As of 15 May 2020, 4 405 680 coronavirus 2019 (COVID-19) cases have been reported worldwide 1. Although figures are increasing, it seems the virus aggression is lowering, significantly reducing the ...pressure on the intensive care unit (ICU) beds. At the time of writing, the lockdown is going through a new phase of remodelling, and the National Authorities are testing the possibility of resuming economic activities. From the general population point of view, this is an encouraging aspect but, all those professionals involved in the pathway of care are aware of the importance this phase has on preventing the spread of the infection.
Considering the expected high burden of respiratory, physical and psychological impairment following the acute phase of COVID-19, a huge number of patients should be referred early to a rehabilitation programme
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Purpose
To assess the independent association between ICU-acquired neuromuscular complications and 5-year mortality and morbidity. To explore the optimal threshold of the Medical Research Council ...(MRC) sum score, assessing weakness, for the prediction of 5-year outcomes.
Methods
Sub-analyses of a prospective, 5-year follow-up study including 883 EPaNIC patients (Early versus Late Parenteral Nutrition in Intensive Care) (Clinicaltrials.gov:NCT00512122), systematically screened in ICU for neuromuscular complications with MRC sum score (‘MRC-cohort’,
N
= 600), electrophysiology on day 8 ± 1 to quantify compound muscle action potential (‘CMAP-cohort’,
N
= 689), or both (‘MRC&CMAP-cohort’,
N
= 415). Associations between ICU-acquired neuromuscular complications and 5-year mortality, hand-grip strength (HGF, %predicted), 6-min-walk distance (6-MWD, %predicted) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36) at 5-years were assessed with Cox regression and linear regression, adjusted for confounders. The optimal threshold for MRC at ICU discharge to predict 5-year outcomes was determined by martingale residual plots (survival) and scatterplots (morbidity).
Results
Both lower MRC sum score at ICU discharge, indicating less strength HR, per-point-increase: 0.946 (95% CI 0.928–0.968),
p
= 0.001, and abnormal CMAP, indicating nerve/muscle dysfunction HR: 1.568 (95% CI 1.165–2.186),
p
= 0.004, independently associated with increased 5-year mortality. In the MRC&CMAP-cohort, MRC HR: 0.956 (95% CI 0.934–0.980),
p
= 0.001 but not CMAP HR: 1.478 (95% CI 0.875–2.838),
p
= 0.088 independently associated with 5-year mortality. Among 205 survivors, low MRC independently associated with low HGF 0.866 (95% CI 0.237–1.527),
p
= 0.004, low 6-MWD 105.1 (95% CI 12.1–212.9),
p
= 0.043 and low PF-SF-36 − 0.119 (95% CI − 0.186 to − 0.057),
p
= 0.002, whereas abnormal CMAP did not correlate with these morbidity endpoints. Exploratory analyses suggested that MRC ≤ 55 best predicted poor long-term morbidity and mortality. Both MRC ≤ 55 and abnormal CMAP independently associated with 5-year mortality.
Conclusions
ICU-acquired neuromuscular complications may impact 5-year morbidity and mortality. MRC sum score, even if slightly reduced, may affect long-term mortality, strength, functional capacity and physical function, whereas abnormal CMAP only related to long-term mortality.
This document outlines recommendations for physiotherapy management for COVID-19 in the acute hospital setting. It includes: recommendations for physiotherapy workforce planning and preparation; a ...screening tool for determining requirement for physiotherapy; and recommendations for the selection of physiotherapy treatments and personal protective equipment. It is intended for use by physiotherapists and other relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected COVID-19.
OBJECTIVES:To investigate whether a daily exercise session, using a bedside cycle ergometer, is a safe and effective intervention in preventing or attenuating the decrease in functional exercise ...capacity, functional status, and quadriceps force that is associated with prolonged intensive care unit stay. A prolonged stay in the intensive care unit is associated with muscle dysfunction, which may contribute to an impaired functional status up to 1 yr after hospital discharge. No evidence is available concerning the effectiveness of an early exercise training intervention to prevent these detrimental complications.
DESIGN:Randomized controlled trial.
SETTING:Medical and surgical intensive care unit at University Hospital Gasthuisberg.
PATIENTS:Ninety critically ill patients were included as soon as their cardiorespiratory condition allowed bedside cycling exercise (starting from day 5), given they still had an expected prolonged intensive care unit stay of at least 7 more days.
INTERVENTIONS:Both groups received respiratory physiotherapy and a daily standardized passive or active motion session of upper and lower limbs. In addition, the treatment group performed a passive or active exercise training session for 20 mins/day, using a bedside ergometer.
MEASUREMENTS AND MAIN RESULTS:All outcome data are reflective for survivors. Quadriceps force and functional status were assessed at intensive care unit discharge and hospital discharge. Six-minute walking distance was measured at hospital discharge. No adverse events were identified during and immediately after the exercise training. At intensive care unit discharge, quadriceps force and functional status were not different between groups. At hospital discharge, 6-min walking distance, isometric quadriceps force, and the subjective feeling of functional well-being (as measured with “Physical Functioning” item of the Short Form 36 Health Survey questionnaire) were significantly higher in the treatment group (p < .05).
