4/13/20

1

ARDS Case StudyRebuilding after ICU

Simone Hunter, PT & Jessica DeMars, PT

1

Jenn• 43 yo female, married with 3 school-aged children, previously healthy; Generally

active/fit. Stay-at-home mom

• In November 2018, was admitted to hospital with 5 day hx of progressive symptoms of flu. Diagnosed with Influenza B and multifocal pneumonia. Progressively deteriorated in hospital for 8 days before admission to ICU.

• 49 days in ICU with hypoxic respiratory failure/ARDS and acute kidney failure. Complications included acalculus cholecystitis, PICC line DVTs, UTIs, anemia, R forearm wound (requiring skin grafting) secondary to interstitial Mg+ infusion, critical illness myopathy and anxiety

2

JennDischarge planning in March 2019

• Initial plan for eRCTP Rehab but managed well enough on weekend home passes, so plan changed to discharge home with home care PT• Ambulating with 4ww x 150m on 3.5lpm (mostly to push her O2 tank). Took 5-10 mins

to ascend x 16 stairs to bedroom requiring seated break as ++ fatigued.• Jenn and family wanted to augment services — highly motivated, resources available.

Requested assistance from allied health managers to find services.• Initial meet’n greet in hospital following home pass — “if I can’t help I’ll find someone who

can”. Called Jess & decided to co-treat.• Joint initial home assessment 2 days following discharge

Total length of stay: 120 days, 49 in ICU, vented for ~5-6 weeks

3

4/13/20

2

Assessment - Subjective• Dsypneic with ADL’s – showering, walking around the house. Going up and down

stairs at home is a challenge due to deconditioning and poor lung function

• Frequent cough – mixture between dry and productive• Reports to have lost 25 - 30 pounds

• Graft was healed and maturing. No ROM limitations or hypertrophic scarring. She kept covered for aesthetic reasons

• Expresses some anxiety over current health situation as well as needs of the family

4

Assessment - Objective• On 3.5L O2 for movement; tolerating 1.5L O2 at rest

• Resp rate 36; mouth breathing and mainly apical/intercostal breathing

• Incentive spirometer: 500mL

• Displays lower muscle tone – posture is quite slouched; reported pain in back, neck, shoulders

• Endurance: 4 BW squats or 2 x8 supine bridge w/ 3 secs holds before coughing limited

5

Treatment Plan• Improve breathing pattern - restore diaphragm recruitment; improve lung volumes and

decrease respiratory rate• Strengthen diaphragm - candidate for IMT once tolerance to incentive spirometry improves.

• Improve conditioning (ICU acquired weakness)• Muscle strength - start with functional, bodyweight movements progressively add

resistance• Cardio exercise - ADLs were enough, must have better breathing regulation before

adding more

• Anxiety - sympathetic/parasympathetic regulation via breathing pattern; education and reassurance; recommended psychologist

6

4/13/20

3

Baseline breathing

NoseDiaphragmRelaxationPrimary focus of week 1 – but used throughout

Breathing and Movement

IntegrationNo breath holdsToleranceStarted week 2 and used throughout

IMT

PowerStrengthEnduranceStarted around 1 month post

7

Chart notes

Standing against the wall, attem pted 'snow angels'; however patient found standing against the wall with feet 3-4"

challenging enough without arm m ovem ents. In crook ly, attem pted belly breaths with snow angels. Pt found getting

from ~120° shoulder abd to 180° very challenging and would hold her breath. Stepped back to just doing overhead shoulder flexion, which she could m anage. Pt could control breath for 4-

6 arm lifts. Provided lateral costal com pression to assist with good belly breaths. (M arch 30)

Reinforced practicing deep breathing every 1/2 hour -alternating between incentive spirom eter and Baseline Calm

breathing. Encouraged to do above M at work 2 tim es per day. NOTE: patient has trouble with retention, so will need to

reinforce strategies and reasons for breathing exercises at each session. (April 4)

8

Strength and Conditioning — 1st year

4-5 months- Summer break- Home travel/program- Keeping up with the 3

kids was enough- Felt slow mentally,

physically- Sea level felt great- Eating or talking

without 02 was hard

Stress + Rest = Progress

6-9 months- 2x strength, 1x

breathing/movement- No exercise guidelines for

ARDS- No lifting experience- Squat-hinge-push-pull or

carry- Warm-up + 3-4 exercises - RPE 6-8, 3x10s- DLs @ 25-50% BW- Cardio: <70%HRR as

coughed/desat- On 2-3lpm for exs, 1-2lpm

for daily- Went snowboarding and

snorkelling wtih family

10-13 months- Big goal: bike trip on e-

bike, 40-50km- 2x strength, 1x cycle- ↑aerobic endurance (HRR

~70%, HR <140)- Karvonen + SpO2 +

observation- ↓ coughing - Pyramid sets (15-10-5-5) or

3-4x 4-5 reps. - DLs @ 50-70% BW,

eccentric U/E- RPE 7-9, lifting HRpeak 160

no cough, but SOB- 2lpm for exs, room air for

daily- Got stronger than before

sick

0-3 months- Functional movements

while breathing well- ↑ endurance, body

awareness- Usual physio-type

strength exercises- T-band, 5-10lbs- RPE 5-7 before

coughing- At start, ADLs were

enough cardio- At end, able to walk

her daughter to school (total 1.2km, 40 mins with 3lpm)

- Reached avg 6MWT for COPD pop.

