Respiratory Hemodynamic

7/27/2019 Respiratory Hemodynamic

1/5Cardiopulmonary Physical Therapy Journal Vol 23 No 1 March 201214

Respiratory and Hemodynamic Responses toMobilization of Critically Ill Obese Patients

Arzu Genc, Assoc. Prof, PT;1 Seher Ozyurek, MSc, PT;1Ugur Koca, Assoc. Prof, MD; 2 Ali Gunerli, Prof, MD 2

1School o Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir, Turkey2

Faculty o Medicine, Department o Anesthesiology, Dokuz Eylul University, Izmir, Turkey

Address correspondence to: Seher Ozyurek, MSc, PT,School o Physical Therapy and Rehabilitation, DokuzEylul University, Izmir, Turkey, Ph: +90 232 412 49 29,Fax: +90 232 277 50 30 ([email protected]).

ABSTRACTPurpose: The aim o this study was to investigate the eects omobilization on respiratory and hemodynamic parameters incritically ill obese patients. Methods: Critically ill obese pa-tients (n=31) were included in this retrospective study. Datawere collected rom patients fles and physiotherapy recordso mobilization sessions. Heart rate (HR), systolic/diastolic/mean blood pressure, respiratory rate (RR), and percutaneousoxygen saturation (SpO

2) were recorded. Cardiorespiratory

parameters were collected just prior to the mobilization, justater the completion o the mobilization and ater 5 minutesrecovery period. Respiratory reserve was calculated beoreand ater the mobilization. Results: A total o 37 mobiliza-tion sessions in 31 obese patients (mean age: 63.3 years,mean BMI: 32.2 kg/m2) who received physiotherapy wereanalyzed. Respiratory rate increased signifcantly ater thecompletion o the mobilization compared to initial values (p< 0.05). SpO

2signifcantly increased (p < 0.05) and all other

parameters remained similar (p > 0.05) compared to initialvalues ater the recovery period. Mobilization resulted in asignifcant increase in respiratory reserve (p < 0.05). Conclu-sion: Early mobilization in intensive care unit promotes respi-

ratory reserve in obese patients. We ound that mobilizationcan be perormed saely in critically ill obese patients i car-diorespiratory parameters are continuously monitored.

Key Words: obesity, mobilization, critically ill patients,physiotherapy

INTRODUCTION AND PURPOSEObesity is among the most serious public health prob-

lems1,2 that aects many people and oten requires multidis-ciplinary treatment.3 There is overwhelming evidence thatthe prevalence o obesity, defned as having a body massindex (BMI) o 30 kg/m2,4 is increasing worldwide.2,5

Obesity is associated with increased risk o chronic dis-eases, secondary medical complications, and reduced healthrelated quality o lie.6 Approximately one-third o patientsadmitted to intensive care units (ICU) are obese and nearly

7% are morbidly obese.7,8 The term morbid obesity reers toadults with BMI greater than or equal to 40 kg/m2.2

Several studies have investigated the eect o obesityon outcome in ICU setting.9-14 Many o these studies haveshown increased morbidity and mortality.12-14 Data on outcomes o critically ill patients indicated that obese patientswere more likely to have complications including acuterespiratory distress syndrome (ARDS),10,12 septic shock,14

acute renal ailure,10,12 and acquired inection.12,14 Besides

these severe events, obesity is associated with increasedrisk o ARDS11 and increased length o ICU stay.11-14

As patients survive chronic illness, immobilizationcomplications such as muscle weakness and atrophy, con-tractures, decreased cardiac reserve, venous thromboem-bolism, and orthostatic hypotension are more apparent.1

For these reasons, physiotherapy interventions should beinitiated as early as possible ater the acutely ill patient isadmitted to the ICU.16 Many studies showed that mobiliza-tion o critically ill patients in the earliest days o criticacare can result in improved patient outcomes.17-20

Recently, there has been an interest in early mobilization o ICU patients. Although many authors agree that mo

bilization o acutely ill patients is easible and sae;20-22 toour knowledge, there are no studies that were specifcallyimplemented in critically ill obese patients.

The aim o this retrospective study was to investigatethe eects o mobilization on respiratory and hemodynamic parameters in critically ill obese patients. We ocusedon whether patients responses to mobilization were withinthe normal ranges.

METHODSDesign

The study was retrospective. Data were collected rompatients fles and physiotherapy evaluation orms.

Patient and settingsCritically ill obese patients who received mobilization

sessions in their physiotherapy program during the ICU stayin the 18-bed Anesthesiology and Reanimation IntensiveCare Unit o the university hospital between January 2007and January 2010 were included in the study. This studywas approved by the Institutional Review Board at DokuzEylul University.

