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Feasibility of physical and occupational

therapy beginning from initiation of
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Feature Articles

Feasibility of physical and occupational therapy beginning from

initiation of mechanical ventilation*
Mark C. Pohlman, MD; William D. Schweickert, MD; Anne S. Pohlman, RN, MSN; Celerina Nigos, RN;
Amy J. Pawlik, PT; Cheryl L. Esbrook, OTR/L; Linda Spears, PT; Megan Miller, OTR/L; Mietka Franczyk, PT;
Deanna Deprizio, OTR/L; Gregory A. Schmidt, MD; Amy Bowman, RN, BSN; Rhonda Barr, PT;
Kathryn McCallister, BS; Jesse B. Hall, MD; John P. Kress, MD

Objective: Physical and occupational therapy are possible im-
mediately after intubation in mechanically ventilated medical
intensive care unit patients. The objective of this study was to
describe a protocol of daily sedative interruption and early phys-
ical and occupational therapy and to specify details of intensive
care unit-based therapy, including neurocognitive state, potential
barriers, and adverse events related to this intervention.
Design and Patients: Detailed descriptive study of the inter-
vention arm of a trial of mechanically ventilated patients receiving
early physical and occupational therapy.
Setting: Two tertiary care academic medical centers partici-
pating in a randomized controlled trial.
Intervention: Patients underwent daily sedative interruption
followed by physical and occupational therapy every hospital day
until achieving independent functional status. Therapy began with
active range of motion and progressed to activities of daily living,
sitting, standing, and walking as tolerated.
Measurements and Main Results: Forty-nine mechanically
ventilated patients received early physical and occupational ther-
apy occurring a median of 1.5 days (range, 1.0 –2.1 days) after
intubation. Therapy was provided on 90% of MICU days during
mechanical ventilation. While endotracheally intubated, subjects
sat at the edge of the bed in 69% of all physical and occupational
therapy sessions, transferred from bed to chair in 33%, stood in
33%, and ambulated during 15% (n ⴝ 26 of 168) of all physical
and occupational therapy sessions (median distance of 15 feet;
range, 15–20 feet). At least one potential barrier to mobilization
during mechanical ventilation (acute lung injury, vasoactive med-
ication administration, delirium, renal replacement therapy, or
body mass index >30 kg/m2) was present in 89% of patient
encounters. Therapy was interrupted prematurely in 4% of all
sessions, most commonly for patient-ventilator asynchrony and
agitation.
Conclusion: Early physical and occupational therapy is feasible
from the onset of mechanical ventilation despite high illness
acuity and presence of life support devices. Adverse events are
uncommon, even in this high-risk group. (Crit Care Med 2010; 38:
2089 –2094)
KEY WORDS: sedation; neuropathy; myopathy; weakness; phys-
ical therapy; occupational therapy; mechanical ventilation; respi-
ratory failure

