Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023).

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Utility of serum immunoglobulin A antibody against glycopeptidolipid core antigen in the diagnosis and management of hypersensitivity pneumonitis associated with Mycobacterium avium complex: A case report.

Measurement of the levels of serum immunoglobulin A antibody against glycopeptidolipid (GPL) core antigen, a cell surface antigen found in Mycobacterium avium complex (MAC), has been reported to be useful in the diagnosis and management of pulmonary MAC infection. However, evidence on its utility in hypersensitivity pneumonitis (HP) associated with MAC (i.e., "hot-tub lung") is limited. We herein report a case of HP associated with MAC in which the GPL core antibody levels were serially measured from diagnosis to treatment and thereafter. A 61-year-old man was suspected to have non-fibrotic HP based on the clinical course, laboratory findings, imaging pattern, bronchoalveolar lavage (BAL) lymphocytosis, and histopathological findings. Based on the history of whirlpool bath use, inhalation of aerosolized MAC was suspected as the cause of HP. The GPL core antibody level, measured using an enzyme-linked immunosorbent assay kit, was elevated, suggesting an immunological sensitization to MAC. A provocation test using the patient's whirlpool bath was positive. An identical MAC strain was isolated from the BAL fluid and bathtub. Accordingly, the patient was diagnosed with HP caused by the inhalation of aerosolized MAC from the whirlpool bath. The patient recovered after steroid treatment and discontinuation of the whirlpool bath. The GPL core antibody levels decreased with disease improvement. In conclusion, GPL core antibody levels could be elevated in HP associated with MAC and decrease with disease improvement. Thus, measurement of the GPL core antibody level may be useful for the diagnosis and management of HP associated with MAC.

Hemodiafiltration combined with polymyxin B-immobilized fiber column direct hemoperfusion is effective for acute postoperative exacerbation of interstitial pneumonia: a case report.

BACKGROUND: Postoperative acute exacerbation of interstitial pneumonia has a high mortality rate; however, its treatment methods have not been standardized. CASE PRESENTATION: A 72-year-old man with rheumatoid arthritis developed acute respiratory failure about 3 weeks after lung cancer surgery. There were increased diffuse frosted shadows in both lung fields. His condition was diagnosed as an acute exacerbation of interstitial pneumonia associated with rheumatoid arthritis, and he was started on steroid pulse therapy; however, his respiratory condition deteriorated. He was urgently intubated and started on veno-venous extracorporeal membrane oxygenation. Further, intensive care, including blood purification therapy, was initiated. The blood purification therapy comprised a combination of hemodiafiltration and 6-h polymyxin B-immobilized fiber column direct hemoperfusion. The patient was weaned off veno-venous extracorporeal membrane oxygenation, extubated, and discharged from the intensive care unit on the ninth day. CONCLUSIONS: Blood purification therapy was effective for acute exacerbation of interstitial pneumonia.

Minimum standards of clinical practice for physical therapists working in intensive care units in Japan.

OBJECTIVE: Early mobilization and rehabilitation has become common and expectations for physical therapists working in intensive care units have increased in Japan. The objective of this study was to establish consensus-based minimum clinical practice standards for physical therapists working in intensive care units in Japan. It also aimed to make an international comparison of minimum clinical practice standards in this area. METHODS: In total, 54 experienced physical therapists gave informed consent and participated in this study. A modified Delphi method with questionnaires was used over three rounds. Participants rated 272 items as "essential/unknown/non-essential". Consensus was considered to be reached on items that over 70% of physical therapists rated as "essential" to clinical practice in the intensive care unit. RESULTS: Of the 272 items in the first round, 188 were deemed essential. In round 2, 11 of the 62 items that failed to reach consensus in round 1 were additionally deemed essential. No item was added to the "essential" consensus in round 3. In total, 199 items were therefore deemed essential as a minimum standard of clinical practice. Participants agreed that 42 items were not essential and failed to reach agreement on 31 others. Identified 199 items were different from those in the UK and Australia due to national laws, cultural and historical backgrounds. CONCLUSIONS: This is the first study to develop a consensus-based minimum clinical practice standard for physical therapists working in intensive care units in Japan.

Effect of pulmonary rehabilitation programs including lower limb endurance training on dyspnea in stable COPD: A systematic review and meta-analysis.

