Respiratory muscle training...

This is a journal article critique on a research which is entitled " INSPIRATORY MUSCLE TRAINING TO ENHANCE RECOVERY FROM MECHANICAL VENTILATION; A RANDOMIZED TRIAL"

1. Respiratory Muscle training for post mechanical ventilation patients Article Critique by; Kimberly Walsh SPT

2. BRIEF INFORMATION ON RESPIRATORY MUSCLE TRAINING ARTICLE OBJECTIVE METHODOLOGY INTERVENTION MEASURES RESULTS DISCUSSION CONCLUSION STRONG POINTS LIMITATIONS REFERENCES

3. Respiratory muscle training A technique that aims to improve function of the respiratory muscles using specific exercises. Normally aimed at people who have Asthma, Bronchitis, Emphysema and COPD

4. RESPIRATORY MUSCLE TRAINING Consist of Inspiratory Muscle Training (IMT) or Expiratory Muscle Training (EMT) or a combination of both

5. Respiratory muscle training Responses to RMT includes: Changes in muscle fiber type Improvements in strength, speed, power, endurance performance MIP and MEP

6. RESPIRATORY MUSCLE TRAINING Training Principles Overload Specificity Reversibility

7. INSPIRATORY MUSCLE TRAINING TO ENHANCE RECOVERY FROM MECHANICAL VENTILATION; A RANDOMIZED TRIAL AUTHORS: Bernie M Bisset , Anne Leditschke , Teresa Neeman , Robert Boots, Jennifer Paratz Published on June 2, 2016

8. Article objective The objective of this research was to see if IMT improves inspiratory muscle strength and quality of life (QOL) in patients recently weaned from invasive ( mechanical) ventilation

9. Methodology Participants were selected by computer – generated random number sequence, managed by off- site administrative staff The study was conducted at the Canberra Hospital ( located in Australia)

10. METHODOLOGY A second hospital was also included (Calvary Hospital) but no patients were recruited due to failure to meet requirements

11. With 48 hours of successful weaning, 70 participants ( mechanically ventilated ≥ 7days) were randomized to receive IMT once daily 5 days/ week for 2 weeks with usual care or just usual care ( control group)

12. METHODOLOGY IMT Group Control Group Inspiratory muscle training ( 2 weeks) Usual physiotherapy ( respiratory treatment and mobilization) Usual physiotherapy ( respiratory treatment and mobilization)

13. Methodology Inclusion Criteria : Patients who are successfully weaned from the mechanical ventilation ( > 48 hrs ) and within the 7 days following the successful weaning Patients aged ≥ 16 years who are able to provide informed consent Patients who are alert and able to train with a Riker score of 4

14. METHODOLOGY EXCLUSION CRITERIA Low neurological status Pregnant Participation in IMT while ventilated Delirium/ agitation Medically unstable Declined to participate Imminent Palliation Intellectual disability Unable to communicate Facial Fractures

15. INTERVENTION Participants were randomized to receive either usual care (control group) or IMT with usual care IMT was performed using a threshold IMT – Inspiratory Muscle Trainer ( threshold IMT device HS730,Respironics, New Jersey, USA)

16. INTERVENTION

17. INTERVENTION This device was used with the mouthpiece, or flexible connector to attach to the tracheostomy Once a tracheostomy in situ, IMT was always performed with the cuff inflated to ensure accurate loading

18. Intervention

19. Intervention The physiotherapist gave an intensity of 50% MIP for the first training set Then quickly increase it to a tolerable intensity that allowed for the pt to complete 6 th breath in a set of six breaths with 5 sets of six breaths completed each session

20. INTERVENTION The intensity was increased daily by the physiotherapist by manually increasing the threshold resistance by 1-2 cm H2O Training started on the day of enrolment and was done once daily for 2 weeks (weekdays only)

21. Measures Primary Endpoints- inspiratory muscle strength and Inspiratory Muscle Fatigue Secondary Endpoints- Dyspnoea, physical function and quality of life, post intensive care length of stay and in- hospital mortality

22. RESULTS MIP improved in both groups with a greater increase in the IMT group than the control group – 17% in the IMT group compared to 6 % in control, p= 0.024. No statistical value change in FRI was observed in both groups (0.03 vs 0.02, p=0.81)

23. Results Quality of Life was greater in the IMT group Changes in dyspnoea scores at rest and during exercise were not statistically significant. No significant difference in post – ICU length of stay, reintubation rate or ICU readmission

24. RESULTS There was a difference in hospital mortality which was higher in the IMT group (p=0.051) with four deaths.

25. Discussion Participants who completed 2 weeks of IMT have greater improvement in respiratory muscle strength than their counterparts IMT group expressed improved quality of life using the EQ5D

26. DISCUSSION In COPD patients IMT has longer term effects including lower rates of hospitalization over a 12 month period The maximum setting on the device is 41cmH2O and it was impossible for 2 participants to achieve greater than 50% MIP

27. DISCUSSION The reasons for improved QOL in the absence of a demonstrated effect on respiratory endurance, dyspnoea or functional level remained unclear

28. Conclusions IMT following successful weaning increases IMT strength and QOL . The researchers cannot confidently rule out an associated increase risk of in- hospital mortality

29. Strong Points The study was approved by the Australian Capital Territory Health Human Ethics Committee and the University of Queensland Medical Research Ethics Committee This study was the first to demonstrate the value of IMT for patients in the postextubation period Clear and concise Inclusion Criteria

30. STRONG POINTS Good reliability , inter – rater reliability and validity of most research tools used in the research There was researcher blinding to group allocation for MIP, QOL, Dyspnoea and physical function measurements

31. LIMITATIONS The physiotherapists could not be blinded in administering IMT training to patients Inability to demonstrate an improvement in Inspiratory M uscle Endurance in the IMT group A lack of follow-up of primary outcomes beyond 2 weeks

32. LIMITATIONS Not all participants achieved greater than 50% MIP which underestimated the effect of IMT in this research

33. LIMITATIONS In assessing QOL the researchers also used SF36 questionnaire which is a lengthy questionnaire.

34. THE IMPORTANCE OF THIS RESEARCH This research can let PTs understand how this specific regime of IMT may be useful adjunct to the medical management pts in post weaning period

35. REFERENCES Buxton, S . Cotton, L. Lowe, R. Respiratory Muscle Training. Retrieved from http:// www.physio-pedia.com/Respiratory _ Muscle_Training Bissett , B., Boots, R., Leditschke , A., Neeman , T., Paratz . (2016). Inspiratory Muscle training to enhance recovery from mechanical ventilation : a randomized trial. Thorax Online First. 71(9) http://thorax.bmj.com/content/71/9/812.short?g=w_thorax_current_tab

36. THE END ANY QUESTIONS??