s

houl

d be

co

nsid

ered

whe

n th

e pr

imar

y ai

m

of R

x is

spu

tum

rem

oval

for

intu

bate

d,

mec

hani

cally

ven

tilat

ed p

atie

nts.

Rx:

as

for

cont

rol b

ut s

ide

lyin

g in

hea

d-do

wn

tilt.

H

odgs

on e

t al 25

20

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted.

Rx

1: p

ositi

onin

g, M

H w

ith

Map

leso

n C

cir

cuit,

suc

tion.

Sput

um w

eigh

t, st

atic

re

spira

tory

com

plia

nce,

V t ,

Pa

o 2 /F

io 2 ,

Pa co

2 bef

ore,

30

-, an

d 60

-min

pos

t-R

x.

MH

with

Map

leso

n C

cir

cuit

clea

red

sign

ifi ca

ntly

mor

e sp

utum

. No

sign

ifi ca

nt d

iffer

ence

bet

wee

n R

xs

for

othe

r ou

tcom

es.

Mor

e se

cret

ions

wer

e cl

eare

d us

ing

the

Map

leso

n C

com

pare

d w

ith th

e L

aerd

al c

ircu

it; h

owev

er, t

his

had

no

cons

eque

nce

in te

rms

of o

xyge

natio

n.R

x 2:

as

for

Rx

1 ex

cept

MH

w

ith L

aerd

al c

ircu

it.

Ber

ney

and

Den

ehy 26

20

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted.

Rx

1: p

ositi

onin

g, M

H,

suct

ion.

Sput

um w

eigh

t, st

atic

re

spir

ator

y co

mpl

ianc

e be

fore

, im

med

iate

ly

and

30-m

in p

ost-

Rx.

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n R

xs

in s

putu

m w

eigh

t or

com

plia

nce.

C

ompl

ianc

e si

gnifi

cant

ly im

prov

ed

afte

r bo

th R

xs.

VH

was

as

effe

ctiv

e as

MH

in s

putu

m

clea

ranc

e an

d im

prov

ing

resp

irat

ory

com

plia

nce.

Rx

2: a

s fo

r R

x 1

exce

pt V

H.

H

odgs

on e

t al 27

18

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted,

lung

co

llaps

e an

d/or

co

nsol

idat

ion

on C

XR

, Pa

o 2 /F io

2 , 35

0.

Con

trol

: pos

ition

ing,

suc

tion.

Stat

ic r

espi

rato

ry c

ompl

ianc

e,

Pa o

2 /F io

2 , Pa

co 2 ,

sput

um

wei

ght,

HR

, MA

P be

fore

, im

med

iate

ly a

nd 2

0-m

in

post

-Rx.

Sign

ifi ca

ntly

gre

ater

incr

ease

in

com

plia

nce

and

sput

um w

eigh

t for

M

H R

x. I

ncre

ase

in c

ompl

ianc

e se

en

imm

edia

tely

and

20-

min

pos

t-R

x. N

o si

gnifi

cant

diff

eren

ce b

etw

een

Rxs

fo

r ot

her

outc

omes

.

Res

pira

tory

com

plia

nce

and

sput

um

clea

ranc

e w

ere

impr

oved

by

the

addi

tion

of M

H to

a R

x of

pos

ition

ing

and

suct

ioni

ng w

ithou

t com

prom

ise

to

card

iova

scul

ar s

tabi

lity

or g

as e

xcha

nge.

Rx:

as

for

cont

rol p

lus

MH

.

(Con

tinu

ed)

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

832 Original Research

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

C

hoi a

nd J

ones

28

15, i

ntub

ated

, m

echa

nica

lly

vent

ilate

d, V

AP.

Con

trol

: sup

ine,

suc

tion.

Stat

ic r

espi

rato

ry c

ompl

ianc

e,

airw

ay r

esis

tanc

e be

fore

, im

med

iate

ly a

nd 3

0-m

in

post

-Rx.

Sign

ifi ca

ntly

gre

ater

incr

ease

in

com

plia

nce

for

MH

Rx.

Sig

nifi c

ant

decr

ease

in a

irw

ay r

esis

tanc

e 30

-min

po

st-M

H R

x bu

t not

con

trol

Rx.

Suct

ion

alon

e di

d no

t cau

se d

eter

iora

tion

in c

ompl

ianc

e an

d ai

rway

res

ista

nce

and

can

prob

ably

be

used

saf

ely

in p

atie

nts

with

VA

P. T

he a

dditi

on o

f MH

impr

oved

re

spir

ator

y m

echa

nics

com

pare

d w

ith

suct

ion

alon

e.

Rx:

as

for

cont

rol p

lus

MH

.

Sa

vian

et a

l 29

14, i

ntub

ated

, m

echa

nica

lly

vent

ilate

d.

Rx

1: p

ositi

onin

g, M

H,

suct

ion.

PEF

R, V

t , P

a o 2 /F

io 2 ,

stat

ic

resp

irato

ry c

ompl

ianc

e, H

R,

MA

P, s

putu

m w

eigh

t, c

o 2

befo

re, i

mm

edia

tely

and

30

-min

pos

t-R

x.

Sign

ifi ca

ntly

hig

her

PEF

R w

ith M

H.

Sign

ifi ca

ntly

hig

her

V t w

ith V

H.

co 2

sign

ifi ca

ntly

diff

eren

t bet

wee

n R

xs

(upw

ard

tren

d M

H, d

ownw

ard

tren

d V

H).

No

sign

ifi ca

nt d

iffer

ence

be

twee

n R

xs fo

r ot

her

outc

omes

.

VH

pro

mot

ed g

reat

er im

prov

emen

ts in

re

spira

tory

mec

hani

cs w

ith le

ss m

etab

olic

di

stur

banc

e th

an M

H. O

ther

var

iabl

es

such

as s

putu

m p

rodu

ctio

n, h

emod

ynam

ics

and

oxyg

enat

ion

wer

e af

fect

ed s

imila

rly

by b

oth

tech

niqu

es.

Rx

2: a

s fo

r R

x 1

exce

pt V

H.

Pros

pect

ive,

syst

emat

ical

ly

allo

cate

d,

cont

rolle

d tr

ial

N

toum

enop

oulo

s et a

l 30

60, i

ntub

ated

, m

echa

nica

lly

vent

ilate

d �

48

h.

Con

trol

: sid

e ly

ing,

suc

tion

as

requ

ired

.In

cide

nce

of V

AP,

CPI

S sc

ore,

du

ratio

n of

mec

hani

cal

vent

ilatio

n, I

CU

LO

S,

ICU

and

28-

d m

orta

lity.

Sign

ifi ca

ntly

low

er in

cide

nce

of V

AP

and

CPI

S sc

ore

in R

x gr

oup.

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n gr

oups

for

othe

r ou

tcom

es.

Res

pira

tory

PT

was

inde

pend

ently

as

soci

ated

with

a r

educ

tion

in V

AP.

Rx:

pos

ition

ing,

exp

irato

ry

ches

t wal

l vib

ratio

ns,

suct

ion,

bid

.Pr

ospe

ctiv

e,

hi

stor

ical

co

ntro

lled

tria

l

Mal

koç

et a

l 31

510,

intu

bate

d,

mec

hani

cally

ve

ntila

ted.

Con

trol

(his

tori

cal):

sta

ndar

d nu

rsin

g ca

re.

Dur

atio

n of

mec

hani

cal

vent

ilatio

n, I

CU

LO

S.Si

gnifi

cant

ly s

hort

er d

urat

ion

of

mec

hani

cal v

entil

atio

n an

d IC

U

LO

S in

Rx

grou

p.

PT c

an r

educ

e th

e pe

riod

of R

x re

quir

ed

in I

CU

.R

x: p

ositi

onin

g, p

ercu

ssio

n,

vibr

atio

n, c

ough

ing,

dee

p br

eath

ing,

suc

tion,

bed

ex

erci

ses,

mob

iliza

tion

(not

des

crib

ed),

bid,

5

d/w

k.(C

onti

nued

)

Tabl

e 2—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 833

From the two prospective observational studies, Thomas et al 32 found that lateral positioning had no signifi cant effect on oxygenation of 34 patients on mechanical ventilation and Clarke et al, 33 studying 25 patients on mechanical ventilation, reported that manual hyperventilation can result in higher infl ation pressures in patients with susceptible lungs.

Mobilization: For the purposes of this review, the definition of mobilization provided by Stiller 1 has been used, whereby mobilization is a broad term that encompasses active limb exercises, actively moving or turning in bed, sitting on the edge of the bed, sitting out of bed in a chair (via mechanical lifting machines, slide board, or standing transfer), standing, and walking. Twenty-six clinical trials were identifi ed that evaluated the use of mobilization interventions. 34-59 Table 3 summarizes their characteristics. There were three RCTs, 34-36 fi ve nonrandomized controlled trials, 37-41 one historical controlled study, 42 and 17 observational studies. 43-59

The largest prospective RCT, by Schweickert et al, 34 involved 104 patients who had been mechanically ventilated for , 72 h and were likely to require venti-lation for a further 24 h. The patients were randomly allocated to receive daily sedative interruption fol-lowed by therapy that concentrated on mobilization activities (eg, range of motion exercises, functional tasks, sit/stand/walk) or daily sedative interruption and standard medical/nursing care. Compared with the control group, the treatment group demonstrated a signifi cantly shorter duration of delirium and mechan-ical ventilation, and signifi cantly more patients in the treatment group achieved an independent functional status at hospital discharge. The second prospective RCT, involving 90 patients whose ICU LOS was anticipated as being . 7 days, investigated the effec-tiveness of adding cycling exercise using a bedside cycle ergometer to a standard physiotherapy mobili-zation regimen (ie, limb exercises, walk). 35 While no signifi cant differences were found between groups at ICU discharge, the treatment group achieved sig-nifi cantly higher distances in the 6-min walk test than the control group at hospital discharge and their quadriceps strength improved signifi cantly between ICU and hospital discharge. The third RCT, by Chang et al, 36 prospectively investigated the effect of sitting out of bed (for at least 30 min, most often on a daily basis) on the respiratory muscle strength of 34 patients over a 6-day study period. The patients in the con-trol group were positioned supine or semirecumbent in bed. No signifi cant differences were seen between groups.