Pulmonary rehabilitation (PR) is recommended as an effective treatment for patients with chronic obstructive pulmonary disease (COPD). Previous meta-analyses showed that PR improves exercise capacity and health-related quality of life (HRQOL). However, they did not evaluate the effect of PR on the sensation of dyspnea. We searched six databases in May 2019 for randomized controlled trials (RCTs) that examined PR, including supervised lower limb endurance training as a minimal essential component that was continued for 4-12 weeks, in patients with stable COPD, with changes from baseline dyspnea as a primary outcome. Secondary outcomes were changes in exercise capacity, HRQOL, activity of daily life (ADL), physical activity (PA), and adverse events. We calculated the pooled weighted mean difference (MD) using a random effects model. We identified 42 studies with 2150 participants. Compared with the control, PR improved dyspnea, as shown using the British Medical Research Council (MRC) questionnaire (MD, -0.64; 95% CI, -0.99 to -0.30; p = 0.0003), transitional dyspnea index (MD, 1.95; 95% CI, 1.09 to 2.81; p = 0.0001), modified Borg score during exercise (MD, -0.62; 95% CI, -1.10 to -0.14; p = 0.01), and Chronic Respiratory Questionnaire (CRQ) dyspnea score (MD, 0.91; 95% CI, 0.39 to 1.44; p = 0.0007). PR significantly increased exercise capacity measured by the 6 min walking distance time, peak workload, and peak VO2. It improved HRQOL measured by the St. George's Respiratory Questionnaire and CRQ, but not on PA or ADL. These results indicated that PR programs including lower limb endurance training improve dyspnea, HRQOL, and exercise capacity in patients with stable COPD.

Comparison of Different Disease-Specific Health-Related Quality of Life Measurements in Patients with Long-Term Noninvasive Ventilation.

BACKGROUND: Two disease-specific questionnaires have been developed to assess health-related quality of life (HRQL) in patients with chronic respiratory failure: the Severe Respiratory Insufficiency (SRI) Questionnaire and the Maugeri Respiratory Failure (MRF) Questionnaire. We aimed to compare the characteristics of the SRI, MRF-26, and St. George's Respiratory Questionnaire (SGRQ) for use in patients with home noninvasive ventilation (NIV). METHODS: Fifty-six outpatients receiving long-term NIV were recruited and underwent assessments of pulmonary function, arterial blood gas, HRQL, dyspnea, and psychological status. RESULTS: Correlations of the SRI and MRF-26 with the SGRQ were modest. While pulmonary function was weakly related to only some domains of the SRI and MRF-26, the modified Medical Research Council (mMRC) dyspnea scale and Hospital Anxiety and Depression Scale (HADS) were significantly related to all domains of the SRI and MRF-26. Multiple regression analyses showed that HADS depression and mMRC accounted for 34% and 27% of the variance in the SRI, 24% and 37% in the MRF-26, and 17% and 46% in the SGRQ, respectively. CONCLUSIONS: The SRI and MRF-26 were reliable questionnaires for patients receiving long-term NIV. Dyspnea and psychological status were their main common determinants. The SRI covers more psychological health impairments than the MRF. This trial is registered with ClinicalTrials.gov Identifier: NCT00905476.

Validation of the Japanese Severe Respiratory Insufficiency Questionnaire in hypercapnic patients with noninvasive ventilation.

BACKGROUND: The Severe Respiratory Insufficiency (SRI) Questionnaire was originally developed in German to assess health-related quality of life (HRQL) and was validated as a multidimensional instrument with high psychometric properties in chronic hypercapnic respiratory failure (CHRF) patients receiving noninvasive ventilation (NIV). We aimed to investigate the intercultural adaptation of the Japanese SRI Questionnaire and whether it is a reliable and valid HRQL questionnaire to administer to those patients. METHODS: The SRI Questionnaire was adapted to Japanese using a translation and back-translation procedure, followed by equivalency assessment. It was validated in 56 stable outpatients receiving NIV for CHRF, primarily due to chronic obstructive pulmonary disease (COPD) and/or pulmonary tuberculosis sequelae. RESULTS: Examination of the frequency distribution of the Japanese SRI Questionnaire showed that the subscales and summary were approximately normally distributed and well balanced. There were no significant differences in SRI scores between patients with COPD and pulmonary tuberculosis sequelae. Cronbach׳s α values representing internal consistency of seven SRI subscales ranged from 0.56 to 0.80; attendant symptoms and sleep had the lowest values. Cronbach׳s α value was 0.92 for the SRI summary. The SRI summary score was significantly related to all eight subscales of the Medical Outcomes Study 36-item short form, with correlation coefficients of 0.41-0.66. CONCLUSIONS: The Japanese SRI Questionnaire was produced using a standardized procedure and an equivalency study. It has high psychometric properties with internal consistency and concurrent validity. The Japanese SRI Questionnaire can be used to assess HRQL in patients on NIV for CHRF.

