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Objective: To assess validity and responsiveness of the Extended Rehabilitation Complexity Scale (RCS-E v13) to in-hospital pulmonary rehabilitation (PR) in individuals with chronic respiratory diseases (CRD)., Design: Cross-sectional, multicentric study. Assessments in individuals attending units on 2 nonconsecutive days., Setting: Fourteen in-hospital PR units., Participants: Five hundred forty-seven individuals (59.2% male, age 72y [range, 65-78y]): 317 with chronic respiratory failure because of various causes (CRF); 96 with chronic obstructive pulmonary disease without CRF (COPD), 39 tracheostomized and ventilated (TX/V), and 95 with other diseases (Miscellaneous)., Intervention: Assessment of RCS-E v13 before and after the PR program., Main Outcome Measures: RCS-E v13 and outcome measures: Barthel Index (BI), Barthel Index Dyspnea (BiD), Medical Research Council scale for dyspnea (MRC), COPD Assessment Test (CAT), Short Physical Performance Battery (SPPB), and 6-minute walk test (6MWT)., Results: The highest RCS-E v13 admission values (median [interquartile range]) were found in TX/V (17 [15-18]) as compared with other groups (8 [7-10], 10 [9-12], and 8 [8-10] in COPD, CRF, and Miscellaneous, respectively, P<.001). At admission and discharge, RCS-E v13 correlated strongly with BI, 6MWT, and SPPB and moderately with MRC and BiD (r=.43-.60). After the program, RCS-E v13 as well as all outcome measures improved significantly in all groups (P<.001 for all). The size of improvement was different among groups according to the different variables. In the overall group, the effect size was high for changes in RCS-E v13 (Cohen's d=-2.0984), CAT (d=-1.1937), MRC (d=-1.0505), BiD (d=-.9364), and SPPB (d=.9231) whereas it was moderate for 6MWT (d=.7670) and BI (d=.6574)., Conclusions: RCS-E v13 varies according to different CRD, is responsive to PR, has good construct and concurrent validity, and correlates with most of the accepted outcome measures of PR. Its scoring may provide useful information on the care burden of individuals undergoing PR., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Diseases associated with chronic respiratory failure have a negative impact on quality of life and life expectancy, notably through a reduction in patients' functional capacity. Assessing balance, coordination, muscular strength and endurance, as well as exercise tolerance, is therefore an important component of the evaluation of individuals with chronic respiratory failure. This evaluation can be made easier by using simple tools such as sit-to-stand tests. This review presents the main sit-to-stand tests that have been described and that can be used in everyday practice. The aim is to provide information to the clinician on the contribution of each test, and to identify the extent to which and the purpose for which these tests can be incorporated into a routine pulmonology and/or respiratory rehabilitation evaluation. Because of their inherently functional nature, these tests could help to identify the indications and/or the effects of respiratory rehabilitation., (Copyright © 2024 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Background: Chronic respiratory failure is a common cause of ventilator dependence in the intensive care unit (ICU). The causes of chronic respiratory failure include primary disease or complications, such as ICU-acquired weakness. Traditional practice requires patients to remain immobile and bedridden; however, recent evidence suggests that early adequate exercise promotes recovery without increasing risks. In this study, we explored the efficacy of planned progressive abdominal sandbag training in promoting the successful withdrawal of patients with chronic respiratory failure from mechanical ventilation., Methods: This study was conducted between April 2019 and November 2020. Patients were recruited and divided into two groups: abdominal sandbag training group and control group (no training). The training group participated in a 3-month daily pulmonary rehabilitation program, which involved a 30-min session of progressive sandbag loading on the upper abdomen as a form of diaphragmatic resistant exercise. The pressure support level of the ventilator was adjusted to maintain a tidal volume of 8 mL/kg. To investigate the effect of abdominal sandbag training on patients with chronic respiratory failure, we compared tidal volume, shallow breathing index, maximum respiratory pressure, and diaphragm characteristics between the training and control groups., Results: This study included 31 patients; of them, 17 (54.8 %) received abdominal sandbag training and 14 (45.2 %) did not. No significant between-group difference was found in baseline characteristics. Compared with the control group, the training group exhibited considerable improvements in ventilation-related parameters (p < 0.001): the tidal volume markedly increased (p = 0.012), rapid shallow breathing index declined (p = 0.016), and maximum respiratory pressure increased (p < 0.001) in the training group. The diaphragm motion value (p = 0.048) and diaphragm thickness (p = 0.041) were greater in the training group than in the control group. Nine patients (52.9 %) in the training group were removed from the ventilator compared with 1 (7.1 %) in the control group (p = 0.008)., Conclusion: Abdominal sandbag training may be beneficial for patients dependent on a ventilator. The training improves the function of the diaphragm muscle, thereby increasing tidal volume and reducing the respiratory rate and rapid shallow breathing index, thus facilitating withdrawal from ventilation. This training approach may also improve the thickness and motion of the diaphragm and the rate of ventilator detachment., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Children with home invasive mechanical ventilation need special health care and rehabilitation services due to complications caused by both the pulmonary system and physical inactivity. Children who are dependent on invasive mechanical ventilators due to breathing difficulties and lung problems can benefit from rehabilitation programs. Rehabilitation requires a close relationship between the child, parents and/or caregivers, and healthcare professionals. The main goal of rehabilitation is to improve breathing, lung function and overall quality of life. In this review, although full standard approaches have not been determined yet, rehabilitation approaches for children dependent on home-type invasive mechanical ventilator will be discussed., (© 2024 Wiley Periodicals LLC.)