S urvivors of critical illness fre-
quently are plagued by severe
and longstanding morbidities
(1–3). As therapies that reduce
mortality in the critically ill become
available, long-term intensive care unit
*See also p. 2254.
From the Department of Medicine, Section of Pul-
monary and Critical Care (JPK, ASP, CN, KM, JBH, JPK)
and Therapy Services (AJP, CLE, LS, MM, MF, DD)
University of Chicago, Chicago, IL; Department of Med-
icine (WDS), Division of Pulmonary, Allergy and Critical
Care Medicine, University of Pennsylvania, Philadel-
phia, PA; and the Department of Medicine, Division of
Pulmonary and Critical Care (GAS, AB) and Therapy
Services (RB), University of Iowa, Iowa City, IA.
The authors have not disclosed any potential
conflicts of interest.
For information regarding this article, E-mail:
jkress@medicine.bsd.uchicago.edu
Copyright © 2010 by the Society of Critical Care
Medicine and Lippincott Williams & Wilkins
DOI: 10.1097/CCM.0b013e3181f270c3
(ICU) survivors will likely increase in
number. Throughout hospitalization and
after discharge, these patients face a va-
riety of neurocognitive and functional
complications (4, 5). Effective therapies
for preventing or treating such problems
are limited (5– 8). However, physical
therapy/occupational therapy (PT/OT)
during critical illness recently has shown
potential for great benefit (9 –13).
Although used in some ICUs, proto-
cols for PT/OT in critically ill patients
have been described in few studies. Older
studies show safety of mobilizing criti-
cally ill patients, although the majority
was not receiving mechanical ventilation
(14). Until recently, early mobilization in
critically ill mechanically ventilated pa-
tients had not been described. Bailey and
colleagues (13) first reported the safety
and feasibility of PT/OT during mechani-
cal ventilation (MV); however, this cohort
was approximately 1 week into their crit-
ical illness, awake at baseline, and trans-
ferred from a medical or trauma ICU into
a respiratory ICU. In a subsequent study
by the same investigators, ambulation
was shown to be markedly increased on
transfer to their respiratory ICU, which
specialized in rehabilitation of critically
ill patients, many of whom were intu-
bated (11). For enrollment, this cohort
required that patients were able to follow
commands, had hemodynamic stability
evidenced by absence of vasoactive drugs,
and had respiratory stability. In this
study, patients were cared for in another
ICU for a mean of 10.3 days before respi-
ratory ICU admission. In another recently
published study, Morris and colleagues
(10) described a nonrandomized trial
evaluating early ICU mobility; however,
in this trial, the time to patient first get-
ting out of bed averaged 8.5 days.