Analysis of the relationship between health status and mortality in hypercapnic patients with noninvasive ventilation.

BACKGROUND: Health status and mortality are important outcomes in patients with advanced pulmonary diseases receiving noninvasive ventilation (NIV). However, their relationship has not been thoroughly investigated. METHODS: The present study prospectively recruited 56 stable outpatients treated with NIV for chronic hypercapnic respiratory failure caused by chronic obstructive pulmonary disease and/or pulmonary tuberculosis sequelae. At baseline, health status was measured by the Medical Outcomes Study 36-item short form, a generic questionnaire; the St. George's Respiratory Questionnaire (SGRQ), a respiratory-specific questionnaire; and two respiratory failure-specific questionnaires, the Maugeri Respiratory Failure questionnaire and the Severe Respiratory Insufficiency (SRI) questionnaire. Arterial blood gas, pulmonary function, dyspnea and psychological status were also measured. RESULTS: In cross-sectional comparisons of the four health status questionnaires, the SGRQ and SRI questionnaire had lower floor and ceiling effects. During the 3-year follow-up, 16 patients (29%) died. Health status shown by the SGRQ and SRI was significantly predictive of mortality, independently of the physiological measures of low body mass index (BMI), hypercapnia, and low pulmonary function. Stepwise multivariate analyses indicated that the SRI summary score was the most significant predictor of mortality (P = 0.0006) followed by BMI (P = 0.012). CONCLUSION: There was a significant relationship between health status and 3-year mortality in patients with NIV, independently of under-nutrition, hypercapnia and low pulmonary function. Health status measurement is important not only to comprehensively evaluate disease severity in relation to its close association with mortality, but also to elucidate factors that improve the survival of patients with advanced respiratory diseases.

[A case of irinotecan or panitumumab-induced interstitial pneumonia successfully treated by steroid pulse therapy].

We report a case of a 58-year-old man suffering from advanced colon cancer with liver metastases. After the sigmoidectomy and left lateral segmentectomy, mFOLFOX6+bevacizumab was initiated. The mFOLFOX6+bevacizumab therapy was performed for 15 courses, but it was stopped because of an increase in serum levels of tumor markers(CEA and CA19-9). For the next treatment, FOLFIRI+panitumumab therapy was performed. At the beginning of the second course, he suffered from dyspnea. Computed tomography showed ground-glass opacities and traction bronchiectasis in both lung fields. He was diagnosed with interstitial pneumonitis induced by irinotecan or panitumumab. Corticosteroid therapy consisting of methyl- prednisolone(1 g/day)administered for three days was significantly effective for treating respiratory failure. Two courses of the therapy were performed, and he was discharged without aftereffects. As with other EGFR tyrosine kinase inhibitors, the frequency of interstitial pneumonitis induced by irinotecan in Japan may increase to European and American levels.

CT-guided ultrathin bronchoscopy: bioptic approach and factors in predicting diagnosis.

BACKGROUND: The diagnostic sensitivity of current bronchoscopy for peripheral lung cancer is inadequate because the bronchoscope insertion range is limited and confirmation of the position of the biopsy apparatus at the lesion under X-ray fluoroscopy is inaccurate. The combination of ultrathin bronchoscopy and computed tomography (CT) is effective for solving these problems. OBJECTIVE: This study was a retrospective study analyzing prospectively collected data to identify factors contributing to the diagnosis and the appropriate biopsy method in CT-guided ultrathin bronchoscopy for peripheral lung cancer. METHODS: The subjects comprised 86 patients (88 lesions) who underwent CT-guided ultrathin bronchoscopy and were finally diagnosed with peripheral lung cancer. We evaluated the diagnostic yield according to specific factors and also according to the sample collection method. RESULTS: Sixty-nine lesions were diagnosed as lung cancer, and the diagnostic yield was 78.4% (80.3% in lesions ≤2 cm in diameter). Multivariate analysis showed that the factors contributing to the diagnosis were the observation range by ultrathin bronchoscopy and the presence/absence of the involved bronchus or pulmonary artery. Pathological evaluation facilitated histological diagnoses in 53 (65.4%) of 81 lesions. In 16 lesions, only the cytological diagnosis was positive. CONCLUSION: CT-guided ultrathin bronchoscopy may be particularly useful for lesions for which the involved bronchus or pulmonary artery can be confirmed, and observation of bronchi of the 6th generation or more is possible. Since the specimen preparation rate is low, the combination of histopathological diagnosis with cytological diagnosis particularly that of the discharge attached to the forceps, is optimal.