Background: Owing to clinical developments and economic strain, perioperative care has undergone considerable changes. Therefore, it is important to review and critique the efficacy of existing practices in a context that is placing increasing emphasis on better efficacy and cost-containment. Considering that the objective involves devising approaches to minimize postoperative complications and reduce medical care, efforts should concentrate on postsurgical pulmonary complications that are common. The present analysis aims to examine how customized rehabilitation nursing intercession impacts the postsurgical restoration of respiratory functions in thoracic surgery patients., Methods: Prespecified search strategies will be employed to perform a methodological search of 6 databases namely EMBASE, Cochrane Library, PubMed, Web of Science, WanFang Database, and China National Knowledge Infrastructure. The analysis will comprise original publications that evaluated how personalized rehabilitation nursing intervention impacts postsurgical restoration of respiratory function in those who have undergone thoracic surgery. All considered publications are before December 25, 2021. Different authors will conduct an independent study selection process to evaluate the quality of the publications and extract required data. Based on the standardized mean difference and its 95% confidence interval, we estimate the summary effects for each meta-analyses. Based on heterogeneity in considered articles, the related data will be pooled through either a random- or fixed-effect meta-analysis. Lastly, the overall quality of evidence using appropriate methods will be performed., Results: The results of this analysis will systematically evaluate how customized rehabilitation nursing interference impact postsurgical healing of respiratory functions in patients who have undergone thoracic surgery by collecting the existing evidence., Ethics and Dissemination: Not required., Open Science Framework Registration Number: 10.17605/OSF.IO/NBVYW., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Some COVID-19 patients develop respiratory failure requiring admission to intensive care unit (ICU). We aim to evaluate the effects of pulmonary rehabilitation (PR) post-ICU in COVID-19 patients., Methods: Twenty-one COVID-19 patients were evaluated pre- and post-PR and compared retrospectively to a non-COVID-19 group of 21 patients rehabilitated after ICU admission due to respiratory failure., Results: PR induced greater 6-min walking distance improvement in COVID-19 patients (+205 ± 121 m) than in other respiratory failure patients post-ICU (+93 ± 66 m). The sooner PR was performed post-ICU, the better patients recovered., Conclusions: PR induced large functional improvements in COVID-19 patients post-ICU although significant physical and psychosocial impairments remained post-PR., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: The procedure of lung parenchyma resection may result in impairment of physical capacity and quality of life. In patients with operable non-small cell lung cancer (NSCLC), lobectomy is an elective procedure. Chronic obstructive pulmonary disease (COPD) is a common coexisting condition in patients with NSCLC. Effectiveness of post-operative pulmonary rehabilitation (PR) in patients who underwent lobectomy due to NSCLC and suffering from COPD as compared to individuals without COPD has not been determined yet. The aim of the study was to compare effectiveness of post-operative PR in patients with COPD after lobectomy due to NSCLC (COPD[+] L [+]) with individuals with COPD without lung parenchyma resection (COPD(+) L(-)) and those who underwent lobectomy due to NSCLC and not suffering from COPD (COPD[-] L[+])., Material and Methods: Thirty-seven patients with non-small cell lung cancer (21 patients with and 16 patients without COPD) who underwent lobectomy and 29 subjects with COPD referred to the Lung Diseases Treatment and Rehabilitation Centre in Lodz in 2018-2019 were included in this retrospective analysis. The patients participated in a 3-week inpatient pulmonary rehabilitation (PR) program which included breathing exercises, physical workout, relaxation exercises, education, psychological support and nutrition consulting. The evaluation included lung function measurements, six-minute walking test (6MWT) and the St. George's Respiratory Questionnaire (SGRQ) score. The results obtained before the rehabilitation were compared to those achieved after the 3-week PR program and compared between the study groups., Results: A significant increase in the distance covered during 6MWT was observed in all the three groups studied: COPD(+) L(+) (Δ = 62.52 ± 14.58 m); COPD(-) L(+) (Δ = 73.67 ± 11.58 m); and COPD(+) L(-) (Δ = 59.93 ± 10.02 m) (p < 0.001 for all). Similarly, a statistically and clinically significant improvement in the total SGRQ score was recorded: COPD(+) L(+) ∆ = -12.05 ± 3.96 points; p < 0.05 and COPD(-) L(+) ∆ = -12.30 ± 4.85 points; p < 0.01 and COPD(+) (L-) ∆= -14.07 ± 3.36 points (p < 0.001). No significant differences in the outcome improvement between the study groups were identified., Conclusions: The results of the study show that COPD(+) L(+) patients gained benefits from post-operative PR comparable to COPD(+) L(-) and COPD(-) L(+) subjects by improving their physical capacity and quality of life.

Introduction: Both physical and mental disorders may be exacerbated in patients with COVID-19 due to the experience of receiving intensive care; undergoing prolonged mechanical ventilation, sedation, proning and paralysis. Pulmonary rehabilitation is aimed to improve dyspnoea, relieve anxiety and depression, reduce the incidence of related complications, as well as prevent and improve dysfunction. However, the impact of respiratory rehabilitation on discharged patients with COVID-19 is currently unclear, especially on patients who have been mechanically ventilated over 24 hours. Therefore, we aim to investigate the efficacy of respiratory rehabilitation programmes, initiated after discharge from the intensive care unit, on the physical and mental health and health-related quality of life in critical patients with COVID-19., Methods and Analysis: We have registered the protocol on PROSPERO and in the process of drafting it, we strictly followed the checklist of Preferred Reporting Items for Systematic Review and Meta-Analysis Potocols. We will search the PubMed, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WanFang, VIP information databases and Chinese Biomedical Literature Database. Additionally, ongoing trials in the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and ISRCTN registry will be searched as well. Studies in English or Chinese and from any country will be accepted regardless of study design. Two review authors will independently extract data and assess the quality of included studies. Continuous data are described as standard mean differences (SMDs) with 95% CIs. Dichotomous data from randomised controlled trials are described as risk ratio(RR) with 95% CIs; otherwise, it is described as odds ratio(OR) with 95% CIs. I 2 and the Cochrane's Q statistic will be used to conduct heterogeneity assessment. The quality of evidence of main outcomes will be evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation(GRADE) criteria. When included studies are sufficient, we will conduct subgroup analysis and sensitivity analysis; the publication bias will be statistically analysed using a funnel plot analysis and Egger's test., Ethics and Dissemination: Our review, planning to include published studies, does not need the request to the ethical committee. The final results of this review will be published in a peer-reviewed journal after completion., Patient and Public Involvement: No patient involved., Prospero Registration Number: CRD42020186791., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore and describe current UK physiotherapy practice relating to airway clearance techniques and mucoactive agents in critically ill adult patients with acute respiratory failure in the intensive care unit., Design: A descriptive, qualitative study using focus group interviews. Focus groups were audio-recorded, independently transcribed, and data analysed thematically. Participants Senior, experienced physiotherapists, clinically active in critical care., Results: Fifteen physiotherapists participated in four interview sessions. Five themes emerged describing airway clearance techniques: 'Repertoire of airway clearance techniques', 'Staffing and skillset', 'Commencing respiratory physiotherapy', 'Technique selection', and 'Determining effectiveness' were themes related to airway clearance techniques. Five themes were also identified in relation to mucoactive agents: 'Use in clinical practice', 'Decision to commence', 'Selection of agent', 'Stopping mucoactive agents', and 'Determining effectiveness'. A summary of key features of standard practice was developed., Conclusions: Standard UK physiotherapy practice of airway clearance techniques is variable, but patient-centred and targeted to individual need, with adjunctive use of mucoactive agents to enhance and optimise patient management if required. Based on this study, key features of airway clearance techniques have been summarised to help capture standard care, which could be used in future trials involving ACT as part of usual care., (Copyright © 2020. Published by Elsevier Ltd.)

There is a need of consensus about the pulmonary rehabilitation (PR) in patients with COVID-19 after discharge from acute care. To facilitate the knowledge of the evidence and its translation into practice, we developed suggestions based on experts' opinion. A steering committee identified areas and questions sent to experts. Other international experts participated to a RAND Delphi method in reaching consensus and proposing further suggestions. Strong agreement in suggestions was defined when the mean agreement was >7 (1 = no agreement and 9 = maximal agreement). Panelists response rate was >95%. Twenty-three questions from 4 areas: Personnel protection equipment, phenotypes, assessments, interventions, were identified and experts answered with 121 suggestions, 119 of which received high level of concordance. The evidence-based suggestions provide the clinicians with current evidence and clinical experts opinion. This framework can be used to facilitate clinical decision making within the context of the individual patient. Further studies will evaluate the clinical usefulness of these suggestions.

Background: International Classification Functioning (ICF) Core Sets represent a holistic approach to functioning within rehabilitation field. Information-reporting efficacy of a rehabilitation-based Respiratory ICF set applied on a large scale throughout the ICS Maugeri network was tested., Methods: A prospective multi-center study (May-November 2018) was conducted for all respiratory inpatients consecutively admitted for rehabilitation. Doctors, physiotherapists, psychologists, nurses used an electronic Respiratory ICF set (33 items among the ICF body functions, activity and participations components) at admission and at discharge to assess the disability changes. The ICF report qualifiers, from 0 (no impairment) to 4 (maximum impairment), guided clinical, diagnostic and rehabilitation prescriptions., Results: 1886 patients (69.6±10.8 years; M=1045) were admitted (589 chronic obstructive pulmonary disease, 494 chronic respiratory failure [CRF], 21 prolonged mechanical ventilation [PMV], 496 with other respiratory diseases), of whom 15 died, and 117 were transferred to acute care. The mean length of stay was 23.1±11.8 days (range 1-122). The mean time to fill in the ICF set was 23.16±0.70 min. The rate of filled charts improved from 16% in May to 100% in November. The baseline distribution of the more severe qualifiers (>2) progressively increased from the whole sample to the PMV subgroup. After rehabilitation, in the whole sample and in the CRF and PMV subgroups, the severity qualifiers significantly decreased (P<0.0001), showing a positive effect of the intervention on patients' disability., Conclusions: Routine use of a Respiratory ICF set for chronic respiratory diseases helps to prepare a personalized rehabilitation program discriminating disability level in different respiratory diseases and assessing disability outcomes pre-post rehabilitation.