Two of the fi ve nonrandomized controlled stud ies pro-spectively allocated patients to a control group (standard medical/nursing care) or a treatment group (progressive St

udy

Part

icip

ants

, No.

, Ty

peIn

terv

entio

nO

utco

mes

Res

ults

Sum

mar

y of

Aut

hors

’ Con

clus

ions

Pros

pect

ive,

obse

rvat

iona

l stu

dies

T

hom

as e

t al 32

34

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted

with

or

with

out

pulm

onar

y in

fi ltr

ates

on

CX

R.

90°

side

lyin

g.Pa

o 2 /F

io 2 ,

Pa co

2 , V t

, dy

nam

ic re

spira

tory

co

mpl

ianc

e, a

irway

pre

ssur

e,

MA

P, H

R, c

ardi

ac in

dex,

ad

vers

e ev

ents

bef

ore,

du

ring

, and

30-

and

12

0-m

in p

ost-

Rx.

No

sign

ifi ca

nt c

hang

e in

Pa o

2 /F io

2 , Pa

co 2 ,

MA

P, H

R.

The

resu

lts d

id n

ot su

ppor

t the

use

of l

ater

al

posi

tioni

ng to

impr

ove

oxyg

enat

ion

in

vent

ilate

d pa

tient

s w

ithou

t lun

g pa

thol

ogy

or w

ith p

ulm

onar

y in

fi ltr

ates

.C

ompl

ianc

e an

d V t

sig

nifi c

antly

de

crea

sed

duri

ng p

ositi

onin

g, c

ardi

ac

inde

x si

gnifi

cant

ly in

crea

sed

30-m

in

post

-Rx.

21%

inci

denc

e of

adv

erse

ev

ents

(min

or, t

rans

ient

).

Cla

rke

et a

l 33

25, s

edat

ed,

intu

bate

d,

mec

hani

cally

ve

ntila

ted.

Man

ual h

yper

vent

ilatio

n w

ith M

aple

son

C c

ircu

it.V t

, pea

k ai

rway

pre

ssur

e,

Pa o

2 , Pa

co 2 b

efor

e,

duri

ng, a

nd im

med

iate

ly

post

-Rx.

Sign

ifi ca

nt n

egat

ive

corr

elat

ion

betw

een

aver

age

V t a

nd lu

ng in

jury

sco

re.

Sign

ifi ca

nt p

ositi

ve c

orre

latio

n be

twee

n av

erag

e pe

ak a

irw

ay p

ress

ure

and

lung

in

jury

scor

e. P

a o 2 s

igni

fi can

tly im

prov

ed

from

pre

- to

imm

edia

tely

pos

t-R

x. N

o si

gnifi

cant

cha

nge

in P

a co

2 .

Man

ual h

yper

vent

ilatio

n ca

uses

hig

her

infl a

tion

pres

sure

s an

d sm

alle

r V t

s as

th

e lu

ng s

core

incr

ease

s, s

ugge

stin

g an

in

crea

sed

pote

ntia

l for

bar

otra

uma

or

volu

trau

ma

in s

usce

ptib

le lu

ngs.

AL

I 5 ac

ute

lung

inju

ry; C

PIS

5 cl

inic

al p

ulm

onar

y in

fect

ion

scor

e; C

XR

5 ch

est

radi

ogra

ph; H

R 5

hea

rt r

ate;

L 5

left

; MA

P 5

mea

n ar

teri

al B

P; P

EE

P 5

pos

itive

end

exp

irat

ory

pres

sure

; PE

FR

5 p

eak

expi

rato

ry fl

ow r

ate;

R 5

righ

t; S v

o 2 5

mix

ed v

enou

s ox

ygen

sat

urat

ion;

co

2 5 C

O 2 o

utpu

t; V

H 5

vent

ilato

r hy

peri

nfl a

tion;

V t

5 ti

dal v

olum

e. S

ee T

able

1 le

gend

for

expa

nsio

n of

oth

er a

bbre

viat

ions

.

Tabl

e 2—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

834 Original Research

Tabl

e 3—

Cha

ract

eris

tics

of

Stu

dies

Eva

luat

ing

Mob

iliz

atio

n

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

Pros

pect

ive,

ran

dom

ized

,

cont

rolle

d/co

mpa

rativ

e tr

ials

Sc

hwei

cker

t et a

l 34

104,

intu

bate

d,

mec

hani

cally

ve

ntila

ted

, 7

2 h,

lik

ely

to

cont

inue

� 2

4 h.

Con

trol

: dai

ly s

edat

ive

inte

rrup

tion

and

stan

dard

ca

re (i

nclu

ded

PT a

nd O

T

per

prim

ary

care

team

).

Ret

urn

to in

depe

nden

t fu

nctio

nal s

tatu

s at

hos

pita

l D

C, d

urat

ion

of d

elir

ium

an

d m

echa

nica

l ven

tilat

ion,

ve

ntila

tor-

free

day

s, I

CU

an

d ho

spita

l LO

S, a

dver

se

even

ts.

Ret

urn

to in

depe

nden

t fun

ctio

nal

stat

us a

t hos

pita

l DC

occ

urre

d in

si

gnifi

cant

ly m

ore

Rx

grou

p pa

tient

s.

Dur

atio

n of

del

iriu

m a

nd m

echa

nica

l ve

ntila

tion

sign

ifi ca

ntly

sho

rter

in R

x gr

oup.

Ven

tilat

or-f

ree

days

, and

IC

U

and

hosp

ital L

OS

not s

igni

fi can

tly

diff

eren

t bet

wee

n gr

oups

. Ser

ious

ad

vers

e ev

ents

: 0.2

%.

Seda

tion

inte

rrup

tion

and

PT/O

T

in th

e ea

rlie

st d

ays

of c

ritic

al

illne

ss w

as s

afe

and

wel

l to

lera

ted,

res

ulte

d in

bet

ter

func

tiona

l out

com

es a

t hos

pita

l D

C, s

hort

er d

urat

ion

of

delir

ium

, and

mor

e ve

ntila

tor-

free

day

s.

Rx:

dai

ly s

edat

ive

inte

rrup

tion

for

PT a

nd O

T (e

g, R

OM

ex

erci

ses,

bed

mob

ility

, fu

nctio

nal a

nd A

DL

task

s,

sit/s

tand

/wal

k).

B

urtin

et a

l 35

90, c

ritic

ally

ill,

antic

ipat

ed

ICU

LO

S .

7 d

po

stre

crui

tmen

t.

Con

trol

: sta

ndar

d PT

m

obili

zatio

n (li

mb

exer

cise

s,

wal

k), 5

d/w

k.

6MW

D a

t hos

pita

l DC

, qu

adri

ceps

forc

e, fu

nctio

nal

stat

us (s

it-to

-sta

nd [B

BS]

an

d ph

ysic

al fu

nctio

ning

[S

F-3

6]) a

t IC

U a

nd h

ospi

tal

DC

, adv

erse

eve

nts.

6MW

D a

nd S

F-3

6 su

bsco

re

sign

ifi ca

ntly

hig

her

in R

x gr

oup

at h

ospi

tal D

C. Q

uadr

icep

s for

ce

impr

oved

sign

ifi ca

ntly

mor

e be

twee

n IC

U a

nd h

ospi

tal D

C in

Rx

grou

p.

Abi

lity

to s

tand

inde

pend

ently

(B

BS

� 2

) not

sig

nifi c

antly

di

ffer

ent b

etw

een

grou

ps.

Seri

ous

adve

rse

even

ts: 0

%.

Whe

n in

stitu

ted

earl

y in

IC

U

surv

ivor

s w

ith a

pro

long

ed

stay

, exe

rcis

e tr

aini

ng m

ay

enha

nce

reco

very

of

func

tiona

l exe

rcis

e ca

paci

ty,

func

tiona

l sta

tus,

and

qu

adri

ceps

forc

e at

ho

spita

l DC

.

Rx:

as

for

cont

rol p

lus

cycl

ing

exer

cise

(bed

side

cyc

le

ergo

met

er),

20 m

in, 5

d/w

k.

C

hang

et a

l 36

34, m

echa

nica

lly

vent

ilate

d �

72

h,

able

to tr

ansf

er to

ch

air

with

two

nurs

es.

Con

trol

: pos

ition

ed s

upin

e to

se

mi-r

ecum

bent

, no

PT.

Rap

id s

hallo

w b

reat

hing

inde

x,

V t , r

espi

rato

ry m

uscl

e st

reng

th b

efor

e an

d 30

-min

po

stin

terv

entio

n ov

er 6

-d

tria

l per

iod.

No

sign

ifi ca

nt d

iffer

ence

s be

twee

n gr

oups

for

any

outc

ome

over

6-

d tr

ial p

erio

d.

6 d

of c

hair

sitt

ing

was

inef

fect

ive

at im

prov

ing

resp

irat

ory

mus

cle

func

tion

in

mec

hani

cally

ven

tilat

ed

patie

nts

in th

e IC

U.

Rx:

sit

in c

hair,

30-

120

min

, at

leas

t 3 d

/wk.

Pros

pect

ive,

nonr

ando

miz

ed,

cont

rolle

d tr

ials

M

orri

s et

al 37

33

0, in

tuba

ted,

m

echa

nica

lly

vent

ilate

d, a

cute

re

spir

ator

y fa

ilure

.

Con

trol

: sta

ndar

d m

edic

al/n

ursi

ng c

are.

Prop

ortio

n re

ceiv

ing

ICU

PT,

da

ys u

ntil

fi rst

out

of b

ed,

vent

ilato

r da

ys, I

CU

and

ho

spita

l LO

S, a

dver

se

even

ts.

ICU

PT

pro

vide

d to

sig

nifi c

antly

m

ore

patie

nts

in R

x gr

oup.

R

x gr

oup

fi rst

out

of b

ed

sign

ifi ca

ntly

ear

lier.

ICU

and

ho

spita

l LO

S si

gnifi

cant

ly s

hort

er

in R

x gr

oup.

Ven

tilat

or d

ays

not

sign

ifi ca

ntly

diff

eren

t bet

wee

n gr

oups

. Ser

ious

adv

erse

eve

nts:

0%.