Crit Care Med 2010 Vol. 38, No. 11 2089

 Recently, we reported a comprehen-
sive protocol for the implementation of
PT/OT in sedated MV patients from the
onset of endotracheal intubation. This
protocol resulted in higher functional in-
dependence at hospital discharge, more
ventilator-free days, and reduced ICU de-
lirium (9). We describe the details of this
protocol for very early PT/OT during MV.
The protocol uses a strategy of coordi-
nated efforts spanning disciplines with
the ultimate goal of awakening patients
from sedation for interactive therapy. In
addition, we describe the activities ac-
complished by patients at various stages
of hospitalization (with emphasis on ICU-
based therapy), the assistance provided by
therapists, the impact of potential barri-
ers to very early mobilization, and safety
issues related to the intervention.
MATERIALS AND METHODS
Patient Population. Study participants
were recruited from two university based ter-
tiary care medical centers: University of Chi-
cago Medical Center, Chicago, IL, and Univer-
sity of Iowa Hospitals, Iowa City, IA. The
Institutional Review Boards at both institu-
tions approved the study, and written in-
formed consent was obtained from partici-
pants or their authorized representatives.
Inclusion criteria consisted of age ⱖ18 yrs,
MV for ⬍72 hrs with an expected 24 hrs of
ventilatory support, and baseline functional
independence (defined as a Barthel index ⱖ70
[15] collected from a proxy describing patient
health 2 wks before hospital admission). Pa-
tients were excluded from participation in this
study for the following reasons: rapidly evolv-
ing neuromuscular disease (for example,
stroke, myasthenia gravis, Guillain-Barré syn-
drome, spinal cord injury), admission after
cardiopulmonary arrest, diagnosis of irrevers-
ible condition with 6-month mortality esti-
mated at ⬎50%, elevated intracranial pres-
sure, multiple absent limbs, or enrollment in
another trial. As previously reported, patients
were randomized in a 1:1 manner to early
PT/OT (intervention) or standard care with
PT/OT delivered as ordered by the primary
team (control) (9). Only patients receiving
early PT/OT (intervention) are analyzed in this
article. Intervention patients underwent ther-
apy until they achieved functional indepen-
dence (defined as the ability to perform six
activities of daily living [bathing, dressing, eat-
ing, grooming, transfer from bed to chair,
toileting] and independent ambulation) or
were discharged from the hospital.
Study Protocols. Every patient underwent
daily sedative interruption (16) unless neuro-
muscular blocking agents were being admin-
istered or severe agitation was noted while
sedatives were infusing at the time of consid-
eration for sedative interruption. In conjunc-
2090
Figure 1. Intensive care unit physical therapy (PT)/occupational therapy (OT) study protocol. h, hour;
ROM, range of motion.
tion with the research team and ICU nurse,
patients were assessed each morning with a
PT/OT safety screen. Patients passed the
screen if they had no contraindications to ini-
tiating therapy (Appendix A). Patients who
failed the screen were reassessed each day.
Patients who passed the screen were placed on
the protocol for daily sedative interruption
and early PT/OT (Fig. 1). If a patient who
passed the screen became agitated or had se-
vere ventilator asynchrony after daily sedative
interruption, sedation was restarted and
PT/OT not performed. A patient was consid-
ered to demonstrate “wakefulness” when able
to follow at least three of four commands:
opening eyes in response to voice, using eyes
to follow investigator on request, squeezing
hand on request, protruding tongue on re-
quest (6). On meeting criteria for wakefulness,
therapy was initiated by the PT/OT team.
If a patient remained unresponsive after
sedative interruption, passive range of motion
(PROM) exercises were performed in all four
limbs and sedation interruption continued.
PROM consisted of the following: glenohu-
meral flexion, elbow flexion/extension, wrist
flexion/extension, finger flexion/extension, hip
flexion, knee flexion/extension, and ankle dor-
siflexion/plantarflexion. The degree of range of
motion varied per patient depending on the
available range of motion at joint. The pres-
ence of an indwelling catheter did not deter
range of motion except in the case of a func-
tioning dialysis catheter in the femoral vein.
In such circumstances, hip flexion was de-
ferred. If wakefulness was not achieved in ⬍6
hrs, a second session of PROM was performed.
For the purposes of our study analysis, a pa-
tient day with only PROM was not considered
a “successful” PT/OT session. The early mobi-
lization therapy intervention was initiated in
both delirious and nondelirious patients as
described subsequently.
If a patient required resedation as a result
of agitation, ventilator asynchrony, or respira-
tory distress during the sedative interruption,
