ON LINE SUPPLEMENT
PHYSIOTHERAPY FOR ADULT PATIENTS WITH CRITICAL ILLNESS:
Recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for critically ill patients
R.Gosselink, PT, PhD1, J.Bott, PT2, M.Connor, PT3, E.Dean, PT, PhD4, S.Nava, MD5, M.Norrenberg, PT6, B.Schonhofer, MD7, K.Stiller, PT, PhD8, H.van de Leur, PT, PhD9, J.L.Vincent, MD, PhD6
I. Methodology task force working group
A literature review was based on keywords and performed by the members of the Task Force for their specific area in PubMed, Medline, CINAHL® (allied health professional database) and a manual search of the peer-reviewed literature. The strength of the evidence for the recommendations is based on previously published guidelines (see Table )[97]. The lack of randomized controlled trials (RCTs) as the gold standard to support or reject physiotherapy interventions in patients with critical illness was recognized by the task force members. However, evidence based care (EBC) in general and for critically ill patients specifically has limitations and should not be restricted to RCTs and meta-analyses[108, 111, 128]. In addition, the validity of grading the strength of collected evidence has also been challenged [7]. In the absence of RCTs, other forms of evidence (expert opinion, case reports, open studies) are also helpful to provide answers and identify the areas where further research is needed to strengthen and advance this evidence base. In areas with weak or no evidence, sound physiological evidence and the expert opinion of the Task Force members were relied on to "fill in the gaps". Agreement was reached, first, by team discussion in 2 formal face to face meetings and, later, through repeated cycling of the draft to all members of the Task Force.
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EvidenceCategory / Sources of
Evidence / Definition
A / RCTs. Rich body of data. / Evidence is from endpoints of well-designed RCTs that provide a consistent pattern of findings in the population for which the recommendation is made. Category A requires substantial numbers of studies involving substantial numbers of participants.
B / RCTs. Limited body of data. / Evidence is from endpoints of intervention studies that include only a limited number of patients, post hoc or subgroup analysis of RCTs, or meta-analysis of RCTs. In general, Category B pertains when few randomized trials exist, they are small in size, or they were undertaken in a population that differs from the target population of the recommendation, or the results are somewhat inconsistent.
C / Nonrandomized trials. Observational studies. / Evidence is from outcomes of uncontrolled or nonrandomized trials or from observational studies.
D / Panel Consensus Judgment. / This category is used only in cases where the provision of some guidance was deemed valuable but the clinical literature addressing the subject was deemed insufficient to justify placement in one of the other categories. The Panel Consensus is based on physiological evidence and clinical experience or knowledge that does not meet the abovelisted criteria.
Table S1. Description of levels of evidence A through D [97]. RCT =randomised controlled trial.
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II. Deconditioning
Although bed rest is often required to support the recovery of critically ill patients, the risks associated with rest are well documented[3, 53] and it needs to be used judiciously[3, 33, 51, 100, 121, 123]. Optimal physiological functioning depends on the upright position[26, 27, 32, 82, 92, 120], so bed rest and limited mobility result in profound physical deconditioning and dysfunction of the respiratory, cardiovascular, musculoskeletal, neurological, and endocrine systems[52, 71, 86, 134]. Muscle atrophy commences within hours of recumbency[63] and can be exacerbated by inflammation and pharmacological agents[16, 83, 112]. Denervation atrophy may also complicate critical illness[10, 11] and sepsis is one of the most important determinants of critical illness polyneuropathy[35, 69]. Development of myo/neuropathy[44, 55, 101] contributes to weaning failure[56].
III. Respiratory Insufficiency
The etiology of respiratory insufficiency includes lung (Type I or hypoxemic) failure, characterized by severe hypoxemia and normo- or hypocapnia, and ventilatory pump (Type II or ventilatory) failure, characterized by hypoxemia, hypercapnia and with uncompensated (acute) or compensated respiratory acidosis (Table S2).