Impl

emen

tatio

n of

an

earl

y m

obili

ty p

roto

col b

y a

mob

ility

te

am r

esul

ted

in m

ore

PT

sess

ions

and

was

ass

ocia

ted

with

a s

hort

er L

OS

for

hosp

ital

surv

ivor

s.

Rx:

pro

gres

sive

mob

iliza

tion

(eg,

RO

M e

xerc

ises,

func

tiona

l ta

sks,

sit/

stan

d/w

alk)

from

a

mob

ility

team

, 7 d

/wk.

(Con

tinu

ed)

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 835

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

Ya

ng e

t al 38

12

6, m

echa

nica

lly

vent

ilate

d .

14

d.C

ontr

ol: r

outin

e pa

ssiv

e jo

int

exer

cise

s by

nur

ses

5-10

min

, bi

d.

Rap

id s

hallo

w b

reat

hing

in

dex,

BI,

wea

ning

suc

cess

. Ti

min

g no

t cle

ar.

Rap

id s

hallo

w b

reat

hing

inde

x di

d no

t sig

nifi c

antly

cha

nge.

BI

sign

ifi ca

ntly

impr

oved

ove

r tim

e in

Rx

grou

p (n

ot c

lear

wha

t ha

ppen

ed to

con

trol

). W

eani

ng

succ

ess

rate

hig

her

in R

x gr

oup

(sig

nifi c

ance

not

sta

ted)

.

Not

sta

ted.

Rx:

bre

athi

ng tr

aini

ng, p

rogr

essiv

e m

obili

zatio

n (e

g, p

assi

ve/a

ctiv

e R

OM

exe

rcis

es, s

it/st

and/

wal

k),

30 m

in, d

aily

, 5 ti

mes

/wk.

W

inke

lman

et a

l 39

75, m

echa

nica

lly

vent

ilate

d .

48

h, li

kely

to

con

tinue

� 2

4 h.

Con

trol

pha

se: s

tand

ard

med

ical

/nur

sing

car

e.In

fl am

mat

ory

biom

arke

rs,

HR

, RR

, sys

tolic

BP,

Sp o

2 , ad

vers

e ev

ents

ove

r 7-

d tr

ial p

erio

d. D

urat

ion

of

mec

hani

cal v

entil

atio

n,

ICU

LO

S.

Dai

ly e

xerc

ise

linke

d to

incr

ease

d IL

-10.

HR

, RR

, sys

tolic

BP,

Sp o

2 no

t sig

nifi c

antly

diff

eren

t bet

wee

n co

ntro

l and

Rx

phas

es. S

erio

us

adve

rse

even

ts: ,

5%

. Dur

atio

n of

ve

ntila

tion

not s

igni

fi can

tly d

iffer

ent

betw

een

phas

es. I

CU

LO

S sig

nifi c

antly

shor

ter d

urin

g R

x ph

ase.

The

res

ults

sho

uld

enco

urag

e cl

inic

ians

to a

dd m

obili

ty

prot

ocol

s to

the

care

of

patie

nts

in th

e IC

U.

Rx

phas

e: p

rogr

essi

ve

mob

iliza

tion

(per

Mor

ris e

t al 37

), 20

min

, dai

ly, 2

-7 d

.

N

eedh

am e

t al 40

57

, mec

hani

cally

ve

ntila

ted

. 4

d.

Con

trol

pha

se: s

tand

ard

med

ical

/nur

sing

car

e.Pr

eval

ence

of d

eep

seda

tion

and

delir

ium

, fun

ctio

nal

mob

ility

, IC

U a

nd h

ospi

tal

LO

S, a

dver

se e

vent

s.

Prev

alen

ce o

f dee

p se

datio

n an

d de

liriu

m si

gnifi

cant

ly lo

wer

dur

ing

Rx

phas

e. F

unct

iona

l mob

ility

sig

nifi c

antly

bet

ter d

urin

g R

x ph

ase.

Si

gnifi

cant

ly sh

orte

r IC

U a

nd

hosp

ital L

OS

durin

g R

x ph

ase

com

pare

d w

ith p

rior

yea

r. Se

riou

s ad

vers

e ev

ents

: 0%

.

Red

ucin

g de

ep s

edat

ion

and

incr

easi

ng e

arly

mob

iliza

tion

resu

lted

in s

ubst

antia

l im

prov

emen

ts in

IC

U d

elir

ium

an

d fu

nctio

nal m

obili

ty, w

ith

a de

crea

se in

IC

U a

nd

hosp

ital L

OS.

Rx

phas

e: r

educ

ed s

edat

ion,

ea

rly

prog

ress

ive

mob

iliza

tion

(eg,

sit/

stan

d/w

alk)

.

C

hian

g et

al 41

32

, mec

hani

cally

ve

ntila

ted

. 1

4 d.

Con

trol

: sta

ndar

d m

edic

al/n

ursin

g ca

re in

clud

ing

prom

otio

n of

m

obili

zatio

n (e

g, e

xerc

ises

, w

alk)

.

Res

pira

tory

mus

cle

stre

ngth

, up

per

and

low

er li

mb

stre

ngth

, BI,

FIM

, ve

ntila

tor-

free

tim

e at

3

and

6 w

k.

Res

pira

tory

mus

cle

and

limb

stre

ngth

sig

nifi c

antly

incr

ease

d at

3

and

6 w

k in

Rx

grou

p bu

t not

co

ntro

l gro

up. B

I and

FIM

scor

es

signi

fi can

tly h

ighe

r in

Rx

grou

p th

an

cont

rol g

roup

at 3

and

6 w

k.

Vent

ilato

r-fr

ee ti

me

incr

ease

d si

gnifi

cant

ly in

Rx

grou

p bu

t not

con

trol

gro

up a

t 6 w

k.

A 6

-wk

phys

ical

trai

ning

pro

gram

m

ay im

prov

e lim

b m

uscl

e st

reng

th a

nd v

entil

ator

-fre

e tim

e an

d im

prov

e fu

nctio

nal

outc

omes

in p

atie

nts

requ

irin

g pr

olon

ged

mec

hani

cal

vent

ilatio

n.

Rx:

pro

gres

sive

mob

iliza

tion

(eg,

str

engt

heni

ng a

nd

RO

M e

xerc

ises,

sit/s

tand

/wal

k),

5 tim

es/w

k fo

r 6

wk.

Pros

pect

ive,

his

tori

cal

co

ntro

lled

tria

l

Bas

sett

et a

l 42

260,

not

sta

ted.

Con

trol

: his

tori

cal c

ontr

ol.

Vent

ilato

r da

ys,

vent

ilato

r-fr

ee d

ays,

IC

U

and

hosp

ital m

orta

lity,

IC

U

and

hosp

ital L

OS,

day

s to

st

andi

ng a

nd a

mbu

latin

g.

No

sign

ifi ca

nt d

iffer

ence

s be

twee

n gr

oups

for

any

outc

omes

.A

n ea

rly

mob

ility

pro

gram

im

prov

ed I

CU

team

focu

s on

th

e pr

oces

s of

ear

ly m

obili

ty,

but n

o si

gnifi

cant

diff

eren

ces

wer

e se

en in

qua

ntita

tive

outc

omes

.

Rx:

pro

gres

sive

mob

iliza

tion

(eg,

RO

M e

xerc

ises,

func

tiona

l ta

sks,

sit/

stan

d/w

alk)

.

(Con

tinu

ed)

Tabl

e 3—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

836 Original Research

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

Pros

pect

ive,

obs

erva

tiona

l

stud

ies

L

edits

chke

et a

l 43

106,

all

patie

nts

in I

CU

.U

sual

pra

ctic

e.F

requ

ency

of m

obili

zatio

n (s

it/st

and/

wal

k), a

dver

se

even

ts, b

arri

ers

to

mob

iliza

tion.

Patie

nts

wer

e m

obili

zed

on 5

4% o

f da

ys a

udite

d. A

dver

se e

vent

s: 1

%.

Avo

idab

le b

arri

ers

incl

uded

lo

catio

n of

vas

cula

r ac

cess

line

s,

sche

dulin

g of

mob

iliza

tion,

seda

tion.

Cri

tical

ly il

l pat

ient

s ca

n be

saf

ely

mob

ilize

d.

T

hom

sen

et a

l 44

104,

tran

sfer

red

from

gen

eral

IC

U to

a sp

ecifi

c re

spira

tory

IC

U,

mec

hani

cally

ve

ntila

ted

. 4

d,

resp

irat

ory

failu

re.

Ear

ly p

rogr

essi

ve

mob

iliza

tion

(eg,

sit/

wal

k)

follo

win

g tr

ansf

er.

Fre

quen

cy o

f am

bula

tion.

Prob

abili

ty o

f am

bula

tion

sign

ifi ca

ntly

in

crea

sed

afte

r tr

ansf

er to

the

resp

irat

ory

ICU

. Aft

er 2

d, n

umbe

r of

pat

ient

s am

bula

ting

incr

ease

d th

reef

old

com

pare

d w

ith

pret

rans

fer.

The

IC

U e

nvir

onm

ent m

ay

cont

ribu

te to

the

unne

cess

ary

imm

obili

zatio

n of

pat

ient

s w

ith

acut

e re

spir

ator

y fa

ilure

.

B

aile

y et

al 45

10

3, m

echa

nica

lly

vent

ilate

d .

4 d

, re

spir

ator

y fa

ilure

.

Ear

ly p

rogr

essi

ve

mob

iliza

tion

(eg,

sit/

wal

k).

Fea

sibi

lity,

adv

erse

eve

nts.

Tota

l of 1

,449

ear

ly m

obili

zatio

n ac

tiviti

es. A

dver

se e

vent

s: ,

1%

.E

arly

mob

iliza

tion

is fe

asib

le a

nd

safe

in r

espi

rato

ry fa

ilure

pa

tient

s.

Clin

i et a

l 46

77, t

rach

eost

omiz

ed,

diffi

cult

to w

ean.

Ear

ly r

ehab

ilita

tion

incl

udin

g pr

ogre

ssiv

e m

obili

zatio

n (e

g,

limb

exer

cise

s, sit

/sta

nd/w

alk)

, w

eani

ng p

roto

col,

nutr

ition

al

supp

ort.