the ICU nursing staff restarted sedatives at half
the previous dose and titrated the medications
to achieve the patient sedation goal (that is,
Richmond Agitation-Sedation Scale 0 to ⫺2)
(17). If during the therapy sessions any of the
PT/OT safety contraindications (Appendix B)
were met, the therapy session was stopped.
Therapy was delivered by a team consisting
of a physical and occupational therapist. Al-
though ICU nursing and therapy staff commu-
nicated to assure coordination of efforts and
screening for safety, nursing and physician
staff were not involved directly in therapy ses-
sions. The nursing to patient ratio was either
1:1 or 1:2, depending on patient acuity on a
given day. All devices (for example, vascular
access catheters, enteric tubes, endotracheal
tubes) were assessed before each intervention.
The patient and all connected devices were
prepared for mobilization. Endotracheal tubes
were secured with oral endotracheal tube fas-
teners (Anchor Fast; Hollister Inc, Liber-
tyville, IL) per usual practice in our ICU. Any
unnecessary noninvasive devices were re-
moved (for example, pneumatic compression
devices, foot drop splints). Enteral feedings
were stopped and tubes disconnected to re-
duce risk of device removal during therapy.
The patient was mobilized toward the side of
the bed where the mechanical ventilator was
situated and equipment was moved to the
Crit Care Med 2010 Vol. 38, No. 11
same side (for example, urine or stool collec-
tion devices and intravenous poles). Patient
ventilator settings were determined by medi-
cal ICU service caring for the patient and not
changed as a result of study intervention. A
transport ventilator was used for patients able
to walk distances beyond the bedside chair.
Initial interaction between a patient and
therapy team involved assessing for wakeful-
ness, as defined previously (6). Patients were
first allowed to attempt each activity indepen-
dently, and assistance was provided only when
required. Level of assistance for all activities
was graded by therapists using standardized
criteria (18). Active or active-assisted range of
motion was performed on all limbs in the
semirecumbent position (active range of mo-
tion consists of the patient completing full
range independently, whereas active-assisted
range of motion involves assistance to com-
plete full range). Active range of motion was
used as an exercise, an opportunity to assess
strength qualitatively, and a gauge to deter-
mine whether a patient was following more
complex commands. Therapy progressed to
bed mobility exercises consisting of lateral
rolling and transferring from semirecumbent
to upright. If a patient could follow the ther-
apists’ commands, he or she was assisted to
sitting at the edge of the bed. This was done in
an attempt to both assess a patient’s indepen-
dence with this activity and to determine
whether a change in position would increase
alertness and command-following. Sitting bal-
ance activities targeting postural muscle
groups were performed at the edge of bed.
Balance activities included reaching in and
out of the base of support, postural retraining,
and providing challenges to elicit righting re-
actions. Activity of daily living training (for
example, bathing, dressing, grooming, toilet-
ing, eating) was performed when appropriate
in both sitting and standing positions. Ther-
apy then progressed to transfers such as sit-
to-stand, bed-to-chair, and bed-to-commode.
Transfer training included repetitions of
transfers and modification of technique to in-
crease patient independence. The ability to
progress to standing was judged by the bedside
therapists and depended on sitting balance,
lower extremity strength, and the absence of
impulsive or unsafe behavior that could make
standing potentially unsafe. In general, most
patients had to be able to partially extend both
knees against gravity and sit with minimal
assistance to have therapy progress to stand-
ing. Transfer training included repetitions
of transfers and modification of technique to
increase patient independence. Activities to
increase standing balance and tolerance in-
cluded reaching, marching in place, and
weight shifting. If a patient could participate
in these activities, ambulation was initiated.
Throughout treatment, education and im-
Crit Care Med 2010 Vol. 38, No. 11
plementation of energy conservation, work
simplification, and breathing techniques
were provided to increase overall activity
tolerance (19).
These treatment modalities were com-
pleted daily until the patient achieved func-
tional independence or was discharged from
the hospital. Spontaneous breathing trials
were performed daily on all patients using an
established protocol (20). Daily sedative inter-
ruption, spontaneous breathing trials, and
PT/OT sessions were coordinated whenever
possible; however, therapy could occur before
or after a spontaneous breathing trial depend-
ing on individual patient daily care plan sched-
