Early Rehabilitation in the ICU: Do We Still Need Chest Physiotherapy?

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1 Early Rehabilitation in the ICU: Do We Still Need Chest Physiotherapy? Michelle Kho, PT, PhD Assistant Professor, School of Rehabilitation Science, McMaster University Adjunct Assistant Professor, Department of Physical Medicine and Rehabilitation, Johns Hopkins University November 12, 2013

2 Financial Interest Disclosure I have no conflict of interest. Funding Canadian Institutes of Health Resarch

3 Overview of today s talk A resource issue Review of evidence Practical considerations

4 We have a potentially serious supply and demand problem in Canada: Landry et al., Human Resources for Health 2007, 5:23.

5 And in the United States: Zimbleman et al., PM R. 2010;2(11):

6 Projected incidence of non-cardiac surgery, mechanically ventilated adults 40% Needham et al., Crit Care Med (3):574-9.

7 Prospective 1 and 5-year follow-up study of 109 ICU survivors Setting: 4 Canadian ICUs Population: Adult patients with ARDS Clinical Course ICU Admission ICU Discharge Outcomes: Primary 6 minute walk test Pulmonary function tests Health-related quality of life 6 minute walk distance 3 months 6 months 12 months N= m 49% predicted N= m 64% predicted N= m 66% predicted 60 months N= m 76% predicted Herridge et al, NEJM :683-93;Herridge et al., NEJM :

8 Prospective 1 year study of 545 ICU survivors Setting: 41 US ICUs Population: Adult pts with ARDS in NHLBI EDEN RCT Clinical Course ICU Admission ICU Discharge Outcomes: Primary SF-36 (V2) Physical function domain Secondary Physical, psychological, & cognitive function; quality of life; employment status Mean (SD) ICU LOS: 14(12); Hospital LOS: 22(16) Outcomes Norms 6 months 12 months SF-36 Physical Function 82(9) 51(32) 55(32) SF-36 Mental Health 76(3) 64(26) 65(25) Substantial PTSD 26% (122/514) 23% (107/487) Employed 52% (116/223) 52% (116/223) Needham et al., BMJ :f1532.

9 Emerging evidence base for early ICU mobility RCT: PT and OT started within 1.5 days of intubation improves independence at hospital discharge Main difference: 19.2 minutes/ day during MV Lancet : RCT: In-bed cycling started ICU day 14 improved 6-minute walk test distance at hospital discharge Crit Care Med (9): Question: What is ICU mobility practice in Canada?

10 Early ICU Rehab in Canada Canadian survey of ICU mobilization practices Rigorous survey of academic ICUs 311 respondents (117 PTs, 194 MDs), 71% response 68% rated early mobilization very important or crucial Reported PT practice: Average 7.2 hours/ day Average caseload 6 ICU + 10 ward patients 83% frequently or routinely provided chest PT After 5:00 pm or on weekends, priority is chest PT, not mobility Koo, KY Open Access Dissertations and Theses. Paper 7499.

11 What is the evidence for chest physiotherapy in patients receiving mechanical ventilation?

12 Terminology: What is chest physiotherapy? percussion vibration suctioning Ventilator hyperinflation All are interventions to improve respiratory function, which can be delivered by a registered physiotherapist or other members of the critical care team.

13 Methodological assessment (AMSTAR) 1. A priori design 2. Duplicate study selection & extraction 3. Comprehensive literature search 4. Use of grey literature 5. List of included and excluded studies 6. Characteristics of included studies AMSTAR reference: 7. Quality assessment of included studies (not GRADE) 8. Incorporation of quality considered in analysis 9. Appropriate pooling? N/A 10.Publication bias assessed N/A 11.Conflict of interest stated Stiller. Chest (3):

14 Results: Multimodality respiratory physiotherapy 18 clinical studies 5 randomized clinical trials 9 randomized crossover trials 1 systematically allocated controlled trial 1 historical controlled trial 2 observational studies Of the 5 RCTs excluded pts w/ pleural effusions, untreated pneumothorax, neuromuscular weakness Stiller. Chest Sep;144(3):

15 Description of RCTs Author Population Intervention Comparison Main Outcomes Patman et al., 2001 / Australia Post-op cardiac surgery MV <24h Positioning, MH, thoracic & arm exs (n=101) No PT during intubation (n=109) # PT Rx while intubated; postop pulmonary complications Patman et al., 2009 / Australia Acquired brain injury >24 h MV Targeted positioning, MH 6x30min q24h until weaned (n=72) General positioning, MH (n=72) 1 : VAP 2 : LOS, MV duration, mortality Barker et al / UK Acute lung injury & MV 1: 1 Rx of positioning, 6 MH breaths, (n=7); 17 min 2: Routine care (n=5); 5 min 3: Positioning (n=5); 15 min Oxygenation, dynamic compliance, & hemodynamics MH = manual hyperinflation; VAP = ventilator-associated pneumonia; LOS = length of stay All groups received suctioning Stiller. Chest Sep;144(3):