Patients were classifed as obese according to the defnitions o the World Health Organization criteria4 based on


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BMI ormula: BMI= body weight (kg)/height2 (m2). Obesepatients were defned as having BMI o 30.00 kg/m2.

Inclusion criteria or receiving mobilization sessionsconsisted o stable conscious state and able to understandand ollow commands appropriately, hemodynamicallystable (not requiring inotropes), body temperature < 38C,hemoglobin levels stable and > 7 g/dL, percutaneous oxy-gen saturation (SpO

2) > 90%, mean blood pressure (MBP)

> 60 mmHg, no orthopedic and neurological contraindica-

tions.23

Mobilization protocolThe standard mobilization protocol is that mobilization

is begun as soon as patients cardiorespiratory system is sta-ble (as defned above). Per hospital standard protocol, mo-bilization was begun as soon as the patients cardiorespira-tory system was stable (as defned above). Hemodynamicand respiratory parameters were continuously recorded atall stages o mobilization sessions. The mobilization pro-gression was based on the patients general clinical status,ability, and willingness.

Physiological responses were monitored continuously

as the patient progressed through the mobilization protocolin order to prevent adverse eects o mobilization.

The ollowing criteria were chosen as intolerance fndings: 20 mmHg increase or decrease in systolic blood

pressure (SBP)/diastolic blood pressure (DPB), 20 beats/minute increase or decrease in heart rate

(HR), SpO

2< 90%, and

paradoxical breathing, dizziness, perspiration, andaintness.18

Intolerance fndings were recorded by the physical ther-apists to evaluate the saety o patients and patients abnor-mal responses to mobilization.

Data collection and outcome measureOne physiotherapist specialized in intensive care col-

lected the inormation retrospectively rom the obese pa-tients fles (see Table 1). Data were collected in 3 categories:patients demographics (age, gender, height, body weight,BMI), patients medical inormation, and physiotherapy re-cords o mobilization sessions during their ICU stay.

Hemoglobin levels, platelet counts, white cell counts,and blood glucose levels were collected rom the most re-cent blood analyses and body temperature was recordedrom the monitor (Draeger Medical Systems Inc, U.S.A) be-ore mobilization.

The ollowing hemodynamic and respiratory param-eters were taken rom the monitor: HR, SBP, DBP, MBP, re-spiratory rate (RR), and SpO

2. Measurements were collect-

ed in 3 stages: (1) just prior to the mobilization in supineposition (premobilization), (2) just ater the completion othe mobilization when the patient had been returned to thesupine position (postmobilization), and (3) ater 5 minutesrecovery period (5 minutes recovery).

The ratio o partial pressure o oxygen in arterial bloodto the inspired raction o oxygen (PaO

2/FiO

2) was calcu-

lated rom the most recent arterial blood gas samples oassessing the respiratory reserve beore and ater the mobilization.Respiratory reserve reects oxygenation.23

Data analysisThe statistical package SPSS 15.0.0 or Windows (SPSS

Inc., Chicago, IL, USA) was used or statistical analysisLevel o signifcance was set at p < 0.05. All continuousvariables were evaluated or normality using Kolmogorov-

Smirnov test with Lillieors Signifcance Correction. Continuous variables were expressed as mean standard de-viation (i data were normally distributed) or as mediansin combination with quartiles and percentiles (i data werenot normally distributed). Mobilization data were analyzedwith a one way repeated measure analysis o variance(ANOVA). Statistically signifcant changes were urther an-alyzed with post-hoc Bonerroni t-test. To compare changesin respiratory reserve between beore and ater mobilization, paired sample t-test was perormed.24

RESULTSRetrospective analysis o 31 patients fles who received

mobilization in their physiotherapy program during theICU stay ulflled all aspects o the study. A total o 31 obesepatients received 37 mobilization sessions in ICU. Baselinecharacteristics o the patients are summarized in Table 1.

All mobilization sessions were perormed ater patientswere extubated. Mobilization events included 26 (70.3%sitting on the edge o the bed, 3 (8.1%) standing, 8 (21.6%walking to the chair and sitting in the chair.

A total o 7 intolerance fndings were recorded in 6patients. One patient had 2 intolerance fndings. Intoler-ance fndings included 4 increase or decrease in SBP (20mmHg or more), 3 increase or decrease in HR (20 beatsminute or more). Despite the intolerance fndings, no de

terioration in clinical status occurred during the mobilization sessions.

