Inspiratory muscle training for mechanically ventilated patients in the intensive care unit: Obstacles and facilitators for implementation. A mixed method quality improvement study.

BACKGROUND: Mechanically ventilated patients are at risk of developing inspiratory muscle weakness (IMW), which is associated with failure to wean and poor outcomes. Inspiratory muscle training (IMT) is a recommended intervention during and after extubation but has not been widely adopted in Dutch intensive care units (ICUs). OBJECTIVES: The objective of this study was to explore the potential, barriers, and facilitators for implementing IMT as treatment modality for mechanically ventilated patients. METHODS: This mixed-method, proof-of-concept study was conducted in a large academic hospital in the Netherlands. An evidence-based protocol for assessing IMW and training was applied to patients ventilated for ≥24 h in the ICU during an 8-month period in 2021. Quantitative data on completed measurements and interventions during and after ICU-stay were collected retrospectively and were analysed descriptively. Qualitative data were collected through semistructured interviews with physiotherapists executing the new protocol. Interview data were transcribed and thematically analysed. FINDINGS: Of the 301 screened patients, 11.6% (n = 35) met the inclusion criteria. Measurements were possible in 94.3% of the participants, and IMW was found in 78.8% of the participants. Ninety-six percent started training in the ICU, and 88.5% continued training after transfer to the ward. Follow-up measurements were achieved in 73.1% of the patients with respiratory muscle weakness. Twelve therapists were interviewed, of whom 41.7% regularly worked in the ICU. When exploring reasons for protocol deviation, three themes emerged: "professional barriers", "external factors", and "patient barriers". CONCLUSIONS: Implementation of measurements of and interventions for IMW showed to be challenging in this single centre study. Clinicians' willingness to change their handling was related to beliefs regarding usefulness, effectiveness, and availability of time and material. We recommend that hospitals aiming to implement IMT during or after ventilator weaning consider these professional and organisational barriers for implementation of novel, evidence-based interventions into daily clinical practice.

Physiotherapy treatment approaches for survivors of critical illness: a proposal from a Delphi study.

Purpose: The aim of this study was to develop practical recommendations for physiotherapy for survivors of critical illness after hospital discharge. Methods: A modified Delphi consensus study was performed. A scoping literature review formed the basis for three Delphi rounds. The first round was used to gather input from the panel to finalize the survey for the next two rounds in which the panel was asked to rank each of the statements on an ordinal scale with the objective to reach consensus. Consensus was defined as a SIQR of ≤ 0.5. Ten Dutch panelists participated in this study: three primary care physiotherapists, four intensive care physiotherapists, one occupational therapist, one ICU-nurse and one former ICU-patient. All involved professionals have treated survivors of critical illness. Our study was performed in parallel with an international Delphi study with hospital-based health-care professionals and researchers. Results: After three Delphi rounds, consensus was reached on 95.5% of the statements. This resulted in practical recommendations for physiotherapy for critical illness survivors in the primary care setting. The panel agreed that the handover should include information on 14 items. Physiotherapy treatment goals should be directed toward improvement of aerobic capacity, physical functioning, activities in daily living, muscle strength, respiratory and pulmonary function, fatigue, pain, and health-related quality of life. Physiotherapy measurements and interventions to improve these outcomes are suggested. Conclusion: This study adds to the knowledge on post-ICU physiotherapy with practical recommendations supporting clinical decision-making in the treatment of survivors of critical illness after hospital discharge.

Coping style and quality of life in Dutch intensive care unit survivors.

OBJECTIVE: The purpose of this study was to explore coping styles among intensive care unit (ICU) survivors and investigate the association between coping style and quality of life (QOL). METHOD: In this cross-sectional multicenter study, 150 adult patients who were mechanically ventilated in an ICU for ≥2 days and discharged to their homes were invited to visit the post-ICU clinic 3 months after discharge. Before the post-ICU visit, the patients completed questionnaires regarding their QOL, coping style, and psychological distress. Coping style was assessed using the Coping Inventory for Stressful Situations (CISS-21; de Ridder & van Heck, 2004), which measures task-oriented coping, emotion-oriented coping, and avoidance coping styles. QOL was assessed using the Physical Component Score (PCS) and Mental Component Score (MCS) derived from the 36-item Short Form Health Survey (SF-36; Aaronson et al., 1998). Univariate and multivariate linear regressions were performed. RESULTS: One hundred four patients (mean age = 59 years; 71 men, 33 women) completed the questionnaires (response rate = 69%). The highest CISS-21 subscale mean was found in the Task-Oriented subscale (21.3), followed by the Avoidance Coping subscale (18.7) and the Emotion-Oriented subscale (15.2). Emotion-oriented coping style was independently associated with reduced mental health (i.e., SF-36 MCS), but not with physical functioning (i.e., SF-36 PCS). CONCLUSIONS: An emotion-oriented coping style is associated with worse mental health among Dutch ICU survivors. Additional research is needed in order to determine the precise role that coping style plays in the long-term recovery of ICU survivors. (PsycINFO Database Record

Impact of ICU-acquired weakness on post-ICU physical functioning: a follow-up study.