Mor

talit

y, w

eani

ng s

ucce

ss,

BA

DL

sco

re a

t bas

elin

e an

d IC

U D

C, a

dver

se

even

ts.

Hos

pita

l mor

talit

y: 8

7%. W

eani

ng

succ

ess:

74%

. BA

DL

sco

re

impr

oved

. Adv

erse

eve

nts:

0%

.

Ear

ly r

ehab

ilita

tion

cont

ribu

tes

to B

AD

L re

cove

ry in

di

ffi cu

lt-to

-wea

n pa

tient

s.

G

arzo

n-Se

rran

o et

al 47

63

, all

patie

nts

in I

CU

.M

obili

zatio

n (e

g, li

mb

exer

cise

s,

bed

mob

ility

, sit/

stan

d/w

alk)

by

nur

sing

or

PT s

taff

.

Lev

el o

f mob

iliza

tion

achi

eved

, adv

erse

eve

nts.

PTs

mob

ilize

d pa

tient

s to

a

sign

ifi ca

ntly

hig

her

leve

l of

mob

ility

than

nur

sing

sta

ff.

Adv

erse

eve

nts:

0%

.

Rou

tine

invo

lvem

ent o

f PTs

in

dire

ctin

g m

obili

zatio

n R

x m

ay

prom

ote

earl

y m

obili

zatio

n of

cr

itica

lly il

l pat

ient

s.

Zann

i et a

l 48

32, m

echa

nica

lly

vent

ilate

d .

4 d

.M

obili

zatio

n (e

g, li

mb

exer

cise

s,

bala

nce,

func

tiona

l act

iviti

es,

sit/s

tand

/wal

k).

HR

, BP,

Sp o

2 bef

ore

and

post

sess

ion,

RO

M,

mus

cle

stre

ngth

, fu

nctio

nal o

utco

mes

, ad

vers

e ev

ents

.

HR

, BP,

Sp o

2 : m

inim

al c

hang

es

duri

ng s

essi

ons.

Low

er-li

mb

join

t co

ntra

ctur

es fr

eque

nt, d

id n

ot

impr

ove

duri

ng h

ospi

taliz

atio

n.

Lim

b w

eakn

ess

com

mon

, im

prov

ed d

urin

g ho

spita

lizat

ion.

A

dver

se e

vent

s: 0

%.

Reh

abili

tatio

n th

erap

y ap

pear

ed

safe

with

out s

igni

fi can

t ph

ysio

logi

c ch

ange

s or

adv

erse

ef

fect

s, b

ut w

as o

nly

prov

ided

in

freq

uent

ly.

St

iller

et a

l 49

31, a

ny p

atie

nt in

IC

U

bein

g m

obili

zed

by P

Ts.

Mob

iliza

tion

(eg,

sit/

stan

d/w

alk)

.H

R, B

P, S

p o 2 b

efor

e,

duri

ng a

nd im

med

iate

ly

post

sess

ion,

adv

erse

ev

ents

.

HR

and

BP

incr

ease

d si

gnifi

cant

ly

duri

ng s

essi

ons.

No

sign

ifi ca

nt

chan

ge in

Sp o

2 . A

dver

se

even

ts: 4

% (m

inor

, tra

nsie

nt).

Acu

tely

ill p

atie

nts

in th

e IC

U

can

be s

afel

y m

obili

zed

with

out m

ajor

det

erio

ratio

n in

thei

r cl

inic

al s

tatu

s.

Bah

adur

et a

l 50

30, t

rach

eost

omiz

ed,

mec

hani

cally

ve

ntila

ted.

Usu

al c

are,

incl

udin

g si

ttin

g.F

requ

ency

of s

ittin

g ou

t of

bed

.63

% s

at o

ut o

f bed

on

a m

edia

n of

two

occa

sion

s.D

espi

te a

cul

ture

of e

arly

m

obili

zatio

n, s

ome

patie

nts

wer

e co

nsid

ered

too

unw

ell

for

it to

occ

ur.

(Con

tinu

ed)

Tabl

e 3—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 837

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

B

ourd

in e

t al 51

20

, mec

hani

cally

ve

ntila

ted

� 2

d,

ICU

sta

y �

7 d

.

Ear

ly p

rogr

essi

ve m

obili

zatio

n (e

g, s

it/til

t tab

le/w

alk)

.F

easi

bilit

y, H

R, R

R, M

AP,

Sp

o 2 b

efor

e an

d po

stse

ssio

n,

adve

rse

even

ts.

Cha

ir s

ittin

g si

gnifi

cant

ly d

ecre

ased

H

R a

nd R

R. H

R a

nd R

R

sign

ifi ca

ntly

incr

ease

d w

ith

tiltin

g-up

and

wal

king

. Sp o

2 si

gnifi

cant

ly d

ecre

ased

with

w

alki

ng. A

dver

se e

vent

s: 3

%

(min

or).

Ear

ly m

obili

zatio

n is

feas

ible

and

sa

fe fo

r pa

tient

s in

IC

U

for

. 7

d.

N

ordo

n-C

raft

et a

l 52

19, m

echa

nica

lly

vent

ilate

d �

7 d

, IC

U a

cqui

red

wea

knes

s.

Prog

ress

ive

mob

iliza

tion

(eg,

lim

b ex

erci

ses,

si

t/sta

nd/w

alk)

, 30

min

, 5

d/w

k.

Adv

erse

eve

nts,

feas

ibili

ty,

mus

cle

stre

ngth

, fu

nctio

nal o

utco

mes

.

Adv

erse

eve

nts:

0%

. 170

ses

sion

s pr

ovid

ed. P

atie

nts

DC

hom

e ha

d hi

gher

str

engt

h an

d fu

nctio

nal s

core

s.

Ear

ly m

obili

zatio

n an

d PT

wer

e sa

fe a

nd fe

asib

le fo

r pa

tient

s w

ith I

CU

acq

uire

d w

eakn

ess.

N

orre

nber

g et

al 53

16

, pat

ient

s in

IC

U.

Pass

ive

limb

mov

emen

ts.

o 2 ,

CIX

, O 2 E

R b

efor

e an

d du

ring

inte

rven

tion.

o 2 s

igni

fi can

tly in

crea

sed

duri

ng

inte

rven

tion:

ach

ieve

d by

incr

ease

in

O 2 E

R in

pat

ient

s w

ith c

ardi

ac

dysf

unct

ion,

by

incr

ease

in C

IX in

pa

tient

s with

out c

ardi

ac d

ysfu

nctio

n.

Sim

ple

man

euve

rs li

ke p

assi

ve

limb

mov

emen

ts c

an in

fl uen

ce

the

hem

odyn

amic

sta

tus

of

patie

nts

in I

CU

.

C

hang

et a

l 54

15, i

ntub

ated

, m

echa

nica

lly

vent

ilate

d .

5 d

.

Stan

ding

on

a til

t tab

le

(70°

from

hor

izon

tal),

5

min

.

e , V

t , R

R, P

a o 2 ,

Pa co

2 be

fore

, dur

ing,

im

med

iate

ly a

nd 2

0-m

in

post

inte

rven

tion.

e , R

R, a

nd V

t si

gnifi

cant

ly

incr

ease

d du

ring

and

imm

edia

tely

po

st-t

ilt, n

ot s

igni

fi can

t by

20 m

in

post

-tilt

. Pa o

2 and

Pa c

o 2 :

no

sign

ifi ca

nt c

hang

e.

Stan

ding

on

a til

t tab

le p

rodu

ced

a tr

ansi

ent i

ncre

ase

in

vent

ilatio

n in

cri

tical

ly il

l pa

tient

s.

Za

fi rop

oulo

s et

al 55

15

, int

ubat

ed,

mec

hani

cally

ve

ntila

ted,

el

ectiv

e m

ajor

ab

dom

inal

su

rger

y.

Ear

ly m

obili

zatio

n (e

g, s

it/st

and/

wal

k) w

hile

sp

onta

neou

sly

brea

thin

g on

F io

2 5 1

.0.

Rib

cag

e an

d ab

dom

en

disp

lace

men

t, V t

, RR

, e

, HR

, BP,

Sp o

2, P

a o 2 ,

Pa co

2 bef

ore,

dur

ing,

an

d 20

-min

po

stin

terv

entio

n.

Stan

ding

sig

nifi c

antly

incr

ease

d ri

b ca

ge d

ispl

acem

ent,

V t , R

R, a

nd

e .

No

furt

her

sign

ifi ca

nt c

hang

es s

een

with

wal

king

. BP

and

HR

si

gnifi

cant

ly in

crea

sed

whe

n th

e pa

tient

s sa

t on

edge

of b

ed. P

a o 2

and

Pa co

2 : no

sig

nifi c

ant c

hang

e.

Cha

nges

in V

t , R

R, a

nd

e du

ring

m

obili

zatio

n w

ere

larg

ely

due

to p

ositi

onal

cha

nge

from

su

pine

to s

tand

ing.

Sk

inne

r et

al 56

12

, tra

cheo

stom

ized

, m

echa

nica

lly

vent

ilate

d.

Prog

ress

ive

mob

iliza

tion

(eg,

lim

b ex

erci

ses,

si

t/sta

nd/w

alk)

.

Res

pons

iven

ess

and

relia

bilit

y of

the

phys

ical

fu

nctio

n IC

U te

st,

adve

rse

even

ts.

The

test

was

eas

y to

per

form

, re

spon

sive

and

rel

iabl

e. A

dver

se

even

ts: 0

%.

Thi

s te

st m

ay b

e us

ed to

pre

scri

be

and

eval

uate

exe

rcis

e fo

r w

eak,

de

bilit

ated

pat

ient

s in

IC

U.

T

hela

nder

sson

et a

l 57

12, m

echa

nica

lly

vent

ilate

d, u

nabl

e to

act

ivel

y m

ove,

se

vere

hea

d in

jury

.

Pass

ive

RO

M e

xerc

ises

upp

er

and

low

er li

mbs

.IC

P, C

PP, C

BF

V, P

I, B

P,

and

HR

bef

ore,

du

ring

, and

10

min

po

stin

terv

entio

n.

ICP

sign

ifi ca

ntly

dec

reas

ed

post

inte

rven

tion.