Effects of mobilization on hemodynamic parametersThe results showed that HR was signifcantly dieren

when 3 mobilization stages were compared (F= 3.79, p=0.049). Heart rate signifcantly decreased in the 5 minuterecovery period when compared with postmobilizationvalues (p < 0.05). There were no signifcant dierences inother hemodynamic parameters (p > 0.05) (Table 2).

Effects of mobilization on respiratory parametersSignifcant changes were seen in RR (F = 17.35, p = 0.00

with progression o mobilization. Respiratory rate signifcantly increased rom premobilization to postmobilization. A signifcant RR reduction was seen in the 5 minute recovery period when compared with postmobilization values (p < 0.05)

Mobilization caused a signifcant change in SpO2(F=

4.11, p= 0.02). Ater a 5 minute recovery period, SpO2sig

nifcantly increased compared with premobilization value(p < 0.05) (Table 2). Mobilization resulted in a signifcanincrease in respiratory reserve when compared with pre-mobilization values (t = -5.440 p = 0.00) (Table 2).



DISCUSSIONIn this retrospective study, we investigated the hemody-

namic and respiratory responses to early mobilization andeects o the mobilization on oxygenation in critically ilobese patients. Although mobilization resulted in signif-cant increases in RR ater mobilization, all parameters weresimilar in the 5 minute recovery period when comparedwith initial values, except or SpO

2. Increases in RR may be

due to the patients eorts to compensate or the increased

physical activity. It was an expected response to increasedwork o breathing. Nonsignifcant HR, SBP, DBP, and MBPincreases were seen during postmobilization period. Thisresult showed that mobilization did not put excess hemo-dynamic stress on obese patients. Signifcant increase wasobserved in SpO

2in the recovery period when the patient

was taken back to supine position in bed.Additionally, we

ound that respiratory reserve signifcantly improved atemobilization. Although the 7 o 37 mobilization sessionshad intolerance fndings, mobilization did not result in deterioration in clinical status. On the two o 7 intolerencefndings, the magnitude o SBP or HR increases were verysmall when compared to chosen intolerance fndings (in

one patient: 21 beats/minute increase in HR, in the otherpatient: 21 mmHg increase in SBP). No specifc interven-tion was applied during mobilization to stabilize cardiorespiratory parameters. Patients hemodynamic and respiratory responses to mobilization were within the normal value

The main fnding o the present study is that mobiliza-tion can be perormed saely in critically ill obese patients icardiorespiratory parameters are continuously monitoredThis fnding is similar to other mobilization studies,18,20-2

which investigated the eects o mobilization in criticallyill patients with other diagnosis.

There are several outcome studies investigating the eect o obesity in ICU.9-11 It is well known that obesity is

related to increased morbidity and mortality.12-14 In the literature, it is shown that early mobilization improves unc-tional outcomes in critically ill patients.17-20 Although mo

Table 1. Baseline Characteristics of the Patients

Age (years)

Mean SD 63.3512.25

Range 38.00-83.00

Gender [n(%)]

Male 15 (48.4%)

Female 16 (51.6%)

Body weight (kg)

Mean SD 87.4811.78Range 70.00-120.00

Height (cm)

Mean SD 164.549.79

Range 145.00-184.00

BMI (kg/m2)

Mean SD 32.242.53

Range 30.04-39.56

Diagnosis at ICU admission [n(%)]

Medical 3 (9.7%)

Surgery 28 (90.3%)

Body temperature (0C)

Mean SD 36.970.38

Range 36.00-37.70

Hemoglobin levels (g/dL)

Mean SD 10.691.75

Range 7.10-13.70

Platelet counts (cells/mm3)

Mean SD 214.229128.587

Range 51.000-621.000

White cell counts (cells/mm3)

Mean SD 12.0703.009

Range 5.600-18.300

Blood glucose levels (mg/dL)Mean SD 161.2148.65

Range 101.00-286.000

Table 2. The Comparison of Hemodynamic and Respiratory Parameters between Premobilization, Postmobilization,and Recovery Period (mean standard deviation)

Premobilization Postmobilization Recovery p

HR(beat/minute) 91.56 17.50 94.4515.97 90.4014.91 0.049

SBP(mmHg) 130.9415.89 134.0817.85 130.7216.68 0.194

DBP(mmHg) 70.0012.30 72.5612.80 69.5611.63 0.081

MBP(mmHg) 91.4814.92 94.3714.75 90.5613.88 0.119RR(breath/minute) 23.324.97 25.895.51 23.294.71 0.000

SpO2*

(%) 98.0

(95.5-100.0)99.0

(96.0-100.0)99.0

(96.5-100.0)0.020

PaO2/FiO

2230.1585.80 276.8299.46 - 0.000a

HR: heart rate, SBP: systolic blood pressure, DBP: diastolic blood pressure, MBP: mean blood pressure, RR: respiratory rate, SpO2= percutaneous oxygen saturation, %=percent, PaO

2/FiO

2: the ratio o partial

pressure o oxygen in arterial blood to the raction o inspired oxygen

: statistically dierent rom post-mobilization values( p < 0.05).

