• Prolonged mechanical ventilation (MV) was costly in the year 2008, the “mean 12-month medical cost per prolonged MV patient was $306,000” and it is predicted that by the year 2020 the annual cost for patients requiring MV will be $64 billion (Daniel Martin, Smith, & Gabrielli, 2013).

• 25% to 60% of patients on MV may have ICU-acquired weakness (Kayambu, Boots, & Paratz, 2013).

• Early rehabilitation of MV patients in the ICU has been shown not only to be safe but to reduce ICU length of stay, decrease time spent on MV, and improve outcomes after discharge (Clini et al., 2011; Kayambu et al., 2013; Mendez-Tellez & Needham, 2012).

• Inactivity quickly leads to atrophy in skeletal muscles; evidence from animal studies shows that the diaphragm has significant amounts of atrophy within 12-18 hours, compared to other skeletal muscle which shows no signs of atrophy during this time (Mendez-Tellez & Needham, 2012).

Effects of Inspiratory Muscle Training on Weaning from Mechanical Ventilation and ICU Length of Stay

Citation Oxford Level of

Evidence

Purpose Results Answer to clinical

questionChoi, J., et al. (2008).

2a The purpose of the study was to review published research on improving mobility outcomes in patients undergoing prolonged mechanical ventilation (PMV).

Inspiratory muscle training (IMT) increased MIP, VC, weaning success

Yes

Moodie, L., et al. (2011).

2a The purpose of the study was to determine if IMT improves inspiratory muscle strength and endurance, facilitates weaning, improves survival, and reduces rates of reintubation and tracheostomy in adults receiving mechanical ventilation.

IMT improved MIP. Favoring IMT (not statistically significant): weaning duration, survival

Yes

Padula, C., & Yeaw, E. (2007).

3a The purpose of the study was to review IMT in asthma, bronchiectasis, cystic fibrosis, chronic heart failure, ventilator weaning, pre- and post-surgery and neuromuscular diseases.

Improvements in IM endurance, ADLs, increased duration of spontaneous breathing

Yes

Martin A.D., et al. (2011).

1b The purpose of this study was to determine if IMT improves weaning outcomes in failure to wean patients (FTW).

IMT improved MIP and weaning outcome in FTW patients

Yes

Malkoç, M., et al. (2009).

2b The purpose of the study was to determine the effects of physical therapy on ventilator dependency and length of stay in the ICU.

Chest focused PT decreased time spent on mechanical ventilation and length of stay in the ICU

Yes

Crisafulli, E., et al. (2013)

1b The purpose of the study was to evaluate the efficacy and feasibility of an expiratory muscle training device in patients who recently had cardiothoracic surgery.

MEP and VAS dyspnea were significantly higher in treatment group

No

Cader, S. A., et al. (2010)

1b The purpose of the study was to determine if IMT improves MIP, breathing pattern, and time to weaning from mechanical ventilation in older people.

MIP increased significantly in the treatment group. The treatment group weaned 1.7 days sooner than the control, Index of Tobin worsened in both groups but to a lesser extent in the treatment group

Yes

Condessa, R. L., et al. (2013)

1b The purpose of the study was to determine if IMT accelerates weaning from mechanical ventilation, improves the strength of respiratory muscles, increases TV, and improves the rapid shallow breathing index.

The treatment group had statistically significant improvements in MIP, TV, and MEP compared to the control.

Yes

Caruso, P., et al. (2005)

2b The purpose of the study was to determine if inspiratory muscle training from the beginning of mechanical ventilation shortens duration of weaning and decrease reintubation rate.

There was no statistically significant difference between weaning time or reintubation rate between the control and intervention group. MIP was improved in the IMT group compared to the control but not to statistical significance.