Due to COVID-19 outbreak, to lighten the burden of acute and critical care hospitals, some respiratory rehabilitation departments have been used to host patients with COVID-19 in the post-acute phase. This new and unexpected situation required a change of roles and scheduling of the rehabilitation teams. In this manuscript we describe the unexpected and urgent organizational change of the Cardio-Pulmonary Rehabilitation (CPR) service during the COVID-19 emergency in a Northern Italian rehabilitation hospital, focusing on the Respiratory Physiotherapists' (RPTs) role. A quick three-days complete reorganization of the entire hospital was needed. A COVID-19 care team including a multidisciplinary panel of physicians, nurses, and RPTs was quickly performed to manage 90 beds for post acute patients with COVID-19. Within the team, the RPTs changed their shifts, so as to be available 16h per day, 7 days out of 7. Remodelled tasks in charge of RPTs were: oxygen therapy daily monitoring, non invasive ventilation (NIV) and continuous positive airways pressure (CPAP) delivery, pronation and postural changes to improve oxygenation, reconditioning with leg/arm cranking and exercises, initial and final patients' functional assessment by short-physical performance battery (SPPB) and 1-minute sit-to-stand test (1-STS) to evaluate motor conditions and exercise-induced oxygen desaturation. Three "what-to-do" algorithms were developed to guide: i) oxygen de-escalation by reducing inhaled fraction of oxygen (FiO2); ii) oxygenation improvement through the use of Venturi mask; iii) reconditioning and physical activity. One-hundred seventy patients were treated in one month. As main topics, RPTs have been involved in oxygen therapy management in almost a third of the admitted patients, reconditioning exercises in 60% of the cases, and initial and final functional motor capacity assessment in all patients. Details of activities performed by the RPT in one typical working day are also shown. Our reorganization has exploited the professional skills and clinical expertise of the RPTs. This re-organization can provide practical insights to other facilities that are facing this crisis, and may be a starting point for implementing post-COVID-19 rehabilitation. Future studies will have to improve and review this organization.

Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR) On February 2020, Italy, especially the northern regions, was hit by an epidemic of the new SARS-Cov-2 coronavirus that spread from China between December 2019 and January 2020. The entire healthcare system had to respond promptly in a very short time to an exponential growth of the number of subjects affected by COVID-19 (Coronavirus disease 2019) with the need of semi-intensive and intensive care units.

Due to the exponential growth of the number of subjects affected by coronavirus disease 2019 (COVID-19), the entire Italian health care system had to respond promptly and in a very short time with the need of semi-intensive and intensive care units. Moreover, trained dedicated COVID-19 teams consisting of physicians were coming from different specialties (intensivists or pneumologists and infectiologists), while respiratory therapists and nurses have been recruited to work on and on without rest. However, due to still limited and evolving knowledge of COVID-19, there are few recommendations concerning the need in respiratory rehabilitation and physiotherapy interventions. The presentation of this paper is the result of a consensus promoted by the Italian societies of respiratory health care professionals who contacted pulmonologists directly involved in the treatment and rehabilitation of COVID-19. The aim was to formulate the more proper and common suggestions to be applied in different hospital settings in offering rehabilitative programs and physiotherapy workforce planning for COVID-19 patients. Two main areas of intervention were identified: organization and treatment, which are described in this paper to face the emergency., (© 2020 S. Karger AG, Basel.)

Background: Respiratory muscle weakness is a primary cause of morbidity and mortality in patients with Pompe disease. We previously described the effects of our 12-week respiratory muscle training (RMT) regimen in 8 adults with late-onset Pompe disease [1] and 2 children with infantile-onset Pompe disease [2]., Case Report: Here we describe repeat enrollment by one of the pediatric participants who completed a second 12-week RMT regimen after 7 months of detraining. We investigated the effects of two 12-week RMT regimens (RMT #1, RMT #2) using a single-participant A-B-A experimental design. Primary outcome measures were maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP). Effect sizes for changes in MIP and MEP were determined using Cohen's d statistic. Exploratory outcomes targeted motor function., Relevance: From pretest to posttest, RMT #2 was associated with a 25% increase in MIP and a 22% increase in MEP, corresponding with very large effect sizes (d= 2.92 and d= 2.65, respectively). Following two 12-week RMT regimens over 16 months, MIP increased by 69% and MEP increased by 97%, corresponding with very large effect sizes (d= 3.57 and d= 5.10, respectively). MIP and MEP were largely stable over 7 months of detraining between regimens. Magnitude of change was greater for RMT #1 relative to RMT #2.

The CIRO Academy in Horn (the Netherlands) organised a 2-day meeting to present and discuss the studies published in 2017 pertaining to key priority areas of respiratory and critical care medicine. This review summarises studies focussing on pulmonary rehabilitation and exercise training, physical activity, chronic respiratory failure and palliative respiratory care published in 2017., Competing Interests: Competing interests: JRC, MD, MJJ, KK, SN, FP, MS, CLR, AMWJS and MAS have nothing to disclose. MD reports personal fees from Philips, ResMed, Weinmann, Heinen und Löwenstein, Fisher and grants from ResMed, outside the submitted work. FMEF reports personal fees from AstraZeneca, Chiesi, GlaxoSmithKline, Boehringer Ingelheim, Novartis and TEVA, outside the submitted work. NH is on the Pulmonary Research Advisory Board for Philips. NH’s research group has received unrestricted grants (managed by Guy’s) and Philips-Respironics is contributing to the development of the MYOTRACE technology. DJAJ reports personal fees from AstraZeneca, Novartis, Boehringer Ingelheim, GlaxoSmithKline and Mayne Pharma, outside the submitted work., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Summary: We present the clinical case of a 74 years old patient undergoing tracheotomy for persistent hypercapnic respiratory failure after lower right lobectomy surgery, performed as a result of pulmonary cancer recurrence. The patient was transferred to the Department of Respiratory Sub Intensive Care for respiratory weaning, decannulation and cycle of motor and respiratory physiotherapy. The joint evaluation of physicians, nurses and physiotherapists has allowed the identification of ICD-9 and ICF codes of the severe disability shown by the patient in the first days of hospital stay (respiratory failure due to pneumonia that need invasive mechanical ventilation by tracheotomy, prolonged immobility, muscular deconditioning and inability to perform even the simplest activities of daily life; it required also artificial nutrition by naso gastric tube). ICF codes as respiratory functions (respiratory system functions, additional respiratory functions, sensations associated with cardiovascular and respiratory functions, moving with aids, walking, vestibular functions, muscle strength, tolerance to physical exercise, personal care, performing the routine daily sleep functions, energy and drive functions), were particularly compromised at admission. Medical intervention (antibiotic therapy based on microbiological isolations, optimization of inhalatory therapy, management of intestinal complications and cardiological which required cardiological treatment remodulation in order to obtain better heart rate control and better blood pressure control allowed a clear improvement of general and respiratory clinical conditions. The simultaneous physiotherapists'intervention (weaning not only from invasive mechanical ventilation but also from tracheotomic cannula and oxygen therapy, stationary and cycloergometer with arms and exercise training) and nurses'intervention (medication of pressure injuries, surveillance of the sleep-wake rhythm, management of the daily routine) allowed a gradual improvement of both motor and respiratory ability with a consequent indipendence in activities of daily living. Important were also psychological counseling and intervention of speech therapists (removal of naso gastric tube, once excluded dysphagia also by videofluoroscopy). During a long lasting clinical improvement, coincident with patient's discharge to home, has been assessed disability through ICF codes, largely improved under medical, nursing and physiotherapist profile., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by Aracne Editrice, Roma, Italy.)

