Professional Documents
Culture Documents
a
Physical Therapy Department of the Adventist University (Unasp), Sao Paulo, Brazil
b
Respiratory Diseases of the Federal University of Sao Paulo (Unifesp), Sao Paulo, Brazil
c
Heart Institute, Sao Paulo Medical School, Sao Paulo, Brazil
d
Federal University of Pampa (Unipampa), Rio Grande do Sul, Brazil
KEYWORDS Summary
Chest physiotherapy; Introduction: Although physiotherapy is an integral part of the multiprofessional team in
Hospital stay; most ICUs there is only limited evidence concerning the effectiveness of its procedures.
Weaning; The objectives of this study were to verify if physiotherapy care provided within 24 h/day
Pulmonary infection; for hospitalized patients in the ICU reduce the length of stay, mechanical ventilation
Mortality; support, pulmonary infection and mortality compared to a physiotherapy care provided
Intensive care unit within 6 h/day.
patients Methods: A cohort study was designed to assess differences between one hospital where
patients were given physiotherapy care for 24 h/day and another hospital with only 6 h/
day. We considered the following as outcome measurements: clinical diagnosis, medication
in use, presence of associated diseases, APACHE II and SOFA scores, ICU and mechanical
ventilation length of stay, development of pulmonary infections and survival.
Results: One hundred and forty-six patients were enrolled. Patients admitted in the service
A presented a lower length of stay in mechanical ventilation (p < 0.0001), ICU stay
(p Z 0.0003), respiratory infections (p Z 0.0043) than patients admitted in service B. No
difference was found for APACHE II score (p Z 0.8) and SOFA scores (p Z 0.2) between
groups. The mortality risk was OR 1.3 (1.01e2.33) (p Z 0.04) for patients in the service B.
* Corresponding author. Rua Conego Eugenio Leite, 632 apt 132, Pinheiros, 05414000 Sao Paulo, SP, Brazil. Tel.: 55 11 30627606.
E-mail addresses: antonioamcastro@yahoo.com.br (A.A.M. Castro), suleimacalil@gmail.com (S.R. Calil), susifreitas@yahoo.com.br
(S.A. Freitas), alexandreoliveira@gmail.com (A.B. Oliveira), eliasfporto@gmail.com (E.F. Porto).
e
Present address: Estrada de Itapecerica, 5859 Jardim IAE, Sao Paulo/SP e 05858-001, Brazil.
0954-6111/$ - see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.rmed.2012.09.016
Chest physiotherapy and weaning 69
Conclusion: The presence of a physiotherapist in the intensive care unit contributes deci-
sively to the early recovery of the patient, reducing mechanical ventilation support need,
number of hospitalization days, incidence of respiratory infection and risk of mortality.
2012 Elsevier Ltd. All rights reserved.
patients diagnosed with terminal phase cancer and patients between the baseline data obtained by the patients
with clinically proven brain death on the first day of medical records, laboratory tests, APACHE II, SOFA, Glas-
hospitalization. gow and Ramsay scores. The proportion of individuals with
The technological devices such as mechanical ventila- different ages, length of hospitalization and mechanical
tion and monitoring equipment, patients exams, drugs use, ventilation time and survival was analyzed by the Kaplan
number of doctors and nurses per bed were similar in both Mayer method. We used a regression model and the odds
hospitals. All patients were evaluated by a medical ratio analysis to assess the chance of mortality in both
specialist according to each diagnosis, however, the refer- services. Statistical significance was set at p < 0.05. We
ring doctor responsible for the treatment during the ICU used the SigmaStat software in order to analyze our data.
stay was an intensive care specialist in both hospitals. The A minimum sample of 64 patients per group was calculated
only end-point that differed between one hospital to by the formula E/S (the expected effect/standard devia-
another was the physiotherapy care given into two tion of the sample) as necessary for an a Z 0.05 and
manners: 24 h per day in the first hospital (service A) and a b Z 0.80, as the minimal clinical difference.4,7 There-
6 h per day in the second hospital (service B). fore, to ensure the statistical power we analyzed 73
patients in each group.
