Mr. David TW Yu, Senior Physiotherapist, Queen Elizabeth Hospital, May 2010
Figure. Neuromuscular electrical stimulation
Introduction
Advances in the management of mechanically ventilated patients have improved outcomes and survival rates for critically ill patients1. As patients survive the acute illness with improved mortality, the long-term complications can significantly hamper the independence of the patients with prominent morbidity2. These complications can delay weaning due to respiratory muscle weakness, prolonged mechanical ventilation, and delay rehabilitation progress owing to limb weakness3,4. A longer period of dependency on support and rehabilitation services results in an increase in length of hospital stay, both of which can have significant cost implications5.
Neuromuscular complications are frequent in patients with severe diseases that require admission to the Intensive Care Unit (ICU). Weaknesses of limbs and respiratory muscles are most frequently due to Critical Illness Polyneuropathy (CIP) and Myopathy (CIM)6 which accounted for 33% to 57% of patients staying in ICU for more than 7 days7. Observational studies of patients on mechanical ventilation for at least 4 days who were subsequently transferred to a dedicated respiratory ICU (post-acute care) have demonstrated that Physiotherapy (PT) was safe and could promote more rapid return to ambulation8. In addition, most authors agree that PT is useful by reducing the disuse atrophy that is prominent in this disorder9. A prospective cohort study by Morris and colleagues8 also concluded that early PT mobilization can shorten the length of stay in the ICU and in hospital8. In this regard, an “Enhanced Early Physiotherapy Rehabilitation Protocol in Intensive Care Unit” had been formulated in Queen Elizabeth Hospital since November 2009 to fulfil the service needs with a view to improving mortality and morbidity in mechanically ventilated patients with critical illnesses.
Definition of CIP and CIM
CIP is defined as acute primary axonal sensori-motor degeneration, accompanied by degeneration of skeletal muscle as a result of their degeneration10. CIM is defined as acute primary myopathy whose spectrum extends from pure functional impairment with normal histology to muscle atrophy and necrosis11.
Risk Factors
Length of ICU stays > 7 days6,10,11
Sepsis and systemic inflammatory response syndrome6,10,11
Multi-organ dysfunction syndrome11,12
High Acute Physiology and Chronic Health Evaluation III (APACHE III) score13
The use of neuromuscular-blocking agents6,11,14
Received high dose steroids e.g. treatment of acute asthma, recipients of organ transplantation, patients with myasthenia gravis etc15
Hyperglycemia15
Objectives of the Enhanced Early Physiotherapy Rehabilitation Program
To reduce the incidence of CIP and CIM for patients who stay in the ICU
To reduce the length of stay in ICU & hospital by enhancing the PT services
To reduce the sequel of ICU-acquired neuromuscular dysfunction and de-conditioning,
and to hasten recovery from both CIP and CIM
To facilitate weaning of mechanically ventilated patients
To decrease the duration of disability
To improve clinical outcomes & optimize the level of functional independence
Program Contents
The program in Adult ICU in QEH embraces three levels of interventions:
Level I
Target patients:
For unconscious, semiconscious or deeply sedated patients with Glasgow Coma Scale (GCS) < 11 (for intubated patient) or GCS < 8 (for non-intubated patient).
Interventions:
a. Cardiopulmonary PT for supported weaning from mechanical ventilation
b. Passive range of motion (PROM) therapy for prevention of joint contracture and bedsore
c. Assisted active range of motion therapy for those who can follow instructions
Figure 1. Passive and assisted active range of motion therapy
Level II
Target patients:
For those patients who have regained consciousness with GCS =11 (for intubated patient) or GCS > 8 (for non-intubated patient) and is able to interact with case physiotherapist. Muscle power of larger muscle groups < Grade 3.
Interventions:
a. Cardiopulmonary PT for supported weaning.
b. Inspiratory muscle training for indicated patients
c. PROM therapy
c. Assisted active range of motion therapy
d. Neuromuscular electrical stimulation
Figure 2. Neuromuscular electrical stimulation
Level III
For those patients who have regained consciousness with GCS =11 (for intubated patient) or GCS > 8 (for non-intubated patient) and is able to interact with case physiotherapist. Muscle power of larger muscle groups > Grade 3.