Rationale: Survivorship from critical illness has improved; however, factors mediating the functional recovery of persons experiencing a critical illness remain incompletely understood., Objectives: To identify groups of acute respiratory failure (ARF) survivors with similar patterns of physical function recovery after discharge and to determine the characteristics associated with group membership in each physical function trajectory group., Methods: We performed a secondary analysis of a randomized controlled trial, using group-based trajectory modeling to identify distinct subgroups of patients with similar physical function recovery patterns after ARF. Chi-square tests and one-way analysis of variance were used to determine which variables were associated with trajectory membership. A multinomial logistic regression analysis was performed to identify variables jointly associated with trajectory group membership., Results: A total of 260 patients enrolled in a trial evaluating standardized rehabilitation therapy in patients with ARF and discharged alive (NCT00976833) were included in this analysis. Physical function was quantified using the Short Physical Performance Battery at hospital discharge and 2, 4, and 6 months after enrollment. Latent class analysis of the Short Physical Performance Battery scores identified four trajectory groups. These groups differ in both the degree and rate of physical function recovery. A multinomial logistic regression analysis was performed using covariates that have been previously identified in the literature as influencing recovery after critical illness. By multinomial logistic regression, age (P < 0.001), female sex (P = 0.001), intensive care unit (ICU) length of stay (LOS) (P = 0.003), and continuous intravenous sedation days (P = 0.004) were the variables that jointly influenced trajectory group membership. Participants in the trajectory demonstrating most rapid and complete functional recovery consisted of younger females with fewer continuous sedation days and a shorter LOS. The participant trajectory that failed to functionally recover consisted of older patients with greater sedation time and the longest LOS., Conclusions: We identified distinct trajectories of physical function recovery after critical illness. Age, sex, continuous sedation time, and ICU length of stay impact the trajectory of functional recovery after critical illness. Further examination of these groups may assist in clinical trial design to tailor interventions to specific subgroups.

The effect of early rehabilitation on the outcome of patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF) in intensive care units (ICUs) remains unclear. We examined the effect of early rehabilitation on the outcomes of COPD patients requiring mechanical ventilation (MV) in the ICU. This retrospective, observational, case-control study was conducted in a medical center with a 19-bed ICU. The records of all 105 ICU patients with COPD and ARF who required MV from January to December 2011 were examined. The outcomes (MV duration, rates of successful weaning and survival, lengths of ICU and hospital stays, and medical costs) were recorded and analyzed. During the study period, 35 patients with COPD underwent early rehabilitation in the ICU and 70 demographically and clinically matched patients with similar COPD stage, cause of intubation, type of respiratory failure, and levels of disease severity who had not undergone early rehabilitation in the ICU were selected as comparative controls. Multiple regression analysis showed that early rehabilitation was significantly negatively associated with MV duration. Early rehabilitation for COPD patients in the ICU with ARF shortened the duration of their MV.

Purpose: This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research., Materials and Methods: We searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type., Results: 12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events., Conclusions: Gaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Rationale: Respiratory muscle weakness is common in critically ill patients; the role of targeted inspiratory muscle training (IMT) in intensive care unit rehabilitation strategies remains poorly defined., Objectives: The primary objective of the present study was to describe the range and tolerability of published methods for IMT. The secondary objectives were to determine whether IMT improves respiratory muscle strength and clinical outcomes in critically ill patients., Methods: We conducted a systematic review to identify randomized and nonrandomized studies of physical rehabilitation interventions intended to strengthen the respiratory muscles in critically ill adults. We searched the MEDLINE, Embase, HealthSTAR, CINAHL, and CENTRAL databases (inception to September Week 3, 2017) and conference proceedings (2012 to 2017). Data were independently extracted by two authors and collected on a standardized report form., Results: A total of 28 studies (N = 1,185 patients) were included. IMT was initiated during early mechanical ventilation (8 studies), after patients proved difficult to wean (14 studies), or after extubation (3 studies), and 3 other studies did not report exact timing. Threshold loading was the most common technique; 13 studies employed strength training regimens, 11 studies employed endurance training regimens, and 4 could not be classified. IMT was feasible, and there were few adverse events during IMT sessions (nine studies; median, 0%; interquartile range, 0-0%). In randomized trials (n = 20), IMT improved maximal inspiratory pressure compared with control (15 trials; mean increase, 6 cm H 2 O; 95% confidence interval [CI], 5-8 cm H 2 O; pooled relative ratio of means, 1.19; 95% CI, 1.14-1.25) and maximal expiratory pressure (4 trials; mean increase, 9 cm H 2 O; 95% CI, 5-14 cm H 2 O). IMT was associated with a shorter duration of ventilation (nine trials; mean difference, 4.1 d; 95% CI, 0.8-7.4 d) and a shorter duration of weaning (eight trials; mean difference, 2.3 d; 95% CI, 0.7-4.0 d), but confidence in these pooled estimates was low owing to methodological limitations, including substantial statistical and methodological heterogeneity., Conclusions: Most studies of IMT in critically ill patients have employed inspiratory threshold loading. IMT is feasible and well tolerated in critically ill patients and improves both inspiratory and expiratory muscle strength. The impact of IMT on clinical outcomes requires future confirmation.

A 62-year-old man with a background of type 2 diabetes mellitus presented to the emergency department (ED) with a 5-day history of dental pain, progressive right facial swelling, trismus, dysphagia and voice changes. The oropharynx could not be directly examined completely due to trismus. The patient had a National Early Warning Score of 0 and so was triaged into the 'minors' section of ED. Following assessment by the on-call oral and maxillofacial surgeon, an urgent contrast-enhanced CT demonstrated a large parapharyngeal collection, which required urgent anaesthetic and surgical intervention. The patient developed pulmonary complications postoperatively, but eventually made a full recovery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background and Objective: The role of non-invasive ventilation (NIV) during exercise training (ET) in patients with chronic respiratory failure (CRF) is still unclear. The aim of this study was to test whether NIV during ET had an additional effect in increasing the 6-min walking distance (6MWD) and cycle endurance time compared with ET alone., Methods: All patients underwent 20 sessions of cycle training over 3 weeks and were randomly assigned to ET with NIV or ET alone. Outcome measures were 6MWD (primary outcome), incremental and endurance cycle ergometer exercise time, respiratory muscle function, quality of life by the Maugeri Respiratory Failure questionnaire (MRF-28), dyspnoea (Medical Research Council scale) and leg fatigue at rest., Results: Forty-two patients completed the study. Following training, no significant difference in 6MWD changes were found between groups. Improvement in endurance time was significantly greater in the NIV group compared with the non-NIV training group (754 ± 973 vs 51 ± 406 s, P = 0.0271); dyspnoea improved in both groups, while respiratory muscle function and leg fatigue improved only in the NIV ET group. MRF-28 improved only in the group training without NIV., Conclusion: In CRF patients on long-term NIV and long-term oxygen therapy (LTOT), the addition of NIV to ET sessions resulted in an improvement in endurance time, but not in 6MWD., (© 2017 Asian Pacific Society of Respirology.)

Purpose: Obese subjects have decreased pulmonary function. The hypothesis of our study was that poor coordination of the lumbar-pelvic musculature secondary to obesity may hinder the synergic activation of the respiratory muscles. The aim of the paper was to evaluate whether specific motor control exercises of the lumbar-pelvic musculature were able to improve respiratory function., Method: Twenty obese male patients underwent a rehabilitation program including adapted physical activity and respiratory physiotherapy. Patients were randomly assigned to a Specific Motor Control Exercise Group (SG) and a Control Group (CG). SG followed a protocol according to the SMARTERehab concept aimed at improving posture, intra-abdominal pressure, rib cage mobility, and perception of correct muscle activation. CG performed an exercise training protocol to improve aerobic capacity and muscle strength., Result: After intervention, both groups showed similar changes in body weight, fat, and fat-free mass. Respiratory function indexes improved in SG due to improved proprioception and coordination of the deep lumbar-pelvic muscles., Conclusion: Our study provides preliminary evidence that breathing, postural control, and spinal stability are intertwined. Positive respiratory effects in obese men can be obtained by prescribing specific motor control exercises of the lumbar-pelvic muscles. Implications for rehabilitation Obese subjects present with decreased pulmonary function and postural changes. Poor coordination of the lumbar-pelvic muscles affects posture and the synergic activation of the respiratory muscles. Specific motor control exercises of the lumbar-pelvic musculature can improve respiratory function. Breathing and postural control are intertwined: positive respiratory effects can be obtained by enhancing motor control of the lumbar-pelvic muscles.