No

sign

ifi ca

nt

chan

ge in

oth

er o

utco

mes

.

Pass

ive

RO

M e

xerc

ises

can

be

used

saf

ely

in c

ritic

ally

ill

neur

osur

gica

l pat

ient

s in

IC

U.

(Con

tinu

ed)

Tabl

e 3—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

838 Original Research

mobilization [eg, limb exercises, sit/stand/walk]). 37,41 Despite marked differences in sam ple size (n 5 330 37 ; n 5 32 41 ), both demonstrated advantages for the treat-ment group, including signifi cantly better functional ability, which translated into benefi ts such as a signif-icantly shorter ICU and hospital LOS. Two nonran-domized controlled studies prospectively compared a control phase, where patients received standard med-ical/nursing care, to a treatment phase follow ing the introduction of a progressive mobilization program. 39,40 Needham et al 40 demonstrated benefi ts following imple-mentation of the mobilization program (which included reduced sedation), including signifi cantly better func-tional mobility in the ICU and significantly shorter ICU and hospital LOS. Similarly, Winkelman et al 39 found that the ICU LOS was significantly shorter after implementation of a progressive mobilization pro-gram, although no signifi cant difference was found for duration of mechanical ventilation. Yang et al 38 found that progressive mobilization enhanced the success rate of ventilator weaning.

Bassett et al 42 compared outcomes between a his-torical controlled group, where data were collated retrospectively, and a treatment group after the imple-mentation of an early mobilization program across 13 ICUs. While details are scarce, no signifi cant dif-ferences were seen between the two groups for out-comes such as the length of mechanical ventilation, and ICU and hospital LOS.

The 17 observational studies recorded outcomes regarding the feasibility, safety, and physiologic effects of mobilization on patients in the ICU. 43-59 Overall, mobilization activities were found to be feasible and safe, although associated at times with short-term changes in physiologic parameters, with the frequency of serious adverse events � 1%. Garzon-Serrano et al 47 prospectively compared the level of mobility achieved for 63 patients in the ICU according to whether mobilization was performed by nursing or physical therapy staff, fi nding that physical therapists mobilized patients to a signifi cantly higher level than nursing staff. Barriers to the mobilization of patients in the ICU that were identifi ed included the ICU culture, 44 sedation, 48 limited rehabilitation staffi ng, 48 and patients being medically unfi t. 50 Skinner et al 56 developed a clinical exercise outcome measure for use in the ICU, namely, the physical function ICU test (PFIT), fi nding it easy to use, responsive, and reliable in a study of 12 patients in the ICU.

Inspiratory Muscle Training: Five clinical trials were found that evaluated the effectiveness of IMT in the ICU. 60-64 These studies are summarized in Table 4 . There were two RCTs, 60,61 two case series, 62,63 and one single case report. 64

Stud

yPa

rtic

ipan

ts, N

o.,

Type

Inte

rven

tion

Out

com

esR

esul

tsSu

mm

ary

of A

utho

rs’ C

oncl

usio

ns

T

hela

nder

sson

et a

l 58

12, m

echa

nica

lly

vent

ilate

d, u

nabl

e to

act

ivel

y m

ove,

se

vere

hea

d in

jury

.

Pass

ive

RO

M e

xerc

ises

to

one

leg.

Blo

od fl

ow v

eloc

ity a

nd

resi

stan

ce in

dex

of

com

mon

fem

oral

art

ery,

H

R, B

P be

fore

and

10-m

in p

ostin

terv

entio

n.

No

sign

ifi ca

nt c

hang

e in

any

ou

tcom

e.Pa

ssiv

e R

OM

doe

s no

t alte

r bl

ood

fl ow

vel

ocity

or r

esis

tanc

e in

dex

in th

e co

mm

on fe

mor

al a

rter

y in

com

atos

e an

d/or

sed

ated

cr

itica

lly il

l pat

ient

s.

Has

him

et a

l 59

1, m

echa

nica

lly

vent

ilate

d,

frac

ture

d ri

bs.

Stan

ding

on

a til

t tab

le,

daily

.D

escr

iptiv

e da

ta.

Tilt

tabl

e pr

ompt

ed fa

ster

sta

ndin

g th

an o

ther

app

roac

hes

and

impr

oved

re

spir

ator

y fu

nctio

n.

Ear

ly m

obili

zatio

n us

ing

a til

t ta

ble

may

enh

ance

resp

irato

ry

func

tion

and

shor

ten

reco

very

.

6MW

D 5

6-m

in w

alk

dist

ance

; AD

L 5

activ

ities

of d

aily

livi

ng; B

AD

L 5

bas

ic a

ctiv

ities

of d

aily

livi

ng; B

BS

5 B

erg

Bal

ance

Sca

le; B

I 5 B

arth

el I

ndex

; CB

FV

5 ce

rebr

al b

lood

fl ow

vel

ocity

; CIX

5 ca

rdia

c in

dex;

CPP

5 ce

rebr

al p

erfu

sion

pre

ssur

e; D

C 5

dis

char

ge; F

IM 5

func

tiona

l ind

epen

denc

e m

easu

re; I

CP

5 in

trac

rani

al p

ress

ure;

O 2 E

R 5

oxy

gen

extr

actio

n ra

tio; P

I 5 p

ulsa

tility

inde

x; R

OM

5 ra

nge

of

mot

ion;

RR

5 re

spir

ator

y ra

te; S

F-3

6 5

Med

ical

Out

com

es S

tudy

36-

Item

Sho

rt F

orm

Hea

lth S

urve

y; S

p o 2 5

per

cuta

neou

s ox

ygen

sat

urat

ion;

e

5 m

inut

e ve

ntila

tion;

o

2 5 o

xyge

n co

nsum

ptio

n. S

ee

Tabl

e 1

and

2 le

gend

s fo

r ex

pans

ion

of o

ther

abb

revi

atio

ns.

Tabl

e 3—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 839

with joint contractures in the ICU had a signifi cantly longer ICU LOS and lower ambulatory level at the time of hospital discharge than those without joint contractures.

Nonclinical Studies: Study and Sample Characteristics

Expert Opinion: Three articles, summarized in Table 5 , provided expert opinions regarding the role of physiotherapy in the ICU. 71-73 Gosselink et al 71 sum-marized the fi ndings of the European Respiratory Society and European Society of Intensive Care Medi-cine Task Force on the effectiveness of physiotherapy for acute and chronic critically ill patients. Despite noting a lack of high-level evidence, they identifi ed the following evidence-based targets for physiother-apy: deconditioning, muscle weakness, joint stiffness, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. The two studies by Hanekom et al 72,73 used a Delphi process to develop evidence-based clinical management algorithms for the prevention, identifi cation, and management of pulmonary dysfunction in intubated patients in the ICU and for the early physical activity and mobiliza-tion of critically ill patients.

Surveys: A total of 15 surveys ( Table 5 ) were iden-tifi ed that evaluated physiotherapy interventions in the ICU. 74-88 Sample sizes ranged from 32 88 to 482; 74 most samples comprised physiotherapists alone, 74-76,78-81,84-86,88 two included physiotherapists and nursing staff, 82,83 one study included ICU directors and physiothera-pists, 77 and the last included patients in the ICU. 87 All studies used purpose-designed surveys. Topics surveyed were general physiotherapy service provision, 74,79,80,82,85 use of passive movements, 75,86 rehabilitation and exer-cise prescription, 78 positioning, 83 VH, 76,84 MH, 88 use of tilt tables, 81 ICU directors’ perceptions of their physiotherapy service, 77 and patient satisfaction with the ICU physiotherapy service. 87 The fi ndings of each study are summarized in Table 5 .

Discussion

This systematic review updates a summary of the research evidence concerning the effectiveness of phys-iotherapy in the ICU published in 2000. A total of 85 new studies (55 clinical and 30 nonclinical) were reviewed.

The most striking change in the evidence base since the review published by Stiller in 2000 1 has been the advent and growth of research, particularly in the last 5 years, evaluating the use of early progressive mobi-lization. In contrast to 2000, when no studies were

Cader et al, 60 in a well-designed prospective RCT involving 41 elderly patients who were mechanically ventilated for . 48 h due to type 1 respiratory failure, found that daily progressive IMT using a thresh-old training device was associated with signifi cant benefi ts (eg, shorter weaning time) compared with a control group. In contrast, the prospective RCT by Caruso et al, 61 whose study sample comprised 25 patients likely to require mechanical ventilation . 72 h, found that IMT using the trigger sensitivity on the venti-lator did not have signifi cant benefi ts in terms of weaning duration or rate of reintubation.

Threshold IMT was found to be effective in terms of weaning ventilator-dependent patients in the case series by Sprague and Hopkins 63 involving six patients, and a single case study by Bissett and Leditschke. 64 Bissett et al, 62 in another case series, evaluated the safety of IMT, with no deleterious effects on physio-logic parameters or clinically important adverse effects recorded.

Neuromuscular Electrical Stimulation: Three clin-ical studies, summarized in Table 4 , were identifi ed that evaluated the effectiveness of NMES. 65-67 There were two prospective, stratifi ed RCTs 65,66 and one within-subject RCT. 67

The RCT by Routsi et al 65 involved 52 critically ill patients, stratifi ed according to age and sex, and evaluated the effect of daily NMES to the quadriceps and peroneous longus muscles. They demonstrated a signifi cantly lower incidence of critical-illness poly-neuromyopathy and reduced weaning time in the treatment group. The stratifi ed RCT by Gruther et al 66 allocated 33 patients to a daily session of NMES to the quadriceps muscle or a sham treatment, with the sample stratifi ed according to ICU LOS. While no signifi cant difference was seen between the treatment and sham groups for short-stay patients ( , 7 days), longer-term patients ( . 14 days) who received NMES had a signif-icant increase in muscle thickness at 4 weeks, whereas the sham group had no signifi cant change in muscle thickness. The within-subject RCT by Poulsen et al, 67 involving eight male patients in the ICU with septic shock, found no signifi cant difference in quadriceps muscle volume between patients’ control and treat-ment sides after 7 days.

