1. Early activity is feasible and safe in respiratory failure patients Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine. January 2007;35(1):139-145. Abstract OBJECTIVE: To determine whether early activity is feasible and safe in respiratory failure patients. DESIGN: Prospective cohort study. SETTING: From June 1, 2003, through December 31, 2003, we assessed safety and feasibility of early activity in all consecutive respiratory failure patients who required mechanical ventilation for >4 days admitted to our respiratory intensive care unit (RICU). A majority of patients were treated in another intensive care unit (ICU) before RICU admission. We excluded patients who required mechanical ventilation for < or =4 days. PATIENTS: Eight-bed RICU at LDS Hospital. INTERVENTIONS: We assessed patients for early activity as part of routine respiratory ICU care. We prospectively recorded activity events and adverse events. We defined three activity events as sit on bed, sit in chair, and ambulate. We defined six activity-related adverse events as fall to knees, tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, oxygen desaturation <80%, and extubation. MEASUREMENTS AND MAIN RESULTS: During the study period, we conducted a total of 1,449 activity events in 103 patients. The activity events included 233 (16%) sit on bed, 454 (31%) sit in chair, and 762 (53%) ambulate. In patients with an endotracheal tube in place, there were a total of 593 activity events, of which 249 (42%) were ambulation. There were 200 mm Hg, systolic blood pressure <90 mm Hg, and desaturation <80%. No patient was extubated during activity. CONCLUSIONS: We conclude that early activity is feasible and safe in respiratory failure patients. A majority of survivors (69%) were able to ambulate >100 feet at RICU discharge. Early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness. Methods and Materials 103 patients were utilized over a seven month period in the eight-bed respiratory ICU of LDS Hospital Inclusion criteria involved patients requiring mechanical ventilation for >4 days because these patients were at greater risk of developing physical incapacitation Early activity timeframe was considered to be at the start of physiologic stability Stability was gauged off the patient’s ability to respond to verbal stimulation, fraction of inspired oxygen (F IO 2 ) of ≤0.6, positive end-expiratory pressure of ≤10 cm H 2 O, and absence of orthostatic hypotension and catecholamine drips For those who did not meet the entire criteria but seemed like a probable candidate, a trial of activity began with close observation for harmful occurrences Before RICU discharge, the patient’s goal was to ambulate >100 feet RICU staff monitoring treatment consisted of a physical therapist, respiratory therapist, nurse, or a critical care technician Therapy was administered two times a day with attempted increase in activity based off the patient’s progress Pre- and post-activity rest period with assist-control ventilation for 30 minutes was utilized if necessary Three activity events were selected beforehand: short sitting on hospital bed without back support, sit in chair after bed transfer, and ambulate with a walker, support from RICU staff, or without any assistance Adverse events included: fall to knees, tube removal, >200 mmHg systolic blood pressure, <90 mmHg systolic blood pressure, <80% desaturation, and extubation Descriptive statistics used for demographic, medical, activity, and adverse events Results Prospective enrollment of 103 consecutive respiratory failure patients included: 20 with no comorbidities, 26 with one comorbidity, and 57 had multiple comorbidities 34 patients returned home, 25 went to skilled nursing facility, 20 went to rehab unit, 4 went to long-term acute care facility, 2 went to hospice, and 18 died before discharge 1449 activity events completed: 233 sit on bed, 454 sit in chair, and 762 ambulate Mean distance ambulated: 337 ± 130 ft for patients who went home, 293 ± 124 ft who went to skilled nursing, 271 ± 168 ft who went to rehab, and 138 ± 13 ft who went to long-term acute care facility Respiratory failure patients completed a daily activity on 88% of RICU days Patients missed treatments due to medical procedures, complications, or newly found instability Increased comorbidities did not raise time to ambulate 100 ft Total of 14 adverse events out of 1449 activities (0.96%) and did not result in extubation, requirement of additional therapy, increase cost, or longer length of stay Clinical Significance Acute care physical therapists frequently see ICU patients and should attempt physical activity as early as possible Critically ill patients should not be viewed as unable to perform activity Prolonged immobilization can result in neuromuscular abnormalities and add more complications such as muscle atrophy, contractures, and motor control Article 1 Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical Care Medicine. November 2010;38(11):2089-2094. Design: Randomized control trial Mechanically ventilated patients with sedation interruption can endure PT/OT on a regular basis from onset of ventilation while in ICU It is safe and feasible to start intervention immediately after intubation Only on rare occurrences did treatment get permanently discontinued due to patient instability or discomfort. Discussion Progressive activity in respiratory failure patients is practical Strengths include: prospective application of activity protocol and amount of patients able to ambulate before RICU discharge Limitations include: no objective measure of muscle strength and lack of control group shows no direct comparison Need for more clinical studies examining early mobilization practices with relation to functional outcomes and complications Conclusions Early activity is safe and realistic in respiratory failure patients Additional studies are needed to show improved outcomes after hospital discharge Background Previous studies indicate that patients on mechanical ventilation tend to have poor physical outcomes due to the outdated approach that critically ill patients cannot endure physical activity in the beginning of their sickness Lengthened immobilization can provide more complications to their already diminished state Activity at onset of physiologic permanence can improve function to where the patient may ambulate at the time of intensive care unit discharge Purpose Establish that physical activity was practical and harmless in patients identified with respiratory failure Article 2 Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine. August 2008;36(8):2238-2243. Design: Prospective cohort study Early mobility execution by a Mobility team resulted in more Physical therapy sessions and was linked to shorter length of stay for hospital survivors It is more cost effective to incorporate the Mobility team as it lowers the patient’s overall cost by decreasing their length of stay in the hospital Patients were enrolled into the program within 48 hours of intubation Summary Beginning activity earlier after mechanical ventilation is safe and encouraged for patients with respiratory failure Appropriate screening must be used to determine the patient is able to safely proceed in activity Early mobility suggests a decrease in the overall cost in medical expenses because the length of stay was also decreased Further higher level research is needed in order to provide more support and standardization on the optimal practices Presented by Sara Halliday, DPT Student Bellarmine University Figure 1: A patient with exacerbation of chronic obstructive pulmonary disease and pneumonia on assist-control ventilation ambulating with the aid of the respiratory therapist on the right, physical therapist on the left adjacent to the patient, and a critical care technician following with a wheelchair in the background.