Protocol
Results
Patients were evaluated on the first day of his/her ICU
admittance and daily during their stay. We considered the Seventy-three out of 146 patients were selected from the
following evaluation parameters: clinical diagnosis, time of hospital which had 24 h/day of physiotherapy care (service
diagnosis, medication in use and current drug introduced in A), and the remaining 73 patients from the hospital which
the ICU period, presence of associated diseases, need of had 6 h/day of physiotherapy care (service B). In both
mechanical ventilation support, previous surgeries, duration services the male gender was prevalent and patients mean
of antibiotics use, severity of disease analysis of patients by age was 54.51 18.4 and 50.25 18.9 for service A and B,
means of the APACHE II score, incidence and severity of organ respectively (Table 1).
dysfunction analysis by means of the SOFA score (Sequential Patients heart rate (88.85 18.7 vs. 89.03 24.3 bpm;
Evaluation of failure of organs), the Glasgow coma scale (for p Z 0.78), respiratory rate (18.34 5.1 vs.
patients without sedation) and sedation scale of Ramsay (for 16.48 7.2 rpm; p Z 0.08), leukocytes count (13.84 6.4
sedated patients). Data were collected daily through the vs. 12.37 5.2 mm3; p Z 0.09), plasmatic sodium
patients medical records and the laboratory tests taken. (137.70 6.3 vs. 136.37 11.4 mEq/L; p Z 0.08), plas-
The mechanical ventilation (MV) time which the patient matic potassium (4.42 0.6 vs. 4.22 0.8 mEq/L;
was submitted to was measured in days and it was considered p Z 0.72), creatinine (1.74 0.7 vs. 1.04 0.5 mg/dL;
from the moment of the tracheal intubation to the moment p Z 0.41), initial and 48 h after admission C-reactive
of extubation. Noninvasive ventilation period was not protein (70.18 10.6 vs. 65.71 12.1 mg/L; p Z 0.40), pH
considered mechanical ventilation length of stay. Respira- (7.36 0.1 vs. 7.37 0.1; p Z 0.91), SpO2 (93.14 10.9 vs.
tory infection occurred after patients were admitted into 95.01 12.8%; p Z 0.10), FiO2 (0.47 0.2 vs. 0.48 0.2%;
each hospital. Therefore, ventilator-associated pneumonia p Z 0.53) and alveolar arterial oxygen (305.57 105.1 vs.
(VAP) was characterized by the definitions as follows: 1) 312.99 121.5; p Z 0.53) were similar between service A
Pneumonia occurring >48 h after endotracheal intubation; 2) and B, respectively. In addition, the Glasgow score, number
Risk factors for multidrug-resistant (MDR) bacteria causing of organs with dysfunction, APACHE II score and SOFA score
VAP. Additionally, nosocomial pneumonia was also assessed were also similar in both hospitals (Table 1).
by the worsening of the patients radiological pattern on
a chest radiogram prior to ICU hospitalization as well as to the
increase in the white blood cells count. Table 1 Baseline characteristic of the 146 studied
Survival and mortality were considered to be major patients in both services.
outcome variables. Patients who were discharged from the Variables Service A Service B p
ICU to another clinical ward of the hospital, to an outpa- (24 h) (6 h)
tient or home-care system were considered to have Sex (Female/Male) 27/46 25/48 e
survived the ICU period. Mortality was considered in those Age (years) 54.51 18.4 50.25 18.9 0.16
cases where death occurred within the ICU hospitalization Ramsay score 4.66 0.7 5.48 0.6 0.01
period. The duration of ICU stay was measured in days. Glasgow score 13.05 3.1 11.19 4.1 0.08
The instruments used for assessing the patient were: APACHE II score 19.90 12.2 20.40 7.7 0.76
APACHE II and SOFA score to assess the severity of the SOFA score 7.97 0.8 8.37 0.9 0.76
disease8,9; the Glasgow coma scale, which assesses the Number of 1.61 0.7 1.87 0.8 0.05
level of consciousness and neurological status10; and the dysfunctional
Ramsay scale, which assesses the level of sedation.11 organs
Overall time of 52.8 2 21.6 1.5 0.001
Statistical analysis chest physical
therapy (h)
Data are expressed in mean and standard deviation. Man- Data expressed as mean standard deviation.
