Effectiveness of Early Mobilization among Mechanically Ventilated Patients in Intensive Care Unit

Research indicated that very many patients are admitted to the Intensive Care Unit globally, however not all make their way out of the ICU. In Australia, it is approximated that more than 125,000 patients end up in the ICU with only 80% surviving. Growing evidence shows that out of the survivors from the ICU, they experience long-term physical, neuro-cognitive and mental health complications from the ICU experience. For the purpose of reducing the difficulties, many researchers have recommended rehabilitation exercises for the primary role of addressing the weakness and the functional limitation observed among ICU survivors. Despite these recommendations, only a few trials have shown the evidence of the effectiveness beyond the hospital discharge.

Immobilization among ICU patients who are mechanically ventilated is associated with the subsequent weaknesses. In the recent past, there have been researching studies which have suggested that early mobilization of mechanically ventilated patients is safe and effective. While it has been associated with several benefits, there is inconsistency in the standards of care with only a few patients reaching the levels of active mobilization. Among mechanically ventilated patients in the Intensive unit, there is the increased risk of developing complications as a result of immobilization. Researchers have conducted research for the purpose of coming up with strategies aimed at reducing these complications. Some of the identified early mobilization activities include standing, ambulation, passive exercises such as ergometry and passive activities. There is no specific definition of early since some studies show that the onset of the interventions is often as soon as one week.

In the ICU, the long-term use of the mechanical ventilators is feared to be associated with ICU acquired weakness which is common among patients on the mechanical ventilation for more than 7 days. The excessive immobilization in the ICU has been associated with ICU- related weakness with a relationship between muscle weakness and the time during immobilization being observed in the majority of the patients. Consequently, among ICU patients on the mechanical ventilation is more likely experience more and better benefits from early mobilization which has for long been associated with the prevention of ICU acquired weakness, the maintenance of the long-term function as well as the preservation of the quality of life.

Research by Schweickert et al. 2009, noted the effectiveness of the early rehabilitation interventions on the physical and the mental wellbeing of mechanical patients. Recently, researchers on the same have reported similar results. From the research studies on the limitation regarding the different mobilization activities, there has been a consensus in respect of neither timing of the mobilization nor the prescription of the standardized interventions. In the ICU, there has been the implementation of early mobilization among mechanically ventilated patients, however, intensely few randomized trials have explored on its effectiveness. Schweickert et., 20009 conducted a randomized clinical trial among 104 mechanically ventilated patients in the ICU and exposed them to early occupational and physical therapy while the controlled group was presented to the usual care, and their functional status was compared upon discharge. Among patients in the intervention group who have commenced the mobilization as early as 1.5 days, there was regain of 59% of independent functional status while among patients in the control group whom the mobilization started 7.4 achieved 35% of their useful state. In addition, for the patients in the early mobilization, there were fewer cases of delirium, and further, these patients required fewer days to be in the mechanical ventilator than those in the control group.

Despite the numerous research studies on the effectiveness and the safety of the early mobilization among ICU patients who are mechanically ventilated, there are few studies which offer convincing statement, Therefore, in spite of the theoretical advantage of physical therapy to address the problem, there is no evidence that early initiation of physical therapy in the ICU for the mechanically ventilated patients offers any benefits.

Purpose statement

The research will aim at identifying the effects of early mobilization among mechanically ventilated patients in the Intensive care Unit.

