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Effects of Inspiratory Muscle Training on Weaning from Mechanical Ventilation and ICU Length of Stay
K. Violet Drinnan, SPT, Advised by Fred Carey, P.T., Ph.D.
University of New Mexico School of Medicine, Division of Physical Therapy, Department of Orthopedics & Rehabilitation
University of New Mexico, Albuquerque, New Mexico
Abstract
Findings
Background/Purpose: Prolonged mechanical ventilation produces staggering health care costs
and overall poor patient outcomes short and long term. Persistent muscle weakness in the limbs
and respiratory muscles contributes to poor long term outcomes. The purpose of this evidencebased analysis is to compare the effects of standard care versus inspiratory or expiratory muscle
training on length of ICU stay and time on mechanical ventilation in difficult to wean adult patients
on mechanical ventilation.
Case Description: A 46-year old previously independent male patient was admitted to the ICU
following a decortication and parietal pleurectomy procedure. He initially was intubated for the
night following his surgical procedures but was unable to wean after a two and a half week ICU
stay and was transferred to a Long Term Acute Care (LTAC) facility. The patient received usual
physical therapy interventions including active and passive range of motion exercises and
mobilization within his room.
Outcomes: The patient did not participate in an inspiratory or expiratory muscle training program
during his ICU stay and follow-up data was not available after discharge to the LTAC facility.
Evidence from this literature review supports the use of inspiratory or expiratory muscle strength
training to improve time to wean from mechanical ventilation and improve outcome measures
related to respiratory health.
Discussion: The patient may have benefitted from an inspiratory or expiratory muscle training
program to encourage weaning from mechanical ventilation. There is limited quality research on
inspiratory or expiratory muscle strength training in mechanically ventilated patients making it
difficult to synthesize a succinct recommendation for its application. In the studies reviewed, this
treatment was considered to be safe for patients on mechanical ventilation. Further quality
research is indicated on this topic.
Citation
Choi, J., et
al. (2008).
Moodie, L.,
et al. (2011).
Padula, C.,
& Yeaw, E.
(2007).
Martin A.D.,
et al. (2011).
Background
• Prolonged mechanical ventilation (MV) was costly in the year 2008, the “mean 12-month
medical cost per prolonged MV patient was $306,000” and it is predicted that by the year
2020 the annual cost for patients requiring MV will be $64 billion (Daniel Martin, Smith, &
Gabrielli, 2013).
• 25% to 60% of patients on MV may have ICU-acquired weakness (Kayambu, Boots, &
Paratz, 2013).
Malkoç, M.,
et al. (2009).
Crisafulli,
E., et al.
(2013)
• Early rehabilitation of MV patients in the ICU has been shown not only to be safe but to
reduce ICU length of stay, decrease time spent on MV, and improve outcomes after
discharge (Clini et al., 2011; Kayambu et al., 2013; Mendez-Tellez & Needham, 2012).
• Inactivity quickly leads to atrophy in skeletal muscles; evidence from animal studies
shows that the diaphragm has significant amounts of atrophy within 12-18 hours,
compared to other skeletal muscle which shows no signs of atrophy during this time
(Mendez-Tellez & Needham, 2012).
Cader, S. A.,
et al. (2010)
Condessa,
R. L., et al.
(2013)
Oxford
Purpose
Level of
Evidence
2a
The purpose of the study was to
review published research on
improving mobility outcomes in
patients undergoing prolonged
mechanical ventilation (PMV).
2a
The purpose of the study was to
determine if IMT improves
inspiratory muscle strength and
endurance, facilitates weaning,
improves survival, and reduces
rates of reintubation and
tracheostomy in adults receiving
mechanical ventilation.
3a
The purpose of the study was to
review IMT in asthma,
bronchiectasis, cystic fibrosis,
chronic heart failure, ventilator
weaning, pre- and post-surgery
and neuromuscular diseases.
1b
The purpose of this study was to
determine if IMT improves
weaning outcomes in failure to
wean patients (FTW).
2b
The purpose of the study was to
determine the effects of physical
therapy on ventilator
dependency and length of stay
in the ICU.
1b
The purpose of the study was to
evaluate the efficacy and
feasibility of an expiratory
muscle training device in
patients who recently had
cardiothoracic surgery.