neWhitney U test was used to determine differences
Chest physiotherapy and weaning 71
time physiotherapy care are less likely of death. We found and by that means I take responsibility for the integrity and
that patients with less physiotherapy care present at least accuracy of the data.
30% more chance of death than patients with full-time
physiotherapy care (Fig. 4).
The limitation of this study was the fact that the service
References
B presented more patients diagnosed with brain trauma
than in the service A (Table 2). Since we designed our study
1. Schweickert W, Pohlman M, Pohlman A, et al. Early physical
as a cohort we did not control the recruitment in order to and occupational therapy in mechanically ventilated, critically
avoid a bias. However, this does not invalidate our results ill patients: a randomised controlled trial. The Lancet 2009;
since the severity of the disease was similar between 373:1874e82.
patients of both services. 2. Bailey P, George T, Vick S, et al. Early activity is feasible and
safe in respiratory failure patients. Crit Care Med 2007;35:
139e45.
Conclusions 3. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in criti-
cally ill patients enhances short-term functional recovery. Crit
We conclude that the presence of the chest physiotherapist Care Med 2009;37(9):2499e505.
in the intensive care unit contributes to the early recovery 4. Stiller K. Physiotherapy in intensive care: towards an evidence-
of the patient, reducing length of stay on mechanical based practice. Chest 2000;118:1801e13.
ventilation and hospitalization as well as the incidence of 5. Norrenberg M, Vincent JL. A profile of European intensive care
respiratory infection and mortality. unit physiotherapists. European Society of Intensive Care
Medicine. Intensive Care Med 2000;26:988e94.
6. Chaboyer W, Gass E, Foster M. Patterns of chest physiotherapy
Key message in Australian intensive care units. J Crit Care 2004;19:145e51.
7. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult
Chest physical therapy care given in a 24 h basis can reduce patients with critical illness: recommendations of the Euro-
mechanical ventilation and hospitalization length of stay as pean Respiratory Society and European Society of Intensive
Care Medicine Task Force on physiotherapy for critically ill
well as the incidence of respiratory infections and
patients. Intensive Care Med 2008;34(7):1188e99.
mortality. 8. Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE e acute
physiology and chronic health evaluation: a physiologically
Acknowledgments based classification system. Crit Care Med 1981;9(8):591e7.
9. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related
Organ Failure Assessment) score to describe organ dysfunc-
The authors would like to acknowledge the partnership we tion/failure. Intensive Care Med 1996;22:707e10.
had with both hospitals while in subject enrollment. 10. Teasdale G, Jennet B. Assessment of coma and impaired
consciousness, a practical scale. Lancet 1974;78(2):81e4.
11. Ramsay MA, Savege TM, Simpson BR, et al. Controlled sedation
with alphaxaloneealphadolone. Br Med J 1974;2:656e9.
Authors contributions 12. Horiuchi K, Jordan D, Cohen D, et al. Insights into the increased
oxygen demand during chest physiotherapy. Crit Care Med
Antonio A.M. Castro; Suleima Ramos Calil; Susi Andrea 1997;25:1347e51.
Freitas; Alexandre B. Oliveira, Elias Ferreira Porto: for 13. Jones AYM, Hutchinson RC, Oh TE. Effects of bagging and
assistance in subject recruitment, data collection, data percussion on total static compliance of the respiratory
analysis and manuscript preparation. system. Physiotherapy 1992;78:661e6.