ules and/or plans for extubation. In general,
patients underwent spontaneous breathing
trial assessments and completion in the early
morning, and PT/OT assessment occurred af-
ter the trial. Patients not eligible for a spon-
taneous breathing trial would undergo PT/OT
on awakening from sedation. Patients who had
passed their spontaneous breathing trial and
were eligible for extubation had therapy ses-
sions after extubation.
Data Collection. On completion of each
session, a therapist documented all exercises
performed and the level of assistance that was
required (18). This documentation consisted
of the performance of PROM, active range of
motion, and active-assisted range of motion
while semirecumbent in both upper and lower
extremities, transfers (bed mobility, sit-to-
stand, bed-to-chair), ambulation distance and
level of assist needed, balance while sitting
and standing, and activities of daily living.
Percentage of days patients could follow ther-
apists’ instructions, duration of participation
in therapy sessions, vital signs at rest and with
activity (heart rate and pulse oximetry rou-
tinely, respiratory rate and blood pressure if
altered during therapy), ventilator asyn-
chrony, and dependent prespecified mile-
stones (out of bed, standing alone, marching
in place, transferring to chair, ambulating)
were also recorded at this time. Data were
analyzed for all sessions of recorded therapy
during enrollment.
Several barriers to PT/OT were expected and
thus identified a priori. These anticipated barri-
ers included: 1) cardiovascular problems (for ex-
ample, vasoactive medication use; 2) respiratory
problems (for example, acute lung injury); 3)
neurocognitive impairment (for example, pres-
ence of ICU delirium [21]); and 4) obesity (body
mass index ⬎30 kg/m2). Other anticipated bar-
riers recorded included: intermittent hemodial-
ysis, continuous renal replacement, and invasive
procedures (for example, vascular catheter, tho-
racentesis, paracentesis, lumbar puncture) per-
formed on the day of therapy.
Safety Assessments. Study personnel mon-
itored patients daily for adverse events. Before
each therapy session, relative contraindica-
tions for initiating PT/OT (Appendix A) were
sought. Patients meeting any of the contrain-
dications did not receive PT/OT that day. We
also recorded unplanned extubations and de-
vice or equipment removal. PT/OT continued
unless patients manifested an adverse event
requiring premature discontinuation (11, 13),
as defined in Appendix B. Decisions by the
PT/OT team to discontinue a therapy session
were categorized and reported in detail.
Statistics. Data for descriptive statistics are
expressed as percentages, mean ⫾ SD, or me-
dian (interquartile range). Data are analyzed
for all days that therapy occurred during the
enrollment period while on MC, in the ICU not
on MV, and on the regular medical ward.
RESULTS
Unless stated otherwise, data are pre-
sented as mean ⫾ SD or median (inter-
quartile range).
From June 2005 to October 2007, 49
patients underwent early PT/OT. Therapy
occurred on 87% of total eligible days
while on study (n ⫽ 498 of 570): 90%
(244 of 270) of days on MV, 90% (113 of
125) of days in the medical ICU not on
MV, and 81% (141 of 175) days on the
regular medical ward. Ten patients ulti-
mately underwent a tracheostomy. The
mean number of days from intubation to
tracheostomy was 8.2 ⫾ 4.7. Patient de-
mographics and outcomes are listed in
Table 1. Time from intubation to in-
formed consent, and time from intuba-
tion to initial therapy were 1.1 (0.6 –1.6)
and 1.5 (1.0 –2.1) days, respectively.
Therapy Protocol. Therapy sessions oc-
curred for 26 ⫾ 14 mins per session while
on MV, 28 ⫾ 11 mins per session while in
the medical ICU not on MV, and 28 ⫾ 10
mins while on the ward. In the majority of
sessions, intubated patients were able to
perform upper and lower extremity exer-
cises (85%), actively move in bed (76%),
sit at the edge of the bed (69%), groom
themselves (64%), and simulate eating
(67%). While intubated, subjects moved
from bed to chair in 33% of sessions and
stood in 33% of sessions (Fig. 2). Subjects
ambulated in 15% of all PT/OT sessions
while intubated (median distance of 15
feet [15–20 feet]) and 63% of all PT/OT
sessions after extubation while still in the
medical ICU (median distance of 30 feet
[15–161 feet]). Level of assistance by
Functional Independence Measure score
(18) is shown in Table 2. Patients gener-
ally accomplished a greater percentage of
activities and required less assistance as
they progressed from mechanically ven-
tilated, to extubated in the ICU, to the
medical ward.
Sedation Protocol, Neurocognitive
State, and Wakefulness. Sedative infu-
2091
Table 1. Demographics and outcomes of early therapy patient out of the ICU for a test (n ⫽ 1).
On 21 of 244 occasions, patients were
Demographics n ⫽ 49
receiving intermittent sedation boluses
Age, yrs 57.7 (36.3–69.1) and were already awake and able to follow