Lung Failure§ pneumonia / consolidation
§ atelectasis
§ acute lung injury (ALI) / acute respiratory distress syndrome (ARDS)
§ hemodynamic pulmonary edema
§ interstitial lung disease
§ acute on chronic airflow obstruction with V/Q mismatch
Pump Failure
§ decompensated obstructive airway disease
§ decompensated chest wall disease
§ neuromuscular disease
§ reduced respiratory drive
Table S2. Common causes of lung failure and pump failure
Reduced ventilatory pump capacity results from:§ muscle weakness, from factors such as :
o inactivity [70, 122], reduced neuromuscular function , e.g., myasthenia gravis,
drugs [12, 116], malnutrition, altered pH, hypoxemia, critical care neuropathy
o poor length/tension ratio of muscle, e.g., as in hyperinflation [105]
o reduced respiratory drive
o central nervous system dysfunction
Increased ventilatory pump load results from:
§ decreased compliance
o e.g., atelectasis, pneumothorax, pleural effusion, pulmonary edema
o hyperinflation and intrinsic peep (PEEPi)
§ airway obstruction
o bronchospasm, airway inflammation, upper airway obstruction, excessive airway secretions
Table S3. Causes of need for ventilatory support or weaning failure
IV. Effectiveness of physiotherapy in specific pulmonary conditions related to critical illness.
Atelectasis
Atelectasis is prevalent in critically ill patients[76]. Immobility, slumped and prolonged static body positioning, sedation, and monotonous tidal ventilation, increase the incidence of atelectasis[76, 77]. Two studies in ventilated patients reported that bronchoscopy offered no additional benefit over physiotherapy (postural drainage, percussion, MHI and suctioning) in the management of acute lobar atelectasis[38, 78]. The effectiveness of physiotherapy has been confirmed in other studies[50, 66, 113, 114]. Stiller and coworkers examined the components and, although the sample sizes were small, MHI and suctioning were found to be equally effective with either traditional postural drainage or modified postural drainage (side lying with the affected lung uppermost) [113, 114]. Chest wall vibration provided no additional benefit. Hourly treatment over six hours appeared to be more effective than a single treatment. Additional evening chest physiotherapy over and above routine day only physiotherapy failed to reduce the incidence of atelectasis in postoperative abdominal surgical patients[88]. Benefit was reported of continuous rotation (kinetic therapy) with mechanical percussion, compared to 2 hourly manual repositioning and percussion[99]. In the kinetic therapy group, resolution of atelectasis was facilitated, with a tendency for improved oxygenation and reduced need for bronchoscopy. No studies have specifically examined the role of physiotherapy interventions either in resolving other types of atelectasis or preventing atelectasis in critically ill patients. CPAP has been shown to be effective in the treatment of atelectasis[5].
RECOMMENDATIONS:
· Physiotherapy should be considered for the treatment of acute lobar atelectasis (level B).
· Treatment of acute lobar atelectasis and airway clearance should incorporate body positioning and techniques to increase inspiratory volume and enhance forced expiration (level B).
· If the patient is intubated, manual hyperinflation and suctioning are the techniques indicated, with the patient positioned with the affected lung up (level B).
Pneumonia
Patients may be hospitalized with community acquired pneumonia (CAP), or acquire it during their stay (i.e., nosocomial pneumonia)[109, 127]. VAP is associated with higher mortality rates, prolonged hospitalization, and high medical costs [65]. Studies have shown that NIV reduces the incidence of nosocomial pneumonia[42, 47], as well as providing effective ventilatory support, in, for example, patients with COPD and CAP[25]. CPAP has been used successfully in Pneumocystis carinii pneumonia[45, 80]. Other studies were performed on the effects of physiotherapy on the incidence of VAP. The first study randomly allocated 46 trauma patients to each arm (MHI, positioning plus suctioning vs suctioning alone) and found no significant differences between the two groups[87]. The second study reported a significantly lower incidence of VAP in the group receiving additional physiotherapy (8% vs 39%)[89]. However, the duration of mechanical ventilation, length of ICU stay and mortality were not significantly different between the groups. In a third study of adults with acquired brain injury, routine physiotherapy, in addition to standard nursing care, did not significantly alter the incidence of VAP, length of ventilation, or ICU stay[96]. In a fourth study, short term improvements on lung compliance and airway resistance were seen with MHI and suctioning, compared to suctioning alone [22].
RECOMMENDATIONS:
· NIV or CPAP may be used for the treatment of selected patients with pneumonia (level B)
· It is not possible to make any specific recommendations for or against other physiotherapy treatments for pneumonia due to lack of evidence in critically ill patients.
