Early Mobilization in the ICU

LUNG DAY 2010

C. Terri Hough, MD MSc
Assistant Professor of Medicine
Pulmonary and Critical Care Medicine
Harborview Medical Center
 Case presentation

ID: JL is a 31 year old man

CC: Admitted with fever and shortness of breath
PMH: Mild depression
Meds: None
Soc History: Runs a business (dog walking/ grooming).
Non-smoker, occasional EtOH
Admitting diagnosis:
Seasonal influenza
Secondary MRSA pneumonia
 ICU Course

• Developed ARDS and MRSA bacteremia

– On mechanical ventilation for 13 days
– Required surgical debridement of pleural space
• First 3 days
– Hypotensive, on vasopressors
– Frequent desaturations with turns and suctioning
• Then stabilized
– Remained on ventilator for poor oxygenation,
then for rapid shallow breathing on SBTs
– Received high doses of lorazepam for agitation,
especially at night
 Post-ICU course

• On transfer to ward
– Too delirious to participate in therapy
– Markedly weak
– Transferred to SNF to complete antibiotics
– Returned home 5 weeks after initial illness began
• 6 months later
– Describes difficulty with concentration, memory
– Recurring nightmares about spiders and suffocation
– Regaining strength, still couldn’t walk up 1 flight of
stairs without stopping
– Still not back to work
Long-term outcomes after critical illness

• Cognitive impairment is common

– 100% of ALI survivors impaired at d/c
– ~ 50% with persisting impairment at 1 year
• Anxiety, depression and post-traumatic stress
seen in many survivors
– 25-50% of survivors may be affected
• MOST survivors have persisting problems
with physical function
• Prolonged disability is common
Hopkins RO. AJRCCM 1999
Herridge MS. NEJM 2003
COULD EARLY MOBILIZATION HAVE HELPED
THIS PATIENT?
 Outline

• ICU-acquired weakness
• Why mobilize critically ill patients
• What is current practice?
• A multidisciplinary approach at HMC
Why do critically ill patients develop weakness?

• Critical illness myopathy and neuropathy

– Resulting from critical illness and its treatments
• Muscle dysfunction due to
– Catabolism
– Deconditioning
– Immobility
• Other causes of weakness or impaired mobility
– Pain
– Contractures
– Compression neuropathies
– Heterotopic ossification
 How common is ICU-acquired weakness?
MICU/SICU patients (n=95) on MV > 7d

• At least 25% of ICU 120

patients develop 100

weakness
80 Weak
• BUT
Not weak
– Many ICU patients cannot 60
be assessed by clinical Not
examination 40 assessed

20

De Jonghe B. JAMA 2002

Weak patients could not even lift up arms or legs

5= full strength
4= moves against resistance
3= opposes gravity
2= moves without gravity
1= twitch
De Jonghe B. JAMA 2002
0= no movement
Weak patients have worse outcomes

• Increased duration of mechanical ventilation

• Time of ventilation increases by 1-3 weeks
• Most significant predictor of prolonged MV
• Longer ICU and hospital stay
• More likely to need re-intubation
• Less likely to go home at hospital discharge
• More likely to die in the hospital
• Experience delays in rehabilitation
– Take longer to regain strength, walk, work

Leijten JAMA 1995 ;De Jonghe JAMA 2002; Hough ICM 2009; Ali AJRCCM 2008
Strength testing underestimates ICU-acquired
neuromuscular dysfunction
100
90 MV > 7 d (95)
80 MV > 7 d (98)
70 Asthma (25)
60 MV > 7 d (38)
50
Sepsis (43)
40
30 Sepsis (22)
20 ICU (31)
10 ICU (23)
0
Clinical exam EMG Muscle biopsy ALI (61)

Hough CL. Crit Care Clin 2006

 Respiratory muscles are also affected

• Phrenic nerve conduction studies show changes

consistent with critical illness neuromyopathy
– Abnormal in 48 of 52 (92%) of patients with weakness
and failure to wean
• Diaphragm atrophies on mechanical ventilation
– Atrophic changes within 1 week on CMV

Zifko UA. JNS 1998

Levine S. NEJM 2008
Nerve and muscle changes happen early in ICU

• Neuropathy and
myopathy
– Changes detected
within 2-3 days
• Loss of muscle
thickness
– Most dramatic in
first 2-3 weeks

