ArticlesEarly physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
Introduction
Advances in the management of mechanically ventilated patients have improved outcomes and survival rates for this patient population.1, 2, 3 As patients survive acute illness, long-term complications are more apparent. Weakness is a frequent complication and is associated with major disability and protracted rehabilitation.4, 5, 6 In addition to physical debility, neuropsychiatric dysfunction is often profound. Delirium during intensive care unit (ICU) stay (ICU-associated delirium) is common in patients undergoing mechanical ventilation, and is associated with increased mortality,7 longer length of stay in intensive care and in hospital,8 and increased duration of ventilation.7
Clinicians working in the ICU often focus on treating circulatory, respiratory, and renal function to ensure patient survival. Accordingly, most patients on mechanical ventilation receive sedative and analgesic drugs to reduce distress and oxygen consumption;9 however, this approach can result in long periods of unconsciousness and immobility.10 Protocols geared to keeping sedation to a minimum, such as daily interruption of sedation,11 and mobilisation of mechanically ventilated patients via physical therapy12, 13 in the earliest days of critical care, can result in improved patient outcomes. Specifically, observational studies of patients on mechanical ventilation for at least 4 days who were subsequently transferred to a dedicated respiratory ICU (post-acute care) have shown that physical therapy is feasible, safe, and promotes more rapid return to ambulation.12, 13 More recently, in a prospective, non-randomised cohort study, Morris and colleagues14 showed that an early mobilisation team increased physical therapy services for medical ICU patients with respiratory failure; this intervention also shortened length of stay in the ICU and in hospital.
Additionally, the identification of ICU-associated delirium and its association with poor outcomes has highlighted the need for interventions that might alter its course.15 Although several possible factors might result in ICU-associated delirium, so far only sedation with dexmedetomidine as a replacement for a benzodiazepine has been shown to reduce the duration of ICU-associated delirium.16
The implementation of daily interruption of sedation combined with physical and occupational therapy in the earliest days of critical illness might prevent sedative-related immobility. We postulated that this intervention, tested in a randomised controlled trial, would affect both functional outcomes and neuropsychiatric outcomes, such as ICU-associated delirium.
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Patients
We recruited study participants at two medical centres: University of Chicago Medical Center (Chicago, IL, USA) and University of Iowa Hospitals (Iowa City, IA, USA). The institutional review boards at both centres approved the study, and written informed consent was obtained from participants or their authorised representatives.
Patients in the medical ICU were screened daily to identify adults (≥18 years of age) who had been on mechanical ventilation for less than 72 h, were expected to
Results
From June, 2005, to October, 2007, 1161 patients were screened, of whom 104 were enrolled and randomised. Figure 1 shows the trial profile. Nine (18%) patients in the intervention group and 14 (25%) patients in the control group died before hospital discharge. All 104 patients were included in the intention-to-treat population. Table 1 shows the baseline characteristics of the enrolled patients.
Of the 49 patients in the intervention group, 46 (94%) underwent physical and occupational therapy
Discussion
In this randomised controlled trial, daily interruption of sedation combined with physical and occupational therapy from the start of critical illness in patients on mechanical ventilation resulted in an improved return to (premorbid) independent functional status at hospital discharge compared with daily interruption of sedation and standard care. Additionally, patients in the intervention group had a shorter duration of ICU-associated delirium by 2·0 days and spent 2·4 more days alive and
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