: statistically dierent rom pre-mobilization values( p < 0.05).

p: ANOVA, boldace p values were s tatistically signifcant.a: paired sample t- test

*: expressedas medians in combination with quartiles and percentiles


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bilization is a common practice in most ICUs, there is alack o data available on obese population. There is onlyone case report o a morbidly obese patient (BMI: 69 kg/m2)

with multiorgan ailure successully mobilized throughouther ICU stay.25 However that report did not investigate thehemodynamic and respiratory responses to mobilization.To the best o our knowledge, no previous studies have in-vestigated the eects o mobilization on hemodynamic andrespiratory parameters in critically ill obese patients. This

study is the frst research related to early mobilization inobese patients in ICU. Our current fndings showed sig-nifcant increases in RR ater mobilization that returnedpremobilization values in the recovery period indicatingthe saety o mobilization as a consequence o normal re-sponses to physical demand. Increases in SpO

2and PaO

2/

FiO2

reect the improvement o oxygenation and this resultshowed that mobilization may improve patient outcomes.

Our obese patients were able to participate in early mo-bilization and the patients demonstrated clinical stabilitythrough the ICU stay. Clinical and physiologic stability of apatient has been described as the whole state of neurologi-cal and cardiorespiratory stability.27 Stiller et al23 has outlined

the safety issues that should be considered when mobilizingcritically ill patients. We selected the inclusion criteria ac-cording to these safety issues. The mobilization progressionwas based on the patients general clinical status, and ability.None of the patients had an adverse event in mobilization.

The majority o the patients (n=28, 90.3%) in the cur-rent study had surgery. Although our patients did not havepulmonary complications, it is well documented in theliterature that obese patients have been reported to havea higher incidence o postsurgical pulmonary complica-tions.26 Efcacy and saety o earlypostoperativemobi-lization in critically ill patients has been shown in priorstudies.18,20,27,28 All the patients in Sendurans18 and Zaf-

ropoulos20 studies and 38.7% o the patients in Stillers21study were postoperative. All o these authors appliedearly mobilization in ICU and ound that mobilization iseasible and sae in patients postsurgery. Our fndings sup-port these literature fndings.

Zafropoulos et al20 investigated the eects o mobiliza-tion on respiratory and hemodynamic variables in intubat-ed, ventilated abdominal surgical patients and ound thatmobilization was associated with signifcant increases inRR.Similar to Zafropoulos et als20 fnding an increase inRR was ound in our study ater mobilization. We did notinclude the intubated and mechanically ventilated patientsin our study. However, in Stillers21 study, 7 patients (22.6%)were intubated, ventilated and they ound the same resultas well. In contrast with results o Zafropoulos,20 Still-ers,21 and Sendurans18 studies, we did not fnd a signifcantincrease in HR ater mobilization.

We ound that the respiratory reserve o the patientssignifcantly increased ater mobilization and SpO

2signif-

cantly increased ater 5 minutes recovery. It was expectedthat the mobilization would enhance the oxygen transporto these patients, due to positive eects o erect position onalveolar ventilation and ventilation/perusion matching.29

Researchers have speculated that duration o sitting andwalking distance may aect the cardiopulmonary respons-es to a recovery period.18 In our study, we did not measurethe duration o sitting and walking distance to the chairThis is a limitation o our study.

In our study, only 8 patients (21.6%) managed to walkto the chair and sit in the chair. The majority o our pa-tients (n=26, 70.3%) were seated on the edge o the bedWe think that participation o a large number o subjects in

higher level o mobilization stages may aect the resultsThis may be a limitation o our study.

CONCLUSION

We conclude that early mobilization is easible and saein critically ill obese patients. Additionally, our study showsthe benefts o early mobilization on oxygenation improvement. Further randomized-control studies with larger number o patients are needed to contribute new knowledgeto physiotherapy literature or the obese population in theICU setting.

ACKNOWLEDGEMENTS

Abstract o this work was presented as a poster presentation in 23rd Annual Congress o the ESICM in Barcelona2010 and ESICM published the abstracts in Intensive CareMedicine 2010 Supplement 2 which contains abstracts oscientifc papers presented at the 23rd Annual Congress othe European Society o Intensive Care Medicine.

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