1b
The purpose of the study was to
determine if IMT improves MIP,
breathing pattern, and time to
weaning from mechanical
ventilation in older people.
1b
A
Caruso, P., 2b
et al. (2005)
A diagram of a threshold respiratory training device and its use (Galvan, C.C.R., & Cataneo, A.J.M.
2007; Pitts, T., et al. 2009).
Methods
Results
Inspiratory muscle training
(IMT) increased MIP, VC,
weaning success
IMT improved MIP. Favoring
IMT (not statistically
significant): weaning duration,
survival
Improvements in IM
endurance, ADLs, increased
duration of spontaneous
breathing
PICO Question: In difficult to wean adult patients on a mechanical ventilator, what is the
Answer to
clinical
question
Yes
effect of standard care compared to inspiratory or expiratory muscle training on length of
ICU stay and time on mechanical ventilation?
PubMed
Pedro
Cochrane
Cinahl
Yes
367
22
Yes
258
4
94
2
5
.
1
Screened for relevance based on
abstract
23 articles eliminated due to
duplicates, subject population,
sample size
Yes
Discussion
Chest focused PT decreased Yes
time spent on mechanical
ventilation and length of stay in
the ICU
MEP and VAS dyspnea were No
significantly higher in treatment
group
MIP increased significantly in
the treatment group. The
treatment group weaned 1.7
days sooner than the control,
Index of Tobin worsened in
both groups but to a lesser
extent in the treatment group
The purpose of the study was to The treatment group had
determine if IMT accelerates
statistically significant
weaning from mechanical
improvements in MIP, TV, and
ventilation, improves the
MEP compared to the control.
strength of respiratory muscles,
increases TV, and improves the
rapid shallow breathing index.
The purpose of the study was to There was no statistically
determine if inspiratory muscle significant difference between
training from the beginning of
weaning time or reintubation
mechanical ventilation shortens rate between the control and
duration of weaning and
intervention group. MIP was
decrease reintubation rate.
improved in the IMT group
compared to the control but
not to statistical significance.
Screened for relevance based on
title
.
9 articles selected for review
IMT improved MIP and
weaning outcome in FTW
patients
Keyword search: inspiratory
muscle training, physical
therapy ventilator, ventilator
weaning
Published within 10 years of
search date, Human Subjects
•
Statistically significant improvements in time to wean and weaning outcome were found in four
studies reviewed (Choi, J et al 2008; Martin A.D., et al. 2011; Malkoç, M., et al. 2009; Cader, S.
A., et al.2010).
•
Decreased length of ICU stay was found in one out of three studies reviewed that specifically
measured this outcome measure (Malkoç, M., et al. 2009).
•
Many of the studies reviewed failed to reach a statistically significant level of improvement in the
treatment group in weaning time and length of stay in the ICU, however this treatment may have
clinically significant benefits.
•
Outcome measures that correlate to weaning success and respiratory health such as maximal
inspiratory pressure, vital capacity, and maximal expiratory pressure were found to increase to a
statistically significant amount in treatment groups receiving inspiratory muscle training in seven
out of eight studies measuring those variables.
•
The long term effects of inspiratory or expiratory muscle training in this patient population on
respiratory health, quality of life, and reintubation rates may provide more justification for
treatment.
•
Adverse events were not reported to have occurred with this treatment in the studies reviewed.
•
This treatment appears appropriate and safe for the case study patient based on this research.
Yes
Yes
References
No
Ambrosino, N., Venturelli, E., Vagheggini, G., & Clini, E. (2012). Rehabilitation, weaning and
physical therapy strategies in chronic critically ill patients. European Respiratory Journal, 39(2),
487–492. http://doi.org/10.1183/09031936.00094411
Bissett, B., Leditschke, I. A., Neeman, T., Boots, R., & Paratz, J. (2015). Weaned but weary: One
third of adult intensive care patients mechanically ventilated for 7 days or more have impaired
inspiratory muscle endurance after successful weaning. Heart & Lung: The Journal of Acute and
Critical Care, 44(1), 15–20. http://doi.org/10.1016/j.hrtlng.2014.10.001
Cader, S. A., de Vale, R. G. S., Castro, J. C., Bacelar, S. C., Biehl, C., Gomes, M. C. V., … Dantas,
E. H. M. (2010). Inspiratory muscle training improves maximal inspiratory pressure and may assist
weaning in older intubated patients: a randomised trial. Journal of Physiotherapy, 56(3), 171–177.
doi:10.1016/S1836-9553(10)70022-9
Caruso, P., Denari, S. D., Ruiz, S. A., Bernal, K. G., Manfrin, G. M., Friedrich, C., & Deheinzelin, D.