Other Clinical Trials: Three other clinical trials that investigated physiotherapy interventions in the ICU are summarized in Table 4 . 68-70 Zeppos et al 68 documented a low incidence of adverse physiologic effects associated with all physiotherapy interven-tions in the ICU; De Freitas 69 found that patients who received physiotherapy were predominantly male, elderly, nonsurgical, and with high disease severity and mortality; and Clavet et al 70 reported that patients

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

840 Original Research

Tabl

e 4—

Cha

ract

eris

tics

of

Stu

dies

Eva

luat

ing

Insp

irat

ory

Mu

scle

Tra

inin

g, N

euro

mu

scu

lar

Ele

ctri

cal

Stim

ula

tion

, and

Oth

er I

nter

vent

ions

Stud

ySt

udy

Des

ign

Part

icip

ants

, No.

, Typ

eIn

terv

entio

nO

utco

mes

Res

ults

Sum

mar

y of

Aut

hors

’ Con

clus

ions

Insp

irat

ory

m

uscl

e tr

aini

ng

Cad

er e

t al 60

Pr

ospe

ctiv

e,

ra

ndom

ized

, co

ntro

lled

tria

l.

41, i

ntub

ated

,

mec

hani

cally

ve

ntila

ted

. 4

8 h,

.

70

y ol

d, ty

pe 1

re

spir

ator

y fa

ilure

.

Con

trol

: usu

al c

are.

MIP

, Ind

ex o

f Tob

in

(R

R/V

t du

ring

a

1-m

in s

pont

aneo

us

brea

thin

g tr

ial)

befo

re a

nd p

ostw

eani

ng,

wea

ning

tim

e.

MIP

incr

ease

d si

gnifi

cant

ly m

ore

in

Rx

grou

p. I

ndex

of T

obin

w

orse

ned

in b

oth

grou

ps, b

ut

sign

ifi ca

ntly

less

so

in R

x gr

oup.

W

eani

ng ti

me

sign

ifi ca

ntly

sh

orte

r in

Rx

grou

p.

In in

tuba

ted

olde

r pe

ople

,

IMT

impr

oves

MIP

and

the

Inde

x of

Tob

in, w

ith a

re

duce

d w

eani

ng ti

me

in

som

e pa

tient

s.

Rx:

IM

T (t

hres

hold

devi

ce, p

rogr

essi

ve

resi

stan

ce),

5 m

in

bid,

7 d

/wk.

C

arus

o et

al 61

Pr

ospe

ctiv

e,

ra

ndom

ized

, co

ntro

lled

tria

l.

25, l

ikel

y to

req

uire

mec

hani

cal

vent

ilatio

n .

72

h.

Con

trol

: usu

al c

are.

MIP

dai

ly u

ntil

wea

ned,

wea

ning

dur

atio

n,

rein

tuba

tion

rate

.

No

sign

ifi ca

nt d

iffer

ence

bet

wee

n

grou

ps fo

r an

y ou

tcom

e.IM

T fr

om th

e be

ginn

ing

of

m

echa

nica

l ven

tilat

ion

did

not s

hort

en w

eani

ng d

urat

ion

or d

ecre

ase

rein

tuba

tion

rate

.

Rx:

IM

T (i

nspi

rato

ry

tr

igge

r se

nsiti

vity

on

ven

tilat

or,

prog

ress

ive

resi

stan

ce),

up to

30

min

per

se

ssio

n bi

d.

Bis

sett

et a

l 62

Cas

e se

ries

10, t

rach

eost

omiz

ed,

ve

ntila

tor

depe

nden

t.

IMT

(thr

esho

ld

de

vice

, pro

gres

sive

re

sist

ance

), da

ily,

5-6

d/w

k.

HR

, MA

P, S

p o 2 ,

RR

befo

re a

nd p

ost-

sess

ions

un

til w

eane

d, a

dver

se

even

ts.

HR

, MA

P, S

p o 2 ,

RR

: no

si

gnifi

cant

cha

nge.

Adv

erse

ev

ents

: 0%

.

Thr

esho

ld I

MT

can

be

de

liver

ed s

afel

y in

se

lect

ed v

entil

ator

-dep

ende

nt

patie

nts.

Sp

ragu

e an

d H

opki

ns 63

C

ase

seri

es.

6, tr

ache

osto

miz

ed,

ve

ntila

tor

depe

nden

t.

IMT

(thr

esho

ld

de

vice

, pro

gres

sive

re

sist

ance

), 30

-50

min

pe

r se

ssio

n, d

aily

, 6-

7 d/

wk.

Wea

ning

suc

cess

,

trai

ning

pre

ssur

es,

MIP

.

All

patie

nts

wer

e w

eane

d fr

om

th

e ve

ntila

tor

afte

r in

itiat

ion

of I

MT.

Mea

n tr

aini

ng p

ress

ures

an

d M

IP in

crea

sed

over

tim

e.

IMT

may

pro

mot

e w

eani

ng

in

pat

ient

s w

ho a

re

vent

ilato

r-de

pend

ent.

B

isset

t and

Led

itsch

ke 64

Si

ngle

case

stu

dy.

1, tr

ache

osto

miz

ed,

ve

ntila

tor

depe

nden

t.

IMT

(thr

esho

ld

de

vice

, pro

gres

sive

re

sist

ance

), up

to

30 m

in p

er s

essi

on,

daily

, 7 d

/wk.

Wea

ning

suc

cess

.W

eane

d of

f mec

hani

cal v

entil

atio

n

afte

r in

itiat

ion

of I

MT.

IMT

sho

uld

be c

onsi

dere

d as

a th

erap

eutic

str

ateg

y fo

r ve

ntila

tor-

depe

nden

t pat

ient

s.

Neu

rom

uscu

lar

el

ectr

ical

stim

ulat

ion

R

outs

i et a

l 65

Pros

pect

ive,

stra

tifi e

d,

rand

omiz

ed,

cont

rolle

d tr

ial.

52, m

echa

nica

lly

ve

ntila

ted,

A

PAC

HE

II

scor

e �

13.

Str

atifi

ed

acco

rdin

g to

age

an

d se

x.

Con

trol

:

no in

terv

entio

n.M

RC

mus

cle

stre

ngth

,

freq

uenc

y of

cr

itica

l illn

ess

poly

neur

omyo

path

y,

wea

ning

per

iod,

du

ratio

n of

mec

hani

cal

vent

ilatio

n, I

CU

LO

S.

MR

C s

core

sig

nifi c

antly

hig

her

in

Rx

grou

p. I

ncid

ence

of

poly

neur

omyo

path

y si

gnifi

cant

ly

low

er in

Rx

grou

p. W

eani

ng

peri

od s

igni

fi can

tly s

hort

er in

R

x gr

oup.

No

sign

ifi ca

nt

diff

eren

ce b

etw

een

grou

ps

for

othe

r ou

tcom

es.

Dai

ly N

ME

S ca

n pr

even

t cri

tical

illne

ss p

olyn

euro

myo

path

y in

cri

tical

ly il

l pat

ient

s an

d ca

n sh

orte

n th

e du

ratio

n of

wea

ning

.R

x: N

ME

S to

quad

rice

ps a

nd

pero

neou

s lo

ngus

bi

late

rally

, 55

min

dai

ly.

(Con

tinu

ed)

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 841

Stud

ySt

udy

Des

ign

Part

icip

ants

, No.

, Typ

eIn

terv

entio

nO

utco

mes

Res

ults

Sum

mar

y of

Aut

hors

’ Con

clus

ions

G

ruth

er e

t al 66

Pr

ospe

ctiv

e,

st

ratifi

ed,

ra

ndom

ized

, co

ntro

lled

tria

l.

33, s

trat

ifi ed

acco

rdin

g to

IC

U L

OS:

acu

te

subg

roup

: IC

U

LO

S ,

7 d

; lo

ng-t

erm

su

bgro

up: I

CU

L

OS

. 1

4 d.

Con

trol

: sha

m

st

imul

atio

n.Q

uadr

icep

s m

uscl

e

laye

r th

ickn

ess

(ultr

ason

ogra

phy)

at

base

line

and

4 w

k.

Acu

te s

ubgr

oup:

mus

cle

th

ickn

ess

sign

ifi ca

ntly

de

crea

sed

over

tim

e in

bot

h gr

oups

, no

sign

ifi ca

nt d

iffer

ence

be

twee

n gr

oups

. Lon

g-te

rm

subg

roup

: mus

cle

thic

knes

s si

gnifi

cant

ly in

crea

sed

over

tim

e in

Rx

grou

p bu

t not

con

trol

gr

oup,

thic

knes

s si

gnifi

cant

ly

grea

ter

in R

x gr

oup

at 4

wk.

NM

ES

coul

d be

an

effe

ctiv

e

adju

nct i

n IC

U to

rev

erse

m

uscl

e w

astin

g in

lo

ng-t

erm

pat

ient

s.R

x: N

ME

S to

quad

rice

ps, d

aily

, 5

d/w

k fo

r 4

wk.

Po

ulse

n et

al 67

W

ithin

-sub

ject

,

rand

omiz

ed,

cont

rolle

d tr

ial.

8, m

echa

nica

lly

ve

ntila

ted,

sep

tic

shoc

k, p

redi

cted

IC

U L

OS

� 7

d.

Con

trol

sid

e: n

o

inte

rven

tion.

Qua

dric

eps

mus

cle

vo

lum

e (C

T im

age)

at

day

s 1

and

7.

Mus

cle

volu

me

sign

ifi ca

ntly

decr

ease

d ov

er ti

me.

N

o si

gnifi

cant

diff

eren

ce

betw

een

grou

ps.

Los

s of

mus

cle

mas

s in

pat

ient

s

with

sep

tic s

hock

was

una

ffec

ted

by N

ME

S.R

x si

de: N

ME

S to

quad

rice

ps, 6

0 m

in,

daily

for

7 d.

Oth

er in

terv

entio

ns

Zepp

os e

t al 68

Pr

ospe

ctiv

e,

ob

serv

atio

nal

stud

y.

Any

pat

ient

in th

e

ICU

rec

eivi

ng P

T

inte

rven

tion.

Any

PT

inte

rven

tion.

Adv

erse

eve

nts.

12,2

81 in

terv

entio

ns p

rovi

ded.

Adv

erse

eve

nts:

0.2

%.