Female, % 59 commands. Agitation after sedative inter-
Black race, % 61 ruption, which required stopping therapy
Body mass index, kg/m2 27.4 (25.1–32.4)
APACHE II score (22) 20 (15.8–24)
and resedation, was uncommon with an
ICU Primary admission diagnosis, % (no./total) incidence of ⬍10% of sessions. With re-
Acute lung injury; ARDS 55 (27/49); 43 (21/49) gard to ICU delirium, patients were Con-
COPD exacerbation 8 (4/49) fusion Assessment Method for the Inten-
Status asthmaticus 10 (5/49)
Sepsis 14 (7/49) sive Care Unit-negative (not delirious or
Hemorrhage 2 (1/49) comatose) during 40% (97 of 244) of ses-
Malignancy 4 (2/49) sions and Confusion Assessment Method
Other 6 (3/49)
Patients receiving vasopressor(s), % (no./total) 61 (30/49) for the Intensive Care Unit-positive (de-
Renal replacement therapy required, % (no./total) 20 (10/49) lirious) during 53% (129 of 244) of ses-
Septic shock, % (no./total) 57 (28/49) sions. Of note, 18 sessions resulted in
Neuromuscular blocking agent used, % (no./total) 4 (2/49) PROM only as a result of lack of respon-
Corticosteroids used, % (no./total) 69 (34/49)
Acute CNS disorder (eg, CVA, seizure), % (no./total) 0 (0/49) siveness (that is, coma) after 6 hrs of
Duration of mechanical ventilation, days 3.4 (2.3–7.3) sedative interruption.
ICU length of stay, days 5.9 (4.5–13.2) Potential Barriers. Acute lung injury
Hospital length of stay, days 13.5 (8.0–23.1)
Functional independence at hospital discharge, %a 59 was present during 58% of therapy ses-
ICU acquired paresis at hospital discharge, % 31 sions and FIO2 was ⱖ60% during 35% of
Barthel index (15) before admission 100 (85–100) therapy sessions on MV. A single vasoac-
Barthel index (15) at hospital discharge 75 (7.5–95)
Mortality, % 18
tive drug was infusing during 17% of
Time to death, days 13.6 (6.4–30.3) therapy sessions and two or more vaso-
active drugs were present during 14% of
APACHE, Acute Physiology and Chronic Health Evaluation; ICU, intensive care unit; ARDS, acute therapy sessions on MV. Details regarding
respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; CNS, central nervous respiratory and circulatory status of pa-
system; CVA, cerebrovascular accident. tients during therapy sessions are pre-
a
Functional Independence ⫽ able to perform all activities of daily living and able to walk sented in Table 3. Continuous renal re-
independently (9). Unless otherwise indicated, data are presented as median (interquartile range).
placement occurred during 9% of therapy
sessions while on MV. Intermittent he-
498 therapy modialysis occurred on the day of therapy
sessions
570 hospital days for 5% of sessions on MV. At least one
(87%) central venous catheter was present dur-
ing 75% of sessions on MV. Internal
jugular catheters accounted for 43% of
357 therapy sessions 141 therapy sessions
395 MICU days 175 non-ICU days catheter-days, whereas subclavian and
(90%) (81%) femoral catheters accounted for 29% and
10%, respectively. A dialysis catheter was
present during 18% of therapy sessions
244 therapy 113 therapy sessions
sessions during MV without MV
on MV. Internal jugular catheters ac-
(68%) (32%) counted for 9% of dialysis catheter-days,
whereas subclavian and femoral catheters
accounted for 3% and 7%, respectively.
Therapy Activities Accomplished During MV; (median [IQR] time to reach
milestone)
Arterial lines were present during 47% of
UE/LE exercise = 207/244 (85%); (3.0 (3 0 [3
[3, 3]) sessions. Body mass index was 30 –39
Bed mobility = 185/244 (76%); (1.7 [1.1, 3.0])
Sit = 168/244 (69%); (3.0 [3, 5]) kg/m2 in 26% (64 of 244) and ⱖ40 kg/m2
Stand = 80/244 (33%); (3.2 [1.5, 5.6]) in 15% (36 of 244) of therapy sessions
Chair = 80/244 (33%); (3.1 [1.8, 4.5])
Eat* = 163/244 (67%); (3.0 [3, 4]) during MV. Eighteen of 49 patients were
Groom = 156/244 ((64%); ) ((3.0 [[3, 4])
])
Ambulate 37/244 (15%); (3.8 [1.5, 5.8])
obese (body mass index ⬎30 kg/m2). Obe-
(distance in those patients capable (ft) = 15 [15,20]) sity per se was never a barrier to early
PT/OT. Other details of potential barriers
MV = mechanical ventilation; MICU = medical intensive care unit; are presented in Table 1.
UE/LE = upper extremity / lower extremity; * = eating simulated; ft = feet
Therapy did not occur on 72 of 570
Figure 2. Therapy activities accomplished during mechanical ventilation. eligible patient-days (26 patient-days while
on MV; 46 patient days after extubation).
During MV, reasons therapy did not occur
sions were stopped before the majority of administration of neuromuscular block- (n ⫽ 26 total) included: marked ventilator
therapy sessions (83% [203 of 244]). On ing agents (n ⫽ 12), severe agitation dysynchrony (n ⫽ 20), mean arterial pres-
20 of 244 occasions, sedative infusions while sedatives were infusing, which re- sure ⬍65 mm Hg despite vasoactive med-
were not stopped at all. Reasons included: quired increased sedation (n ⫽ 7), and ications (n ⫽ 4), and active gastrointestinal

