CHICAGO – A culture change that allows mechanically ventilated critically ill patients to have more mobility correlates with better outcomes.
"Physicians should consider how respiratory therapies for critically ill patients in the intensive care unit impact patient mobility," Dr. Gregory A. Schmidt said at the annual meeting of the American College of Chest Physicians. Dr. Schmidt was the moderator of a plenary session titled "Liberating the Critically Ill."
"The past thirty years have shown us that many things that we thought were helpful and protective and nurturing of our patients in fact were not," said Dr. Schmidt, professor of internal medicine – pulmonary, critical care, and occupational medicine at the University of Iowa, Iowa City.
Current therapies result in greater levels of diaphragmatic dysfunction and peripheral muscle weakness, two primary causes of longer lengths of stay and overall worse outcomes in critically ill ICU patients, according to Dr. Schmidt.
Several studies he cited indicate that there is a correlation between the length of time a patient is mechanically ventilated, and at what level, and prognosis.
Although there are a number of aspects of diaphragmatic dysfunction attributable to how the body responds to critical illness regardless of therapies used, there are even more factors directly related to care protocols for the critically ill that can result in ICU-acquired weakness, said Dr. Schmidt.
"Ventilation and critical illness cause impaired force generation and atrophy, and this happens acutely and progressively," said Dr. Schmidt. "Diaphragm dysfunction is associated with impeding liberation from the ventilator, and it predicts death."
The dysfunction can be ameliorated with active contraction, said Dr. Schmidt, who presented data indicating that the more independent a patient’s respiration, the less atrophy experienced.
Because the phrenic nerve impulse is not implicated but peripheral muscle weakness is, Dr. Schmidt suggested that engaging these muscles improves outcomes, including shortening time to extubation and length of stay.
"Similar to the diaphragm, contraction lessens dysfunction," said Dr. Schmidt, who cited data on how electrical stimulation of the muscles preserved muscle mass, as well as how early physical therapy and occupational therapy increased independent function of patients at discharge.
The key to improving outcomes, said Dr. Schmidt, is to change our current culture and "liberate our patients." It is a cultural change that requires changing the view that current therapies are always "nurturing and helpful." It also means physicians should not keep patients so deeply sedated that it is impossible for them to participate in moving their muscles. "You need to animate your patients," said Dr. Schmidt, adding that it’s important to avoid keeping patients completely passive and to set ventilators accordingly.
Patients should be seen as active participants in their recovery and supported with a culture that empowers respiration therapists to do their job. "You need to find champions with an attitude that this is absolutely essential to do," he advised.
Noting that liberating patients can result in setbacks, Dr. Schmidt said there are many cultural barriers to this move, including "blame and criticisms and ‘you shouldn’t have done this.’ " Without a champion for this mindset, and the dedicated resources for it, "this will fail," he concluded.