[Which parameters should be chosen to evaluate daily activities of the patients with chronic lung disease?].

In Japan medically handicapped persons are given government support. Currently the government uses selection criteria including FEV1, PaO2, and dyspnea rating to identify level 3 handicaps, however, these criteria lack a scientific basis. The purpose of this study was to investigate the validity of the current criteria and to try to create more appropriate one. We retrospectively reviewed the clinical records of 204 cases with chronic lung disease (COPD 111, non-COPD 93). The accuracy of the current criteria was assessed by sensitivity and specificity. To find the parameters that could determine ADL, we searched for clinical parameters using simple logistic regression models, ROC curves, and cross-table analyses. To compare the accuracy of the current and newly created criteria, we assessed the sensitivity, specificity of the two criteria. Sensitivity, specificity, and overall accuracy of the current criteria were 77.6%, 74.8%, and 75.5%, respectively, however, the positive predictive value was low (46.4%). The results of the screening of the parameters showed that the following three parameters were useful discriminators of ADL: (1) supplemental oxygen use, (2) MRC scale > or =4, and (3) 6-minute walking distance <340 m. The newly created criteria using these three parameters showed better sensitivity, specificity, and overall accuracy (81.6%, 80.7%, and 80.9%, respectively) than those of the current criteria. The positive predictive value also improved. In conclusion, our results suggest that the newly created criteria that include the 6-minute walking distance are more suitable than the criteria currently used to assess the ADL of the patients with chronic respiratory disease.

[Prevalence of myeloperoxidase-anti-neutrophil cytoplasmic antibody (MPO-ANCA) in patients with interstitial pneumonia].

Myeloperoxidase-anti-neutrophil cytoplasmic antibody (MPO-ANCA) is an autoantibody that is frequently found in patients with vasculitides. We encountered some MPO-ANCA positive patients with interstitial pneumonia who lacked vasculitides, but its meaning remains unclear. We measured MPO-ANCA titers in 69 patients with interstitial pneumonia (IP) who did not have collagen vascular diseases and observed their outcome. MPO-ANCA was positive in 5 patients and its prevalence was 7.2%. Patients with MPO-ANCA positive showed higher positivity in rheumatoid factor (RF) than patients with MPO-ANCA negative. The sensitivity and specificity of a combination of anti-nuclear antibody-negative and RF-positive were 80.0% and 87.7%, respectively. Two patients were accompanied by microscopic polyangiitis and the 3-year survival rate was 40% in all patients with MPO-ANCA. Measurement of MPO-ANCA titers in patients with IPs is meaningful for determining therapeutic strategy.

[A case of primary pulmonary MALT lymphoma with diffuse micronodules and anemia].

A 52-year-old woman presented with low grade fever and fatigue. She had diffuse micronodules in both lung fields on chest X-ray. Chest CT showed diffuse multiple small nodules. Laboratory examination revealed high values for C-reactive protein, together with anemia and polyclonal hyper-immunoglobulinemia and an elevated interleukin-6 level. Although we suspected multicentric Castleman's disease, thoracoscopic lung biopsy revealed primary pulmonary MALT lymphoma by immunohistochemical analysis of tissue specimens. After COP and rituximab therapy, partial remission was obtained.

[Development of a Japanese version of the Modified Questionnaire on the Pulmonary Functional Status and Dyspnea].

A Japanese version of the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M) was made through a translation-backtranslation procedure under agreement with the original author, Dr. Lareau, SC. Three components of the Japanese version, dyspnea with activities (DA), fatigue with activities (FA), and change experienced by patients with activities (CA), were tested using 63 chronic respiratory disease (CRD) patients. Cronbach's alpha was the same, 0.93, for DA, FA and CA. Average values for DA, FA, and CA were significantly associated with the MRC and BDI scores in 63 patients. In 43 Chronic Obstructive Pulmonary Disease (COPD) patients, average values for DA, FA, and CA were significantly associated with the % predicted FEV1.0. After 26 patients were randomly selected, the same protocol was repeated with a 10- to 14-day interval to validate the reproducibility of the PFSDQ-M. Correlation coefficients were 0.94, 0.88, and 0.91 for DA, FA, and CA, respectively. Then, 52 patients were randomly selected and the same protocol was repeated with a 6- to 12-month interval to evaluate the sensitivity of PFQD-M. The changes in DA, FA and CA with the 6- to 12-month interval were significantly associated with changes in MRC and TDI. In 37 COPD patients, changes in DA, FA, and CA with the 6- to 12-month interval were significantly associated with the changes in the % predicted FEV1.0. These results show that the Japanese version of PFSDQ-M is valid in its reproducibility and internal consistency, and may also have construct validity and sensitivity for evaluating the functional status and dyspnea of patients with chronic respiratory illness.