2092 Crit Care Med 2010 Vol. 38, No. 11

Table 2. Functional Independence Measure (FIM) during intubation and mechanical ventilation (18): Level of assistance required based on activity type
and location

UE/LE Bed
Activity Exercise Mobility Sit Stand Chair Eata Groom Ambulate

FIM score 3 (2–4) 2 (1–4) 4 (2–5) 3 (3–4) 3 (1–4) 3 (2–4) 3 (2–4) 4 (3–5)

UE/LE, upper extremity/lower extremity; FIM, Functional Independence Measure (scale 1–7) (18): 1 ⫽ total assistance (subject ⫽ 0%), 2 ⫽ maximal
assistance (subject ⫽ 25%), 3 ⫽ moderate assistance (subject ⫽ 50%), 4 ⫽ minimal assistance (subject ⫽ 75%), 5 ⫽ supervision only without assistance,
6 ⫽ modified independence (device used, eg, walker), 7 ⫽ complete independence.
a
Eating simulated. Data are presented as median (interquartile range).

Table 3. Respiratory and circulatory parameters at each therapy activity level

UE/LE
Activity Exercise Bed Mobility Sit Stand Chair Eata Groom Ambulate

FIO2, % 50 (40–60) 50 (40–60) 50 (40–60) 50 (40–60) 50 (40–60) 50 (40–60) 50 (40–60) 50 (40–60)

Maximum 100 Maximum 100 Maximum 60 Maximum 75 Maximum 75 Maximum 100 Maximum 100 Maximum 60
PEEP, cm H2O 5 (5–8) 5 (5–8) 5 (5–7) 5 (5–7) 5 (5–7) 5 (5–8) 5 (5–8) 5 (5–5.5)
Maximum 12 Maximum 10 Maximum 10 Maximum 12 Maximum 12 Maximum 12 Maximum 12 Maximum 10
Circulatory SOFA 1 (0–3) 1 (0–2.75) 1 (0–2) 1 (0–2) 1 (0–1) 1 (0–2.25) 1 (0–2.5) 1 (0–2)
(23) score Maximum 4 Maximum 4 Maximum 4 Maximum 4 Maximum 4 Maximum 4 Maximum 4 Maximum 3

UE/LE, upper extremity/lower extremity; FIO2, fraction of inspired oxygen; Maximum, maximum level for any patient in the study; PEEP, positive
end-expiratory pressure (cm H2O); SOFA, Sepsis-related Organ Failure Assessment. Data are presented as median (interquartile range).
a
Eating simulated.