Interventions:
a. Cardiopulmonary PT for supported weaning or maintenance of chest conditions
b. Vasomotor training by tilt table / electrical standing wheelchair
Daily treatment. Start with 45 inclination for 5 minutes. Gentle incline to maximum of 70 for 30 minutes16
c. Graded resisted exercise therapy
d. Early pre-ambulation training program (basic transfer training, sit-out-bed training, static bike exercise, etc.)
e. Supervised and/or assisted ambulatory training program (early ambulation with / without portable ventilator / oxyvent / oxygenated manual bag with frame / rollator / Arjo Walker)
Advancement to the next level will be based on the level of consciousness, paresis, functional independence and respiratory status. To ensure safety in this vulnerable client, explicit criteria for withholding rehabilitation interventions will include:
Hypoxemia with frequent oxygen desaturations below 88% or patient shows respiratory distress
Hypotensive (drop in SBP of >10 mmHg from baseline) or hypertensive response to exercises (SBP of more than 250mmHg and a DBP of more than 115 mmHg)
Sustained ventricular tachycardia (VT)
Arrhythmias other than VT, including multifocal premature ventricular contractions, supraventricular tachycardia, heart block, or bradyarrhythmias
Recent administration of a new vasopressor agent
Recent documented myocardial infarction by ECG and enzyme changes
Dysrhythmia requiring the addition of a new anti-arrhythmic agent
Recent increase in positive-end expiratory pressure, or revert back to assist control mode once in a weaning mode
Outcome indicators / performance indicators
Outcome indicators / performance indicators include evaluation on impairment, specific bodily function and administrative outcome measures as stipulated below:
Incidence of CIP and CIM during ICU stay
Duration of mechanical ventilation
Weaning from mechanical ventilation. This is defined as the time to actual and final liberation from the ventilator
Length of ICU stay and overall hospital stay
Manual Muscle Testing (MMT) (Dynamometer) / Handgrip strength
APACHE score
References
1. Girad TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomized controlled trial. Lancet 2008; 371: 126-34.
2. Schweickert WD, Hall J. ICU-acquired weakness. Chest 2007; 131:1541-49.
3. Keaveney AM. Critical illness polyneuropathy on adults after cardiac surgery: a case study. Am J Crit Care 2004;13(5):421–4.
4. Polkey MI, Moxham J. Clinical aspects of respiratory muscle dysfunction in the critically ill. Chest 2001;119(3):926–39.
5. Griffiths RD, Jones C. Intensive care aftercare. 1st ed. Oxford: Butterworth–Heinemann; 2002.
6. Hermans G, De Jonghe B, Bruynincks F, Van den Berghe G. Interventions for preventing critical illness polyneuropathy and critical illness myopathy (Review) The Cochrane Collaboration 2009.
7. Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise prescription in Australian intensive care units. Physiotherapy 2008; 94: 220-29.
8. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36:2238-43.
9. Pandit L, Agrawal A. Neuromuscular disorders in critical illness. Clinl Neuro Neurosurg 2006;108:621-7.
10. Latronico N, Fenzi F, Recupero D, et al. Critical illness myopathy and neuropathy. Lancet 1996;347:1579-1582.
11. Tennila A, Salmi T, Pettila V, Roine RO, Varpula T, Takkunen O. Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis. Intensive Care Med 2000;26:1360–3.
12. Tepper M, Rakic S, Haas JA. Incidence and onset of critical illness polyneuropathy in patients with septic shock. Neth J Med 2000;56:211–4.
13. de Letter MA, Schmitz PI, Visser LH, Verheul FA, Schellens RL, Op de Coul DA, et al. Risk factors for the development of polyneuropathy and myopathy in critically ill patients. Crit Care Med 2001;29:2281–6.
14. Fletcher SN, Kennedy DD, Ghosh IR, Misra VD, Kiff K, Coakley JH, et al. Persistent neuromuscular and neurophysiologic abnormalities in long term survivors of prolonged critical illness. Crit Care Med 2003;31(4):1012–6.
15. Hund E. Myopathy in critically ill patients. Crit Care Med 1999;27:2544-7.
16. Chang AT, Boots R, Hodges PW, Paratz J. Standing with assistance of a tilt table in intensive care: A survey of Australian physiotherapy practice. Aust J Physio 2004;50:51-54.
