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Jayachandran B, Venkatesan K, Tan SBC, Yeo LSH, Venkatacham J, Selvakumar MP, Tan BY. Feasibility of Combining Functional Mobilisation with Resistance and Endurance Training for Mechanically Ventilated Patients in Intensive Care Unit Setting-A Pilot Study. J Clin Med 2024; 13:2412. [PMID: 38673684 PMCID: PMC11051037 DOI: 10.3390/jcm13082412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Intensive-care-acquired weakness resulting in functional impairment is common in critical care survivors. This study aims to evaluate the feasibility of a combined early functional training with endurance and resistance training and its effect on the functional outcome. Methods: It is a pilot study performed in a 39-bed Medical and Surgical Intensive Care Unit (ICU). Patients who were premorbidly independent and were mechanically ventilated for ≥24 h were recruited to receive functional mobilisation (sit out of bed, ambulation), endurance (bed cycling), and resistance training (selected upper and lower limb muscle training using weights). The primary outcomes were feasibility of training, muscle strength, handgrip strength, quadricep strength, and Functional Status Score-Intensive Care Unit (FSS-ICU) collected at the first assessment in the ICU, at the ICU discharge, and at hospital discharge. Secondary outcomes were functional capacity (6-Minute Walk Distance) and quality of life measures, EQ-5D, at hospital discharge and at 3 months. Results: Out of the 11 patients, 6 (54.54%) patients achieved level 2 functional mobilisation, 2 (18.18%) patients achieved level 2 resistance training, and 1 (9.09%) patient achieved level 2 endurance training. There were no significant differences in the medical research council (MRC) score, quadricep strength, and handgrip strength between the first assessment in the ICU, at the ICU discharge, and at hospital discharge. However, there was a significant difference in FSS_ICU (p < 0.008) from the first assessment in the ICU up to hospital discharge. EQ-5D visual analogue scale also showed a change of 8.5% at 3-month follow-up. 6MWD showed significant difference (p < 0.043) at 3-month follow-up compared to that at hospital discharge. Conclusions: The study found low compliance to resistance and endurance training in patients with mechanical ventilation. However, functional mobilisation in terms of sit out of bed was possible in more than half of the recruited patients.
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Affiliation(s)
| | - Kumaresh Venkatesan
- Anaesthesia Department, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Sunny Boon Chai Tan
- Rehabilitation Department, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore;
| | - Lynn Soo Hoon Yeo
- Anaesthesia Department, Woodlands Health, 17 Woodlands Dr 17, Singapore 737628, Singapore;
| | - Jonathen Venkatacham
- General Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore;
| | | | - Bryan Yijia Tan
- Orthopaedic Surgery, Woodlands Health, 17 Woodlands Dr 17, Singapore 737628, Singapore;
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Le Stang V, Latronico N, Dres M, Bertoni M. Critical illness-associated limb and diaphragmatic weakness. Curr Opin Crit Care 2024; 30:121-130. [PMID: 38441088 PMCID: PMC10919276 DOI: 10.1097/mcc.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). RECENT FINDINGS In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. SUMMARY This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.
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Affiliation(s)
- Valentine Le Stang
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- ‘Alessandra BONO’ Interdepartmental University Research Center on LOng Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Michele Bertoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
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de Gomes Figueiredo T, Frazão M, Werlang LA, Peltz M, Sobral Filho DC. Functional electrical stimulation cycling-based muscular evaluation method in mechanically ventilated patients. Artif Organs 2024; 48:254-262. [PMID: 37930042 DOI: 10.1111/aor.14677] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/22/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Intensive care acquired muscle weakness is a common feature in critically ill patients. Beyond the therapeutic uses, FES-cycling could represent a promising nonvolitional evaluation method for detecting acquired muscle weakness. OBJECTIVES To assess whether FES-cycling is able to identify muscle dysfunctions, and to evaluate the survival rate in patients with detected muscle dysfunction. METHODS A prospective observational study was carried out, with 29 critically ill patients and 20 healthy subjects. Maximum torque and power achieved were recorded, in addition to the stimulation cost, and patients were followed up for six months. RESULTS Torque (2.64 [1.53 to 4.81] vs 6.03 [4.56 to 6.73] Nm) and power (3.31 [2.33 to 6.37] vs 6.35 [5.22 to 10.70] watts) were lower and stimulation cost (22 915 [5069 to 37 750] vs 3411 [2080 to 4024] μC/W) was higher in patients compared to healthy people (p < 0.05). Surviving patients showed a nonsignificant difference in power and torque in relation to nonsurvivors (p > 0.05), but they had a lower stimulation cost (4462 [3598 to 11 788] vs 23 538 [10 164 to 39 836] μC/W) (p < 0.05). In total, 34% of all patients survived during the six months of follow-up. Furthermore, 62% of patients with a stimulation cost below 15 371 μC/W and 7% of patients with a stimulation cost above 15 371 μC/W survived. CONCLUSIONS FES-cycling has good sensitivity and specificity for detecting muscle disorders. Critical patients have low torque and power and a high stimulation cost. Stimulation cost is related to survival. A low stimulation cost was related to a 3 times greater chance of survival.
