Long-Term Acute Care Patients Weaning From Prolonged Mechanical Ventilation Maintain Circadian Rhythm

Abstract

BACKGROUND Circadian rhythm regulates many physiologic and immunologic processes. Disruption of these processes has been demonstrated in acutely ill, mechanically ventilated patients in the ICU setting. Light has not been studied as an entraining stimulus in the chronically mechanically ventilated patient. The purpose of this study was to determine the association of naturally occurring ambient light levels in a long-term acute care (LTAC) hospital with circadian rhythm in patients recovering from critical illness and requiring prolonged mechanical ventilation (PMV). METHODS We performed a prospective observational study of 15 adult patients who were recovering from critical illness and receiving PMV and who were admitted to the ventilator weaning unit at an LTAC hospital. Demographic data were obtained from chart review. Light stimuli in each patient room were assessed using a photometer device placed at eye level. Circadian rhythm was assessed by wrist actigraphy. Cumulative data were obtained from each device for a 48-h period, averaged into 4-h intervals, and analyzed. RESULTS Patients receiving PMV were obese (mean body mass index of 32.7 ± 10.3 kg/m2) and predominantly female (73%) and had an average age of 63.1 ± 14.3 y. Light exposure to this cohort maintained diurnal variation (P < .001) and was significantly different across time periods. Circadian rhythm, as represented by actigraphy, also maintained diurnal variation (P < .001) and was in phase with light. Linear regression of movement and time demonstrated a moderate relationship between light and actigraphy (R2 = 0.56). CONCLUSIONS Despite requiring continued high-level care and a prolonged stay in a medical facility, patients recovering from critical illness and actively weaning from PMV maintain their circadian rhythm in phase with normal diurnal variations of light.

Use of Accelerometry to Monitor Physical Activity in Critically Ill Subjects: A Systematic Review

“…14-17 Three studies used accelerometry to measure physical activity and movement as surrogates for adequacy of sedation, 18-20 and 2 studies used accelerometry as a surrogate for measuring sleep/wake cycles. 21,22 …”

“…The last 2 studies by Koldobskiy et al 21 and van der Kooi et al 22 used accelerometry as a surrogate for measuring sleep/wake cycles. Both studies evaluated accelerometry in clinically distinct populations: post-acute, ventilator-dependent subjects 21 and acutely ill, postoperative cardiac surgery subjects.…”

“…Both studies evaluated accelerometry in clinically distinct populations: post-acute, ventilator-dependent subjects 21 and acutely ill, postoperative cardiac surgery subjects. 22 Both had small sample sizes ( N = 15 and 7, respectively) and quantified sleep by decreased accelerometric activity.…”

Multidisciplinary rehabilitation in ventilator-dependent patients: Call for action in specialized inpatient facilities

“…In an observational study Koldobskyi et al have shown that specific facilities (like LTAC's) maintain the patients' circadian rhythm compared to the ICU environment. 35 In a recent meta-analysis, examining three trials involving a heterogeneous group of patients, inspiratory muscle training was found to significantly increase inspiratory muscle strength in adults undergoing mechanical ventilation. 36 Further research is needed including more homogeneous PMV populations and analyzing more relevant outcomes.…”

“…Cognitive rehabilitation 8,33,34 Feeding/nutrition and swallowing NA Sleep 35 Respiratory ---respiratory muscle training Secretion management; Weaning/decannulation protocols 36 37 38,39 Physical therapy ---limb exercises, exercise training, neuromuscular electrical stimulation See Table 1 Co-morbidities management (e.g. CHF, DM, COPD), Multidisciplinary rehabilitation in ventilator-dependent patients: Call for action in specialized inpatient facilities 5 Table 5 Members of the team and roles.…”