Background: Pulmonary rehabilitation (PR) in patients awaiting lung transplantation is crucial to ensure a transplant benefit. However, PR in patients with end-stage lung disease treated with noninvasive ventilation (NIV) remains an area of uncertainty., Objectives: The aim of the study was to assess the potential benefit of PR in patients awaiting lung transplantation treated with NIV., Methods: Patients awaiting lung transplantation who underwent comprehensive inpatient PR from 1998 to 2015 were retrospectively analyzed. Success of PR was assessed by comparing admission and discharge. Multivariate regression models were applied to assess the impact of long-term nocturnal NIV on PR success., Results: In total, 1,044 patients were included in the analysis. Thereof, 296 patients (28%) were treated with NIV. PR in patients treated with NIV resulted in a significant increase in 6-min walk distance (6MWD; from 250 ± 117 to 309 ± 116 m; p < 0.0001) and in various items of the Short Form Health Survey (SF)-36 questionnaire. The increase in 6MWD was higher in patients treated with NIV than in patients without NIV (59 ± 63 vs. 48 ± 55 m; p = 0.003). Furthermore, improvements of various lung function variables were higher in patients with NIV. Finally, multivariate generalized regression analysis revealed that NIV therapy was associated with improvement of 6MWD (p = 0.023) while controlling for various baseline characteristics., Conclusions: PR in patients with end-stage lung disease awaiting lung transplantation on nocturnal NIV is feasible and is associated with improvements of exercise capacity and quality of life. Furthermore, despite more advanced lung disease, patients treated with NIV have an increased benefit of PR compared to patients without NIV while awaiting lung transplantation., (© 2017 S. Karger AG, Basel.)

Introduction: Defining stability before discharge for children with severe chronic lung disease requiring home ventilation has historically been dependent on an individual provider's opinion., Methods: An institutional guideline based on expert opinion was used for patients who were first discharged home on mechanical ventilation. A retrospective review determined if the guideline was used. Electronic medical record changes were initiated to improve compliance with the guideline., Results: The retrospective review showed that the guideline is documented in less than one third of patients, and 36% of patients met the requirements of the guideline before discharge. Following these results, electronic medical record documentation was changed., Discussion: Results showed a low utilization rate for the discharge home guideline for patients receiving long-term ventilation. Utilization of electronic medical record charting can improve the tracking of stability guidelines and provide the opportunity to further define stability in ventilator-dependent children., (Copyright © 2017 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

Individuals with cervical spinal cord lesions (SCLs) typically depend on caregivers to manually assist in coughing by pressing against their abdominal wall. Coughing can also be assisted by functional electric stimulation (FES) applied to abdominal muscles via surface electrodes. Efficacy of FES, however, depends on precise temporal synchronization. The sniff controller is a trigger that enables paralyzed individuals to precisely control external devices through alterations in nasal airflow. We hypothesized that FES self-triggering by sniff controller may allow for effective cough timing. After optimizing parameters in 16 able-bodied subjects, we measured peak expiratory flow (PEF) in 14 subjects with SCL who coughed with or without assistance. Assistance was either manual assistance of a caregiver, caregiver activated FES, button self-activated FES (for SCL participants who could press a button), or sniff-controlled self-activated FES. We found that all assisted methods provided equally effective improvements, increasing PEF on average by 25 ± 27% (F[4,52] = 7.99, p = 0.00004 ). There was no difference in efficacy between methods of assistance ( F[3,39] = 0.41, p = 0.75 ). Notably, sniff-controlled FES was the only method of those tested that can be activated by all paralyzed patients alone. This provides for added independence that is a critical factor in quality of life following SCL.

Background: The proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate., Methods: We performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ≥4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score., Results: Of the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4-29.8) points lower (p < 0.0001) than patients who were discharged to home. However, there was no difference in the rate at which physical function improved from 3 to 6 months for patients who required prolonged admission compared with those who returned home (p = 0.24 for interaction between prolonged admission and time). Adjusted for age, Acute Physiology and Chronic Health Evaluation II score, and sex, both groups had CS-PFP-10 scores that were 8.2 (CI 4.5-12.0) points higher at 6 months than at 3 months (p < 0.0001). For each additional year in patient age, CS-PFP-10 recovered 0.36 points slower (95% CI 0.12-0.61; p = 0.004)., Conclusions: Patients who require prolonged admission after acute respiratory failure have significantly lower physical functional performance than patients who return home. However, the rates of physical functional recovery between the two groups do not differ. The majority of survivors do not recover sufficiently to achieve functional independence by 6 months. Older age negatively influences the trajectory of functional recovery., Trial Registration: ClinicalTrials.gov, NCT01058421 . Registered on 26 January 2010.

Objective: To evaluate the effects of a quality improvement program to introduce early mobilization on the outcomes of patients with mechanical ventilation (MV) in the intensive care unit (ICU)., Design: A retrospective observational study., Setting: Nineteen-bed ICU at a medical center., Participants: Adults patients with MV (N=153) admitted to a medical ICU., Interventions: A multidisciplinary team (critical care nurse, nursing assistant, respiratory therapist, physical therapist, patient's family) initiated the protocol within 72 hours of MV when patients become hemodynamically stable. We did early mobilization twice daily, 5d/wk during family visits (30min each time), and cooperated with family, if possible., Main Outcome Measures: MV duration, rate of successful weaning, and length of ICU and hospital stay., Results: We enrolled 63 patients in the before protocol group and 90 in the after protocol group. The 2 groups were well matched in age, sex, body height, body weight, body mass index, disease severity, cause of intubation, number of comorbidities, and most underlying diseases. After protocol group patients had shorter MV durations (4.7d vs 7.5d; P<.001) and ICU stays (6.9d vs 9.9d; P=.001) than did before protocol group patients. Early mobilization was negatively associated with the duration of MV (β=-.269; P<.002; 95% confidence interval [CI], -4.767 to -1.072), and the risk of MV for ≥7 days was lower in patients who underwent early mobilization (odds ratio, .082; 95% CI, .021-.311)., Conclusions: The introduction of early mobilization for patients with MV in the ICU shortened MV durations and ICU stays. A multidisciplinary team that includes the patient's family can work together to improve the patient's clinical outcomes., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

To determine and/or adjust exercise training intensity for patients when the cardiopulmonary exercise test is not accessible, the determination of dyspnoea threshold (defined as the onset of self-perceived breathing discomfort) during the 6-min walk test (6MWT) could be a good alternative. The aim of this study was to evaluate the feasibility and reproducibility of self-perceived dyspnoea threshold and to determine whether a useful equation to estimate ventilatory threshold from self-perceived dyspnoea threshold could be derived. A total of 82 patients were included and performed two 6MWTs, during which they raised a hand to signal self-perceived dyspnoea threshold. The reproducibility in terms of heart rate (HR) was analysed. On a subsample of patients (n=27), a stepwise regression analysis was carried out to obtain a predictive equation of HR at ventilatory threshold measured during a cardiopulmonary exercise test estimated from HR at self-perceived dyspnoea threshold, age and forced expiratory volume in 1 s. Overall, 80% of patients could identify self-perceived dyspnoea threshold during the 6MWT. Self-perceived dyspnoea threshold was reproducibly expressed in HR (coefficient of variation=2.8%). A stepwise regression analysis enabled estimation of HR at ventilatory threshold from HR at self-perceived dyspnoea threshold, age and forced expiratory volume in 1 s (adjusted r=0.79, r=0.63, and relative standard deviation=9.8 bpm). This study shows that a majority of patients with chronic obstructive pulmonary disease can identify a self-perceived dyspnoea threshold during the 6MWT. This HR at the dyspnoea threshold is highly reproducible and enable estimation of the HR at the ventilatory threshold.