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Affiliation(s)
| | - Murillo Frazão
- Lauro Wanderley University Hospital, João Pessoa, Brazil
- CLINAR Exercise Physiology, João Pessoa, Brazil
| | | | - Maikel Peltz
- INBRAMED-Brazilian Medical Equipment Industry, Porto Alegre, Brazil
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Elkalawy H, Sekhar P, Abosena W. Early detection and assessment of intensive care unit-acquired weakness: a comprehensive review. Acute Crit Care 2023; 38:409-424. [PMID: 38052508 DOI: 10.4266/acc.2023.00703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 10/17/2023] [Indexed: 12/07/2023] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW) is a serious complication in critically ill patients. Therefore, timely and accurate diagnosis and monitoring of ICU-AW are crucial for effectively preventing its associated morbidity and mortality. This article provides a comprehensive review of ICU-AW, focusing on the different methods used for its diagnosis and monitoring. Additionally, it highlights the role of bedside ultrasound in muscle assessment and early detection of ICU-AW. Furthermore, the article explores potential strategies for preventing ICU-AW. Healthcare providers who manage critically ill patients utilize diagnostic approaches such as physical exams, imaging, and assessment tools to identify ICU-AW. However, each method has its own limitations. The diagnosis of ICU-AW needs improvement due to the lack of a consensus on the appropriate approach for its detection. Nevertheless, bedside ultrasound has proven to be the most reliable and cost-effective tool for muscle assessment in the ICU. Combining the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score assessment, and ultrasound can be a convenient approach for the early detection of ICU-AW. This approach can facilitate timely intervention and prevent catastrophic consequences. However, further studies are needed to strengthen the evidence.
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Affiliation(s)
- Hanan Elkalawy
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Pavan Sekhar
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Wael Abosena
- Department of Surgery, Faculty of Medicine, Tanta University, Gharbeya, Egypt
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Bertoni M, Piva S, Beretta A, Bongiovanni F, Contarino R, Artigas RM, Ceresoli L, Marchesi M, Falappi M, Belleri M, Goffi A, Pozzi M, Rasulo FA, Latronico N. Occurrence and Effects on Weaning From Mechanical Ventilation of Intensive Care Unit Acquired and Diaphragm Weakness: A Pilot Study. Front Med (Lausanne) 2022; 9:930262. [PMID: 35935791 PMCID: PMC9354572 DOI: 10.3389/fmed.2022.930262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeLimb intensive care unit (ICU)-acquired weakness (ICUAW) and ICU acquired diaphragm weakness (DW) occur frequently in mechanically ventilated (MV) patients; their coexistence in cooperative and uncooperative patients is unknown. This study was designed to (1) describe the co-occurrence of the two conditions (2) evaluate the impact of ICUAW and DW on the ventilator-free days (VFDs) at 28 days and weaning success, and (3) assess the correlation between maximal inspiratory pressure (MIP) and thickening fraction (TFdi) in patients with DW.MethodsThis prospective pilot study was conducted in a single-center on 73 critically ill MV patients. Muscle weakness was defined as a Medical Research Council score < 48 in cooperative patients or a bilateral mean simplified peroneal nerve test < 5.26 mV in uncooperative patients. Diaphragm dysfunction was defined as MIP < 30 cm H2O or as a TFdi < 29%. Weaning success was defined according to weaning according to a new definition (WIND).ResultsFifty-seven patients (78%) had ICUAW and 59 (81%) had DW. The coexistence of the two conditions occurred in 48 patients (65%), without association (χ2 = 1.06, p = 0.304). In the adjusted analysis, ICUAW was independently related to VFDs at 28-days (estimate difference 6 days, p = 0.016), and WIND (OR of 3.62 for having WIND different than short weaning), whereas DW was not. The linear mixed model showed a significant but weak correlation between MIP and TFdi (p < 0.001).ConclusionThis pilot study is the first to explore the coexistence of ICUAW and DW in both cooperative and uncooperative patients; a lack of association was found between DW and ICUAW when considering both cooperative and uncooperative patients. We found a strong correlation between ICUAW but not DW with the VFDs at 28 days and weaning success. A future larger study is warranted in order to confirm our results, and should also investigate the use of transdiaphragmatic twitch pressure measurement during bilateral anterior magnetic phrenic nerve stimulation for the diagnosis of DW.