PT in

terv

entio

n in

IC

U is

saf

e.

D

e F

reita

s 69

Pros

pect

ive,

obse

rvat

iona

l st

udy.

146,

any

pat

ient

s in

the

ICU

rec

eivi

ng

PT in

terv

entio

n.

Not

sta

ted.

APA

CH

E I

I in

dex.

APA

CH

E I

I in

dex

scor

es

re

fl ect

ed s

ever

e di

seas

e in

pa

tient

s re

ceiv

ing

PT.

Prov

ided

des

crip

tive

data

for

pa

tient

s in

IC

U r

ecei

ving

PT.

C

lave

t et a

l 70

Ret

rosp

ectiv

e,

ch

art r

evie

w.

155,

IC

U

L

OS

� 1

4 d.

Not

app

licab

le.

Am

bula

tory

sta

tus

at

ho

spita

l DC

acc

ordi

ng

to p

rese

nce/

abse

nce

of jo

int c

ontr

actu

res

in I

CU

, IC

U L

OS.

Sign

ifi ca

ntly

mor

e pa

tient

s w

ith

co

ntra

ctur

es in

IC

U h

ad a

low

am

bula

tory

leve

l at h

ospi

tal

DC

than

thos

e w

ithou

t co

ntra

ctur

es. I

CU

LO

S si

gnifi

cant

ly lo

nger

in th

ose

with

con

trac

ture

s.

The

dev

elop

men

t of j

oint

cont

ract

ures

in I

CU

adv

erse

ly

affe

cted

am

bula

tory

sta

tus

at D

C fr

om h

ospi

tal.

APA

CH

E 5

Acu

te P

hysi

olog

ic a

nd C

hron

ic H

ealth

Eva

luat

ion;

IM

T 5

insp

irat

ory

mus

cle

trai

ning

; M

IP 5

max

imal

ins

pira

tory

pre

ssur

e; M

RC

5 M

edic

al R

esea

rch

Cou

ncil;

NM

ES

5 n

euro

mus

cula

r el

ectr

ical

stim

ulat

ion.

See

Tab

le 1

-3 le

gend

s fo

r ex

pans

ion

of o

ther

abb

revi

atio

ns.

Tabl

e 4—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

842 Original Research

Tabl

e 5—

Cha

ract

eris

tics

of

Non

clin

ical

Stu

dies

Stud

yPa

rtic

ipan

ts, N

o., T

ype

Topi

cSu

mm

ary

of R

esul

ts

Exp

ert o

pini

on

Gos

selin

k et

al 71

10

, ER

S an

d E

SIC

M ta

skfo

rce.

PT fo

r cr

itica

lly il

l pat

ient

s.D

espi

te a

lack

of h

igh-

leve

l evi

denc

e, th

e fo

llow

ing

evid

ence

-bas

ed ta

rget

s fo

r

PT w

ere

iden

tifi e

d: d

econ

ditio

ning

, mus

cle

wea

knes

s, jo

int s

tiffn

ess,

impa

ired

ai

rway

cle

aran

ce, a

tele

ctas

is, i

ntub

atio

n av

oida

nce,

and

wea

ning

failu

re.

H

anek

om e

t al 72

7,

Del

phi p

anel

ists

.C

linic

al m

anag

emen

t alg

orith

m fo

r

the

prev

entio

n, id

entifi

cat

ion,

and

m

anag

emen

t of p

ulm

onar

y dy

sfun

ctio

n in

pat

ient

s in

the

ICU

.

The

pan

elis

ts a

gree

d on

a s

erie

s of

sta

tem

ents

con

cern

ing

the

indi

catio

ns,

te

chni

que

and

dosa

ge o

f PT

Rxs

for

man

agin

g pu

lmon

ary

dysf

unct

ion

in

intu

bate

d pa

tient

s in

IC

U.

H

anek

om e

t al 73

7,

Del

phi p

anel

ists

.C

linic

al m

anag

emen

t alg

orith

m fo

r

the

earl

y m

obili

zatio

n of

cri

tical

ly

ill p

atie

nts.

The

pan

elis

ts c

oncl

uded

that

an

indi

vidu

al m

obili

zatio

n pl

an m

ust b

e de

velo

ped

fo

r ea

ch p

atie

nt a

dmitt

ed to

an

ICU

, and

mad

e a

case

that

ear

ly p

hysi

cal a

ctiv

ity

and

mob

iliza

tion

shou

ld b

e th

e fo

unda

tion

pilla

rs o

f PT

man

agem

ent i

n IC

U.

Surv

eys

H

odgi

n et

al 74

48

2, U

S PT

s w

orki

ng w

ith c

ritic

ally

ill p

atie

nts.

Cur

rent

PT

pra

ctic

es fo

r pa

tient

s

reco

veri

ng fr

om c

ritic

al il

lnes

s in

th

e U

S.

PT w

as c

omm

only

adm

inis

tere

d to

pat

ient

s in

the

ICU

dur

ing

thei

r re

cove

ry.

89

% r

equi

red

med

ical

ref

erra

l to

initi

ate

PT. T

he fr

eque

ncy

and

type

of

inte

rven

tion

vari

ed b

ased

on

hosp

ital t

ype

and

the

clin

ical

sce

nari

o.

Stoc

kley

et a

l 75

165,

PTs

wor

king

in U

K I

CU

s.C

urre

nt u

se o

f pas

sive

mov

emen

ts

in

UK

IC

Us.

92%

rou

tinel

y tr

eate

d ve

ntila

ted,

sed

ated

pat

ient

s in

IC

Us.

Of t

hese

, 99%

use

d

pass

ive

mov

emen

ts r

outin

ely

and

78%

per

form

ed p

assi

ve m

ovem

ents

dai

ly.

Join

ts m

ost c

omm

only

trea

ted

wer

e th

e sh

ould

er, h

ip, k

nee,

elb

ow, a

nd a

nkle

, fo

r a

med

ian

of 5

tim

es p

er a

rea,

and

join

ts w

ere

take

n to

the

end

of R

OM

. 78

% m

onito

red

the

effe

cts

of p

assi

ve m

ovem

ents

, with

HR

and

BP

mos

t fr

eque

ntly

mon

itore

d.

Hay

es e

t al 76

16

5, s

enio

r PT

s w

orki

ng in

Aus

tral

ian

or

NZ

ICU

s.C

urre

nt P

T p

ract

ice

with

res

pect

to

V

H, b

arri

ers

to it

s us

e, d

escr

iptio

n of

its

tech

niqu

e in

Aus

tral

ia a

nd N

Z.

Onl

y 21

% u

sed

VH

. Lac

k of

trai

ning

and

med

ical

app

rova

l wer

e th

e m

ain

barr

iers

to it

s us

e. W

hen

VH

was

use

d, it

s ap

plic

atio

n va

ried

con

side

rabl

y be

twee

n re

spon

dent

s.

Jone

s 77

54 d

irec

tors

and

103

sen

ior

PT

s in

Aus

tral

ian,

UK

, Can

adia

n,

Hon

g K

ong,

and

So

uth

Afr

ican

IC

Us.

ICU

dir

ecto

rs’ p

erce

ptio

n of

thei

r

PT s

ervi

ce. S

enio

r PT

s’ qu

alifi

catio

ns,

expe

rien

ce, r

esea

rch,

teac

hing

, and

jo

b ov

erla

p.

79%

of I

CU

dir

ecto

rs th

ough

t the

PT

ser

vice

was

out

stan

ding

or

very

goo

d.

Se

cret

ion

rem

oval

was

see

n as

the

PTs’

mai

n ro

le. 6

0% b

elie

ved

the

PTs’

wor

k co

uld

be c

over

ed b

y ot

her

disc

iplin

es.

40%

of P

Ts w

ere

awar

e of

mer

ging

pro

fess

iona

l bou

ndar

ies.

Sk

inne

r et

al 78

11

1, P

Ts w

orki

ng in

Aus

tral

ian

ICU

s.E

xerc

ise

pres

crip

tion

by P

Ts fo

r

patie

nts

in th

e IC

U in

Aus

tral

ia.

94%

pre

scri

bed

exer

cise

rou

tinel

y fo

r pa

tient

s in

IC

U, w

ith a

ctiv

e,

ac

tive-

assi

sted

exe

rcis

es, a

nd m

obili

zatio

n (e

g, s

it to

sta

nd, s

it on

edg

e of

bed

) m

ost c

omm

only

pre

scri

bed.

34%

rou

tinel

y us

ed o

utco

me

mea

sure

s to

mon

itor

exer

cise

pre

scri

ptio

n, in

clud

ing

Sp o

2 , R

R, a

nd fu

nctio

nal t

ests

.

Nor

renb

urg

and

Vinc

ent 79

10

2, P

Ts w

orki

ng in

Eur

opea

n IC

Us.

Profi

le a

nd r

ole

of P

Ts in

Eur

opea

n IC

Us.

The

pro

fi le

and

role

of P

Ts in

IC

U v

arie

d ac

ross

Eur

ope.

100

% r

epor

ted

that

PTs

wer

e in

volv

ed in

the

prov

isio

n of

res

pira

tory

ther

apy,

pos

ition

ing,

and

m

obili

zatio

n.

Kum

ar e

t al 80

89

, PTs

wor

king

in I

ndia

n IC

Us.

Rol

e of

PTs

in I

ndia

n IC

Us.

55%

req

uire

d m

edic

al r

efer

ral t

o in

itiat

e th

e pr

ovis

ion

of P

T. 9

1% w

ere

in

volv

ed in

the

prov

isio

n of

res

pira

tory

ther

apy

and

100%

in th

e pr

ovis

ion

of

mob

iliza

tion.

C

hang

et a

l 81

86, s

enio

r PT

s w

orki

ng in

Aus

tral

ian

ICU

s.U

se o

f tilt

tabl

es in

the

PT m

anag

emen

t

of p

atie

nts

in th

e IC

U in

Aus

tral

ia.