[Long-term outcome of patients treated by home mechanical ventilation].

To investigate the long-term survival of 95 patients treated by home mechanical ventilation, we prospectively analyzed the outcomes of their cases (treatments: 34, tracheostomy; 61, non-invasive methods) using the database of the local registration system in Aichi Prefecture. The annual actuarial probability of continuing home mechanical ventilation for the tracheostomized patients was 97.0% in the first year, 79.0% in the second year, 79.0% in the third year, and 69.2% in the fourth year, and those for the patients treated by non-invasive ventilation were 85.6%, 67.9%, 56.8%, and 46.4%, respectively. In comparison with patients with neuromuscular disease, patients with respiratory disease (both tracheostomized and non-tracheostomized) tended to show a lower continuation ratio, but the difference was not statistically significant. These data were comparable to those of previous reports, suggesting that home respiratory care in Aichi Prefecture satisfied the normal standards of quality.

The effect of pulmonary rehabilitation in patients with post-tuberculosis lung disorder.

STUDY OBJECTIVES: Although the benefit of pulmonary rehabilitation (PR) has been demonstrated for patients with COPD, the benefit for patients with non-COPD lung disorders is still unclear. In the present study, we compared the effect of PR on patients with post-tuberculosis (TBC) lung disorders and patients with COPD. DESIGN: We performed a prospective nonrandomized open trial over a 9-week period. PATIENTS AND METHODS: Thirty-two patients with post-TBC lung disorders (thoracoplasty, 25 patients; mean [+/- SD] age, 71 +/- 5 years; FEV(1), 0.84 +/- 0.29 L) and 32 age-matched and FEV(1)-matched COPD patients were enrolled in the study. First, we compared the exercise tolerance between groups using a 6-min walking test. Next, we trained the patients using a 9-week outpatient PR program. We assessed improvement using clinical dyspnea ratings, a daily activity score, and the results of a 6-min walking test. RESULTS: When age and FEV(1) were matched, the distance covered during the 6-min walking test did not differ between the groups. After rehabilitation, significant improvement was observed in both the post-TBC group and the COPD group in terms of Medical Research Council dyspnea grade, transition dyspnea index, activity score, and 6-min walking distance (42 m [p < 0.01] vs 47 m [p < 0.01], respectively). The magnitudes of the improvement in these parameters were comparable between the groups. CONCLUSIONS: PR is as beneficial in post-TBC lung disorder patients as in COPD patients if the severity of the disability is similar.

[The effects of pulmonary rehabilitation in elderly patients].

Pulmonary rehabilitation is one of the most important treatment modalities for patients with chronic lung disease. To determine the effects of an outpatient pulmonary rehabilitation program for the older members (aged 77 +/- 3 years; seniors) of an elderly patient group with chronic lung disease, we prospectively compared the degrees of improvement of lung function, dyspnea, daily activities and exercise tolerance (6-minute walking distance) after a 9-week rehabilitation program in 27 seniors with chronic lung disease (COPD 18, post-tuberculosis lung disorders 8, lung fibrosis 1; %FEV1 50.9 +/- 17.1%) with that in disease- and %FEV1-matched younger members (aged 70 +/- 2 years; juniors; %FEV1 49.3 +/- 16.1%) of the elderly patient group. All patients performed supervised weekly outpatient exercise and education activities for 9 weeks and a home exercise regimen. Assessments were made before and after the program. Twenty-three of the seniors and 25 of the juniors completed the program. There was no significant difference in the withdrawal rates between these groups. Although lung function and blood gas data had not changed significantly after rehabilitation, the clinical symptoms and the 6-minute walking exercise improved significantly in both groups (Baseline Dyspnea Index focal score: +1.3 +/- 0.9 in the seniors and +0.6 +/- 0.9 in the juniors: 6-minute walking distance: +/- 52 m and +/- 62 m, respectively) and the improvement of the Baseline Dyspnea Index focal score was significantly greater in the seniors than in the juniors. We observed the patients after they had followed the program for 2,000 days and found that the continuation ratio of rehabilitation in the seniors was far inferior to that in the juniors (continuation ratios for 1.2 and 3 years in the seniors were 50.5, 18.0 and 0%, respectively, and in the juniors, 79.5, 66.2 and 61.5%). We concluded that, although the senior elderly patients could benefit from the pulmonary rehabilitation program, it is difficult to maintain this benefit for many years.