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Affiliation(s)
- Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- *Correspondence: Simone Piva,
| | - Alessandra Beretta
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Federica Bongiovanni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Contarino
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Ricard Mellado Artigas
- Department of Anesthesiology, Surgical ICU, Hospital Clinic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Lucia Ceresoli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Marchesi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Michele Falappi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marta Belleri
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Goffi
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
| | - Frank Antonio Rasulo
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Tortuyaux R, Davion JB, Jourdain M. Intensive care unit-acquired weakness: Questions the clinician should ask. Rev Neurol (Paris) 2022; 178:84-92. [PMID: 34998522 DOI: 10.1016/j.neurol.2021.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
Intensive care unit (ICU)-acquired weakness (ICU-AW) is defined as clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness. Using electrophysiological methods, patients with ICU-AW are classified in three subcategories: critical illness polyneuropathy, critical illness myopathy and critical illness neuromyopathy. ICU-AW is a frequent complication occurring in critical ill patients. Risk factors include illness severity and organ failure, age, hyperglycemia, parenteral nutrition, drugs and immobility. Due to short- and long-term complications, ICU-AW results in longer hospital stay and increased mortality. Its management is essentially preventive avoiding modifiable risk factors, especially duration of sedation and immobilization that should be as short as possible. Pharmacological approaches have been studied but none have proven efficacy. In the present review, we propose practical questions that the clinician should ask in case of acquired weakness during ICU stay: when to suspect ICU-AW, what risk factors should be identified, how to diagnose ICU-AW, what is the prognosis and how can recovery be improved?
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Affiliation(s)
- R Tortuyaux
- CHU de Lille, médecine intensive-réanimation, 59000 Lille, France; CHU de Lille, department of clinical neurophysiology, 59000 Lille, France.
| | - J-B Davion
- CHU de Lille, centre de référence des maladies neuromusculaires, 59000 Lille, France
| | - M Jourdain
- CHU de Lille, médecine intensive-réanimation, 59000 Lille, France; Université Lille, Inserm U1190, 59000 Lille, France
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Cottereau G, Messika J, Megarbane B, Guérin L, da Silva D, Bornstain C, Santos M, Ricard JD, Sztrymf B. Handgrip strength to predict extubation outcome: a prospective multicenter trial. Ann Intensive Care 2021; 11:144. [PMID: 34601639 PMCID: PMC8487340 DOI: 10.1186/s13613-021-00932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ICU-acquired weakness (ICUAW) has been shown to be associated with prolonged duration of mechanical ventilation and extubation failure. It is usually assessed through Medical Research Council (MRC) score, a time-consuming score performed by physiotherapists. Handgrip strength (HG) can be monitored very easily at the bedside. It has been shown to be a reproducible and reliable marker of global muscular strength in critical care patients. We sought to test if muscular weakness, as assessed by handgrip strength, was associated with extubation outcome. METHODS Prospective multicenter trial over an 18 months period in six mixed ICUs. Adults receiving mechanical ventilation for at least 48 h were eligible. Just before weaning trial, HG, Maximal Inspiratory Pressure (MIP), Peak Cough Expiratory Flow (PCEF) and Medical Research Council (MRC) score were registered. The attending physicians were unaware of the tests results and weaning procedures were conducted according to guidelines. Occurrence of unscheduled reintubation, non-invasive ventilation (NIV) or high-flow nasal continuous oxygen (HFNC) because of respiratory failure within 7 days after extubation defined extubation failure. The main outcome was the link between HG and extubation outcome. RESULTS 233 patients