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

Financial Interest Disclosure

• I have no conflict of interest.

• Funding – Canadian Institutes of Health Resarch

Overview of today’s talk

A resource issue

Review of evidence

Practical considerations

We have a potentially serious supply and demand problem in Canada:

Landry et al., Human Resources for Health 2007, 5:23.

1991 - 2005

And in the United States:

http://dmc122011.delmar.edu/socsci/rlong/intro/usmap.htm; Zimbleman et al., PM R. 2010;2(11):1021-9.

Needham et al., Crit Care Med. 2005. 33(3):574-9.

40%

Projected incidence of non-cardiac surgery, mechanically ventilated adults

Prospective 1 and 5-year follow-up study of 109 ICU survivors

Clinical

Course

ICU

Discharge

ICU

Admission

Setting: 4 Canadian ICUs Population: Adult patients with ARDS

3 months 6 months 12 months

Outcomes: Primary – 6 minute walk test Pulmonary function tests Health-related quality of life

60 months

N=83

281 m

49% predicted

N=83

422 m

66% predicted

6 minute walk

distance

N=82

396 m

64% predicted

N=64

436 m

76% predicted

Herridge et al, NEJM. 2003. 348:683-93;Herridge et al., NEJM. 2011. 364:1293-304.

Prospective 1 year study of 545 ICU survivors

Clinical

Course

ICU

Discharge

ICU

Admission

6 months

Outcomes: Primary – SF-36 (V2) Physical function domain Secondary – Physical, psychological, & cognitive function; quality of life; employment status

12 months

Needham et al., BMJ. 2013. 346:f1532.

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)

Outcomes

Mean (SD) ICU LOS: 14(12); Hospital LOS: 22(16)

Norms

Setting: 41 US ICUs Population: Adult pts with ARDS in NHLBI EDEN RCT

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

• RCT: In-bed cycling started ICU day 14 improved 6-minute walk test distance at hospital discharge

• Question: What is ICU mobility practice in Canada?

Crit Care Med. 2009. 37(9): 2499-2505.

Lancet. 2009. 373: 1874-1882.

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. 2012. Open Access Dissertations and Theses. Paper 7499.

What is the evidence for chest physiotherapy in patients receiving

mechanical ventilation?

Terminology: What is chest physiotherapy?

Ventilator

hyperinflation

percussion

vibration

suctioning

All are interventions to improve respiratory function, which can be delivered by a registered physiotherapist or other members

of the critical care team.

Stiller. Chest. 2013. 144(3):825-47.

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 ✔

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 ✔

Methodological assessment (AMSTAR)

AMSTAR reference:

Stiller. Chest. 2013 Sep;144(3):825-47.

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

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; post-op 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. 2002 / 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

Description of RCTs

Stiller. Chest. 2013 Sep;144(3):825-47.

Author Population Intervention Comparison Main Outcomes

Templeton et al., 2007 / UK

Med-Surg ICU >48 h MV

Positioning, MH, rib springing, mobility BID (n=87)*

Positioning, mobility BID (n=85)*

1°: time to ventilator free 2°: LOS, mortality, VAP

Pattanshetty et al. 2010 / India

ICU >48 h MV Positioning, MH, chest vibration BID until weaned (n=50)

MH BID until weaned (n=50)

1°: VAP 2°: LOS, mortality

Pattanshetty et al., 2011 / India NEW

ICU >48 h MV Same as above; (n=87)

Same as above; (n=86)

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

Description of RCTs (cont’d)

Stiller. Chest. 2013 Sep;144(3):825-47. Pattanshetty et al., Indian J Med Sci. 2011;65(5):175-185.

GRADE = Grades of Recommendation Assessment, Development and Evaluation

CMAJ 2003, BMJ 2004, BMC 2004, BMC 2005,

AJRCCM 2006, Chest 2006, BMJ 2008

2 part framework:

1. Quality of Evidence

2. Strength of recommendations

“Extent to which we are confident that an estimate of effect is correct.”

GRADE Quality assessment criteria

Lower if…

Quality of

evidence

High

Moderate

Low

Very low

Study limitations

(design and execution)

Inconsistency

Indirectness

Imprecision

Publication bias

Observational

studies

Study

design

Randomized

trials

Higher if…

Large effect (e.g., RR 0.5)

Very large effect (e.g., RR 0.2)

Evidence of dose-response

gradient

All plausible confounding

would reduce a

demonstrated effect

Slide from Schünemann/ Falck-Ytter

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.

Author Population Main Results

Patman et al., 2001 / Australia

Post-op cardiac surgery MV <24h

No difference in duration of MV, ICU or hospital LOS

Patman et al., 2009 / Australia

Acquired brain injury >24 h MV

1°: VAP – no difference 2°: LOS, MV duration, mortality - no difference

Barker et al. 2002 / UK

Acute lung injury & MV

Oxygenation, dynamic compliance, & hemodynamics

MH = manual hyperinflation; VAP = ventilator-associated pneumonia; all groups received suctioning

Results by patient population

Outcome # studies Summary of Results

Duration of mechanical ventilation

3 1 study, time to ventilator free 4 d longer in group receiving chest PT (median 15 vs. 11; p=0.045)

Ventilator-associated pneumonia

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

RCTs of routine chest PT for all patients receiving mechanical ventilation

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 patient-specific outcomes – E.g., Function

Practical considerations

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

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

What are the opportunity costs with limited resources and increased demands?

Summary of today’s talk

A resource issue

Review of evidence

Practical considerations khome@mcmaster.ca