Stefannie Vorona1, Umberto Sabatini1, Sulaiman Al-Maqbali1, Michele Bertoni1, Martin Dres2,3, Bernie Bissett4,5, Frank Van Haren6,5,7, A Daniel Martin8, Cristian Urrea1, Debbie Brace1, Matteo Parotto9,10,11, Margaret S Herridge1,10,12, Neill K J Adhikari10,13,14, Eddy Fan1,10,12,15, Luana T Melo16, W Darlene Reid10,16, Laurent J Brochard2,10,12, Niall D Ferguson1,10,12,13,15, Ewan C Goligher1,10,15. 1. 1 Division of Respirology, Department of Medicine, and. 2. 2 Keenan Centre for Biomedical Research, St. Michael's Hospital, Toronto, Ontario, Canada. 3. 3 Respiratory and Critical Care Department, Pitié Salpetriere Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. 4. 4 Physiotherapy Department and. 5. 5 University of Canberra, Canberra, Australia. 6. 6 Intensive Care Unit, Canberra Hospital, Canberra, Australia. 7. 7 Australian National University Medical School, Canberra, Australia. 8. 8 Department of Physical Therapy, University of Florida, Gainesville, Florida. 9. 10 Department of Anesthesia, University Health Network, Toronto, Ontario, Canada. 10. 9 Interdepartmental Division of Critical Care Medicine. 11. 11 Department of Anesthesia. 12. 12 Department of Medicine. 13. 14 Institute for Health Policy, Management, and Evaluation. 14. 13 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. 15. 15 Department of Physiology, and. 16. 16 Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; and.
Abstract
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 H2O; 95% confidence interval [CI], 5-8 cm H2O; pooled relative ratio of means, 1.19; 95% CI, 1.14-1.25) and maximal expiratory pressure (4 trials; mean increase, 9 cm H2O; 95% CI, 5-14 cm H2O). 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.
RATIONALE: Respiratory muscle weakness is common in critically illpatients; 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 illpatients. 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 H2O; 95% confidence interval [CI], 5-8 cm H2O; pooled relative ratio of means, 1.19; 95% CI, 1.14-1.25) and maximal expiratory pressure (4 trials; mean increase, 9 cm H2O; 95% CI, 5-14 cm H2O). 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 illpatients have employed inspiratory threshold loading. IMT is feasible and well tolerated in critically illpatients and improves both inspiratory and expiratory muscle strength. The impact of IMT on clinical outcomes requires future confirmation.
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