Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study

Published online: 13 October 2016Background: Many patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness. ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention. Methods: This will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients. Discussion: This study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study. Trial registration: ANZCTR ACTRN12616000206426Yasmine Ali Abdelhamid, Liza Phillips, Michael Horowitz and Adam Dean

Factors affecting adherence to progressive resistance exercise for persons with COPD

PURPOSE: Exercise is an important treatment modality for persons with chronic obstructive pulmonary disease (COPD), but factors influencing adherence have been examined infrequently. The purpose of this investigation was to explore adherence factors to a progressive resistance exercise program for persons with COPD. METHODS: Persons with COPD enrolled in a 12-week trial of progressive resistance exercise were invited to participate in 2 semistructured qualitative interviews exploring program adherence. Interviews were audio-taped, transcribed, and then coded independently by 2 researchers. Themes relating to short-term and long-term adherence were then developed and described. RESULTS: Twenty-two participants were interviewed at the conclusion of the intervention (12 weeks), and 19 completed a second interview at 24 weeks. Short-term exercise adherence was facilitated by expected outcomes, self-motivation, supervision, and group support, whereas health and weather factors were the major barriers to adherence. The barriers to exercise remained unchanged at 24 weeks despite a large decline in exercise adherence. Removal of environmental support at 12 weeks may have contributed to poor long-term exercise maintenance, with participants identifying group support and regular monitoring by a therapist as the most important strategies for maintaining exercise. CONCLUSIONS: The provision of external support in training program design appears important for persons with COPD. Longer-term adherence declined when group support and regular monitoring by a therapist was removed, despite the major perceived exercise barriers remaining unchanged. Therefore, further investigation is required to determine effective strategies for maximizing longer-term exercise adherence in this population

Comparison of flow rates produced by two frequently used manual hyperinflation circuits: A benchtop study

Background: Manual hyperinflation is a treatment technique commonly used by physiotherapists in intensive care units to reverse or prevent atelectasis and mobilize airway secretions in intubated patients. The aim of this study was to determine which of the Magill (Rusch Manufacturing Ltd, Craigavon, UK) or Mapleson-C (CIG DF 655, CIG Medishield, Sydney, Australia) manual hyperinflation circuits was theoretically more effective at mobilizing secretions. Methods: A semi-blinded crossover study of 12 physiotherapists with tertiary level intensive care unit experience was conducted on a benchtop model. The order of circuits and compliance settings was randomized. Results: The Mapleson-C circuit produced a significantly faster peak expiratory flow (F[1, 210] = 14.51, P ≤ .01) and smaller inspiratory to expiratory flow ratio (F[1, 210] = 28.44, P ≤ .01) than the Magill circuit regardless of compliance settings. Conclusion: The results of this study suggest that the Mapleson-C manual hyperinflation circuit may be more effective at mobilizing secretions

The time taken for the regional distribution of ventilation to stabilise: An investigation using electrical impedance tomography

Electrical impedance tomography is a novel technology capable of quantifying ventilation distribution in the lung in real time during various therapeutic manoeuvres. The technique requires changes to the patient’s position to place the electrical impedance tomography electrodes circumferentially around the thorax. The impact of these position changes on the time taken to stabilise the regional distribution of ventilation determined by electrical impedance tomography is unknown. This study aimed to determine the time taken for the regional distribution of ventilation determined by electrical impedance tomography to stabilise after changing position. Eight healthy, male volunteers were connected to electrical impedance tomography and a pneumotachometer. After 30 minutes stabilisation supine, participants were moved into 60 degrees Fowler’s position and then returned to supine. Thirty minutes was spent in each position. Concurrent readings of ventilation distribution and tidal volumes were taken every five minutes. A mixed regression model with a random intercept was used to compare the positions and changes over time. The anterior-posterior distribution stabilised after ten minutes in Fowler’s position and ten minutes after returning to supine. Left-right stabilisation was achieved after 15 minutes in Fowler’s position and supine. A minimum of 15 minutes of stabilisation should be allowed for spontaneously breathing individuals when assessing ventilation distribution. This time allows stabilisation to occur in the anterior-posterior direction as well as the left-right direction.Full Tex

A Simple Clinical Measure of Quadriceps Muscle Strength Identifies Responders to Pulmonary Rehabilitation

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Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study

Background: Critical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. Objectives: The objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach–style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. Methods: A new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. Results: The service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. Conclusions: Critical care outreach–style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.No Full Tex

