IntroductionCritical illness is a well-recognized cause of neuromuscular weakness and impaired physical functioning. Physical therapy (PT) has been demonstrated to be safe and effective for critically ill patients. The impact of such an intervention on patients receiving extracorporeal membrane oxygenation (ECMO) has not been well characterized. We describe the feasibility and impact of active PT on ECMO patients.MethodsWe performed a retrospective cohort study of 100 consecutive patients receiving ECMO in the medical intensive care unit of a university hospital.ResultsOf the 100 patients receiving ECMO, 35 (35%) participated in active PT; 19 as bridge to transplant and 16 as bridge to recovery. Duration of ECMO was 14.3 ± 10.9 days. Patients received 7.2 ± 6.5 PT sessions while on ECMO. During PT sessions, 18 patients (51%) ambulated (median distance 175 feet, range 4 to 2,800) and 9 patients were on vasopressors. Whilst receiving ECMO, 23 patients were liberated from invasive mechanical ventilation. Of the 16 bridge to recovery patients, 14 (88%) survived to discharge; 10 bridge to transplant patients (53%) survived to transplantation, with 9 (90%) surviving to discharge. Of the 23 survivors, 13 (57%) went directly home, 8 (35%) went to acute rehabilitation, and 2 (9%) went to subacute rehabilitation. There were no PT-related complications.ConclusionsActive PT, including ambulation, can be achieved safely and reliably in ECMO patients when an experienced, multidisciplinary team is utilized. More research is needed to define the barriers to PT and the impact on survival and long-term functional, neurocognitive outcomes in this population.
Background The supplemental oxygen flow rate is a common bedside measure of gas exchange impairment. We aimed to determine whether a titrated oxygen requirement predicted mortality in idiopathic pulmonary fibrosis. Methods We examined 104 adults with idiopathic pulmonary fibrosis enrolled in a prospective cohort study and a validation cohort of 151 adults with a variety of interstitial lung diseases. The titrated oxygen requirement was defined as the lowest oxygen flow rate required to maintain an oxyhemoglobin saturation of 96% while standing. Cox proportional hazards models and time-dependent receiver operating characteristic curves were used to examine survival time. Results A higher titrated oxygen requirement was associated with a greater mortality rate independent of forced vital capacity and six-minute walk test results in idiopathic pulmonary fibrosis (adjusted hazard ratio per 1 L/min = 1.10, 95% confidence interval 1.01 to 1.20). The titrated oxygen requirement was at least as accurate as pulmonary function and six-minute walk testing at predicting 1-year mortality. Findings were similar in other interstitial lung diseases. Conclusion The titrated oxygen requirement is a simple, inexpensive bedside measurement that aids prognostication in idiopathic pulmonary fibrosis.
Supplemental oxygen use has not been examined as a predictor of mortality in idiopathic pulmonary fibrosis (IPF). We RATIONALE: hypothesized that a greater resting oxygen requirement during a structured oxygen titration study would predict survival in IPF. We aimed to derive a clinical prediction rule for death or lung transplantation at one year.We performed a prospective cohort study of 104 patients with IPF enrolled between February 2007 and June 2010. Prior to METHODS: 6MWT, an oxygen titration study was performed according to a standardized protocol to determine the titrated oxygen requirement (TOR), defined as the lowest oxygen flow rate required to maintain SpO of at least 96% while standing. 6MWT was performed on the 2 oxygen flow determined by the titration study. Competing risk survival models, time-dependent ROC curves, and classification and regression trees (CART) were used to examine time to death and lung transplantation. Survival models were adjusted for age, six-minute walk distance (6MWD), end-walk SpO , and FVC%.2 The mean±SD age was 62±7 yrs, 79% were male, mean FVC% was 54±21%, DLCO% was 37±13%, 6MWD was 394±133m, and RESULTS: 56% had an end-walk SpO of 88% or less. The median TOR was 2 L/min (interquartile range 0 to 4 L/min). Greater TOR was associated 2 with a higher mortality rate independent of FVC% and 6MWT results (adjusted hazard ratio per 1 L/min = 1.10, 95% confidence interval 1.01 to 1.20, p = 0.03). The TOR was at least as good as standard pulmonary function and 6MWT at predicting one-year mortality (area under the ROC curve = 0.74 vs. less than 0.70 for other measures). A TOR of at least 1 L/min was 89% sensitive for death within one year. A clinical prediction rule composed of the TOR, exertional desaturation, and DLCO identified a group with 100% two-year transplant-free survival ( Figure & Table). Figure. Classification and regression tree (CART) for the prediction of death or transplantation. Oxygen requirement, end-walk SpO2, and DLCO remained in the model Cumulative incidence of death Cumulative incidence of lung transplantation Group 1yr 2yr 1yr 2yr 1 0% 0% 0% 0% 2 3% 12% 14% 28% 3 17% 42% 9% 29% 4 16% 22% 55% 63%The TOR is a simple bedside measurement that aids prognostication in IPF. The oxygen flow rate required to reach a CONCLUSIONS: resting oxyhemoglobin saturation of at least 96% may aid in identifying those at high and low risks of death.
Rationale: Impaired gas exchange during exercise is an important prognostic factor in interstitial lung disease (ILD). We hypothesized that greater resting supplemental oxygen requirements during a formal, structured point-of-care oxygen titration study would be associated with more severe disease and greater risk of poor outcomes in ILD and specifically in idiopathic pulmonary fibrosis (IPF). Methods: We examined 157 patients with ILD who completed pulmonary function testing (PFTs) and six-minute walk testing (6MWT) at our center between February 2007 and June 2009. Prior to 6MWT, one of two physical therapists performed a resting oxygen titration study according to a novel standardized protocol. In short, oxygen flow was increased in pre-determined increments each minute until the oxyhemoglobin saturation was 96 to 98% while standing. 6MWT was performed on the oxygen flow determined by the titration study. Generalized linear models were used to examine the associations between oxygen requirement and PFTs and 6MWT variables with adjustment for age, smoking status, cigarette packyears, and diagnosis. Cox models were used to examine survival time (censoring upon lung transplantation) and the combined endpoint of death or transplantation adjusting for the above covariates plus FVC, six-minute walk distance (6MWD), and oxyhemoglobin saturation at the end of the 6MWT. Results: The mean age was 57 ± 10, 60% were male, 53% had IPF, 17% had connective tissue disease-related ILD, and 13% had idiopathic NSIP. At the end of the titration study, 39% were breathing room air, 18% were using 1 to 2 liters of oxygen, 19% were using 3 to 5 liters, and 23% were using 6 to 15 liters. After adjusting for potential confounders, there were significant associations between greater oxygen requirement and lower FVC% (p = 0.002), DLCO% (p < 0.001), 6MWD (p < 0.001), and Borg dyspnea score at the end of 6MWT (p < 0.001); see Table. Greater oxygen requirement was not significantly associated with oxyhemoglobin saturation at the end of the 6MWT (p = 0.43), but it was associated with a greater risk of death or transplantation for all participants (p < 0.001) and for those with IPF (p = 0.04).Multivariable-adjusted least-squares means +-SE measures of disease severity and hazard ratios (95% CI) across categories of oxygen requirement during a standardized resting oxygen titration study Oxygen liter flow determined by point-of-care oxygen titration p for trend
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