No abstract

The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However, the following evidence-based targets for physiotherapy were identified: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. Discrepancies and lack of data on the efficacy of physiotherapy in clinical trials support the need to identify guidelines for physiotherapy assessments, in particular to identify patient characteristics that enable treatments to be prescribed and modified on an individual basis. There is a need to standardize pathways for clinical decision-making and education, to define the professional profile of physiotherapists, and increase the awareness of the benefits of prevention and treatment of immobility and deconditioning for critically ill adult patients.

Difficult-to-wean patients have a high hospital mortality rate and poor long-term prognosis. Age, main diagnosis, severity of illness, weaning success and institution of NIV predict survival.

This study was designed to evaluate the performance of movement detectors (pedometers) in measuring daily activity of patients with chronic lung disease. Three groups of subjects were studied: group 1: 25 patients with stable nonhypercapnic chronic obstructive pulmonary disease (COPD) (forced expiratory volume in one second (FEV1) = 47+/-9% predicted) studied twice, one month apart; group 2: 25 patients with chronic respiratory failure studied before and three months after nasal nocturnal mechanical ventilation; and group 3: 25 normal healthy subjects studied once. The median level of activity in the healthy subjects (group 3) was three times greater than in either group of patients (groups 1 and 2). Activity levels were not correlated with age, sex or employment status. The repeatability of the activity counts in the nonhypercapnic COPD patients was high (intraclass correlation coefficient=0.94) and in these patients activity correlated significantly with FEV1 (r=0.54, p=0.006). In the respiratory failure patients, daytime arterial carbon dioxide pressure (Pa,CO2) improved following nasal nocturnal mechanical ventilation (NMV) (pre NMV: 8.5+/-1.2 kPa; post NMV: 6.2+/-0.5 kPa), health status improved (p<0.004) and daily movement count doubled (p<0.0001). This increase correlated with change in Pa,CO2 (r-0.53, p=0.006), but not with improved health status. We conclude that motion detectors may provide repeatable measures of daily activity that are related to physiological impairment and improvement following treatment. Activity counts appear to be complementary to estimates of exercise limitation obtained using health questionnaires.

Anaemia of chronic disease (ACD), with chronically low levels of circulating haemoglobin, is an immune driven abnormality that occurs in many inflammatory diseases, and also in chronic heart failure. Although chronic obstructive pulmonary disease (COPD) is ''traditionally'' associated with polycythaemia, the systemic inflammation that is now recognised as a feature of COPD makes it a possible cause of ACD. If present in COPD, anaemia could worsen dyspnoea and limit exercise tolerance.Preliminary evidence suggests that anaemia in COPD patients may be more prevalent than expected, concerning 10-15% of patients suffering from severe forms of the disease. A database study conducted in 2,524 COPD patients being prescribed long-term oxygen therapy has shown that a low haematocrit is a strong predictor of survival in this population, before body mass index, and is associated with more hospitalisations and a longer cumulative duration of hospitalisation. COPD patients with low haemoglobin levels have a poorer prognosis than COPD patients with normal haemoglobin levels in the event of acute gastrointestinal bleeding or after elective aneurysm repair. Raising haemoglobinaemia through transfusion decreases minute ventilation and work of breathing in COPD patients.These preliminary evidences point to the need to study the prevalence of anaemia, and its physiological and clinical impact in chronic obstructive pulmonary disease. When this body of knowledge is available, the question of the putative benefits of raising haemoglobinaemia in chronic obstructive pulmonary disease will have to be addressed.