Objective: This study aims to determine whether a 6-month home physiotherapy program can improve outcomes in critical care survivors., Design: Forty-eight consecutive patients were randomized. The treatment group underwent 2 sessions/day of breathing retraining and bronchial hygiene, physical activity (mobilization, sit-to-stand gait, limb strengthening), and exercise re-conditioning whereas controls underwent standard care. Maximum inspiratory/expiratory pressures (MIP/MEP), forced volumes, blood gases, dyspnea, respiratory rate, disability, peripheral force measurements, perceived health status (Euroquol-5D), patient adherence/satisfaction, safety, and costs were assessed., Results: Outcomes of treatment versus controls: MIP 14 ± 17 vs. -0.2 ± 14 cm H2O, MEP 27 ± 27 vs. 6 ± 21 cm H2O both P < 0.03; in addition, quality of life (Euroquol-5D) (P = 0.04), FEV1 (P = 0.03), dyspnea (P = 0.002), and respiratory rate (P = 0.009) were significantly improved for treated cardiorespiratory patients only. Eighty-three percent of the treated patients were decannulated versus 14% of controls (P = 0.01). Compliance was high (74 ± 25%) and there were no side effects. The majority (87.4%) expressed satisfaction with the program. Treatment cost was 459&OV0556;/patient/month., Conclusions: Carrying over regular bronchial hygiene techniques, physical activity, and exercise into the home after long critical care stays is safe and has a beneficial effect on respiratory muscles, decannulation, pulmonary function, and quality of life.

Background and Purpose: Respiratory insufficiency is the primary cause of morbidity and mortality in individuals with amyotrophic lateral sclerosis (ALS). Although mechanical interventions are effective in prolonging survival through respiratory support, pulmonary physical therapy interventions are being investigated. The purpose of this systematic review was to examine the effectiveness of pulmonary physical therapy interventions across the progressive stages of ALS., Methods: Six databases were searched for articles from inception to December 2014 investigating pulmonary physical therapy interventions in the ALS population. The search strategy followed Cochrane Collaboration guidelines with replication per database. Effect sizes (ES) were calculated for primary outcome measures: forced vital capacity (FVC) and peak cough expiratory flow (PCEF)., Results: Seven studies met inclusion criteria. Four studies used control groups whereas the remainder used repeated measures. With the exception of diaphragmatic breathing, pulmonary physical therapy interventions were effective in improving multiple respiratory outcome measures in this population. Inspiratory muscle training (IMT) was shown to prolong respiratory muscle strength with a strong effect size (ES = 1.48) for FVC. In addition, mean length of survival increased by 12 months. Lung volume recruitment training (LVRT) strongly enhanced immediate cough efficacy with improved FVC (ES = 1.02) and PCEF (ES = 1.82). Manually assisted cough (MAC) only improved PCEF by a small amount (ES = 0.15, bulbar ALS; ES = 0.16, classical ALS groups)., Discussion and Conclusions: Specific pulmonary physical therapy interventions (IMT, LVRT, and MAC) have effectiveness in improving respiratory outcome measures and increasing survival. These should be routinely incorporated into the comprehensive management of individuals with ALS. More rigorous methodological investigations should be performed to replicate these findings.Video abstract available with brief technique demonstration of IMT and LVRT (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A136).

Mechanical ventilation is an essential part of modern intensive care. It is used in patients with acute respiratory failure and, depending on the type of respiratory failure, different modes of application. In particular, invasive mechanical ventilation should be terminated as raidly as possible to avoid the associated risks.The major proportion of ventilated patients can be weaned from mechanical ventilation without problems after a short treatment period. In about 20% of ventilated patients, however, an extremely protracted and complex weaning process can be observed, even though the cause necessitating ventilation has long since been eliminated. In addition to the stages in the process of weaning from the ventilator, in particular the pathophysiological processes that lead to prolonged weaning are addressed in this article., (© Georg Thieme Verlag Stuttgart · New York.)

Purpose: Venovenous extracorporeal membrane oxygenation (VV ECMO) is an effective therapy in patients with acute lung injury and end-stage lung disease. Although immobility increases the risk of complications, ambulation of patients on VV ECMO is not the standard of care in many institutions. Staff concerns for patient safety remain a barrier to ambulation. In this case series, we present our experience utilizing a nurse-driven ambulatory VV ECMO process to safely rehabilitate patients., Methods: We retrospectively reviewed all VV ECMO cases at our institution between January 1, 2011, and November 1, 2013. Inclusion criteria for this study required patients to be cannulated in the right internal jugular vein and ambulated while on VV ECMO., Results: During the period from January 1, 2011, to November 1, 2013, 18 patients (mean age 49 ± 15 years, 12 male) were ambulated while on ECMO. Eight received a transplant and survived to discharge. Of the remaining patients, 4 were successfully weaned from VV ECMO and 6 died following decisions by the family to withdraw care. The mean duration of VV ECMO support was 18 ± 16 days with the maximum duration being 61 days. All patients received physical therapy, range of motion at the bedside, and ambulated in the hospital. There were no patient falls, decannulations, or any other complications related to ambulation., Conclusion: The adoption of a nurse-driven program to ambulate patients on VV ECMO is safe and may reduce other complications associated with immobility., (© 2016, NATCO.)

Background and Purpose: Pompe disease is an inherited disorder notable for severe, progressive ventilatory compromise. Although ventilatory failure has been attributed to myofiber dysfunction secondary to diaphragmatic glycogen accumulation, neural involvement of the phrenic motor system is also a prominent feature. Direct diaphragm pacing supplements respiratory function in other disorders of the phrenic motor system. Accordingly, it is hypothesized that augmented neuromuscular activity via diaphragm pacing would promote weaning from mechanical ventilation in patients with Pompe disease who are unresponsive to conventional, muscle-directed treatments., Case Description: Three patients with Pompe disease developed diaphragm paresis that resulted in chronic mechanical ventilation dependence. After preoperative inspiratory muscle strengthening exercises failed to improve function, fine-wire pacing electrodes were laparoscopically implanted into the diaphragm. Diaphragm conditioning was initiated the first postoperative week and consisted of gradual increases in stimulation parameters, lengthening of stimulation sessions, and ventilator weaning. Ventilation and intramuscular electromyographic activity were recorded periodically during conditioning to quantify diaphragm neuromuscular function., Outcomes: During paced breathing without mechanical ventilation, tidal volumes increased, and 2 patients were weaned from daytime ventilator dependence within the first 3 months of pacing, which has been sustained over the long-term. A third patient reduced reliance on daytime ventilation, but weaning was delayed by malacia of the large airways. In all patients, pacing appeared to facilitate spontaneous phrenic motor unit activity during independent breathing without ventilator or pacer support., Discussion: The findings are consistent with the view that diaphragm pacing has potential rehabilitative value to reduce reliance on mechanical ventilation in people with Pompe disease, but further study is needed. Diaphragm pacing represents a paradigm shift in the management of respiratory insufficiency for Pompe disease that warrants further controlled examination., (© 2016 American Physical Therapy Association.)

Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.