Global tidal variations, regional distribution of ventilation, and the regional onset of filling determined by electrical impedance tomography: reproducibility

The reproducibility of the regional distribution of ventilation and the timing of onset of regional filling as measured by electrical impedance tomography lacks evidence. This study investigated whether electrical impedance tomography measurements in healthy males were reproducible when electrodes were replaced between measurements. Part 1: Recordings of five volunteers lying supine were made using electrical impedance tomography and a pneumotachometer. Measurements were repeated at least three hours later. Skin marking ensured accurate replacement of electrodes. No stabilisation period was allowed. Part 2: Electrical impedance tomography recordings of ten volunteers; a 15 minute stabilisation period, extra skin markings, and time-averaging were incorporated to improve the reproducibility. Reproducibility was determined using the Bland-Altman method. To judge the transferability of the limits of agreement, a Pearson correlation was used for electrical impedance tomography tidal variation and tidal volume. Tidal variation was judged to be reproducible due to the significant correlation between tidal variation and tidal volume (r2 = 0.93). The ventilation distribution was not reproducible. A stabilisation period, extra skin markings and time-averaging did not improve the outcome. The timing of regional onset of filling was reproducible and could prove clinically valuable. The reproducibility of the tidal variation indicates that non-reproducibility of the ventilation distribution was probably a biological difference and not measurement error. Other causes of variability such as electrode placement variability or lack of stabilisation when accounted for did not improve the reproducibility of the ventilation distribution.Full Tex

Secretion clearance strategies in Australian and New Zealand Intensive Care Units

© 2017 Introduction/aims: To describe the processes of care for secretion clearance in adult, intubated and mechanically ventilated patients in Australian and New Zealand Intensive Care Units (ICUs). Methods/results: A prospective, cross-sectional study was conducted through the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) Point Prevalence Program. Forty-seven ICUs collected data from 230 patients intubated and ventilated on the study day. Secretion clearance techniques beyond standard suctioning were used in 84/230 (37%) of patients during the study period. Chest wall vibration 34/84 (40%), manual lung hyperinflation 24/84 (29%), chest wall percussion 20/84 (24%), postural drainage/patient positioning 17/84 (20%) and other techniques including mobilisation 15/84 (18%), were the most common secretion clearance techniques employed. On average (SD), patients received airway suctioning 8.8 (5.0) times during the 24-h study period. Mucus plugging events were infrequent (2.7%). The additional secretion clearance techniques were provided by physiotherapy staff in 24/47 (51%) ICUs and by both nursing and physiotherapy staff in the remaining 23/47 (49%) ICUs. Conclusion: One-third of intubated and ventilated patients received additional secretion clearance techniques. Mucus plugging events were infrequent with these additional secretion clearance approaches. Prospective studies must examine additional secretion clearance practices, prevalence of mucus plugging episodes and impact on patient outcomes

Fatigue, muscle strength and vitamin D status in women with systemic lupus erythematosus compared with healthy controls

Recent studies have demonstrated an inverse relationship between vitamin D levels and fatigue in systemic lupus erythematosus (SLE). The aims of this study were to evaluate proximal muscle strength, fatigue and vitamin D levels in women with SLE compared with healthy controls and to investigate relationships between these factors in a cohort of women with SLE. Forty-five women (24 SLE, 21 healthy controls) participated. Primary outcome measures were the fatigue severity scale (FSS), isometric muscle strength of dominant limbs using hand held dynamometry, two functional tests-the 30-second chair stand test and the 1-kg arm lift test, with vitamin D status measured using 25(OH)D. Overall 25(OH)D levels were 68.4 (22.4) nmol/L with no difference between SLE and control groups. There was a statistically and clinically significant difference in fatigue, 1-kg arm lift, 30-second sit to stand, knee extension, hip flexion, hip abduction, shoulder flexion and grip strength in the SLE group compared with the control group (p < 0.05). In the SLE group FSS was moderately correlated with both functional measures (1-kg arm lift r = -0.42, 30-second chair stand r = -0.44, p < 0.05). However, no statistically significant correlation between dynamometry measures and fatigue was evident. There was no association between fatigue and 25(OH)D level (r = -0.12). In summary, women with SLE were weaker and demonstrated reduced physical function and higher fatigue levels than healthy controls. Fatigue was related to physical function but not vitamin D status or maximal isometric strength in vitamin D replete individuals with SLE