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Supported Arm Training in Patients Recently Weaned from Mechanical Ventilation. Study Objectives : To evaluate the effects of early exercise training in patients recovering from acute respiratory failure needing mechanical ventilation (MV). Design : Prospective, randomized, and controlled study.
Study Objectives: To evaluate the effects of early exercise training in patients recovering from acute respiratory failure needing mechanical ventilation (MV).
Design: Prospective, randomized, and controlled study.
Setting: Three respiratory intermediate ICUs (RIICUs).
Subjects: Of 228 patients admitted to an RIICU, 66 patients weaned from MV from >48 to <96 h were considered eligible and enrolled in the study.
Intervention: Sixty-six patients were randomized to either supported arm exercise training plus general physiotherapy (gPT) [group 1, 32 patients] or to gPT alone (group 2, 34 patients).
Methods and Results: Twenty-five patients in each group completed the protocol. Group 1 showed a greater improvement in exercise capacity, as assessed by an arm incremental test (IT) [p=0.003] and as endurance test (ET) [p=0.021], compared to group 2. Posttraining maximal inspiratory pressure (MIP) significantly improved in both groups (p<0.001 and p=0.003 in groups 1 and 2 respectively; not significant). IT isoworkload dyspnea improved significantly in both groups (p=0.005 and p=0.009 in groups 1 and 2 respectively, not significant between groups), whereas IT isoworkload peripheral muscle fatigue (p<0.001), ET isotime dyspnea (p<0.01), and ET isotime muscular fatigue (p<0.005) improved significantly in group 1 but not in group 2. IT improvers (x2=0.004) and ET improvers (x2=0.047) were more frequently observed in group 1 than in group 2. Baseline MIP could discriminate for IT (p=0.013; odds ratio [OR], 1.116) and ET improvers (p=0.022; OR 1.067).
Conclusions: Early upper-limb exercise training is feasible in RIICU patients recently weaned from MV and can enhance the effects of gPT. Baseline inspiratory muscle function is related to exercise capacity improvements.
Patients were successfully weaned from MV when they were able to:
Breathe spontaneously for 48 hours with a respiratory rate <35 breaths per minute,
Maintain an oxygen partial pressure >50 mmHg,
Maintain a heart rate <145 beats per minute,
Exhibit no major arrhythmias,
Exhibit no hemodynamic instability , and
Reveal no changes in diaphoresis.
An IT included use of an isotonic arm ergometer for one minute of incremental exercise, a one minute period of unloaded exercise at a rate of 40 cycles per minutes, and continued with an increased load of 2.5 watts per minute. Subjects were encouraged to cycle until the point of intolerable breathlessness, discomfort, or exhaustion. Cycling was stopped if the subject reached their maximum heart rate or abnormal ECG findings were noted. An ET was performed using an arm ergometer at 50% of the maximum work rate achieved during the exercise test, with a cycle rate of 40 cycles per minute. FEV1, FVC, PaO2, PaCO2, pH, ABGs, respiratory muscle function, perceived breathlessness, oxygen saturation, and respiratory rate were recorded.
Group 1 received gPT and supported arm exercise training, using the IT and the ET. Group 2 received gPT alone as a control.
GPT included six 45 minute sessions per week of assisted and active LE and UE mobilization, chest PT, assisted deambulation, functional and strengthening exercises, reinforcement techniques for head and trunk control, sitting and standing balance, transfers, and safe gait pattern.
The supported arm exercise training included 20 minutes of UE cycling on the arm ergometer. The first session was performed at 0 watts, while the load was increased by 2.5 watts each of the 14 consecutive sessions.
A two-sample t-test, Wilcoxon matched-paired tests and Mann-Whitney U tests were utilized to examine the data.
Methods and Materials
The study reveals:
Early gPT along with supported arm exercise training in patients recently weaned from MV can enhance exercise capacity, reduce muscular fatigue and prolong time until dyspnea and muscular fatigue occur.
Both groups exhibited increased MIP and workload before dyspnea.
Pulmonary rehab programs are beneficial to patients with COPD.
Early intervention is possible in 30% of all patients recently weaned from MV in high dependency units, such as the RIICU.
Greater improvement in tolerance to UE exercise is more likely in patients who have higher baseline inspiratory muscle strength.
Little research has been performed regarding the effects of physical therapy in patients to reduce complications, improve pulmonary function, shorten weaning processes, and reduce ICU or hospital length of stay.