INTRODUCTION: ICU-acquired weakness is thought to mediate physical impairments in survivors of critical illness, but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-acquired weakness at 6 months after ICU discharge. METHOD: ICU patients, mechanically ventilated ≥ 2 days, were included in a single-center prospective observational cohort study. ICU-acquired weakness was diagnosed when the average Medical Research Council score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients, physical functioning was assessed using the Short-Form Health Survey physical functioning domain. The independent effect of ICU-acquired weakness on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-acquired weakness on the physical functioning domain score was analyzed using a multivariable linear regression model. RESULTS: Of the 156 patients included, 80 had ICU-acquired weakness. Twenty-three patients died in the ICU (20 with ICU-acquired weakness); during 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-acquired weakness). Physical functioning domain scores were available for 96 survivors (39 patients with ICU-acquired weakness). ICU-acquired weakness was independently associated with an increase in post-ICU mortality (hazard ratio 3.6, 95% confidence interval, 1.3 to 9.8; P = 0.01) and with a decrease in physical functioning (ß: -16.7 points; 95% confidence interval, -30.2 to -3.1; P = 0.02). CONCLUSION: ICU-acquired weakness is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.

Feasibility and diagnostic accuracy of early electrophysiological recordings for ICU-acquired weakness: an observational cohort study.

BACKGROUND: An early diagnosis of ICU-acquired weakness (ICU-AW) is difficult because disorders of consciousness frequently preclude muscle strength assessment. In this study, we investigated feasibility and accuracy of electrophysiological recordings to diagnose ICU-AW early in non-awake critically ill patients. METHODS: Newly admitted patients, mechanically ventilated ≥2 days and unreactive to verbal stimuli, were included in this study. Electrophysiological recordings comprised nerve conduction studies (NCS) of three nerves and, if coagulation was normal, myography in three muscles. Upon awakening, strength was assessed (ICU-AW: average Medical Research Council score <4), blinded for electrophysiological recordings. Feasibility was expressed as the percentage of recordings that were both possible and had sufficient technical quality. Diagnostic accuracy of feasible (i.e., feasibility >75 %) recordings was analyzed based on cut-off values from healthy controls and from critically ill patients with and without ICU-AW. RESULTS: Thirty-five patients were included (17 with ICU-AW). Recordings were obtained on day 4 (IQR: 3-6). Feasibility was acceptable for ulnar and peroneal nerve recordings, and low for sural recordings and myography. Diagnostic accuracy based on cut-off values from healthy controls was low. When using cut-off values from critically ill patients with and without ICU-AW, the peroneal compound muscle action potential amplitude and ulnar sensory nerve action potential amplitude had good diagnostic accuracy. CONCLUSION: Nerve conduction studies of the ulnar and peroneal nerve are feasible in critically ill patients. The diagnostic accuracy is low using cut-off values from healthy controls. Cut-off values validated specifically for discrimination between critically ill patients with and without ICU-AW may improve diagnostic accuracy.

Early prediction of intensive care unit-acquired weakness using easily available parameters: a prospective observational study.

INTRODUCTION: An early diagnosis of Intensive Care Unit-acquired weakness (ICU-AW) using muscle strength assessment is not possible in most critically ill patients. We hypothesized that development of ICU-AW can be predicted reliably two days after ICU admission, using patient characteristics, early available clinical parameters, laboratory results and use of medication as parameters. METHODS: Newly admitted ICU patients mechanically ventilated ≥2 days were included in this prospective observational cohort study. Manual muscle strength was measured according to the Medical Research Council (MRC) scale, when patients were awake and attentive. ICU-AW was defined as an average MRC score <4. A prediction model was developed by selecting predictors from an a-priori defined set of candidate predictors, based on known risk factors. Discriminative performance of the prediction model was evaluated, validated internally and compared to the APACHE IV and SOFA score. RESULTS: Of 212 included patients, 103 developed ICU-AW. Highest lactate levels, treatment with any aminoglycoside in the first two days after admission and age were selected as predictors. The area under the receiver operating characteristic curve of the prediction model was 0.71 after internal validation. The new prediction model improved discrimination compared to the APACHE IV and the SOFA score. CONCLUSION: The new early prediction model for ICU-AW using a set of 3 easily available parameters has fair discriminative performance. This model needs external validation.