Patients surviving critical illness requiring intense medical interventions such as prolonged mechanical ventilation (PMV) or prolonged immobility are at significant risk of developing lingering functional impairments [1-5]. These impairments can be physical, neurocognitive or both. Physical impairments include acquired weakness, loss of physical function, and loss of one’s ability to care for oneself and live independently. Neurocognitive effects include delirium, depression, post-traumatic stress disorder and an increased risk of dementia over the long-term [1-5]. Though most patients return to their physical and neurocognitive baselines after mechanical ventilation, the recovery process can be long, and some may experience lingering impairments for up to 5 years [1].
Depending on the severity of illness and duration of PMV, patients are at increased risk of mortality. A study by Wilson et al. analyzed the long-term return to functional baseline in mechanically ventilated ICU patients. Their study showed PMV patients experienced a mortality rate of 26% at 1 year and 38% at 5 years. Additional studies showed staggering mortality rates of up to 52% to 60% at 1 year post-mechanical ventilation [2,3].
These statistics demonstrate a need for interventions that lower the risk of functional decline and death in mechanically ventilated patients. One such intervention is physical therapy. PMV patients experience prolonged immobility and sedation, leading to muscle atrophy and weakness and a potential for long-term physical decline. One study by Chiang et al. found that post-ICU PMV patient’s undergoing 6 weeks of intensive physical therapy experienced significantly improved respiratory and limb muscle strength, increased ventilator-free days, and increased functional status compared to the control group; this study and numerous others support the idea that early implementation of physical therapy is incredibly beneficial to recovery in patients that underwent mechanical ventilation [2, 5-6].
A literature review conducted by Ntoumenopoulos emphasizes that mechanically ventilated ICU patients can benefit from early mobilization efforts, including passive limb movements, active limb exercises, passive/active mobilization out of bed and passive/active cycling in bed. The level of mobilization is of course dependent on illness status, patient safety, level of consciousness, cognitive functioning, and patient strength [5,6]. Overall, though, the review highlights that safely implementing mobilization efforts may reduce duration of ventilation, decrease delirium, improve functional status and reduce ICU length of stay.
Evidence for the use of physical therapy and mobilization to accelerate recovery in mechanical ventilation patients, both during and after their hospital stay, is abundant. However, not all centers have the proper protocols and/or support to implement such interventions. The challenges to fostering a “mobility culture”, as described by Ntoumenopoulos, lies in assembling a well-staffed, multidisciplinary team that communicates effectively and follows standardized rehabilitation practices. Staffing aside, one way care teams can achieve such a culture is by adopting the Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle, which is a set of evidence-based practices that, when applied correctly, greatly improves patient outcomes and promotes earlier mobilization from bed. Another way is by placing greater efforts into educating care providers on the importance reducing sedation and ventilation, thereby decreasing mortality and preserving physical functioning long after discharge.
References
- Wilson, M. E., Barwise, A., Heise, K. J., Loftsgard, T. O., Dziadzko, M., Cheville, A., … & Biehl, M. (2018). Long-term return to functional baseline after mechanical ventilation in the ICU. Critical Care Medicine, 46(4), 562-569. doi: 10.1097/CCM.0000000000002927
- Damuth, E., Mitchell, J. A., Bartock, J. L., Roberts, B. W., & Trzeciak, S. (2015). Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. The Lancet Respiratory Medicine, 3(7), 544-553. doi: 10.1016/S2213-2600(15)00150-2
- Scheinhorn, D. J., Hassenpflug, M. S., Votto, J. J., Chao, D. C., Epstein, S. K., Doig, G. S., … & Ventilation Outcomes Study Group. (2007). Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest, 131(1), 85-93. doi: 10.1378/chest.06-1081
- Chiang, L. L., Wang, L. Y., Wu, C. P., Wu, H. D., & Wu, Y. T. (2006). Effects of physical training on functional status in patients with prolonged mechanical ventilation. Physical Therapy, 86(9), 1271-1281. doi: 10.2522/ptj.20050036
- Ntoumenopoulos, G. (2015). Rehabilitation during mechanical ventilation: Review of the recent literature. Intensive and Critical Care Nursing, 31(3), 125-132. doi: 10.1016/j.iccn.2015.02.001
- Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., … & Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238-2243. doi: 10.1097/CCM.0b013e318180b90e