were included. Extubation failure occurred in 51 (22.5%) patients, 39 (17.2%) required reintubation. Handgrip strength was 12 [6-20] kg and 12 [8-20] kg, respectively, in extubation success and failure (p = 0.85). There was no association between extubation outcome and MRC score, MIP or PCEF. Handgrip strength was well correlated with MRC score (r = 0.718, p < 0.0001). ICU and hospital length of stay were significantly higher in the subset of patients harboring muscular weakness as defined by handgrip performed at the first weaning trial (respectively, 15 [10-25] days vs. 11 [7-17] days, p = 0.001 and 34 [19-66] days vs. 22 [15-43] days, p = 0.002). CONCLUSION No association was found between handgrip strength and extubation outcome. Whether this was explained by the appropriateness of the tool in this specific setting, or by the precise impact of ICUAW on extubation outcome deserves to be further evaluated. Trial registration Clinical Trials; NCT02946502, 10/27/2016, URL: https://clinicaltrials.gov/ct2/results?cond=&term=gripwean&cntry=&state=&city=&dist=.
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Affiliation(s)
- Guillaume Cottereau
- AP-HP, Service de Rééducation Fonctionnelle et Kinésithérapie, Hôpital Antoine Béclère, 92140, Clamart, France
| | - Jonathan Messika
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
- PHERE UMRS 1152, Université de Paris, 75018, Paris, France
| | - Bruno Megarbane
- Réanimation Médicale et Toxicologique, Fédération de toxicologie, Hôpital Lariboisière, Université Paris-Diderot, Inserm UMRS 1144, 2, rue Ambroise-Paré, 75010, Paris, France
| | - Laurent Guérin
- AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service de Réanimation Médicale, 78, Rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
- Faculté de Médecine Paris-Sud, Univ Paris-Sud, Inserm UMR_S 999, 94270, Le Kremlin-Bicêtre, France
| | - Daniel da Silva
- Réanimation Polyvalente, Hôpital Delafontaine, 93200, Saint-Denis, France
| | - Caroline Bornstain
- Réanimation Polyvalente, Hôpital Intercommunal de Montfermeil, 93370, Montfermeil, France
| | - Matilde Santos
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
| | - Jean-Damien Ricard
- AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Université de Paris, 92700, Colombes, France
- PHERE UMRS 1152, Université de Paris, 75018, Paris, France
| | - Benjamin Sztrymf
- AP-HP, Service de réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, 157 rue de la porte de Triveaux, 92140, Clamart, France.
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Wang TH, Wu CP, Wang LY. Impact of peripheral muscle strength on prognosis after extubation and functional outcomes in critically ill patients: a feasibility study. Sci Rep 2021; 11:16082. [PMID: 34373543 PMCID: PMC8352971 DOI: 10.1038/s41598-021-95647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
The influence of peripheral muscle strength on prognosis after extubation and subsequent functional outcomes is not evident. The objectives of this study were to determine (1) whether peripheral muscle strength can be used as a predictor for patients' prognoses after extubation, and (2) whether the peripheral muscle strength before extubation is correlated with patients' subsequent ambulation ability and in-hospital mortality. This study was a prospective observational cohort study. A hand-held dynamometer was used for evaluated the muscle strength of the biceps and quadriceps right before extubation. Besides, after the patients had been transferred from the ICU to the general ward, a 2-minute walk test was performed. A total of 52 patients were enrolled in this study, and the rate of extubation failure was 15%. The muscle strength of the quadriceps was significantly correlated with the prognosis after extubation, 48% of the patients were able to ambulate after being transferred to the general ward. The overall mortality rate was 11%, and there was a significant correlation between the biceps muscle strength and in-hospital mortality. Peripheral muscle strength may serve as an important predictor of a patients' prognoses after extubation. Poor peripheral muscle strength is indicative of not only a higher risk of re-intubation but also higher in-hospital mortality and poorer functional outcomes.Trial registration: ISRCTN16370134. Registered 30 May 2019, prospectively registered. https://www.isrctn.com/ISRCTN16370134 .