No

K. Violet Drinnan, SPT , Advised by Fred Carey, P.T., Ph.D.University of New Mexico School of Medicine, Division of Physical Therapy, Department of Orthopedics & Rehabilitation

University of New Mexico, Albuquerque, New Mexico

Background/Purpose: Prolonged mechanical ventilation produces staggering health care costs and overall poor patient outcomes short and long term. Persistent muscle weakness in the limbs and respiratory muscles contributes to poor long term outcomes. The purpose of this evidence-based analysis is to compare the effects of standard care versus inspiratory or expiratory muscle training on length of ICU stay and time on mechanical ventilation in difficult to wean adult patients on mechanical ventilation.

Case Description: A 46-year old previously independent male patient was admitted to the ICU following a decortication and parietal pleurectomy procedure. He initially was intubated for the night following his surgical procedures but was unable to wean after a two and a half week ICU stay and was transferred to a Long Term Acute Care (LTAC) facility. The patient received usual physical therapy interventions including active and passive range of motion exercises and mobilization within his room.

Outcomes: The patient did not participate in an inspiratory or expiratory muscle training program during his ICU stay and follow-up data was not available after discharge to the LTAC facility. Evidence from this literature review supports the use of inspiratory or expiratory muscle strength training to improve time to wean from mechanical ventilation and improve outcome measures related to respiratory health.

Discussion: The patient may have benefitted from an inspiratory or expiratory muscle training program to encourage weaning from mechanical ventilation. There is limited quality research on inspiratory or expiratory muscle strength training in mechanically ventilated patients making it difficult to synthesize a succinct recommendation for its application. In the studies reviewed, this treatment was considered to be safe for patients on mechanical ventilation. Further quality research is indicated on this topic.

AbstractAbstract

BackgroundBackgroundDiscussionDiscussion

MethodsMethodsFindingsFindings

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Cinahl

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9 articles selected for review

Keyword search: inspiratory muscle training, physical

therapy ventilator, ventilator weaning

Published within 10 years of search date, Human Subjects

Screened for relevance based on title

Screened for relevance based on abstract

23 articles eliminated due to duplicates, subject population,

sample size

ReferencesReferences

PICO Question: In difficult to wean adult patients on a mechanical ventilator, what is the effect of standard care compared to inspiratory or expiratory muscle training on length of ICU stay and time on mechanical ventilation?

• Statistically significant improvements in time to wean and weaning outcome were found in four studies reviewed (Choi, J et al 2008; Martin A.D., et al. 2011; Malkoç, M., et al. 2009; Cader, S. A., et al.2010).

• Decreased length of ICU stay was found in one out of three studies reviewed that specifically measured this outcome measure (Malkoç, M., et al. 2009).

• Many of the studies reviewed failed to reach a statistically significant level of improvement in the treatment group in weaning time and length of stay in the ICU, however this treatment may have clinically significant benefits.

• Outcome measures that correlate to weaning success and respiratory health such as maximal inspiratory pressure, vital capacity, and maximal expiratory pressure were found to increase to a statistically significant amount in treatment groups receiving inspiratory muscle training in seven out of eight studies measuring those variables.

• The long term effects of inspiratory or expiratory muscle training in this patient population on respiratory health, quality of life, and reintubation rates may provide more justification for treatment.

• Adverse events were not reported to have occurred with this treatment in the studies reviewed.

• This treatment appears appropriate and safe for the case study patient based on this research.

