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Exercise in Critical Care

Original Editor - David Gillette

Top Contributors - Safiya Naz, Admin, Ali Gomaa, Kim Jackson, Rachael Lowe, WikiSysop, David Gillette, Karen Wilson, Samuel Adedigba and Alexandra Stead  

Introduction

Early mobility in the hospital setting is getting more scrutiny and study.[1]  This page discusses ambulation/active mobility on a ventilator, prolonged mechanical ventilation and immobility leading to complications, the aim is to reduce the incidence of these complications.

Result of inactivity/ bedrest

  • Bed rest: muscles deteriorate[2]
  • Contractures start[3]
  • Reduced perfusion, increased hemodynamic instability, increased risk for ischemia and injury[4]
  • Muscles – sarcomeres shorten, reducing contracting force and strength; slow fibres convert to fast[5]
  • Inflammatory diseases – can cause diaphragmatic contractile dysfunction
  • Unloading/ resting diaphragm = decreased endurance
  • Sensory deprivation – anxiety, depression, disturbed sleep (therefore medicated)
  • Sense of fatigue – leads to self-limitation[6][7]
  • ICU-acquired weakness (rapid muscle wasting)

Critical Illness Neuromyopathy

  • Develops during ICU (vs Guillain-Barré syndrome or myasthenia gravis).
  • Cardinal locomotor sign – proximal weakness, grossly symmetrical scored by a manual muscle testing sum of arm abduction, elbow flexion, wrist extension, hip flexion, knee extension, dorsiflexion, with 0 = no visible contraction, 1 = visible but no movement, 2 = active but not Antigravity, 3 = active, Antigravity, 4 = active, Antigravity and resistance (NOTE: doesn't say how much resistance!), 5 = normal power <48 – significant weakness; may have sensory, Golgi tendon reflex, muscle mass loss can be diagnosed with Electromyography(EMG) which shows reduced action potential and spontaneous activity occurring but noted to not always be feasible.
  • Patients with critical illness neuromyopathy(CINM) – increased days on a vent, longer weaning, immobility.[8]

Outcomes of prolonged ventilation

Physiotherapist Involvement

Early exercise in critically ill patients is life-saving and helps prevent complications, particularly with early ambulation.[16] However, during pressure support ventilation (PSV), mismatched assistance to breathing demand can increase breathing effort and limit exercise capability.[17] In contrast, a proportional ventilation mode (such as Proportional Assist Ventilation, PAV+, and Neurally Adjusted Ventilatory Assist, NAVA) may enhance exercise tolerance.[17] This study investigated whether PSV and proportional ventilation differently affect respiratory muscle relief and work efficiency during exercise in critically ill patients.[17] Results indicate that proportional ventilation during exercise leads to greater work efficiency and a smaller increase in VO2 compared to PSV, suggesting that proportional ventilation might boost training effects and support rehabilitation.

Early mobilisation increases the number of ventilator-free days and the discharged-to-home rate for patients with critical illnesses in the ICU setting.[18]

Also can benefit from active mobility general benefits :[18]

  • prevent loss of muscle strength and mass, and reduce systemic inflammation
  • prevent respiratory complications
  • increase survival, and reduce possible disability
  • prevent contractures and maintain joint flexibility
  • maintain available joint ROM

Future Directions

We know that immobility has negative repercussions for the patient and that being on a ventilator has even more negative repercussions.

[19]

Barriers to mobility

  • Safety concerns
  • Dislodging lines or tubes
  • Reducing already low oxygenation and hemodynamic parameters
  • Sedation (which reduces mentation)
  • Cost
  • Number of workers needed
  • Mobility aids needed (do we need to build our own?)
  • Obesity
  • Time

References

  1. ↑ Clarissa, C., Salisbury, L., Rodgers, S., & Kean, S. Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities. J Intensive Care. 2019;7:3. Published 2019 Jan 17.
  2. ↑ Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Ext Physiol Med. 2015 Dec;4(1):1-8.
  3. ↑ Knight J, Nigam Y, Jones A. Effects of bedrest 5: the muscles, joints and mobility. Nurs Times. 2019;115(4):54-7.
  4. ↑ Bose EL, Hravnak M, Pinsky MR. The interface between monitoring and physiology at the bedside. Crit Care Clin. 2015 Jan;31(1):1-24.
  5. ↑ Chambers MA, Moylan JS, Reid MB. Physical inactivity and muscle weakness in the critically ill. Crit Care Med. 2009 Oct;37(10 Suppl)
  6. ↑ Winkelman C. Inactivity and inflammation in the critically ill patient. Crit Care Clin. 2007 Jan;23(1):21-34.
  7. ↑ Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008 Oct 8;300(14):1685-90.
  8. ↑ De Jonghe B, Lacherade JC, Durand MC, Sharshar T. Critical illness neuromuscular syndromes. Crit Care Clin. 2007 Jan;23(1):55-69.
  9. ↑ Mouchtouris N, Lang MJ, Barkley K, Barros G, Turpin J, Sweid A, et al. Predictors of hospital-associated complications prolonging ICU stay in patients with low-grade aneurysmal subarachnoid hemorrhage. J Neurosurg. 2019 May;132(6):1829-35.
  10. ↑ Clum SR, Rumbak MJ. Mobilizing the patient in the intensive care unit: the role of early tracheotomy. Crit Care Clin. 2007;23(1):71-9.
  11. ↑ Moodie L, Reeve J, Elkins M. Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation: a systematic review. Journal of physiotherapy. 2011 Jan 1;57(4):213-21.
  12. ↑ Choi J, Tasota FJ, Hoffman LA. Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of the literature. Biol Res Nurs. 2008 Jul;10(1):21-33.
  13. ↑ Clum SR, Rumbak MJ. Mobilizing the patient in the intensive care unit: the role of early tracheotomy. Crit Care Clin. 2007;23(1):71-9.
  14. ↑ Dowdy DW, Eid MP, Dennison CR, Mendez-Tellez PA, Herridge MS, Guallar E, et al. Quality of life after acute respiratory distress syndrome: a meta-analysis. Intensive Care Med. 2006 Aug;32(8):1115-24.
  15. ↑ Davydow DS, Gifford JM, Desai SV, Bienvenu OJ, Needham DM. Depression in general intensive care unit survivors: a systematic review. Intensive Care Med. 2009 May;35(5):796-809.
  16. ↑ Hashem MD, Nelliot A, Needham DM. Early mobilization and rehabilitation in the ICU: moving back to the future. Respiratory care. 2016 Jul 1;61(7):971-9.
  17. ↑ 17.0 17.1 17.2 Akoumianaki, E., Dousse, N., Lyazidi, A., Lefebvre, J. C., Graf, S., Cordioli, R. L., Rey, N., Richard, J. M., & Brochard, L. Can proportional ventilation modes facilitate exercise in critically ill patients? A physiological cross-over study : Pressure support versus proportional ventilation during lower limb exercise in ventilated critically ill patients. Ann Intensive Care. 2017;7(1):64.
  18. ↑ 18.0 18.1 Zhang, L., Hu, W., Cai, Z., Liu, J., Wu, J., Deng, Y., Yu, K., Chen, X., Zhu, L., Ma, J., & Qin, Y. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One. 2019;14(10):e0223185. Published 2019 Oct 3.
  19. ↑ Johns Hopkins Medicine: Early Mobility in the ICU https://www.youtube.com/watch?v=D53gygWRhLM
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