Bolton CM. ICM 2000

Gruther W. J Rehab Med 2008
 Summary

• ICU-acquired weakness
– Common
– Underestimated by clinical examination
– Associated with poor outcomes
– Involves respiratory muscles
– Begins early in the ICU stay
– Is likely worsened by immobility
 Outline

• ICU-acquired weakness
• Why mobilize critically ill patients
• What is current practice?
• A multidisciplinary approach at HMC
Potential benefits of activity during critical illness
• Effects on the body
– Reducing muscle atrophy and weakness
– Improving respiratory function
• Optimizing V/Q matching
• Increasing lung volumes
• Improving airway clearance
– Increasing functional independence
– Improving cardiovascular fitness
• Effects on the mind
– Increasing psychological well being
– Increasing level of consciousness
Stiller K. Crit Care Clin 2007
 Consequences of immobility
• Space program
– Rapid muscle atrophy in zero
gravity
• Experimental models of
pseudo-weightlessness
– Induce similar changes as
critical illness
– Magnitude of muscle loss is
much less than in the ICU

Cosmonaut Yury Usachev on Space Station

 Bed rest might not be good for you!
• Immobility contributes to
– Muscle atrophy
– Switch of muscle myosin isoforms from slow to fast twitch
– Inflammation (local and systemic)
– Metabolic changes: insulin resistance, decreased protein
synthesis, and decreased fatty acid metabolism
• Effects are amplified during critical illness

Needham DM. JAMA 2008

 Can we mobilize ICU patients?

• Is it safe?
– And, if so, for which patients?
• Is it feasible?
• Is it helpful?
2 cohort studies and 1
randomized controlled trial
have been completed in
attempts to answer these
questions
 “Early activity is feasible and safe in respiratory
failure patients”
• Prospective cohort study
– 8 bed RICU
– Included all patients with > 4 days MV
– 3 criteria to begin activity (guidelines)
• Neurologic (response to verbal stimulus)
• Respiratory (FIO2< 0.6 and PEEP < 10)
• Circulatory (no orthostasis or vasopressors)
• Intervention: progressive increase in activity
– Sit on bed, sit in chair, ambulate (twice daily)
• Team: PT, RT, RN and critical care technician
• Outcome: Ambulation > 100 ft at ICU d/c

Bailey P. CCM 2007

Intubated patients were able to participate
• Enrolled: 103 patients
– Nearly all transferred from other ICUs (med, surg)
– Mean time to transfer: 10.5 days
– 89% on MV at RICU admission
• Ambulation occurred by RICU day 3 (mean)

Bailey P. CCM 2007

 Safety and feasibility
• Safety
– 14 adverse events out of 1449 activity events
• Fall to knees (5)
• SBP < 90 (4– all orthostatic)
• SBP > 200 (1)
• O2 desaturation to <80% (3– all rapidly resolved)
• Removal of nasal feeding tube (1)
• Feasibility
– No change in staffing was needed for protocol
• RN: patient 1:2
• RT: patient 1:4
• PT: no increasing in staffing (? Ratio)
Bailey P. CCM 2007
 “Early intensive care unit mobility therapy in the
treatment of acute respiratory failure”
• Prospective cohort study
– Block allocation design
• Study question:
– Does a mobility protocol and team
increase the proportion of ICU patients
receiving PT?
• Population: MICU patients requiring
MV on admission
• Intervention: Mobility Team (RN, PT,
NA) initiating progressive protocol
within 48 hours of MV
– Control: RN-PROM, positioning
• Outcome: proportion of hospital
survivors receiving PT Morris PE. CCM 2008
Protocol
Safety criteria*

•Hypoxia: desats <

88%
•Hypotension: MAP
<65 mmHg
•New vasopressor
•New myocardial
infarction
•Dysrhythmia
requiring new agent
•Increase in PEEP
•Return to AC when
in weaning mode

*Mobility withheld
for 1 day, then
reassessed
Morris PE. CCM 2008
 Mobility protocol increased PT, and
associated with improved outcomes
• Mobility protocol increased PT
– More patients seen in hospital (80% vs. 47%)
– More sessions (5.5 vs. 4.1 sessions)
– Patients out of bed sooner (day 8.5 vs. 13.7)
• Mobility protocol improved outcomes
– Shortened ICU and hospital LOS (1.5, 3.3 days less)
– Duration of MV not significantly different
• No increase in costs
• No adverse events