Supporting Evidence: Article 1
Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT (2006) Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther 86:1271-1281
Physical rehabilitation performed over 6 weeks during and after MV in the hospital increased arm, leg, and respiratory muscle strength post discharge. Rehab included weights for extremities, breathing exercises, transfers, and ambulation.
Early rehab prevents deconditioning.
Significant improvement in ability to perform ADLs and walk short distances was seen in the intervention group, while those who did not receive rehab had little change in their functional level.
Both max inspiratory and expiratory pressure increased in the intervention group and decreased in the control group.
The FIM is the best measure of functional ability and correlates strength with functional ability.
This article supports Porta. Physical rehab improves functional ability after discharge from the hospital post-prolonged MV. There is a positive correlation between UE/LE muscle strength, functional ability, and MV free or wean time.
Supporting Evidence: Article 2
Martin UJ, Hinapie L, Nimchuck M, Gaughan J, Criner GJ (2005) Impact of whole-body rehabilitation in patients receiving chronic mechanical ventilation. Crit Care Med 33 (10): 2259-2265
Chronically ventilated patients are severely deconditioned.
Whole-body rehab conducted by a multidisciplinary team appears to improve both motor strength and functional capacity.
Benefits of rehab occur in all patients, regardless of condition.
An increment of one point in the UE strength scale results in a reduction of seven days in weaning time.
Training improves ability to ambulate, stand, transfer, sit, and perform activities of daily living. Overall muscular strength also improved.
Guidelines set for standard patients are not acceptable for those who have had chronic MV.
MV leads to deconditioning, strength is inversely related to wean time, and training during MV improves function.
Pectoralis muscle strength is directly related to respiratory function.
Martin determined that those with COPD demonstrate stronger UE strength and less respiratory weakness. Information obtained by Martin can be applied to any patient undergoing long-term MV.
Prolonged MV leads to deconditioning that can be prevented or reduced with early intervention of UE, LE, and respiratory physical rehabilitation. Muscular strength is positively correlated to a respiratory patient’s ability to return to previous level of function, and may reduce time required to successfully wean a patient from MV. Porta, Chiang, and Martin agree that more research is needed to gain information regarding patients on prolonged MV, interventions, ability to return to ADLs, and methods to assess these patients.
Patients with COPD often report dyspnea while performing activities of daily living (ADLs) involving their upper extremities (UE).
Lower extremity (LE) exercise has been shown to improve long-term treatment of COPD, including optimizing function and alleviating symptoms.
There is little research regarding the effects of UE exercise on rehabilitation during or after MV.
Kristen M. Storrie
Student Physical Therapist
Pre-score on the left connected to the post-score on the right
Figure A: Intervention group max workload during IT
Figure B: Control group max workload during IT
Figure C: Intervention group max endurance time during ET
Figure D: Control group max endurance time during ET
Porta et al. explored effects of early exercise training in patients after an acute respiratory failure requiring MV. UE exercise is feasible on patients recently weaned from MV in RIICUs. Respiratory function is strongly correlated to level of function. A decrease in symptoms and MV weaning time, and an increase in workload, respiratory muscle strength, and endurance occurred with the UE exercise. Overall, the study confirmed the benefits of arm-training in patients recovering from an acute exacerbation of respiratory failure.
This article is relevant to physical therapists, particularly those in acute care hospital settings and RIICUs. Early physical therapy is important and practical for those on or recently weaned from long term MV. Weaning time for patients can be significantly reduced, while ability to perform ADLs improves if rehab is begun while still in the RIICU. Therefore, therapists should utilize UE rehab for best results in patient care and rehab potential.
Twenty-five subjects in each group completed the study. No significant differences existed among baseline data of the groups.
Both groups showed significant improvements in the maximum workload during IT and ET.
Greater improvement was noted in the intervention group in maximum effort and exercise tests.
Subjects in the intervention group were able to tolerate exercise testing for twice as long as the control group.
Significant improvement was found in MIP and perceived breathlessness equally among groups.
The intervention group revealed decreased muscular fatigue, breathlessness, and muscular fatigue during the IT.
Eleven subjects in the intervention group and two subjects of the control group were considered to improve in one test, while eight subjects (one from the control group) improved in both tests.
Determine feasibility of early intervention in ICUs to wean patients from prolonged MV
Investigate the effects of early supported arm training in patients recovering from acute respiratory failure on MV
Porta R, Vitacca M, Gile LS, Clini E, Bianchi L, Zanotti E, Ambrosino N (2005) Supported arm training in
patients recently weaned from mechanical ventilation. Chest 128:2511-2520