14. Mackenzie CF, Shin B. Cardiorespiratory function before and
Antonio A.M. Castro and Elias Ferreira Porto: Statistical
after chest physiotherapy in mechanically ventilated patients
analysis and guidance.
with post-traumatic respiratory failure. Crit Care Med 1985;
13:483e6.
15. Novak RA, Shumaker L, Snyder JV, et al. Do periodic hyperin-
Conflict of interest statement flations improve gas exchange in patients with hypoxemic
respiratory failure? Crit Care Med 1987;15:1081e5.
16. Jones AYM, Hutchinson RC, Oh T. Chest physiotherapy practice
The protocol was submitted and approved by the Ethics in intensive care units in Australia, the UK and Hong Kong.
Committee of our University and all family members gave Physiother Theory Pract 1992;8:39e47.
written signed consent. This material has not been entirely 17. Daber SE, Jackson SE. Role of the physiotherapist in the
or in part published and it is not being considered for intensive care unit. Intensive Care Nurs 1987;3:165e71.
publication elsewhere. All authors wish to state that no 18. Ciesla ND. Chest physical therapy for patients in the intensive
company has provided grants, gifts, equipments and or any care unit. Phys Ther 1996;76:609e25.
drugs to this study or any participant. Also, any tobacco 19. Hedstrand U, Liw M, Rooth G, et al. Effect of respiratory
company has not funded any part of this manuscript. Any physiotherapy on arterial oxygen tension. Acta Anaesthesiol
Scand 1978;22(4):349e52.
unexpected adverse effects or changes in protocols have
20. Patrick P, Martin RT, Bernhard W. Prophylactic respiratory
been disclosed. All authors have made significant contri- physiotherapy after cardiac surgery: systematic review. BMJ
butions to the study and have read and approved the Publishing Group Ltd 2003;13:327e35.
manuscript. All authors agreed with the statements above 21. Morris P, Goad A, Thompson C, et al. Early intensive care unit
and gave away the editorial rights of this manuscript. Also, mobility therapy in the treatment of acute respiratory failure.
as the main author I had access to the entire manuscript Crit Care Med 2008;36(8):2238e43.
74 A.A.M. Castro et al.
22. Thomsen GE, Snow GL, Rodriguez L, et al. Patients with production in intubated and ventilated intensive care patients.
respiratory failure increase ambulation after transfer to an Physiother Res Int 2002;7:100e8.
intensive care unit where early activity is a priority. Crit Care 27. Berney S, Denehy L, Pretto J. Head-down tilt and manual
Med 2008;36(4):1119e24. hyperinflation enhance sputum clearance in patients who are
23. Clini E, Ambrosino N. Early physiotherapy in the respiratory intubated and ventilated. Aust J Physiother 2004;50:9e14.
intensive care unit. Respir Med 2005;99:1096e104. 28. Kollef MH. What is ventilator-associated pneumonia and why is
24. Chiang LL, Wang LY, Wu CP, et al. Effects of physical training on it important? Respir Care 2005;50(6):714e21.
functional status in patients with prolonged mechanical 29. Stiller Kathy. Safety issues that should be considered when
ventilation. Phys Ther 2006;86:1271e81. mobilizing critically ill patients. Crit Care Clin 2007;23:35e53.
25. Natasha K Brusco, Jennifer Paratz. The effect of additional 30. Ali NA, OBrien JM, Hoffmann SP, et al. Acquired weakness,
physiotherapy to hospital inpatients outside of regular business handgrip strength, and mortality in critically ill patients. Am J
hours: a systematic review. Phys Theory Pract 2006;22(6): Respir Crit Care Med 2008;178:261e8.
291e307. 31. Hodgin KE, Nordon-Craft A, McFann KK, et al. Physical therapy
26. Berney S, Denehy L. A comparison of the effects of manual and utilization in intensive care units: results from a national
ventilator hyperinflation on static lung compliance and sputum survey. Crit Care Med 2009;37(2):561e8.
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