Historically, respiratory physiotherapy has been considered as an integral part of the daily rehabilitation of the intensive care unit (ICU) patient. However, not since 2000 has there been a specific evaluation of the various physiotherapy modalities available. Kathy Stiller, PhD, conducted a systematic review to evaluate evidence appearing over the last 13 years either supporting or refuting the role of physiotherapy in the care of the adult, intubated ICU patient.
The review is deliberately broad, encompassing clinical studies as well as expert opinion pieces and surveys. A literature review focused on papers published between 1999 and 2012 and accessible through PubMed, MEDLINE, CINAHL, Embase, the Physiotherapy Evidence Database and the Cochrane Library databases. The broad criteria naturally resulted in culling studies with variable study designs and outcomes, hence precluding a meta-analysis. Eighty-five new studies were identified including 12 focused systematic literature reviews. The identified trials evaluated several physiotherapy interventions including multimodality respiratory physiotherapy (an umbrella term encompassing diverse interventions such as manual or ventilator hyperinflation, positioning, chest wall vibrations, and rib-cage compression), mobilization, inspiratory muscle training and neuromuscular electrical stimulation. Read more…
Critically ill patients are at risk for significant oxidative stress; however, several small analyses have proposed that supplementation with glutamine, with or without antioxidants, may improve survival. Heyland and colleagues from the Canadian Critical Care Trials Group conducted an international, multicenter study to test the hypothesis that 28-day mortality in critically ill adults would be reduced by supplementation with glutamine, with or without antioxidants. Results were published in a recent issue of The New England Journal of Medicine.
There were 1,223 patients randomized to one of four groups. Overall 28-day mortality was 29.8%. Patients who received glutamine had a trend towards worse mortality at 28 days compared to patients who did not receive glutamine (32.4% vs. 27.2%; adjusted odds ratio [AOR], 1.28; 95% confidence interval [CI], 1.00 to 1.64; P=0.05). The combination of glutamine with antioxidants made no significant difference in survival (AOR, 1.09; 95% CI, 0.86 to 1.40; P=0.48). In-hospital mortality and mortality at 6 months were significantly higher among patients who received glutamine; they also had increases in ICU length of stay, length of mechanical ventilation, and overall hospital length of stay. Antioxidant supplementation had no effect on secondary outcomes. The findings from this large, robust randomized study are in opposition to those of previous smaller studies. Read the full Concise Critical Appraisal.
Observational and qualitative studies have suggested positive benefits associated with family presence during cardiopulmonary resuscitation (CPR). Family presence may help alleviate the emotional burden and improve the bereavement process. Concerns about interference with resuscitative efforts and medicolegal ramifications have yet to be answered in rigorously designed studies. Patricia Jabre and colleagues in France conducted a multicenter, randomized controlled trial to determine if family presence during CPR was associated with a reduction in the likelihood of posttraumatic stress disorder (PTSD)-related symptoms. Results were published in the March 14 issue of The New England Journal of Medicine.
The primary end point was the proportion of relatives with PTSD-related symptoms, while secondary end points included the effect of family presence on medical efforts at resuscitation, the well-being of the healthcare team, and the filing of medicolegal claims. Of the 570 family members enrolled in an intention-to-treat analysis, 79% of the experimental group witnessed resuscitation versus 43% in the control group. Seventeen percent (n=95) of family members did not complete the 90-day post-event psychological assessment. There were no significant differences between the two groups in the characteristics of the resuscitation procedure, survival or characteristics of patients or enrolled family members. One significant limitation to this work was the prehospital environment; the results from this trial deserve replication in an intensive care unit. Read the full Concise Critical Appraisal.