Mar 022012

Daily interruption of sedation (daily awakening or sedation holidays) works like a charm to get patients off the ventilator, faster. After proving that a decade or so ago, practice-changers John Kress and William Schweickert have turned their attention to early mobilization as the next intervention that could help mechanically ventilated patients escape the ventilator faster.

How early? How about, while still intubated, with all that comes with that (sedation, agitation, delirium, pain, need for keeping an endotracheal tube in place, etc.) That's insane, you say? Kress and Schweickert beg to differ. There've been just two randomized trials so far, but they're interesting. Both were published in 2009:

  • Schweickert et al randomized ~100 patients to early physical & occupational therapy (~1.5 days after intubation) or usual care (after extubation, typically). More of those getting early mobilization were functionally independent at discharge (59% vs. 34%), more went directly home at discharge (43% vs 26%), and they had fewer days of ICU delirium (2 vs 4). Patients were bag-mask ventilated or attached to portable ventilators for their daily strolls. "Device removal" including dislodgement of an ET tube occurred in ~1% of sessions.
  • Burtin et al randomized intubated patients who were becoming "chronic players" on ICU day ~14 to use a bedside bicycle ergometer 5 days a week, or get usual physical therapy care. At discharge, the patients who bed-biked had slightly farther 6-minute walk distances (196 m vs. 143 m) and stronger quadriceps.

Clinical Takeaway: Implementing this widely would require additional expense in training, equipment and personnel, which would mean a large-scale shift in collective practice patterns and culture, with much of the extra work and stress falling on nurses. No doubt, Schweickert & Kress are plotting a larger trial that would help encourage this change in practice (which I don't see happening at my institution now or any time soon). A web search shows Harvard's Mass General are enrolling 200 intubated trauma patients to test early mobilization in the SICU.

Having said that, it costs nothing to change one's own mind. I'm easily convinced (& sometimes duped) by things that make good common sense and which I like; this is one of them. I may not be able to change local practice or deploy ergometers system-wide, but I can nag a physical therapist and give her a copy of Schweickert's 2009 article to boost her enthusiasm at working diligently with an ICU patient she maybe otherwise wouldn't.

Schweickert WD, Kress JP. Implementing Early Mobilization Interventions in Mechanically Ventilated Patients in the ICU. CHEST 2011;140:1612-1617.

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Walk to wean: Early mobilization for ventilated patients (Review, CHEST)