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Affiliation(s)
- Tsung-Hsien Wang
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan ,Departments of Critical Care Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Chin-Pyng Wu
- Departments of Critical Care Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Li-Ying Wang
- grid.19188.390000 0004 0546 0241School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
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Shen Y, Ru W, Huang X, Chen S, Yan J, Yang Z, Cai G. Impact of chronic respiratory diseases on re-intubation rate in critically ill patients: a cohort study. Sci Rep 2021; 11:8663. [PMID: 33883614 PMCID: PMC8060362 DOI: 10.1038/s41598-021-88007-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/26/2021] [Indexed: 01/18/2023] Open
Abstract
Chronic respiratory diseases’ (CRDs) impact on re-intubation rate remains unclear. We investigated the association between these factors in mechanically ventilated patients. Data were extracted from the freely available online Medical Information Mart for Intensive Care III database. CRDs were defined according to ICD-9 codes. Generalised linear regression and propensity score matching were performed. Of 13,132 patients, 7.9% required re-intubation. Patients with chronic obstructive pulmonary disease (COPD) had higher re-intubation (OR 2.48, 95% CI 1.83–3.33) and mortality rates (OR 1.64, 95% CI 1.15–2.34) than those without. Patients with asthma had a lower mortality rate (OR 0.63, 95% CI 0.43–0.92) but a similar re-intubation rate to those of patients without. These findings remained stable after propensity score matching and bootstrapping analysis. The association of COPD with re-intubation was significantly stronger in patients with high oxygen-partial pressure (PaO2) or mild disease severity but was independent of carbon dioxide partial pressure. Corticosteroid use was associated with increased re-intubation rates in subgroups without CRDs (OR 1.77–1.99, p < 0.001) but not in subgroups with CRDs. COPD patients with high post-extubation PaO2 or mild disease severity should be carefully monitored as they have higher re-intubation and mortality rates.
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Affiliation(s)
- Yanfei Shen
- Department of Intensive Care, Zhejiang Hospital, No. 12, Lingyin Road, Hangzhou, 322100, Zhejiang, People's Republic of China
| | - Weizhe Ru
- Department of Oncology, Cixi People's Hospital, Cixi, 315300, Zhejiang, People's Republic of China
| | - Xinmei Huang
- ENT Department, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, People's Republic of China
| | - Shangzhong Chen
- Department of Intensive Care, Zhejiang Hospital, No. 12, Lingyin Road, Hangzhou, 322100, Zhejiang, People's Republic of China
| | - Jing Yan
- Department of Intensive Care, Zhejiang Hospital, No. 12, Lingyin Road, Hangzhou, 322100, Zhejiang, People's Republic of China
| | - Zhouxin Yang
- Department of Intensive Care, Zhejiang Hospital, No. 12, Lingyin Road, Hangzhou, 322100, Zhejiang, People's Republic of China.
| | - Guolong Cai
- Department of Intensive Care, Zhejiang Hospital, No. 12, Lingyin Road, Hangzhou, 322100, Zhejiang, People's Republic of China.
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10
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Krishnakumar M, Muthuchellappan R, Chakrabarti D. Diaphragm Function Assessment During Spontaneous Breathing Trial in Patients with Neuromuscular Diseases. Neurocrit Care 2020; 34:382-389. [PMID: 33210265 PMCID: PMC7673684 DOI: 10.1007/s12028-020-01141-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/27/2020] [Indexed: 12/02/2022]
Abstract
Introduction The optimal time to discontinue patients from mechanical ventilation is critical as premature discontinuation as well as delayed weaning can result in complications. The literature on diaphragm function assessment during the weaning process in the intriguing subpopulation of critically ill neuromuscular disease patients is lacking. Methods Patients with neuromuscular diseases, on mechanical ventilation for more than 7 days, and who were ready for weaning were studied. During multiple T-piece trials over days, diaphragm function using ultrasound and diaphragm electrical activity (Edi peaks using NAVA catheter) was measured every 30 min till a successful 2 h weaning. Results A total of 18 patients were screened for eligibility over 5-month period and eight patients fulfilled the inclusion criteria. Sixty-three data points in these 8 subjects were available for analysis. A successful breathing trial was predicted by Edi reduction (1.22 μV for every 30 min increase in weaning duration; 0.69 μV for every day of weaning) and increase in diaphragm excursion (2.81 mm for every 30 min increase in weaning duration; 2.18 mm for every day of weaning). Conclusion The Edi and diaphragm excursion changes can be used as additional objective tools in the decision-making of the weaning trials in neuromuscular disease. Electronic supplementary material The online version of this article (10.1007/s12028-020-01141-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathangi Krishnakumar
- Department of Neuroanaesthesia and Neurocritical Care, III Floor, Neurosciences Faculty Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India.