Morris PE. CCM 2008

• Randomized controlled study
• Population:
– Previously independent MICU patients requiring < 72
hours mechanical ventilation
• Intervention: Early exercise and mobilization
– Control: Daily interruption of sedation with “usual PT/OT”
• Primary outcome: Independent functional status at
hospital discharge
– Independent performance of 6 ADLs and ambulation
• Additional outcomes: delirium, duration of MV
Schweickert WD. Lancet 2009
 Daily protocol delivered by PT/OT
Safety Restrictions
• Every morning, sedatives were
interrupted • MAP < 65 or >110
• SBP > 200
• Unresponsive patients
– passive range of motion • HR < 40 or > 130
• RR < 5 or > 40
• Once patient interactive,
– Active range of motion • SaO2 < 88%
– Bed mobility activities, transferring • High ICP
to upright sitting • GIB
– Transfer training • Myocardial ischemia
– Pre-gait activities • Intermittent HD
– Walking • Sedation in last 30 min
• Therapy occurred daily until • Unsecure airway
previous function or hospital • Ventilator asynchrony
discharge achieved
• New arrhythmia
Schweickert WD. Lancet 2009
Early therapy leads to early milestones

Schweickert WD. Lancet 2009

 Early therapy improved outcomes
Intervention Control
N=49 N=55
Independent at 29/49 (59%) 19/55 (35%) P=0.02
discharge
Distance walked at 33 m [0-91] 0 m [0-30] P=0.004
discharge
ICU delirium 2 days [0-6] 4 days [2-8] P=0.03

ICU-acquired 31% 49% P=0.09

weakness
Duration of MV 3.4 days [2.3-7.3] 6.1 days [4.0-9.6] P=0.02

Hospital LOS 13.5 days [8-23] 12.9 days 9-20] P=0.93

Hospital mortality 18% 25% P=0.53

Schweickert WD. Lancet 2009

Benefits of early mobilization of critically ill
patients: preliminary evidence

• Improves patient outcomes

– Duration of mechanical ventilation
– Delirium
– Length of hospital stay
– Functional independence at hospital discharge
• Saves hospitals $$
• Even with increased staff
Benefits of early mobilization of critically ill
patients: pure conjecture
• Improved muscle mass, strength and function
– Short and long-term
• Decreased sedation use
• Improved communication with critically ill
patients
• Increased satisfaction with ICU care of
– Patients
– Families
– Clinical staff
• Enhance the team approach in the ICU
 Outline

• ICU-acquired weakness
• Why mobilize critically ill patients
• What is current practice?
• A multidisciplinary approach at HMC
We’re probably not doing as much therapy as
we think we are…

• National PT Survey data

– PTs responded therapy is indicated for ICU pts
• variable timing, frequency and intensity
• Small observational pilot project: JHH
– Observed MICU for 13 weeks
– Found 21/32 eligible patients had orders for PT
– 19 patients received a total of 50 treatments
• 12% of MICU days
– Barriers: sedation, unavailability of staff
– New impairments in physical function were
common at hospital discharge Hodgin KE. CCM 2009
Zanni JM. JCC 2009
 Even patients with prolonged mechanical
ventilation may receive only limited therapy
• All patients on MV at HMC > 14 days in 2005 (176 pts)
– PT consulted by day 14 for 44%
– Most patients did not progress beyond passive ROM (51%) in the ICU
– Not a single patient stood or walked in the ICU
– Only 18% of patients were independent enough to go home at discharge

Jolley and Hough, ATS abstract 2010

 Outline

• ICU-acquired weakness
• Why mobilize critically ill patients
• What is current practice?
• A multidisciplinary approach at HMC
 A multidisciplinary approach at HMC

• Multidisciplinary group
– Debbie Young, Nicole Kupchik (CCRN)
– Louise Wall, Sommer Kleweno-Walley (PT, Rehab)
– Dennis Archer, Terri Hough (RT, MD)
– (Your name here)
• Appealing to HMC for support
– Approved a 6 month pilot; 1 PT FTE for MCICU
• Current status
– Finishing protocols
– Purchasing equipment
– Seeking input from all stakeholders
– Implementing protocol starting August 2nd, 2010!
Let’s get moving!

Needham DM. JAMA 2008