(2005). Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients.
Clinics, 60(6), 479–484. doi:10.1590/S1807-59322005000600009
Choi, J., Tasota, F. J., & Hoffman, L. A. (2008). Mobility Interventions to Improve Outcomes in
Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological
Research For Nursing, 10(1), 21–33.
Clini, E. M., Crisafulli, E., Antoni, F. D., Beneventi, C., Trianni, L., Costi, S., … Nava, S. (2011).
Functional Recovery Following Physical Training in Tracheotomized and Chronically Ventilated
Patients. Respiratory Care, 56(3), 306–313. http://doi.org/10.4187/respcare.00956
Condessa, R. L., Brauner, J. S., Saul, A. L., Baptista, M., Silva, A. C. T., & Vieira, S. R. R. (2013).
Inspiratory muscle training did not accelerate weaning from mechanical ventilation but did improve
tidal volume and maximal respiratory pressures: a randomised trial. Journal of Physiotherapy,
59(2), 101–107. doi:10.1016/S1836-9553(13)70162-0
Crisafulli, E., Venturelli, E., Siscaro, G., Florini, F., Papetti, A., Lugli, D., … Clini, E. (2013).
Respiratory Muscle Training in Patients Recovering Recent Open Cardiothoracic Surgery: A
Randomized-Controlled Trial. BioMed Research International, 2013, e354276.
doi:10.1155/2013/354276
Daniel Martin, A., Smith, B. K., & Gabrielli, A. (2013). Mechanical ventilation, diaphragm weakness and
weaning: a rehabilitation perspective. Respiratory Physiology & Neurobiology, 189(2), 377–383.
http://doi.org/10.1016/j.resp.2013.05.012
Kayambu, G., Boots, R., & Paratz, J. (2013). Physical therapy for the critically ill in the ICU: a
systematic review and meta-analysis. Critical Care Medicine, 41(6), 1543–1554.
http://doi.org/10.1097/CCM.0b013e31827ca637
Galvan, C. C. R., & Cataneo, A. J. M. (2007). Effect of respiratory muscle training on pulmonary
function in preoperative preparation of tobacco smokers. Acta Cirurgica Brasileira, 22(2), 98–104.
http://doi.org/10.1590/S0102-86502007000200004
Mendez-Tellez, P. A., & Needham, D. M. (2012). Early Physical Rehabilitation in the ICU and Ventilator
Liberation. Respiratory Care, 57(10), 1663–1669. http://doi.org/10.4187/respcare.01931
Smith, B. K., Gabrielli, A., Davenport, P. W., & Martin, A. D. (2014, January). Effect of training on
inspiratory load compensation in weaned and unweaned mechanically ventilated ICU patients.
Respiratory Care, 59(1), 22+.
Martin, A. D., Smith, B. K., Davenport, P. D., Harman, E., Gonzalez-Rothi, R. J., Baz, M., … Gabrielli,
A. (2011). Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a
randomized trial. Critical Care, 15(2), R84. doi:10.1186/cc10081
Malkoç, M., Karadibak, D., & Yldrm, Y. (2009). The effect of physiotherapy on ventilatory dependency
and the length of stay in an intensive care unit: International Journal of Rehabilitation Research, 32(1),
85–88. doi:10.1097/MRR.0b013e3282fc0fce
Moodie, L., Reeve, J., & Elkins, M. (2011). Inspiratory muscle training increases inspiratory muscle
strength in patients weaning from mechanical ventilation: a systematic review. Journal of
Physiotherapy, 57(4), 213–221. doi:10.1016/S1836-9553(11)70051-0
Padula, C., & Yeaw, E. (2007). Inspiratory muscle training: integrative review of use in conditions other
than COPD. Research & Theory for Nursing Practice, 21(2), 98–118.
Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). IMpact of expiratory
muscle strength training on voluntary cough and swallow function in parkinson disease. Chest, 135(5),
1301–1308. http://doi.org/10.1378/chest.08-1389