Introduction: Pulmonary rehabilitation (PR) for patients undergoing lung resection for cancer remains controversial. We studied the effects of PR, its impact on quality of life and the level of anxiety and depression., Methods: In 2011 and 2012, PR was offered to all patients referred to our institution after lung resection for cancer. Patients were evaluated between admission and discharge by a 6 minutes walking test (6MWD), a Visual Analogue Pain Intensity Scale, a quality of life questionnaire (EORTC QLQ C30) and by the Hospital Anxiety and Depression Scale (HAD). The same questionnaires were mailed 6 months after completing PR., Results: Between early 2011 and late 2012, 133 patients were admitted to our institution following lung resection for cancer. Of these, 59 (44%) patients completed PR and returned their questionnaires 6 months after discharge. During PR of these 59 patients, the mean quality of life score increased from 56.3 to 65.9 (P<0.05), the median anxiety score decreased from 5.5 to 4 (P<0.05) and that of depression from 3 to 2 (P<0.05). At 6 months post-discharge, the mean quality of life score remained stable at 66.3 (P=0.8), the median anxiety score reverted to 6 (P<0.05) and the median depression score reverted to 4.5 (P<0.05)., Conclusion: This observational study during PR, showed that quality of life and the levels of anxiety and depression were improved at the end of the course. After returning home, the average quality of life score remained stable but the level of anxiety and depression increased., (Copyright © 2014 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

All mechanically ventilated patients must be weaned from the ventilator at some stage. According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least 3 weaning attempts (i. e. spontaneous breathing trial, SBT) or require more than 7 days of weaning after the first SBT. This occurs in about 15 - 20 % of patients.Because of the growing number of patients requiring prolonged weaning a German guideline on prolonged weaning has been developed. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies (see acknowledgement) engaged in the field chaired by the Association of Scientific and Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).This guideline deals with the definition, epidemiology, weaning categories, underlying pathophysiology, therapeutic strategies, the weaning unit, transition to out-of-hospital ventilation and therapeutic recommendations for end of life care. This short version summarises recommendations on prolonged weaning from the German guideline., (© Georg Thieme Verlag KG Stuttgart · New York.)

Implanted phrenic nerve stimulation is a technique restoring spontaneous breathing in patients with respiratory control failure, leading to being dependent on mechanical ventilation. This is the case for quadriplegic patients with a high spinal cord injury level and for patients with congenital central hypoventilation syndrome. The electrophysiological diaphragm explorations permits better patient selection, confirming on the one hand a definite issue with central respiratory command and on the other hand the integrity of diaphragmatic phrenic nerves. Today there are two different phrenic stimulation techniques: the quadripolar intrathoracic stimulation and the bipolar intradiaphragmatic stimulation. Both techniques allow patients to be weaned off their mechanical ventilator, improving dramatically their quality of life. In fact, one of the systems (phrenic intradiaphragmatic stimulation) was granted social security reimbursement in 2009, and now both are reimbursed. In the future, phrenic intradiaphragmatic stimulation may find its place in the intensive care unit, for patients needing it temporarily, for example, after certain surgeries with respiratory complications as well as diaphragmatic atrophies induced by prolonged mechanical ventilation., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Pulmonary rehabilitation programs document outcomes to prepare for program certification, to demonstrate the value of the program to upper management, and to provide feedback to pulmonary rehabilitation staff regarding the efficacy of the program. The overall goal of this study was to evaluate the feasibility of using non-research-generated clinical data to report long-term outcomes following a pulmonary rehabilitation program., Methods: Using a longitudinal descriptive design, all subjects who completed pulmonary rehabilitation at one community-based pulmonary rehabilitation program in the San Francisco Bay Area were asked to complete a 6-month and subsequent yearly questionnaires. Adherence to pulmonary rehabilitation techniques was described for 7 y following pulmonary rehabilitation participation, health-care utilization from 1 y before pulmonary rehabilitation was compared with subsequent years, and health-care utilization was compared between those who participated in ongoing regular exercise after pulmonary rehabilitation and those who did not exercise., Results: More than 70% of subjects who completed the questionnaire reported adherence to pulmonary rehabilitation techniques, including exercise for at least 7 y following pulmonary rehabilitation. Health-care utilization declined after pulmonary rehabilitation. Subjects who did not exercise regularly required significantly more health care than those who exercised regularly (P < .05)., Conclusions: This study demonstrated the ability of one pulmonary rehabilitation program to accurately monitor extended long-term follow-up after pulmonary rehabilitation. Implementing this long-term monitoring methodology consistently in pulmonary rehabilitation programs could contribute to evaluation of the comparative effectiveness of various treatment options., (Copyright © 2015 by Daedalus Enterprises.)

Background: Lung volume recruitment (LVR) is a cough assistance technique used in persons with neuromuscular disorders (NMDs), most typically in those requiring noninvasive ventilation (NIV). Whether it may be useful in persons with NMDs who have milder respiratory impairment is unknown., Objective: To assess the feasibility, impact on quality of life (QOL), and preliminary physiological effects of daily LVR in different categories of persons with NMDs who have an early stage of respiratory impairment., Design: Feasibility study., Setting: Academic tertiary care center., Participants: Outpatients diagnosed with amyotrophic lateral sclerosis (n = 8), postpolio syndrome (n = 10), and myotonic dystrophy (n = 6) who had restrictive respiratory defects but were not yet using NIV., Methods: Participants were asked to perform LVR up to 4 times daily and log their LVR use in a diary. Physiological measurements and questionnaires were completed at baseline and after 3 months., Main Outcome Measurements: Compliance with LVR use was assessed, along with QOL and willingness to continue the treatment. Physiological measurements included forced vital capacity (FVC), lung insufflation capacity (LIC), and the LIC minus FVC difference., Results: Of the 24 recruited subjects, 7 with amyotrophic lateral sclerosis, 7 with postpolio syndrome, and 5 with myotonic dystrophy completed the study (n = 19). At baseline, mean values for FVC and spontaneous peak cough flow were 59.9% predicted and 373.1 L/min, respectively. For subjects completing the study, 74% were willing to continue long-term LVR use, and QOL scores were not adversely affected by LVR in any NMD subgroup. The LIC-FVC difference increased from baseline to follow-up by a mean of 0.243 L (P = .006) in all subjects (n = 19), suggesting a possible improvement in respiratory system mechanics., Conclusions: In patients with NMDs who have early restrictive respiratory defects but do not yet require NIV, regular use of LVR is feasible with no negative impact on QOL over a 3-month period and may have physiological benefits. Further work is needed to determine whether early institution of LVR can improve respiratory system mechanics and help delay ventilatory failure in persons with NMDs., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Repeated ghrelin administration leads to improvements in symptoms, muscle wasting and exercise tolerance in cachectic patients with pulmonary disease. We investigated the optimal ghrelin dose for underweight patients with chronic respiratory failure., Methods: In this multicenter, randomized, dose-comparison exploratory study, 44 cachectic patients with chronic respiratory failure were randomly assigned pulmonary rehabilitation with intravenous twice-daily administration of 1 or 2 μg/kg ghrelin for 3 weeks. The primary endpoint was improvement in 6-min walking distance (6 MWD). The secondary endpoint was change in peak VO2., Results: Twenty-one patients were assigned to the 1 μg/kg ghrelin group and 23 to the 2 μg/kg ghrelin group. Change from baseline 6 MWD after treatment was similar between groups(1 μg/kg: 53.9 m, 2 μg/kg: 53.9 m, p = 0.99). Mean change in peak VO2 was significantly greater in the 2 μg/kg group (63.1 ml/min) than in the 1 μg/kg group (-63.8 ml/min, p = 0.048). Food intake and lean body mass significantly increased in both groups, and the St. George Respiratory Questionnaire score, body weight, and body mass index were remarkably improved in only the 2 μg/kg group, although there was no significant difference between groups. No treatment-related serious events were reported for either group., Conclusion: Improvements in the oxygen uptake capacity were greater in patients receiving 2 μg/kg ghrelin twice daily for 3 weeks than in those receiving 1 μg/kg, although exercise tolerance was similar between groups at the end of the 3-week treatment period. Thus, a twice daily dose of 2 μg/kg ghrelin is recommended over 1 μg/kg ghrelin for patients with chronic respiratory failure and weight loss.

