BackgroundDiaphragm dysfunction in mechanically ventilated patients is associated with poor outcome. Maximal inspiratory pressure (MIP) can be used to evaluate inspiratory muscle function. However, it is unclear whether respiratory weakness is independently associated with long-term mortality. The aim of this study was to determine if low MIP is independently associated with one-year mortality.MethodsWe conducted a prospective observational cohort study in an 18-bed ICU. Adults requiring at least 24 hours of mechanical ventilation with scheduled extubation and no evidence of pre-existing muscle weakness underwent MIP evaluation just before extubation. Patients were divided into two groups: low MIP (MIP ≤30 cmH2O) and high MIP (MIP >30 cmH2O). Mortality was recorded for one year after extubation. For the survival analysis, the effect of low MIP was assessed using the log-rank test. The independent effect of low MIP on post mechanical ventilation mortality was analyzed using a multivariable Cox regression model.ResultsOne hundred and twenty-four patients underwent MIP evaluation (median age 66 years (25th–75th percentile 56–74), Simplified Acute Physiology Score (SAPS) 2 = 45 (33–57), duration of mechanical ventilation 7 days (4–10)). Fifty-four percent of patients had low MIP. One-year mortality was 31 % (95 % CI 0.21, 0.43) in the low MIP group and 7 % (95 % CI 0.02, 0.16) in the high MIP group. After adjustment for SAPS 2 score, body mass index and duration of mechanical ventilation, low MIP was independently associated with one-year mortality (hazard ratio 4.41, 95 % CI 1.5, 12.9, p = 0.007). Extubation failure was also associated with low MIP (relative risk 3.0, 95 % CI 1, -9.6; p = 0.03) but tracheostomy and ICU length of stay were not.ConclusionLow MIP is frequent in patients on mechanical ventilation and is an independent risk factor for long-term mortality in ICU patients requiring mechanical ventilation. MIP is easily evaluated at the patient’s bedside.Trial RegistrationThis study was retrospectively registered in www.clinicaltrials.gov (NCT02363231) in February 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1418-y) contains supplementary material, which is available to authorized users.

Background Few studies have evaluated muscle strength in COVID-19 ICU survivors. We aimed to report the incidence of limb and respiratory muscle weakness in COVID-19 ICU survivors. Method We performed a cross sectional study in two ICU tertiary Hospital Settings. COVID-19 ICU survivors were screened and respiratory and limb muscle strength were measured at the time of extubation. An ICU mobility scale was performed at ICU discharge and walking capacity was self-evaluated by patients 30 days after weaning from mechanical ventilation. Results Twenty-three patients were included. Sixteen (69%) had limb muscle weakness and 6 (26%) had overlap limb and respiratory muscle weakness. Amount of physiotherapy was not associated with muscle strength. 44% of patients with limb weakness were unable to walk 100 m 30 days after weaning. Conclusion The large majority of COVID-19 ICU survivors developed ICU acquired limb muscle weakness. 44% of patients with limb weakness still had severely limited function one-month post weaning.

BackgroundIn the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive.MethodsA randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle.ResultsThe results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques.ConclusionMost bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out.Trial registrationClinicalTrials.gov, NCT02920684. Registered on 30 September 2016.Prospectively registered.

Purpose: Cognitive dysfunction is a common impairment associated with COPD. However, little is known about 1) its prevalence among those subjects referred for pulmonary rehabilitation (PR), 2) how it may affect the benefit of PR, 3) whether PR improves cognitive function and 4) whether cognitive dysfunction affects the usability of telehealth technology usually used to deliver in-home PR. Patients and Methods: Fifty-six subjects with stable COPD (54% females, mean age 62 years (SD 9) and median FEV 1 0.9 L (IQR 0.7 to 1.1)) participated in this multicenter observational study and performed 24 sessions of PR. The Montreal Cognitive Assessment tool (MoCA) was used to assess the occurrence of mild cognitive dysfunction (using a screening cutoff <26) at baseline, completion of PR and 3 months of follow-up. Results: Mild cognitive dysfunction was found in 41 subjects (73% [95% CI: 60 to 83%]). The MoCA score significantly improved following PR for those people with baseline mild cognitive dysfunction (p<0.01). There was no significant difference in clinical outcomes between those people with or without mild cognitive dysfunction following PR nor in the proportion of subjects who were autonomous in using the telemonitoring system (83% compared with 71%, p=0.60). Conclusion: Mild cognitive dysfunction is highly prevalent among those people with COPD referred for PR but does not affect the benefits of PR nor the usability of a telemonitoring system. PR may improve short-and mid-term cognitive function for those people who experience mild cognitive dysfunction at the time they are referred to PR.

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Background and objective: We hypothesized that by reducing respiratory work and improving gas exchange, nasal high flow (NHF) would improve exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) following respiratory exacerbation. Methods: This was a monocentric, randomized, controlled crossover study. Patients with severe to very severe COPD carried out two high-intensity constant work-rate exercise tests (CWRET) with and without NHF on two consecutive days. The primary outcome was the mean difference in endurance time between both conditions. The secondary aims included vastus lateralis oxygenation (StO 2 ), dyspnoea, leg discomfort, maximal inspiratory pressure (MIP), transcutaneous CO 2 pressure (PtcCO 2 ), respiratory rate (RR), heart rate (HR) and pulsed O 2 saturation (SpO 2 ), as well as the patients' opinions of the device. Results: A total of 19 patients were included (mean forced expiratory volume in 1 s = 28.7 AE 10.8%, age = 62.1 AE 9.1 years). No significant differences in endurance time during the CWRET were found between the two test conditions (−66.58 (95% CI: −155.9 to 22.7) s, P = 0.12). StO 2 , PtCO 2 and HR were reduced at the end of the exercise with NHF (−2.1% (95% CI: −4.3 to −0.0); −1.3 mm Hg (95% CI: −2.5 to −0.2); −2.7 bpm (95% CI: −5.0 to −0.5), respectively, P ≤ 0.05). No significant differences were found for any of the other secondary outcomes. Half of the patients evaluated the device as being moderately to very uncomfortable.Conclusion: NHF during exercise did not increase endurance time in patients with COPD following exacerbation.Clinical trial registration: NCT03058081 at clinicaltrials. gov Key words: chronic obstructive pulmonary disease, exercise, muscle oxygenation, nasal high flow, pulmonary rehabilitation.

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Study registration and methodologyThe protocol of this systematic review and meta-analysis was prospectively registered at PROSPERO (www.crd.york.ac.uk/prospero ; CRD: 42018103358). It has been designed according to the Cochrane Handbook for Systematic Reviews of Interventions 1 and reported according to the PRISMA statement. Criteria for considering studies for this review Types of studiesParallel and cross-over randomized trials, included those in the format of an abstract, assessing one or more of the considered outcomes. Type of participantsAdult patients with stable COPD (no acute exacerbation in the previous 3 weeks), of any age, diagnosed based on the individual study's criteria. Studies with a mixed population of COPD and other respiratory disease(s) could be included if the data for the participants with COPD could be extracted separately. Type of interventionNHF with air, or supplemental oxygen if indicated by the patient's clinical status, compared with the same gas delivered without NHF.