Early Physical Rehabilitation in the ICU and Ventilator Liberation

Transcription

1 Early Physical Rehabilitation in the ICU and Ventilator Liberation 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權 Respiratory Care 2012 Oct Vol 57 No 10 Pedro A Mendez-Tellez MD and Dale M Needham MD PhD

2 Introduction Physical inactivity and prolonged bedrest affect virtually all mechanically ventilated patient. Skeletal muscle atrophy and muscle weakness 25-65% of subjects mechanically ventilated for at least 5 days. The use of sedation and analgesia Longer duration of mechanical ventilation and ICU and hospital stays.

3 Continuous mandatory ventilation alters diaphragmatic structure and contractile function and promotes oxidative injury, resulting in a rapid-onset diaphragmatic atrophy and weakness Is weaning failure caused by low-frequency fatigue of the diaphgram? Am J Respiratory Crit Care Med 2003 Demonstrating the feasibility, benefit, outcomes and safety of early physical rehabilitation.

4 Physical inactivity and skeletal muscle weakness

5 In healthy young volunteers, 28 days of bed rest result: 0.4 kg loss of lean leg mass 23% reduction in leg extension strength In healthy older adults, 10 days of bed rest 1.5 kg loss of whole body lean mass 15% reduction in muscle strength Essential amino acid and carbohydrate supplementation ameliorates muscle protein loss in human during 28 days bedrest. J Clin Endocrinol Metab 2004; 89(9),

6 Recent evidence suggests that: primary factor promoting disuse muscle atrophy is a decrease in protein synthesis Rate of muscle synthesis declines quickly after onset of muscle inactivity (within 6 hrs) Reaching a new lower steady state of muscle protein synthesis within hrs. Mechanistic links between oxidative stress and disuse muscle atrophy. Antioxid Redox signal 2011;15(9):

7 Severe trauma and sepsis amplifies the effect of inactivity on skeletal muscle mass loss. 21 day period Critical injury Sepsis Total body protein loss 16% 13% Ratio of protein loss from skeletal muscle 67% 67% Skeletal muscle fiber area decreases by 2-4% per day in the ICU

8 Role of proteolysis in disuse muscle atrophy is controversial. Lysosomal proteases Calcium-dependent proteases Proteasome system Disturbances in redox signaling and oxidative stress appear to also play an important role in disuse muscle atrophy.

9 Mechanical ventilation and Diaphragmatic weakness

10 Mechanical ventilator leads to rapid-onset diaphragmatic atrophy change in protein turnover promotes oxidative stress injury Changes in gene expression and cell signaling

11 Rapid-onset of diaphragmatic atrophy Time for diaphragmatic atrophy of both slow-twitch and fast twitch fibers Animal study (CMV) Brain-dead organ donor hours hours Decrease in cross-sectional areas of 57% and 53%

12 Ultra-structural changes in diaphragmatic muscle fibers. myofibrillar disarray alterations in Z-line structure promotes areas of diaphragmatic regeneration without signs of inflammation increase in cytoplasmic lipid vacuoles

13 Changes in diaphragmatic protein turnover Animal study: 6 hours of CMV led to 30% decrease in mixed protein synthesis 65% decline in the rate of myosin-heavy chain protein synthesis. In human hours of CMV led to increased protein degradation.

14 Oxidative stress injury Promote diaphragmatic atrophy and contractile dysfunction Controlled MV >6 hrs redox disturbances from increased reactive oxygen species production increased protein oxidation and lipid peroxidation diminished antioxidant capacity decreased of glutathione, glutathione peroxidase and cooper zinc superoxide dismutase levels

15 Substantial changes in diaphragmatic gene expression gene expression for numerous genes linked with: stress response protein metabolism calcium regulation MV resulted in >350 changes in gene products after 6 and 18 hours of CMV.

16 Early physical rehabilitation of Mechanically ventilated patients

17 Physical rehabilitation started as early as 1 or 2 days after initiating MV is feasible, safe and beneficial improved exercise capacity improved functional status at hospital discharge decreased duration of MV shorter ICU and hospital stay

18 Early mobilization of patients with respiratory failure and prolong MV (>4 days) was feasible and safe. Impressive ambulation distances by ICU discharge Early activity is feasible and safe in respiratory failure patients. Crit Care. Med 2007;35 (1):

19 42% % Early activity is feasible and safe in respiratory failure patients. Crit Care. Med 2007;35 (1):

20 89% were mechanically ventilated 8% of MV patients the pre-activity FiO2 was >=0.7 Adverse events, prospectively evaluated, occurred in <1% of all activity Early activity is feasible and safe in respiratory failure patients. Crit Care. Med 2007;35 (1):

21 Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36(8):

22 Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36(8):

23 Protocol care group received more PT (80% vs 47%) Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36(8):

24 Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678):

25 Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678):

26 Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678):

27 Very early physical rehabilitation is combined with daily sedation interruptions and spontaneous breathing trials Result in shorter duration of MV and better physical recovery after critical illness Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373 (9678):

28 Initiating an Early physical rehabilitation program for mechanically ventilated patients

29 Successful implementation requires: engaging key hospital administrators ICU and rehabilitation leaders help and promote change in ICU culture assembling a multidisciplinary team Frontline clinicians (Critical care medicine, nursing, respiratory therapy, and physical medicine and rehabilitation)

30 Creating a common goal and shared expectation of eraly rehabilitation for all patients Resolve barriers to achieving this goal Obtaining basic equipment to facilitate early rehabilitation. In charge of planning, executing and evaluating the program. Engaging and educating other ICU stakeholders

31 Arranging return visits by ICU patients to share their experiences with sedation, delirium and inactivity or early ambulation identify local barriers to early mobilization and rehabilitation, such as over sedation and delirium status Develop strategies to overcome them Establish safety-related guidelines and/or screening protocols to assist implementing early rehabilitation for critically ill patients.

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34 Conclusion Disuse atrophy is the result of complex mechanisms Longer duration MV Prolongation ICU and hospital stay Poorer function status at hospital discharge Prevention disuse atrophy and muscle weakness by early initiation of physical rehabilitation and minimizing deep sedation is of great importance

35 Early rehabilitation interventions for MV patients are safe and feasible. Benefits of early physical rehabilitation

36 Thanks you and Happy Lunar New Year

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