Acute Lung Injury, Acute Respiratory Distress Syndrome
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are associated with high mortality and increased length of stay[107]. Positioning may optimize oxygenation by improving V/Q matching, using gravity dependency to augment alveolar recruitment and more importantly, lung perfusion, as shown in an animal model[20, 21]. The specific position required will depend on the underlying pathophysiology. Improvements have been documented for patients with unilateral lung disease when they are positioned on their side with the affected lung uppermost [41, 57, 98, 102]. Prone positioning improves oxygenation compared to the supine position in patients with ARDS[15, 131], but its effect on survival is debated [40, 46, 75, 102]. Because oxygenation in these patients is often marginal, ongoing assessment of the patients’ capacity to tolerate more intense physiotherapy is crucial. MHI can improve pulmonary compliance and oxygenation in the short term for patients with ALI due to nonpulmonary causes [39, 93, 124]. In line with other forms of ventilatory assistance, it is likely that damage to the lung could occur if inflation is forced at either the upper or lower inflection points, or higher than safe pressures or volumes are used[34, 49, 81]. Similarly, there is a risk of hypo- as well as hyperventilation during MHI. In patients with ALI, a closed airway suctioning system with recruitment maneuvers prevented hypoxemia but decreased secretion removal in comparison with open suction with prolonged hyperoxygenation[68]. NIV and CPAP have been used with success in some patients with ALI [6, 103].
RECOMMENDATION:
· Positioning can be used in unilateral lung disease and ARDS to optimize V/Q matching and oxygenation, but should be used cautiously since a positive impact on survival has not been demonstrated (level A).
· Manual hyperinflation may be indicated in patients with nonpulmonary causes of ARDS (level C).
· Patients with ALI where desaturation needs to be avoided should be suctioned with the closed suction system (level B).
· Patients with ALI with airway secretion removal as a priority should be suctioned with the open suction system (level B).
· NIV or CPAP may be considered to support ventilation in selected patients with ALI (level D).
Inhalation Injury
Invasive mechanical ventilation and humidification of inspired air in conjunction with antibiotics and systemic hydration are common supportive treatments for inhalation injury[30]. A single study has shown that intermittent percussive ventilation may decrease the incidence of pneumonia in these patients[29]. A retrospective study revealed fewer endotracheal intubations in patients treated with IPPB or Bi-level Positive Airways Pressure (BiPAP)[110].
RECOMMENDATION:
· Intermittent percussive ventilation may be considered as a complementary airway clearance technique (level C).
· BiPAP or IPPB may be considered to support ventilation in selected patients with inhalation injury (level C).
Postoperative pulmonary complications
Pulmonary function is adversely affected by major abdominal, thoracic and cardiac surgery, with a restrictive pattern of pulmonary dysfunction[2, 60] resulting in small airway closure, hence an increased risk of atelectasis [36, 106]. Depending on the definition, the incidence of PPCs ranges from 3 to 90% after major abdominal or cardiac surgery [14, 90]. The majority of patients undergoing major surgery, e.g., sternotomy, thoracotomy, and laparotomy, recover without complications. After routine cardiac surgery, optimal post-operative management includes early mobilization and body positioning[59]. Further prophylactic physiotherapy interventions are not required in uncomplicated patients[94]. The role of physiotherapy in the management of non-routine patients, including those who develop PPCs, has not been investigated. Prophylactic physiotherapy during intubation and mechanical ventilation following cardiac surgery (including positioning, MHI and airway suctioning), in addition to post-extubation physiotherapy, conferred no benefit compared to post-extubation therapy alone[95]. Two randomized controlled studies have provided strong evidence that supports the role of prophylactic physiotherapy in preventing pulmonary complications after upper abdominal surgery[17, 106]. In these studies, patients in control groups (that received no post-operative physiotherapy) had a significantly higher incidence of post-operative pulmonary complications than patients treated with prophylactic breathing and coughing exercises. However, in contrast, another randomized controlled trial involving 81 patients after upper abdominal surgery found that the incidence of pulmonary complications was not significantly different for patients in a control group[23]. Furthermore, a recent and well designed study by Mackay et al. found that deep breathing and coughing did not add to the effectiveness of early mobilization for 56 high risk patients after abdominal surgery[74]. The reason for this contradiction in results is not clear, although it is of interest that the studies that found no benefit associated with the addition of prophylactic physiotherapy treatment were all comparatively recent. Incentive spirometry (IS) is a technique used in the management of non-intubated patients to encourage improved lung volumes and flow rates [8, 9] IS has not been shown to be of added benefit (beyond early mobilization and body position) in the routine management of post-operative patients [13, 43, 54]. Because the effect of IS depends on patient co-operation, critically ill patients may be unable to perform IS effectively. NIV has been used successfully to support patients following thoracotomy[1] and some cancer surgery[125]. CPAP is effective in the treatment of atelectasis, since it increases FRC and improves compliance, minimizing post-operative airways collapse[5, 115, 133].
RECOMMENDATIONS:
· Early mobilization and upright body positioning after major surgery is of primary importance to increase lung volume and to prevent pulmonary complications (level B).