| | - Radhakrishnan Muthuchellappan
- Department of Neuroanaesthesia and Neurocritical Care, III Floor, Neurosciences Faculty Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, III Floor, Neurosciences Faculty Centre, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
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11
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Ko RE, Park C, Nam J, Ko MG, Na SJ, Ahn JH, Carriere KC, Jeon K. Effect of post-extubation high-flow nasal cannula on reintubation in elderly patients: a retrospective propensity score-matched cohort study. Ther Adv Respir Dis 2020; 14:1753466620968497. [PMID: 33121395 PMCID: PMC7607726 DOI: 10.1177/1753466620968497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Studies of mechanically ventilated patients with a low risk of reintubation have suggested that the use of high-flow nasal cannula (HFNC) oxygen therapy reduces the risk of reintubation compared with conventional oxygen therapy (COT). However, the effect of HFNC following extubation in elderly patients with a high risk of reintubation remains unclear. Methods: All consecutive medical intensive care unit (ICU) patients aged >65 years who were mechanically ventilated for >24 h were prospectively registered between July 2017 and June 2018. Control was obtained from a historical database of patients attending the same ICU from January 2012 to December 2013. A total of 152 patients who underwent HFNC after planned extubation according to institutional protocols (HFNC group) were compared with a propensity-matched historical control group who underwent COT (n = 175, COT group). The primary outcome was the proportion of reintubated patients within 48 h after planned extubation. Results: One hundred patients from the HFNC group and 129 patients from the COT group were matched by a propensity score that reflected the probability of receiving HFNC, and all variables were well matched. Post-extubation respiratory failure (41.0% versus 33.3%, p = 0.291) and reintubation rate within 48 h (16.0% versus 11.6%, p = 0.436) did not differ between the HFNC and COT groups. However, decreased levels of consciousness as a sign of post-extubation respiratory failure (27.0% versus 11.7%, p = 0.007) were significantly increased in the HFNC group compared with the COT group. Conclusion: Among elderly patients who underwent planned extubation, HFNC was not associated with a decrease in the risk of reintubation. Further prospective study evaluating the clinical benefits of post-extubation HFNC in elderly patients is needed. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chul Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary Medicine, Department of Internal Medicine, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Republic of Korea
| | - Jimyoung Nam
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joong Hyun Ahn
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keumhee C Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Kyeongman Jeon
- Department of Critical Care Medicine and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
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12
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Thille AW, Boissier F, Muller M, Levrat A, Bourdin G, Rosselli S, Frat JP, Coudroy R, Vivier E. Role of ICU-acquired weakness on extubation outcome among patients at high risk of reintubation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:86. [PMID: 32164739 PMCID: PMC7069045 DOI: 10.1186/s13054-020-2807-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/25/2020] [Indexed: 12/21/2022]
Abstract
Background Whereas ICU-acquired weakness may delay extubation in mechanically ventilated patients, its influence on extubation failure is poorly known. This study aimed at assessing the role of ICU-acquired weakness on extubation failure and the relation between limb weakness and cough strength. Methods A secondary analysis of two previous prospective studies including patients at high risk of reintubation after a planned extubation, i.e., age greater than 65 years, with underlying cardiac or respiratory disease, or intubated for more than 7 days prior to extubation. Patients intubated less than 24 h and those with a do-not-reintubate order were not included. Limb and cough strength were assessed by a physiotherapist just before extubation. ICU-acquired weakness was clinically diagnosed as limb weakness defined as Medical Research Council (MRC) score < 48 points and severe weakness as MRC sum-score < 36. Cough strength was assessed using a semi-quantitative 5-Likert scale. Extubation failure was defined as reintubation or death within the first 7 days following extubation. Results Among 344 patients at high risk of reintubation, 16% experienced extubation failure (56/344). They had greater severity and lower MRC sum-score (41 ± 16 vs. 49 ± 13, p < 0.001) and were more likely to have ineffective cough than the others. The prevalence of ICU-acquired weakness at the time of extubation was 38% (130/244). The extubation failure rate was 12% (25/214) in patients with no limb weakness vs. 18% (12/65) and 29% (19/65) in those with moderate and severe limb weakness, respectively (p < 0.01). MRC sum-score and cough strength were weakly but significantly correlated (rho = 0.28, p < .001). After multivariate logistic regression analyses, the lower the MRC sum-score the greater the risk of reintubation; severe limb weakness was independently associated with extubation failure, even after adjustment on cough strength and severity at admission. Conclusion ICU-acquired weakness was diagnosed in 38% in this population of patients at high risk at the time of extubation and was independently associated with extubation failure in the ICU.
