Early Initiation of Physical Therapy While on Extracorporeal Life Support Improves Patients’ Functional Activity on Discharge

ABSTRACT

Purpose Traditionally, severe acute respiratory distress syndrome (ARDS) patients on veno-venous extracorporeal membrane oxygenation (VV ECMO) receive significant sedation and neuromuscular blockade (NMB) to facilitate lung protective mechanical ventilation. However, we previously showed the feasibility of managing these patients without mechanical ventilation, sedation, or NMB. Reduced levels of sedation allows patients to begin physical and occupational therapy (PT/OT) early on. Here, we investigate the impact of early PT/OT initiation on day of discharge (DOD) functional activity for severe ARDS patients managed on VV ECMO. Methods This is a retrospective review of all patients who underwent VV ECMO as management for severe ARDS at a single academic center from February 2018 to June 2021. Data collected included patients’ demographics, co-morbidities, etiology of ARDS, days of ECMO support before PT/OT initiation, and ambulation distance and PT/OT Activity Measure for Post-Acute Care (AMPAC) Six-Clicks score on DOD. Results 67 patients were included in this study. Those with >7 days on VV ECMO had decreased ambulation and AMPAC scores compared to those with < 7 days (N=41, 70.5 ± 113.3ft vs N=26, 162.1 ± 154.1ft, p<0.01, 12.3 ± 5.9 vs 16.4 ± 6.8, p=0.01, respectively). PT/OT initiation within 7 days after starting VV ECMO significantly improved ambulation and AMPAC scores compared to those with >7 days of VV ECMO prior to any PT/OT (N=30, 163.5 ± 160.5ft vs N=37, 59.5 ± 93.5ft, p<0.001, 16.6 ± 7.1 vs 11.8 ± 5.2, p<0.01, respectively). In patients with >7 days on VV ECMO, those who began PT/OT within 10 days of starting VV-ECMO had improved ambulation and AMPAC scores compared to those with >10 days of VV ECMO prior to PT/OT (N=9, 151.8 ± 164.8ft vs N=32, 44.2 ± 77.8ft, p<0.01, 16.5 ± 7.7 vs 11.0 ± 54.5, p<0.01, respectively). Conclusion Early PT/OT initiation in severe ARDS patients managed on VV ECMO is associated with improved patient functional activity on DOD. This may provide benefits such as enhanced recovery, increased ability to complete activities of daily living, and improved cognitive health. Our study further supports the use of VV ECMO in treatment of severe ARDS without mechanical ventilation, sedation or NMB and specifically demonstrates PT/OT should be started early following initiation of VV ECMO to improve patients’ functional outcomes.