2-3x/week, 1hr sessions, in-home

9

4/13/20

4

Strength and Conditioning — 2nd Year

17 months- Fell off bike while clipped

in- Left 3x lisfranc #s- NWB x 12wks, no

surgery- No bike trip- Mechanism appropriate

to injury??- Jan 2020: bone scan

found osteopenia, endocrine panel: early menopause

- Exercise is medicine, so there will be side effects (ie. injury)

18 months to now- 2x strength, 1x independently

(yoga or bike)- While NWB, ankle/foot AROM, 1-

leg spin, U/E strength- Once FWB, gait, ankle/foot

strength & proprio + 3-4 strength exs (hinge, squat, push, pull)

- Low volume, high impact (eg. hops, skipping) for bone density

- Month 25: DLs 15-10-5-5 reps for 70-95% of her BW on room air, SpO2 >90%, HRpeak 155

- Doing yoga classes, no O2- Need O2 for exs??

13-17 months- 2x/wk cycling, 1x/wk

strength- Ride outside, e-bike +

equipment- Wanted to trial no O2 on

bike- Showed signs of over-

training/++ fatigue- On 2lpm, set HR monitor

alarm @ 140 then either rest or ↑ e-bike power

- Strength in maintenance phase. Same structure, no big increases

- Peaked @ 57km ride outside with husband —“Felt pretty good”

2-3x/week, 1hr sessions, in-home

10

11

Key Takeaways• Post-ARDS recovery is multifactorial• Respiratory — shortness of breath, reduced lung function• Neuromuscular —weakness, +/- pain• Cognitive — memory, emotion, mood, anxiety• Social — relationships, work

• Initial part of recovery is home-based • Time, support, and motivation

12

4/13/20

5

Key Takeaways• Have to breathe to move — check RR, assume respiratory muscle weakness• Pacing and fatigue — some days we hardly did anything, stress + rest= progress

• Spirometry ≠ function• Resistance training → not only combats ICU acquired weakness, but good for bone

density, aging. Moment for behaviour change • Set meaningful goals. Progress is slow and steady over years. Training is

empowering & healing. Moment for behaviour change

• Intensive care deserves intensive rehab. Cost of 1st yr physio ≅1 day in ICU

13

Summary of improvements

Lung function (FVC)• March 15/18: 30%

• May 10/18: 38%• Nov 2/18: 45%• March 19/19 (1 year post): 53%

• October 3/20: 57%

Strength and conditioning • March 2018: 4 x bodyweight squats

• May 2018: 6MWT 310 meters• Nov 2018: Deadlift 4x8 50% bodyweight• March 2019: 60 min spin sessions (2.0L O2)

• March 2020: Deadlift 4x4 95% bodyweight

14

Questions• What is the happening to ARDS patients in our communities after discharge to

connect to appropriate services (public and private)? How does this compare to other cohorts within ICU (eg. burns, brain injury, trauma)?

• Limitations of N=1. How do outcomes of intensive rehab compare to usual care? What is usual care for this group?

• Exercise intensity, O2 guidelines – in terms of what is “allowable” desaturations?

15

4/13/20

6

ReferencesBissett B, Leditschke A, et al. Inspiratory muscle training for intensive care patients: A multidisciplinary practical guide for clinicians. Australian Critical Care, 2019; 32(3): 249-25.

Clifton-Smith T, Rowley J. Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews 2011; 16(1): 75-86

Dres M, Goligher EC, Heunks LMA, Brochard LJ. Critical illness-associated diaphragm weakness. Intensive Care Med. 2017;43:1441–1452. doi: 10.1007/s00134-017-4928-4.

Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364(14):1293–1304.

16

ReferencesRawal J, McPhail MJ, et al. A pilot study of change in fracture risk in patients with acute respiratory distress syndrome. Crit Care: 2015; Apr 14 (19):165.

Spathis A, et al. The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease. npj Primary Care Respiratory Medicine (2017) 27:27 ; doi:10.1038/s41533-017-0024-z

Wischmeyer, P.E., San-Millan, I. Winning the war against ICU-acquired weakness: new innovations in nutrition and exercise physiology. Crit Care; 2015:19(Suppl 3): S6.

17