Literature review

Research shows that early rehabilitation is associated with the improved physical function, improved quality of life as well as muscle strength. In a randomized control study by Pohlman et al., 2013, research findings found that, compared with the usual care, early physical and occupational therapies, there was an association with higher likelihood of reduced ICU acquired weakness, increased independent functional status and greater unassisted walking distance on hospital discharge. In another ICU based rehabilitation through a cycle geometry was associated with improved physical functioning as well as the enhanced quality of life. More evidence shows that the early mobilization of mechanically ventilated patients in the ICU results in the reduced duration of hospitalization as well as the duration of the mechanical ventilation and therefore cost savings. In a research by Needham et al., 2010, there was a definite relationship between the early rehabilitation of ICU patients and the decrease in the ICU and hospitalization among mechanically ventilated patients. In a similar study including 330 subjects, there was a reduction in the mortality cases as well as the rate of readmission reduced. In spite of the associated benefits to the early mobilization of the ICU mechanically ventilated patients, research indicates that some barriers hinder the implementation of the interventions. As such, there is the need for adequate staffing for the successful implementation of the early rehabilitation. Consequently, there is the need for the professional approach to the rapid recovery including the effective leadership, Education of the standard interventions as well as the appropriate use of the mobilization to help in addressing the concerns (Hopkins, Spuhler & Thomsen, 2007).

Despite the benefits of the early mobilization of mechanically ventilated patients in the Intensive unit, some studies have not confirmed the effectiveness of the initial mobilization. In two randomized trials by Denehy et al., 2013 including more than 100mechanically ventilated patients who were critically ill, there was an insignificant improvement of the physical function despite the intensive physical therapy. In another recent randomized controlled trial involving 300 patients who were in the ICU on mechanical ventilation who were reported to be on daily standardized rehabilitation therapy consisting of passive exercises, physical therapy and progressive resistance exercises did not indicate a decrease in the period of a hospital or ICU length of stay, improved physical function an decreased duration of mechanical ventilation as compared to the patients who received the usual care (Morris et al., 2016). In another trial by Hodgson et al.,2016, there was an improvement in the activity level of the intervention group after some passive exercises; however, there was no relationship with the length of the ICU stay for a period of 6 months since it was similar to the patients who were in the control group.

Research methods and procedures

The research study will be conducted using a single center assessor-blinded randomized clinical trial. 300 subjects will be stratified and randomized to receive usual care or the early mobilization intervention. The participants will only include the patients who will be in the Intensive Care Unit for more than 5 days or more without any permanent neurologic deficit. The intervention group will receive intensive exercises in the ICU , the ward and as outpatients. The research subjects will then be assessed at recruitment , ICU admission hospital discharge and at the 3, 6 and 12 months follow up. The physical functional test will be evaluated using the SIX minute Walk Test, the Timed Up and Go Test and the Physical Function in the ICU Test. The data collected from the research subjects will then be analyzed using mixed models. In both, the groups, the usual care including respiratory therapy will be provided based on the individual assessment .

Research design

The research will involve a randomized control trial including a total of 300 mechanically ventilated patients with the case group and the control groups including 165 patients each. Half the total participants will be introduced the interventions as well as the usual care as early as 1.5 days while the other team will be subjected to the similar attention after 7 days.

References

Denehy, L., Skinner, E. H., Edbrooke, L., Haines, K., Warrillow, S., Hawthorne, G., ... & Berney, S. (2013). Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Critical Care, 17(4), R156.
Hodgson, C. L., Bailey, M., Bellomo, R., Berney, S., Buhr, H., Denehy, L., ... & Papworth, R. (2016). A binational multicenter pilot feasibility randomized controlled trial of early goal-directed mobilization in the ICU. Critical care medicine, 44(6), 1145-1152.
Hopkins, R. O., Spuhler, V. J., & Thomsen, G. E. (2007). Transforming ICU culture to facilitate early mobility. Critical care clinics, 23(1), 81-96.
Morris, P. E., Berry, M. J., Files, D. C., Thompson, J. C., Hauser, J., Flores, L., ... & Bakhru, R. N. (2016). Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: a randomized clinical trial. Jama, 315(24), 2694-2702.
Needham, D. M., Korupolu, R., Zanni, J. M., Pradhan, P., Colantuoni, E., Palmer, J. B., ... & Fan, E. (2010). Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Archives of physical medicine and rehabilitation, 91(4), 536-542.
Pohlman, M. C., Schweickert, W. D., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., ... & Schmidt, G. A. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical care medicine, 38(11), 2089-2094.
Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., ... & Schmidt, G. A. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet (London, England), 373(9678), 1874-1882.