CONCLUSIONS:Early exercise training in critically ill intensive care unit survivors enhanced recovery of functional exercise capacity, self-perceived functional status, and muscle force at hospital discharge.
Intensive care unit (ICU)-acquired weakness is a frequent complication of critical illness. It is unclear whether it is a marker or mediator of poor outcomes.
To determine acute outcomes, 1-year ...mortality, and costs of ICU-acquired weakness among long-stay (≥8 d) ICU patients and to assess the impact of recovery of weakness at ICU discharge.
Data were prospectively collected during a randomized controlled trial. Impact of weakness on outcomes and costs was analyzed with a one-to-one propensity-score-matching for baseline characteristics, illness severity, and risk factor exposure before assessment. Among weak patients, impact of persistent weakness at ICU discharge on risk of death after 1 year was examined with multivariable Cox proportional hazards analysis.
A total of 78.6% were admitted to the surgical ICU; 227 of 415 (55%) long-stay assessable ICU patients were weak; 122 weak patients were matched to 122 not-weak patients. As compared with matched not-weak patients, weak patients had a lower likelihood for live weaning from mechanical ventilation (hazard ratio HR, 0.709 0.549-0.888; P = 0.009), live ICU (HR, 0.698 0.553-0.861; P = 0.008) and hospital discharge (HR, 0.680 0.514-0.871; P = 0.007). In-hospital costs per patient (+30.5%, +5,443 Euro per patient; P = 0.04) and 1-year mortality (30.6% vs. 17.2%; P = 0.015) were also higher. The 105 of 227 (46%) weak patients not matchable to not-weak patients had even worse prognosis and higher costs. The 1-year risk of death was further increased if weakness persisted and was more severe as compared with recovery of weakness at ICU discharge (P < 0.001).
After careful matching the data suggest that ICU-acquired weakness worsens acute morbidity and increases healthcare-related costs and 1-year mortality. Persistence and severity of weakness at ICU discharge further increased 1-year mortality. Clinical trial registered with www.clinicaltrials.gov (NCT 00512122).
Among patients with COPD, those with the lowest maximal inspiratory pressures experience greater breathing discomfort (dyspnea) during exercise. In such individuals, inspiratory muscle training (IMT) ...may be associated with improvement of dyspnea but the mechanisms for this are poorly understood. Therefore, we aimed to identify physiological mechanisms of improvement in dyspnea and exercise endurance following inspiratory muscle training (IMT) in patients with COPD and low maximal inspiratory pressure (Pi,max). The effects of 8 weeks of controlled IMT on respiratory muscle function, dyspnea, respiratory mechanics, and diaphragm electromyography (EMGdi) during constant-work rate cycle exercise were evaluated in patients with activity-related dyspnea (Baseline Dyspnea Index <9). Subjects were randomized to either IMT or a sham training control group (n=10 each). Twenty subjects (FEV
= 47±19 %predicted; Pi,max= -59±14 cmH
O; cycle ergometer peak work rate= 47±21 %predicted) completed the study; groups had comparable baseline lung function, respiratory muscle strength, activity-related dyspnea and exercise capacity. IMT, compared with control, was associated with greater increases in inspiratory muscle strength and endurance, with attendant improvements in exertional dyspnea and exercise endurance time (all p<0.05). After IMT, EMGdi expressed relative to its maximum (EMGdi/EMGdi,max) decreased (p<0.05) with no significant change in ventilation, tidal inspiratory pressures, breathing pattern and operating lung volumes during exercise. In conclusion, IMT improved inspiratory muscle strength and endurance in mechanically compromised patients with COPD and low Pi,max. The attendant reduction in EMGdi/EMGdi,max helped explain the decrease in perceived respiratory discomfort despite sustained high ventilation and intrinsic mechanical loading over a longer exercise duration.
Limb muscle dysfunction is prevalent in chronic obstructive pulmonary disease (COPD) and it has important clinical implications, such as reduced exercise tolerance, quality of life, and even ...survival. Since the previous American Thoracic Society/European Respiratory Society (ATS/ERS) statement on limb muscle dysfunction, important progress has been made on the characterization of this problem and on our understanding of its pathophysiology and clinical implications.
The purpose of this document is to update the 1999 ATS/ERS statement on limb muscle dysfunction in COPD.
An interdisciplinary committee of experts from the ATS and ERS Pulmonary Rehabilitation and Clinical Problems assemblies determined that the scope of this document should be limited to limb muscles. Committee members conducted focused reviews of the literature on several topics. A librarian also performed a literature search. An ATS methodologist provided advice to the committee, ensuring that the methodological approach was consistent with ATS standards.
We identified important advances in our understanding of the extent and nature of the structural alterations in limb muscles in patients with COPD. Since the last update, landmark studies were published on the mechanisms of development of limb muscle dysfunction in COPD and on the treatment of this condition. We now have a better understanding of the clinical implications of limb muscle dysfunction. Although exercise training is the most potent intervention to address this condition, other therapies, such as neuromuscular electrical stimulation, are emerging. Assessment of limb muscle function can identify patients who are at increased risk of poor clinical outcomes, such as exercise intolerance and premature mortality.
Limb muscle dysfunction is a key systemic consequence of COPD. However, there are still important gaps in our knowledge about the mechanisms of development of this problem. Strategies for early detection and specific treatments for this condition are also needed.
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