Ambrosino, N., Venturelli, E., Vagheggini, G., & Clini, E. (2012). Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients. European Respiratory Journal, 39(2), 487–492. http://doi.org/10.1183/09031936.00094411Bissett, B., Leditschke, I. A., Neeman, T., Boots, R., & Paratz, J. (2015). Weaned but weary: One third of adult intensive care patients mechanically ventilated for 7 days or more have impaired inspiratory muscle endurance after successful weaning. Heart & Lung: The Journal of Acute and Critical Care, 44(1), 15–20. http://doi.org/10.1016/j.hrtlng.2014.10.001Cader, S. A., de Vale, R. G. S., Castro, J. C., Bacelar, S. C., Biehl, C., Gomes, M. C. V., … Dantas, E. H. M. (2010). Inspiratory muscle training improves maximal inspiratory pressure and may assist weaning in older intubated patients: a randomised trial. Journal of Physiotherapy, 56(3), 171–177. doi:10.1016/S1836-9553(10)70022-9Caruso, P., Denari, S. D., Ruiz, S. A., Bernal, K. G., Manfrin, G. M., Friedrich, C., & Deheinzelin, D. (2005). Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics, 60(6), 479–484. doi:10.1590/S1807-59322005000600009Choi, J., Tasota, F. J., & Hoffman, L. A. (2008). Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research For Nursing, 10(1), 21–33.Clini, E. M., Crisafulli, E., Antoni, F. D., Beneventi, C., Trianni, L., Costi, S., … Nava, S. (2011). Functional Recovery Following Physical Training in Tracheotomized and Chronically Ventilated Patients. Respiratory Care, 56(3), 306–313. http://doi.org/10.4187/respcare.00956Condessa, R. L., Brauner, J. S., Saul, A. L., Baptista, M., Silva, A. C. T., & Vieira, S. R. R. (2013). Inspiratory muscle training did not accelerate weaning from mechanical ventilation but did improve tidal volume and maximal respiratory pressures: a randomised trial. Journal of Physiotherapy, 59(2), 101–107. doi:10.1016/S1836-9553(13)70162-0Crisafulli, E., Venturelli, E., Siscaro, G., Florini, F., Papetti, A., Lugli, D., … Clini, E. (2013). Respiratory Muscle Training in Patients Recovering Recent Open Cardiothoracic Surgery: A Randomized-Controlled Trial. BioMed Research International, 2013, e354276. doi:10.1155/2013/354276

A Daniel Martin, A., Smith, B. K., & Gabrielli, A. (2013). Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective. Respiratory Physiology & Neurobiology, 189(2), 377–383. http://doi.org/10.1016/j.resp.2013.05.012Kayambu, G., Boots, R., & Paratz, J. (2013). Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Critical Care Medicine, 41(6), 1543–1554. http://doi.org/10.1097/CCM.0b013e31827ca637Galvan, C. C. R., & Cataneo, A. J. M. (2007). Effect of respiratory muscle training on pulmonary function in preoperative preparation of tobacco smokers. Acta Cirurgica Brasileira, 22(2), 98–104. http://doi.org/10.1590/S0102-86502007000200004Mendez-Tellez, P. A., & Needham, D. M. (2012). Early Physical Rehabilitation in the ICU and Ventilator Liberation. Respiratory Care, 57(10), 1663–1669. http://doi.org/10.4187/respcare.01931Smith, B. K., Gabrielli, A., Davenport, P. W., & Martin, A. D. (2014, January). Effect of training on inspiratory load compensation in weaned and unweaned mechanically ventilated ICU patients. Respiratory Care, 59(1), 22+.Martin, A. D., Smith, B. K., Davenport, P. D., Harman, E., Gonzalez-Rothi, R. J., Baz, M., … Gabrielli, A. (2011). Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial. Critical Care, 15(2), R84. doi:10.1186/cc10081Malkoç, M., Karadibak, D., & Yldrm, Y. (2009). The effect of physiotherapy on ventilatory dependency and the length of stay in an intensive care unit: International Journal of Rehabilitation Research, 32(1), 85–88. doi:10.1097/MRR.0b013e3282fc0fceMoodie, L., Reeve, J., & Elkins, M. (2011). Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation: a systematic review. Journal of Physiotherapy, 57(4), 213–221. doi:10.1016/S1836-9553(11)70051-0Padula, C., & Yeaw, E. (2007). Inspiratory muscle training: integrative review of use in conditions other than COPD. Research & Theory for Nursing Practice, 21(2), 98–118.Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). IMpact of expiratory muscle strength training on voluntary cough and swallow function in parkinson disease. Chest, 135(5), 1301–1308. http://doi.org/10.1378/chest.08-1389

A diagram of a threshold respiratory training device and its use (Galvan, C.C.R., & Cataneo, A.J.M. 2007; Pitts, T., et al. 2009).