blood loss (n ⫽ 2). After extubation, rea-
sons therapy did not occur (n ⫽ 46 total)
included: patient fatigue leading to refusal
(n ⫽ 34), scheduled procedure (n ⫽ 7), and
respiratory distress (n ⫽ 5).
Safety. Adverse events occurred dur-
ing 16% of all sessions (80 of 498) and
included desaturation ⱖ5% in 6% (31 of
498), heart rate increase ⬎20% in 4.2%
(21 of 498), ventilator asynchrony/
tachypnea in 4% (20 of 498), agitation/
discomfort in 2% (ten of 498), and device
removal in 0.8% (four of 498) of all ther-
apy sessions. One arterial line, one naso-
gastric tube, and one rectal tube were
removed inadvertently with no serious
consequences noted. The expiratory limb
of the ventilator was disconnected briefly
on one occasion without consequence.
Therapy was stopped prematurely on a
given day in 4% (19 of 498) of all ses-
sions, all during mechanical ventilation.
The most common reasons were patient
ventilator asynchrony, agitation, or both.
DISCUSSION
Sedated, mechanically ventilated pa-
tients can routinely undergo PT/OT from
the onset of MV while in a medical ICU.
Our protocol used a sequence of interven-
tions consisting of daily sedative inter-
ruption to attain maximal wakefulness
followed by PT/OT sessions. This inter-
vention recently has been shown to im-
prove functional and neurocognitive out-
comes and shorten duration of MV (9).
Complex activities consisting of sitting
up at the bedside, standing, transfers, ac-
tivities of daily living, and walking oc-
curred frequently in patients during MV.
Similar activities have been reported pre-
viously (10, 11, 13); however, patients in
these previously published studies typi-
cally did not begin therapy sessions until
⬎1 wk after intubation. In contrast, our
trial demonstrates that activity is feasible
in intubated patients immediately after
intubation. This is the first trial that re-
ports the feasibility and safety of such an
extremely early intervention. Level of as-
sistance initially delivered by the thera-
pist depended on the activity performed,
but typically required that the therapist
support between 25% and 75% of the
patient’s effort during mechanical venti-
lation (Functional Independence Measure
scores median 2– 4; Table 2). An awake
and normal neurocognitive state (no de-
lirium or coma) was possible in patients
receiving MV and PT/OT. Many condi-
tions seen in critically ill mechanically
ventilated patients could be perceived as
barriers to early mobilization; however,
patients with high acuities of illness such
as those with acute lung injury or acute
respiratory distress syndrome were fre-
quently treated in our trial without ad-
verse events. Likewise, vasoactive drug
infusions and continuous renal replace-
ment therapy did not preclude simulta-
neous physical therapy. Other potential
impediments to early mobilization such
as obesity and the presence of vascular
access devices did not impair very early
mobilization universally. Certainly, such
conditions require careful, coordinated
planning with multiple care providers
(physicians, nurses, therapy staff) before
initiating mobilization. Because our
study was performed in medical ICU pa-
tients, it is not clear from our results
whether early PT/OT is safe and feasible
in other ICU patients (for example, sur-
gical ICU).
Adverse events occurred in 16% of ses-
sions, although many of these events rep-
resent expected physiological changes
with exercise (such as heart rate or respi-
ratory rate increase). Therapy rarely
needed to be discontinued permanently
as a result of patient instability or dis-
comfort. Although therapy in patients on
MV was protocol-based, the physical and
occupational therapists determined the
nature and details of the interventions,
derived from a daily assessment, which
measured each patient’s physical deficits
and goals. The deficit and goal assess-
ments varied with each session; the over-
all goal was to improve on specific deficits
and thus progress toward increasing
functional independence. Accordingly,

Crit Care Med 2010 Vol. 38, No. 11 2093

each therapy session was guided by a
common principle of sequential progres-
sion of activity based on individual pa-
tient tolerance.
CONCLUSIONS
PT/OT paired with sedative interrup-
tion and occurring immediately from the
onset of MV is both feasible and safe. A
variety of physical activities culminating
in ambulation can be accomplished dur-
ing endotracheal intubation. Patients
most commonly required no sedation
during therapy sessions on MV, and an
awake, nondelirious state of mind oc-
curred commonly. Protocols directed at
sedative interruptions with subsequent
PT/OT can be implemented successfully
in medical ICUs.
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APPENDIX A
Contraindications to Initiating PT/OT
A. Mean arterial pressure ⬍65
B. Heart rate ⬍40, ⬎130 beats/min
C. Respiratory rate ⬍5, ⬎40 breaths/
min
D. Pulse oximetry ⬍88%
E. Evidence of elevated intracranial
pressure
F. Active gastrointestinal blood loss
G. Active myocardial ischemia
H. Actively undergoing a procedure
I. Patient agitation requiring in-
creased sedative administration in
the last 30 mins
J. Insecure airway (device)
APPENDIX B
Adverse Events—Contraindications to
Continuing PT/OT
A. Mean arterial pressure ⬍65
B. Heart rate ⬍40, ⬎130 beats/min
C. Respiratory rate ⬍5, ⬎40 breaths/
min
D. Pulse oximetry ⬍88%
E. Marked ventilator dysynchrony
F. Patient distress
a. Evidenced by nonverbal cues,
gestures
b. Physically combative
G. New arrhythmia
H. Concern for myocardial ischemia
I. Concern for airway device integ-
rity
J. Fall to knees
K. Endotracheal tube removal
Crit Care Med 2010 Vol. 38, No. 11