Respiratory muscle training...
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Transcript of Respiratory muscle training...
RESPIRATO
RY MUSCLE
TRAINING FOR PO
ST
MECHANICAL
VENTIL
ATION PA
TIENTS
A R T I CL E C
R I TI Q
U E BY ; K
I MB E R LY W
A L S H SP T
BRIEF INFORMATION ON RESPIRATORY MUSCLE TRAINING ARTICLE OBJECTIVE METHODOLOGY INTERVENTION MEASURES RESULTS DISCUSSION CONCLUSION STRONG POINTS LIMITATIONS REFERENCES
RESPIRATORY MUSCLE TRAINING A technique that aims to
improve function of the respiratory muscles using specific exercises.
Normally aimed at people who have Asthma, Bronchitis, Emphysema and COPD
RESPIRATORY MUSCLE TRAINING Consist of Inspiratory Muscle
Training (IMT) or Expiratory Muscle Training (EMT) or a combination of both
RESPIRATORY MUSCLE TRAINING
Responses to RMT includes: Changes in muscle fiber type Improvements in strength,
speed, power, endurance performance MIP and MEP
INSPIRATORY MUSCLE TRAINING TO ENHANCERECOVERY FROM MECHANICAL VENTILATION;A RANDOMIZED TRIAL
AUTHORS: Bernie M Bisset, Anne Leditschke, Teresa
Neeman, Robert Boots, Jennifer Paratz
Published on June 2, 2016
ARTICLE OBJECTIVE The objective of this research
was to see if IMT improves inspiratory muscle strength and quality of life (QOL) in patients recently weaned from invasive ( mechanical) ventilation
METHODOLOGY Participants were selected by
computer – generated random number sequence, managed by off- site administrative staff
The study was conducted at the Canberra Hospital ( located in Australia)
METHODOLOGY A second hospital was also
included (Calvary Hospital) but no patients were recruited due to failure to meet requirements
With 48 hours of successful weaning, 70 participants ( mechanically ventilated ≥ 7days) were randomized to receive IMT once daily 5 days/ week for 2 weeks with usual care or just usual care ( control group)
METHODOLOGY
IMT Group Control GroupInspiratory muscle training ( 2 weeks)
Usual physiotherapy ( respiratory treatment and mobilization)
Usual physiotherapy ( respiratory treatment and mobilization)
METHODOLOGYInclusion Criteria : Patients who are successfully weaned
from the mechanical ventilation ( > 48 hrs) and within the 7 days following the successful weaning
Patients aged ≥ 16 years who are able to provide informed consent
Patients who are alert and able to train with a Riker score of 4
METHODOLOGY EXCLUSION CRITERIA
Low neurological statusPregnantParticipation in IMT while ventilated Delirium/ agitationMedically unstableDeclined to participateImminent PalliationIntellectual disabilityUnable to communicateFacial Fractures
INTERVENTION Participants were randomized to
receive either usual care (control group) or IMT with usual care
IMT was performed using a threshold IMT – Inspiratory Muscle Trainer ( threshold IMT device HS730,Respironics, New Jersey, USA)
INTERVENTION This device was used with the
mouthpiece, or flexible connector to attach to the tracheostomy
Once a tracheostomy in situ, IMT was always performed with the cuff inflated to ensure accurate loading
INTERVENTION The physiotherapist gave an intensity
of 50% MIP for the first training set
Then quickly increase it to a tolerable intensity that allowed for the pt to complete 6th breath in a set of six breaths with 5 sets of six breaths completed each session
INTERVENTION The intensity was increased daily
by the physiotherapist by manually increasing the threshold resistance by 1-2 cm H2O
Training started on the day of enrolment and was done once daily for 2 weeks (weekdays only)
MEASURES Primary Endpoints- inspiratory
muscle strength and Inspiratory Muscle Fatigue
Secondary Endpoints- Dyspnoea, physical function and quality of life, post intensive care length of stay and in- hospital mortality
RESULTS MIP improved in both groups with
a greater increase in the IMT group than the control group – 17% in the IMT group compared to 6 % in control, p= 0.024.
No statistical value change in FRI was observed in both groups (0.03 vs 0.02, p=0.81)
RESULTS Quality of Life was greater in the
IMT group Changes in dyspnoea scores at rest
and during exercise were not statistically significant.
No significant difference in post – ICU length of stay, reintubation rate or ICU readmission
RESULTS There was a difference in
hospital mortality which was higher in the IMT group (p=0.051) with four deaths.
DISCUSSION Participants who completed 2
weeks of IMT have greater improvement in respiratory muscle strength than their counterparts
IMT group expressed improved quality of life using the EQ5D
DISCUSSION In COPD patients IMT has longer
term effects including lower rates of hospitalization over a 12 month period
The maximum setting on the device is 41cmH2O and it was impossible for 2 participants to achieve greater than 50% MIP
DISCUSSION The reasons for improved
QOL in the absence of a demonstrated effect on respiratory endurance, dyspnoea or functional level remained unclear
CONCLUSIONS IMT following successful weaningincreases IMT strength and QOL .
The researchers cannot confidently rule out an associated increase risk of in- hospital mortality
STRONG POINTS The study was approved by the Australian
Capital Territory Health Human Ethics Committee and the University of Queensland Medical Research Ethics Committee
This study was the first to demonstrate the value of IMT for patients in the postextubation period
Clear and concise Inclusion Criteria
STRONG POINTS Good reliability , inter – rater
reliability and validity of most research tools used in the research
There was researcher blinding to group allocation for MIP, QOL, Dyspnoea and physical function measurements
LIMITATIONS The physiotherapists could not be
blinded in administering IMT training to patients
Inability to demonstrate an improvement in Inspiratory Muscle Endurance in the IMT group
A lack of follow-up of primary outcomes beyond 2 weeks
LIMITATIONS Not all participants achieved
greater than 50% MIP which underestimated the effect of IMT in this research
LIMITATIONS In assessing QOL the
researchers also used SF36 questionnaire which is a lengthy questionnaire.
THE IMPORTANCE OF THIS RESEARCH This research can let PTs
understand how this specific regime of IMT may be useful adjunct to the medical management pts in post weaning period
REFERENCES Buxton, S . Cotton, L. Lowe, R. Respiratory
Muscle Training. Retrieved from http:// www.physio-pedia.com/Respiratory _Muscle_Training
Bissett, B., Boots, R., Leditschke, A., Neeman, T., Paratz. (2016). Inspiratory Muscle training to enhance recovery from mechanical ventilation : a randomized trial. Thorax Online First. 71(9) http://thorax.bmj.com/content/71/9/812.short?g=w_thorax_current_tab