Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. noninvasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.
This study is the first to identify the most relevant aspects for physical therapy in Brazilian hospitals using the ICF framework. Our results can help to promote the adoption of the ICF in physical therapy clinical practice in the hospital setting.
More sensitive triggers led to faster ventilator response, but also to more frequent auto-triggering. To avoid auto-triggering, less sensitive triggers were required, with consequent slower trigger response. To compare trigger performance in a scenario that more closely represents clinical practice, evaluation of the tradeoff between time delay and frequency of auto-triggering should be considered.
Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the “mobility clock”, in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in “non-compliance” with the protocol was observed compared to the previous period (10.11% vs. 26.97%, p < 0.004). The proportion of patients walking was significantly higher (49.44% vs. 29.21%, p < 0.006) and the ICU readmission rate was lower in the “after” period (2.25% vs. 11.24%; p = 0.017). The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the “non-compliance” rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital.
Background
Patient-ventilator asynchronies are usually detected by visual inspection of ventilator waveforms but with low sensitivity, even when performed by experts in the field. Recently, estimation of the inspiratory muscle pressure (Pmus) waveforms through artificial intelligence algorithm has been proposed (Magnamed®, São Paulo, Brazil). We hypothesized that the display of these waveforms could help healthcare providers identify patient-ventilator asynchronies.
Methods
A prospective single-center randomized study with parallel assignment was conducted to assess whether the display of the estimated Pmus waveform would improve the correct identification of asynchronies in simulated clinical scenarios. The primary outcome was the mean asynchrony detection rate (sensitivity). Physicians and respiratory therapists who work in intensive care units were randomized to control or intervention group. In both groups, participants analyzed pressure and flow waveforms of 49 different scenarios elaborated using the ASL-5000 lung simulator. In the intervention group the estimated Pmus waveform was displayed in addition to pressure and flow waveforms.
Results
A total of 98 participants were included, 49 per group. The sensitivity per participant in identifying asynchronies was significantly higher in the Pmus group (65.8 ± 16.2 vs. 52.94 ± 8.42, p < 0.001). This effect remained when stratifying asynchronies by type.
Conclusions
We showed that the display of the Pmus waveform improved the ability of healthcare professionals to recognize patient-ventilator asynchronies by visual inspection of ventilator tracings. These findings require clinical validation.
Trial registration: ClinicalTrials.gov: NTC05144607. Retrospectively registered 3 December 2021.
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