16 Description of RCTs (cont d) Author Population Intervention Comparison Main Outcomes Templeton et al., 2007 / UK Pattanshetty et al / India Pattanshetty et al., 2011 / India NEW Med-Surg ICU >48 h MV ICU >48 h MV ICU >48 h MV Positioning, MH, rib springing, mobility BID (n=87)* Positioning, MH, chest vibration BID until weaned (n=50) Same as above; (n=87) Positioning, mobility BID (n=85)* MH BID until weaned (n=50) Same as above; (n=86) 1 : time to ventilator free 2 : LOS, mortality, VAP 1 : VAP 2 : LOS, mortality 1 : recovery rate 2 : LOS, VAP MH = manual hyperinflation; VAP = ventilator-associated pneumonia; LOS = length of stay All groups received suctioning *allowed rescue therapy for sudden sustained desaturation due to mucous plugging Stiller. Chest Sep;144(3): Pattanshetty et al., Indian J Med Sci. 2011;65(5):

17 GRADE = Grades of Recommendation Assessment, Development and Evaluation 2 part framework: 1. Quality of Evidence 2. Strength of recommendations Extent to which we are confident that an estimate of effect is correct. CMAJ 2003, BMJ 2004, BMC 2004, BMC 2005, AJRCCM 2006, Chest 2006, BMJ 2008

18 GRADE Quality assessment criteria Study design Quality of evidence Lower if Higher if Randomized trials High Study limitations (design and execution) Large effect (e.g., RR 0.5) Very large effect (e.g., RR 0.2) Moderate Inconsistency Evidence of dose-response gradient Observational studies Low Very low Indirectness Imprecision All plausible confounding would reduce a demonstrated effect Publication bias Slide from Schünemann/ Falck-Ytter

19 GRADE Quality Assessment Of 6 parallel group RCTs (n=816 patients), Most evidence low to very low quality ( ) Reasons for downgrading Imprecision (small sample sizes) Indirectness (differences in interventions) Inconsistent results Study design limitations Outcomes assessors not blinded to group Overall weaknesses in study reporting GRADE Interpretation: Our confidence in the effect is limited: The true effect may be substantially different from the estimate of the effect.

20 Results by patient population Author Population Main Results Patman et al., 2001 / Australia Patman et al., 2009 / Australia Barker et al / UK Post-op cardiac surgery MV <24h Acquired brain injury >24 h MV Acute lung injury & MV No difference in duration of MV, ICU or hospital LOS 1 : VAP no difference 2 : LOS, MV duration, mortality - no difference Oxygenation, dynamic compliance, & hemodynamics MH = manual hyperinflation; VAP = ventilator-associated pneumonia; all groups received suctioning

21 RCTs of routine chest PT for all patients receiving mechanical ventilation Outcome Duration of mechanical ventilation Ventilator-associated pneumonia # studies Summary of Results 3 1 study, time to ventilator free 4 d longer in group receiving chest PT (median 15 vs. 11; p=0.045) 3 No difference ICU LOS 2 No difference Hospital LOS 2 1 study, 3.2 days longer in group receiving chest PT (p=0.000) 1 study, no difference Mortality 2 1 study, lower in group receiving chest PT (12/50 vs. 25/51, p=0.007) 1 study, no difference

22 Strengths and Limitations of Data Strengths Published clinical trials Published systematic review Utilization-focused outcomes Limitations Applicability in Canadian setting Need more focused study of specific populations / indications Need more detailed intervention reporting Frequency, Intensity, Time, Type Need more patientspecific outcomes E.g., Function

23 Practical considerations

24 Based on best available evidence: Supply: Projected future shortage of PTs PT availability ~7 h/ day Demand: Increased demand for MV More ICU survivors at risk for post-icu sequelae What are the opportunity costs with limited resources and increased demands? Q: Should we offer routine chest physiotherapy for all MV patients? A: No Q: Do we still need chest physiotherapy in the ICU? A: It depends. Q: Should we abandon study of chest physiotherapy in the ICU? A: No field ripe for research in specific populations / indications; ideal for interdisciplinary teams

25 Summary of today s talk A resource issue Review of evidence Practical considerations

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