67%

use

d til

t tab

les

to a

ssis

t sta

ndin

g an

d m

obili

zatio

n. T

ilt ta

bles

wer

e m

ost

fr

eque

ntly

use

d to

faci

litat

e w

eigh

t bea

ring

, pre

vent

mus

cle

cont

ract

ures

, im

prov

e lo

wer

lim

b st

reng

th, a

nd in

crea

se a

rous

al. T

itle

tabl

es m

ost f

requ

ently

ap

plie

d to

pat

ient

s w

ith n

euro

logi

c co

nditi

ons

or p

rolo

nged

IC

U L

OS.

(Con

tinu

ed)

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journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 843

Stud

yPa

rtic

ipan

ts, N

o., T

ype

Topi

cSu

mm

ary

of R

esul

ts

C

habo

yer

et a

l 82

71 n

urse

man

ager

s, 6

PTs

wor

king

in A

ustr

alia

n IC

Us.

Ava

ilabi

lity

of P

T s

ervi

ces

in I

CU

s an

d

role

of P

Ts a

nd n

ursi

ng s

taff

in p

rovi

sion

of

“ch

est P

T”

in A

ustr

alia

.

87%

had

wee

kday

PT

cov

er, 6

6% h

ad w

eeke

nd P

T c

over

, , 1

0% h

ad e

veni

ng

PT

cov

er. N

urse

s w

ere

invo

lved

in a

ll as

pect

s of

“ch

est P

T.”

PTs

wer

e m

ost

freq

uent

ly in

volv

ed in

the

prov

isio

n of

mob

iliza

tion,

che

st w

all v

ibra

tions

, po

sitio

ning

, per

cuss

ion,

and

suc

tion.

T

hom

as e

t al 83

71

, PTs

and

nur

ses

wor

king

in

A

ustr

alia

n IC

Us.

Use

of p

ositi

onin

g in

Aus

tral

ian

ICU

s.86

% b

elie

ved

patie

nts

shou

ld b

e tu

rned

eve

ry 2

h. P

ositi

ons

mos

t fre

quen

tly

us

ed o

n a

daily

bas

is w

ere

a qu

arte

r tu

rn fr

om s

upin

e, s

upin

e w

ith th

e he

ad o

f be

d el

evat

ed 3

0°, a

nd s

ittin

g ou

t of b

ed.

D

enni

s et

al 84

64

, PTs

wor

king

in A

ustr

alia

n IC

Us.

Prev

alen

ce o

f usi

ng V

H d

urin

g PT

Rxs

in A

ustr

alia

n IC

Us.

39%

use

d V

H d

urin

g PT

Rxs

. VH

mos

t fre

quen

tly u

sed

in th

e se

ttin

g of

spu

tum

rete

ntio

n an

d re

spir

ator

y in

fect

ion.

M

atila

inen

and

Ols

eni 85

57

, PTs

wor

king

in S

wed

ish

ICU

s.Pr

ofes

sion

al r

ole

and

educ

atio

nal

pr

efer

ence

s of

Sw

edis

h IC

U P

Ts.

89%

of I

CU

PTs

als

o w

orke

d in

oth

er c

linic

al a

reas

. Tim

e sp

ent i

n IC

U r

ange

d

from

5-4

0 h/

wk.

100

% w

ere

invo

lved

in th

e pr

ovis

ion

of r

espi

rato

ry th

erap

y,

mob

iliza

tion,

and

lim

b ex

erci

ses.

W

iles

and

Still

er 86

51

, PTs

wor

king

in A

ustr

alia

n IC

Us.

Use

of p

assi

ve m

ovem

ents

in

A

ustr

alia

n IC

Us.

35%

rou

tinel

y as

sess

ed p

assi

ve li

mb

RO

M o

f all

patie

nts

in th

e IC

U. 1

4%

ro

utin

ely

prov

ided

pas

sive

lim

b ex

erci

ses

as a

Rx

for

all p

atie

nts

in th

e IC

U.

Pres

crip

tion

of p

assi

ve li

mb

RO

M e

xerc

ises

was

var

iabl

e be

twee

n re

spon

dent

s.

Still

er a

nd W

iles 87

35

, pat

ient

s in

the

ICU

.Pa

tient

sat

isfa

ctio

n w

ith P

T s

ervi

ce in

an I

CU

.T

here

was

a h

igh

degr

ee o

f sat

isfa

ctio

n w

ith th

e pe

rson

al c

hara

cter

istic

s of

the

PTs

seen

and

the

PT s

ervi

ce p

rovi

ded

in I

CU

.

Hod

gson

et a

l 88

32, P

Ts w

orki

ng in

Aus

tral

ian

ICU

s.U

se o

f MH

by

PTs

in A

ustr

alia

n IC

Us.

91%

use

d M

H a

s a

Rx

tech

niqu

e. 7

6% u

sed

MH

as

a ro

utin

e R

x fo

r ve

ntila

ted

pa

tient

s. T

here

was

str

ong

agre

emen

t bet

wee

n re

spon

dent

s on

the

com

pone

nts

of M

H, p

refe

rred

Rx

posi

tions

, con

trai

ndic

atio

ns, a

nd p

erce

ived

be

nefi t

s. T

here

was

con

side

rabl

e va

riat

ion

betw

een

resp

onde

nts

in th

e du

ratio

n, n

umbe

r of

bre

aths

, and

cir

cuits

use

d w

hen

perf

orm

ing

MH

.

ER

S 5

Eur

opea

n R

espi

rato

ry S

ocie

ty; E

SIC

M 5

Eur

opea

n So

ciet

y of

Int

ensi

ve C

are

Med

icin

e; N

Z 5

New

Zea

land

; UK

5 U

nite

d K

ingd

om; U

S 5

Uni

ted

Stat

esct

. See

Tab

le 1

-4 le

gend

s fo

r ex

pans

ion

of

othe

r ab

brev

iatio

ns.

Tabl

e 5—

Con

tinu

ed

Downloaded From: http://journal.publications.chestnet.org/ by a University of Pittsburgh User on 10/14/2013

844 Original Research

Limitations of this systematic review included the variable methodological quality of the studies. The diverse range of study samples and study methodology precluded pooling of results and statistical analysis. The interventions that were provided usually com-prised numerous components, making it impossible to determine the effectiveness of individual treatment components.

A strength of this literature review was the inclu-sion of all clinical studies that have evaluated physio-therapy for adult patients in the ICU, irrespective of study design. Additionally, by reviewing the evidence concerning a broad range of physiotherapy practice, rather than focusing on one specifi c type of interven-tion (eg, multimodality respiratory physiotherapy or mobilization alone), it has been possible to highlight the emerging evidence concerning the benefi cial effects of early progressive mobilization compared with other physiotherapy interventions.

Conclusions

In summary, the evidence concerning the effi cacy of routine multimodality respiratory physiotherapy for adult, intubated patients receiving mechanical venti-lation remains unclear. There is strong, albeit limited, evidence published since the review in 2000 showing that physiotherapy intervention focusing on early pro-gressive mobilization is feasible and safe, and results in signifi cant functional benefi ts, which may translate into a reduced ICU and hospital LOS. This emerging evidence confi rms the role of the physiotherapist in ICU and highlights that early progressive mobiliza-tion is an effective area of physiotherapy clinical prac-tice for adult, intubated, mechanically ventilated patients. Further research to confi rm the effi cacy of early progressive mobilization is required, in partic-ular to determine the optimal “dosage” in terms of its most effective components, intensity, duration, and frequency.

Acknowledgments Author contributions: Dr Stiller had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Stiller: contributed to the literature search, identifi cation of relevant studies, data extraction, analysis of the results, and writ-ing of the paper. Financial/nonfi nancial disclosures: The author has reported to CHEST that no potential confl icts of interest exist with any com-panies/organizations whose products or services may be discussed in this article . Other contributions: The author would like to thank Alisia Jedrzejczak, BPhysio (Hons), and Kate Roberts, BAppSc (Physio), BSc, for their helpful comments regarding this paper.

References 1 . Stiller K . Physiotherapy in intensive care: towards an evidence-

based practice . Chest . 2000 ; 118 ( 6 ): 1801 - 1813 .

identifi ed, the current review included 26 clinical studies on this topic and, while study quality was var-iable, statistically signifi cant and clinically important benefi ts resulting from early mobilization were dem-onstrated. These new clinical studies have shown that early progressive mobilization is feasible and safe, and results in signifi cant functional benefi ts that may trans-late into positive effects on the ICU and hospital LOS. Stiller 1 noted that the role of physiotherapy in the ICU would continue to be questioned until physio-therapy has been shown to have a favorable impact on broader outcomes of patients in the ICU. The new evidence demonstrating the benefi cial effects of mobilization on broader outcomes such as the ICU and hospital LOS confi rms an unquestionable role for physiotherapy in the ICU. Given that the demand for physiotherapy services often outstrips the resources available, and the new evidence demonstrating the effectiveness of physiotherapy interventions aimed at early mobilization, ICU physiotherapists should give priority to interventions aimed at early progres-sive mobilization. To be successful, implementation of early progressive mobilization relies on an ICU culture that considers mobilization an essential part of multidisciplinary care. Safety guidelines and pro-tocols for progressive mobilization of patients in the ICU are available. 34,37,42,47,89

Eighteen new clinical trials were identifi ed that eval-uated the effectiveness of multimodality respiratory physiotherapy for adult, intubated, mechanically ven-tilated patients in the ICU. The results of these trials support and extend the conclusions made by Stiller in 2000, 1 namely, that multimodality respiratory phys-iotherapy may result in short-term improvements in pulmonary function. While there is some new evidence from RCTs that the provision of routine multimodal-ity respiratory physiotherapy can impact positively on outcomes such as duration of intubation and the ICU LOS, there is, however, a similar amount of new high-quality evidence suggesting that it may not. In terms of specifi c respiratory physiotherapy interven-tions, there is limited evidence from new randomized crossover trials suggesting that expiratory rib-cage compression is ineffective and that MH may have benefi cial short-term effects on respiratory compli-ance, concurring with the conclusions made in the 2000 review. 1 New evidence has emerged demon-strating that VH is as effective as MH. There is new high-quality evidence concerning the effectiveness of IMT for patients in the ICU; however, this evidence is scarce, hence the routine or selective use of IMT for patients in the ICU cannot be recommended at present. Similarly, the evidence that has been published since 1999 concerning the effectiveness of NMES is limited and, thus, clinical recommendations regarding its use in ICU cannot be made.

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