Recovery from ICU-acquired weakness; do not forget the respiratory muscles!

Transcription

1 Recovery from ICU-acquired weakness; do not forget the respiratory muscles! Beatrix Clerckx Department of Rehabilitation Sciences, Department of Intensive Care Medicine, University Hospitals Leuven, Catholic University of Leuven

2 Respiratory dysfunction: One of the most common causes of critical illness necessitating ICU admission Respiratory muscle dysfunction in patients who are mechanical ventilated is observed in 80% of patients with ICUAW Respiratory conditions relevant to physiotherapy are: lung collaps, retained secretions and weaning failure WEANING FAILURE (±10-20%)

3 Weaning succes The absence of the requirement for ventilatory support within 48 hours after extubation (translaryngeal tube) or withdrawal (tracheostomy tube) of MV. Ladeira MT et al.cochrane Database Syst Rev.2014

4 In the weaning process we must take into account: CNS output Respiratory drive Pump Capacity Respiratory muscle pump Load on the pump After Moxham J. Ventilatory Failure

5 In analogy with the UZL start to move ASAP protocol Start to breathe protocol = start to wean Gosselink R. et al. Netherlands J Crit Care. 2011; 15(2):1-10

6 Task: training of inspiratory muscles Respiratory Assessment Training Endurance training Additional strength training (IMT)

7 Respiratory assessment (prior to treatment) Retained secretions Atelectasis Auscultation Palpation ABG Chest X-Ray Respiratory weaning Inspiratory muscle strength (MIP>-20/-25cmH 2 O) Forced Vital Capacity (>10ml/kg) Clinical signs of muscle fatigue (RSBI<105 breaths/min*l)

8 Assessment Respiratory Weaning Inspiratory muscle strength MIP (max. insp. airway pressure) evaluation of respiratory muscle weakness

9 Assessment Respiratory Weaning

10 Maximal inspiratory pressure ( cmH20) Plat.

11 Task: training of inspiratory muscles Assessement Training Endurance training Additional strength training (= IMT)

12 Endurance training: Start to breathe protocol 3 activities: - Spontaneous breathing - Cycling with legs, arms (bed-chair) - Chair (in bed/out of bed) first activities separately 2 activities at the same time 3 activities at the same time

13 Endurance training: Start to breathe protocol AIM = increasing spontaneous breathing trial and time

14 Strength training: IMT Intermittent loading of the respiratory muscles AIM = increasing strength of the inspiratory muscles

15 Inspiratory muscle training Training regimen: Intensity: perceived exertion 6-8 on 10 point scale (40-50% MIP) 6 à 8 breaths per set 3-5 sets per day Tapered flow resistive loading (POWERbreathe KH1) Martin et al. Critical Care 2011, 15:R84

16 Inspiratory muscle training (IMT) as an adjunct to enhance weaning success What does literature say?

17 (Shorter time) (Shorter time)

18 Case Patient characteristics ICU stay Initials B.J. Medical ICU 17 days Sex M Surgical ICU 39 days Age 38 years Duration MV 10 days Height 185 cm Duration weaning (+start IMT) Weight Diagnose 67 kg SSLTX, cystic fibrosis 19 days PSV: 5p,10ass > 48u T-piece

19 Pathophysiology of weaning failure Pre transplant on venovenous-ecmo Severe critical illness, ICUAW Inspiratory muscle weakness Prolonged weaning

20 MIP (before and after IMT) Test 16/06/2016 date 16/06/2016 Test date: 12/07/2016

21 Evolution of the weaning process DATE Endurance tr. VENT. MODE (SBT) MIP Plateau (-cmh20) MIP Peak (-cmh20) VC (L) 16/06/16 5p 10ass 14 (13% pred.) Start to breathe (5% pred.) 23/06/16 5p Oass (3X30 ) 29/06/16 5p 0ass (12u) 05/07/16 T-piece (3x2u) 12/07/16 T-piece (24u) 24 (24% pred.) (8% pred.) 0.56 (10% pred.) 34 (33% pred.) (26% pred.) 42 (41% pred.) (28% pred.) IMT (cmh20) Not feasible 8 Vt: 0.31L 10 Vt: 0.56 L 15 Vt: 0.92L 20 Vt: 1.15L Strength tr.

22 MIP (CMH 2 O) MRC sum (/60) MIP, VC and MRC-sum score ,53 1, ,48 0,27-13,9 16-juin 23-juin 05-juil. 12-juil. -17,4-24,2-27 Start IMT Muscle Strength -33,9-42,1-41,3-57,1 MIP Peak MIP Plateau MRC VC 2 1,5 1 0,5 0-0,5-1 -1,5-2 VC (L)

23 Tapered flow resistive loading (POWERbreathe KH1)

24 Conclusions Additional, inspiratory muscle training (IMT) can provide benefits such as improved resp. muscle strength, weaning success and decreased RSBI. Objective measurements such as MIP, VC and RSBI can assist to determine the probability of weaning success Our Start to Breathe protocol consists of 3 major activities: spontaneous breathing, (leg/arm) cycling and body positioning (chair sitting) Finally, during the weaning process we must always take into account a good balance between respiratory muscle (pump) workload and muscle (pump) capacity.

25 ICU Physical Therapy Team

26 THANK YOU!