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Affiliation(s)
- Arnaud W Thille
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France. .,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France. .,Réanimation Médicale, CHU de Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France.
| | - Florence Boissier
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Michel Muller
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | - Albrice Levrat
- Centre Hospitalier Annecy Genevoix, Réanimation Polyvalente, Metz-Tessy, France
| | - Gaël Bourdin
- Centre Hospitalier Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
| | - Sylvène Rosselli
- Centre Hospitalier Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
| | - Jean-Pierre Frat
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Rémi Coudroy
- ALIVE Research group INSERM CIC 1402, University of Poitiers, Poitiers, France.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Emmanuel Vivier
- Centre Hospitalier Saint Joseph Saint Luc, Réanimation Polyvalente, Lyon, France
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13
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Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med 2020; 46:637-653. [PMID: 32076765 PMCID: PMC7224132 DOI: 10.1007/s00134-020-05944-4] [Citation(s) in RCA: 247] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 01/04/2023]
Abstract
Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short- and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of “neuropathy”, “myopathy”, “neuromyopathy”, or “weakness” with “critical illness”, “critically ill”, “ICU”, “PICU”, “sepsis” or “burn”. ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short- and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.
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Affiliation(s)
- Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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14
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Jeong BH, Lee KY, Nam J, Ko MG, Na SJ, Suh GY, Jeon K. Validation of a new WIND classification compared to ICC classification for weaning outcome. Ann Intensive Care 2018; 8:115. [PMID: 30498971 PMCID: PMC6265356 DOI: 10.1186/s13613-018-0461-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/26/2018] [Indexed: 12/05/2022] Open
Abstract
Background Although the WIND (Weaning according to a New Definition) classification based on duration of ventilation after the first separation attempt has been proposed, this new classification has not been tested in clinical practice. The objective of this cohort study was to evaluate the clinical relevance of WIND classification and its association with hospital mortality compared to the International Consensus Conference (ICC) classification. Methods All consecutive medical ICU patients who were mechanically ventilated for more than 24 h between July 2010 and September 2013 were prospectively registered. Patients were classified into simple, difficult, or prolonged weaning group according to ICC classification and Groups 1, 2, 3, or no weaning (NW) according to WIND classification. Results During the study period, a total of 1600 patients were eligible. These patients were classified by the WIND classification as follows: Group NW = 580 (36.3%), Group 1 = 617 (38.6%), Group 2 = 186 (11.6%), and Group 3 = 217 (13.6%). However, only 735 (45.9%) patients were classified by ICC classification as follows: simple weaning = 503 (68.4%), difficult weaning = 145 (19.7%), and prolonged weaning = 87 (11.8%). Clinical outcomes were significantly different across weaning groups by ICC classification and WIND classification. However, there were no statistical differences in successful weaning rate (96.6% vs. 95.2%) or hospital mortality (22.5% vs. 25.5%) between simple and difficult weaning groups by the ICC. Conversely, there were statistically significant differences in successful weaning rate (98.5% vs. 76.9%) and hospital mortality (21.2% vs. 33.9%) between Group 1 and Group 2 by WIND. Conclusions The WIND classification could be a better tool for predicting weaning outcomes than the ICC classification. Electronic supplementary material The online version of this article (10.1186/s13613-018-0461-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Byeong-Ho Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Kyeong Yoon Lee
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jimyoung Nam
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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