Home mechanical ventilation is currently expanding in Chile, but its application along the country is hindered by financial and geographical reasons. In 2006 the San José Hospital in Santiago de Chile developed a non-invasive ventilation (NIV) center as a strategy to overcome the limitations of ventilator availability from public resources. Since then, this center provides intermittent diurnal sessions of NIV to patients with chronic hypercapnic respiratory failure. In 2013, a collaboratory work between the Chilean doctors, the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB = Deutsche Interdisziplinäre Gesellschaft für Außerklinische Beatmung) and the German non-invasive (NIV) home care provider "Heinen und Löwenstein" organized a donation of 100 second-hand ventilators (BiPAP Synchrony; Respironics, USA) including masks and tubing systems, which were provided by Heinen und Löwenstein. The ventilator devices arrived in Santiago in January 2014. Since then, the following initiatives have been launched: 1) the establishment of a domiciliary mechanical ventilation program independent of governmental founding, 2) NIV setting-titration, 3) renewal of ventilators at the hospital's intermittent NIV unit. Future goals are the establishment of a rehabilitation unit with concomitant NIV therapy and a clinical research program. Therefore, the German donation of ventilators and equipment has a reported impact on the development of NIV in Chile., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Management of difficult to wean patients is a dilemma for health care system. Recently published studies demonstrated efficacy of donepezil to counteract respiratory depression in sleep apnea. However, to the best of our knowledge, pharmaceutical interventions with donepezil to facilitate weaning have not been tested so far. Therefore in the present study, we evaluated the efficacy of using donepezil on weaning course in difficult to wean patients., Methods: In this non-randomized interventional clinical study, difficult to wean patients with prior inappropriately depressed respiratory responses were included from two referral intensive care units (ICU) in Iran. Patients with another potentially reasons of weaning failure were excluded from the study. Donepezil was started for eligible patients at dose of 10 mg daily for 2-4 weeks. For the primary outcomes, arterial blood gas (ABG) parameters were also measured before and after intervention to evaluate the possible effects of donepezil on them. In addition, weaning outcomes of patients were reported as final outcome in response to this intervention., Results: Twelve out of 16 studied patients experienced successful results to facilitate weaning with donepezil intervention. The mean duration of donepezil treatment until outcome measurement was 12 days. There were not any significant differences in ABG parameters among patients with successful and failed weaning trial on day of donepezil initiation. However after donepezil intervention, mean of PCO2 and HCO3 decreased in patients with successful weaning trial and mean of PCO2 increased in those with weaning failure., Conclusions: Reduced central respiratory drive was infrequently reason of failed weaning attempts but it must be considered especially in patients with hypercapnia secondary to inefficient gas exchange and slow breathing. Our results in the clinical setting suggest that, the use of donepezil can expedite weaning presumably by stimulation of respiratory center and obviate the need to re-intubation in cases of respiratory drive problem in difficult to wean patients. We suggest decrease PCO2 and HCO3 during donepezil steady could be valuable predictors for positive response to donepezil intervention.

Background: Although the endurance shuttle walk test (ESWT) has proven to be responsive to change in exercise capacity after pulmonary rehabilitation (PR) for COPD, the minimally important difference (MID) has not yet been established. We aimed to establish the MID of the ESWT in patients with severe COPD and chronic hypercapnic respiratory failure following PR., Methods: Data were derived from a randomized controlled trial, investigating the value of noninvasive positive pressure ventilation added to PR. Fifty-five patients with stable COPD, GOLD stage IV, with chronic respiratory failure were included (mean (SD) FEV1 31.1 (12.0) % pred, age 62 (9) y). MID estimates of the ESWT in seconds, percentage and meters change were calculated with anchor based and distribution based methods. Six minute walking distance (6MWD), peak work rate on bicycle ergometry (Wpeak) and Chronic Respiratory Questionnaire (CRQ) were used as anchors and Cohen's effect size was used as distribution based method., Results: The estimated MID of the ESWT with the different anchors ranged from 186-199 s, 76-82% and 154-164 m. Using the distribution based method the MID was 144 s, 61% and 137 m., Conclusions: Estimates of the MID for the ESWT after PR showed only small differences using different anchors in patients with COPD and chronic respiratory failure. Therefore we recommend using a range of 186-199 s, 76-82% or 154-164 m as MID of the ESWT in COPD patients with chronic respiratory failure. Further research in larger populations should elucidate whether this cut-off value is also valid in other COPD populations and with other interventions., Trial Registration: ClinicalTrials.Gov (ID NCT00135538).

Inherited neuromuscular disorders inevitably result in severe lung volume restriction associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the long-term effects of the regular use of mechanical insufflation/exsufflation on the course of the vital capacity. This retrospective data analysis included 21 patients (16.1 ± 6.5 years) with neuromuscular disorders and severe lung volume restriction using nocturnal noninvasive ventilation. The patients were advised to regularly use the mechanical insufflation/exsufflation twice a day for 10 minutes applying sets of three insufflation/exsufflation breath via face mask irrespective of respiratory tract infection. Data on the course of vital capacity were collected 2 years prior and 2 years after the introduction of regular use of mechanical insufflation/exsufflation. Before the introduction of mechanical insufflation/exsufflation vital capacity decreased from 0.71 ± 0.38 L to 0.50 ± 0.24 L in the last year and from 0.88 ± 0.45 L to 0.71 ± 0.38 L in the next to last year. In the first year, after regular use of mechanical insufflation/exsufflation vital capacity significantly increased by 28% (from 0.50 L to 0.64 L)-after the second year the vital capacity increase remained stable (0.64 vs. 0.65 L). These data suggest that the regular use of mechanical insufflation/exsufflation improves vital capacity in patients with neuromuscular disorders and severe lung volume restriction., (© The Author(s) 2014.)

Background: Patients with kyphoscoliosis and severe respiratory impairment frequently experience reduction in exercise tolerance, limitation in daily life activities, and deterioration in health-related quality of life (HRQOL). Noninvasive ventilation (NIV) as an add-on treatment to long-term oxygen therapy (LTOT) was shown to improve symptoms and HRQOL in these patients. Pulmonary rehabilitation can increase exercise capacity and HRQOL in patients with COPD, but its role in patients with restrictive thoracic disease, such as kyphoscoliosis, is uncertain. The aim of this study was to analyze the effects of combining pulmonary rehabilitation with LTOT and NIV treatments on arterial blood gases and the 6-min walk test (6MWT) in a homogeneous group of subjects with kyphoscoliosis., Methods: Twenty-three subjects with kyphoscoliosis and respiratory failure who were being treated with both LTOT and NIV and who had been referred to a pulmonary rehabilitation program were retrospectively analyzed. Eighteen subjects were included, and there was no control group. Pulmonary rehabilitation involved educational and physical training sessions and was carried out daily for 4-6 weeks. Exercise intensity was personalized based on individual tolerance, physiologic parameters, or physiotherapist judgment., Results: Upon completion of pulmonary rehabilitation, a significant improvement in 6-min walk distance was observed (P = .04). The dyspnea score at the end of the 6MWT improved as well, although the improvement did not reach statistical significance (P = .06). These changes were not confirmed at a 12-month follow-up visit. No significant effects of pulmonary rehabilitation on arterial blood gases were observed., Conclusions: A combined intervention including a tailored pulmonary rehabilitation program together with LTOT and NIV seems to be of short-term benefit in subjects with kyphoscoliosis and severe respiratory impairment., (Copyright © 2015 by Daedalus Enterprises.)