Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework

Question: From the perspective of intensive care unit (ICU) clinicians, what are the barriers to and facilitators of implementing early mobilisation? Design: A qualitative study using focus groups, with analysis using the Theoretical Domains Framework. Participants: Physicians, nurses, respiratory therapists and physiotherapists from the ICUs of three university-affiliated hospitals in Montreal, Canada. Methods: Four focus group meetings were conducted with 33 participating ICU clinicians. Two researchers independently performed thematic content analysis on verbatim transcriptions of the audio recordings using the Theoretical Domains Framework. Results: Data saturation was reached after the third focus group. Thirty-six barriers were categorised in 13 domains of the Theoretical Domains Framework. The key barriers to early mobilisation were: lack of conviction and knowledge regarding the available evidence about early mobilisation; lack of attention to the provision of optimal care; poor communication; the unpredictable nature of the ICU; and limited staffing, equipment, time and clinical knowledge. Twenty-five facilitators categorised in ten TDF domains were also identified. These included individual-level facilitators (intrinsic motivation, positive outcome expectations, conscious effort to mobilise early, good planning/coordination, the presence of ICU champions, and expert support by a physiotherapist) and organisational-level facilitators (reminder system, pro-early mobilisation culture, implementation of an early mobilisation protocol, and improved ICU organisation). Conclusions: A broad array of barriers to and facilitators of early mobilisation in the ICU were identified in this study. Clinicians can consider whether these barriers and facilitators are operating in their ICU. These may inform the design of tailored knowledge translation interventions to promote early mobilisation in the ICU

Spinal Cord Injury Modulates the Lung Inflammatory Response in Mechanically Ventilated Rats: A Comparative Animal Study

Mechanical ventilation (MV) is widely used in spinal injury patients to compensate for respiratory muscle failure. MV is known to induce lung inflammation, while spinal cord injury (SCI) is known to contribute to local inflammatory response. Interaction between MV and SCI was evaluated in order to assess the impact it may have on the pulmonary inflammatory profile. Sprague Dawley rats were anesthetized for 24 h and randomized to receive either MV or not. The MV group included C4–C5 SCI, T10 SCI and uninjured animals. The nonventilated (NV) group included T10 SCI and uninjured animals. Inflammatory cytokine profile, inflammation related to the SCI level, and oxidative stress mediators were measured in the bronchoalveolar lavage (BAL). The cytokine profile in BAL of MV animals showed increased levels of TNF-α, IL-1β, IL-6 and a decrease in IL-10 (P = 0.007) compared to the NV group. SCI did not modify IL-6 and IL-10 levels either in the MV or the NV groups, but cervical injury induced a decrease in IL-1β levels in MV animals. Cervical injury also reduced MV-induced pulmonary oxidative stress responses by decreasing isoprostane levels while increasing heme oxygenase-1 level. The thoracic SCI in NV animals increased M-CSF expression and promoted antioxidant pulmonary responses with low isoprostane and high heme oxygenase-1 levels. SCI shows a positive impact on MV-induced pulmonary inflammation, modulating specific lung immune and oxidative stress responses. Inflammation induced by MV and SCI interact closely and may have strong clinical implications since effective treatment of ventilated SCI patients may amplify pulmonary biotrauma

Pursed-lips breathing in health and disease

The investigations contained within this thesis were performed to gain a more comprehensive understanding of pursed-lips breathing (PLB). The first study compared the load compensatory responses of expiratory resistive loading (ERL) and volitional pursed-lips breathing (PLB) in healthy individuals. Although ERL and PLB promoted similar respiratory muscle recruitment responses, ERL did not fully simulate the breathing pattern and end-expiratory lung volume (EELV) changes induced by PLB. PLB promoted a slower and deeper breathing pattern during both rest and exercise. It had no effect on resting inspiratory muscle recruitment patterns, but modestly increased the contribution of the rib cage/accessory muscles and abdominal muscle relaxation during exercise. Greater expiratory muscle recruitment was promoted by PLB during rest and exercise. In the second study, volitional PLB produced a slower and deeper breathing pattern in patients with COPD at rest and during exercise. Inspiratory muscle recruitment patterns were not altered by PLB in either condition. Expiratory muscle recruitment was increased at rest. Because such muscles were markedly recruited during exercise alone, PLB produced no further effect. PLB had an inconsistent effect on dyspnea across patients. This effect was related to the changes it concurrently promoted to EELV and tidal volume and the impact of such on ventilatory muscle force generating capacity and performance. The third study endeavoured to determine the prevalence of spontaneous PLB in 57 patients with COPD during conditions of rest, exercise and recovery. Patients who spontaneously performed PLB at rest, invariably continued during exercise and recovery, whereas patients who commenced PLB during exercise continued during recovery. In our patients, 11% used PLB at rest, 42% during exercise, 54% during recovery, 35% did not perform PLB at any time, and 11% performed such other maneuvers as grunting or hissing. Factors distinguishing patien

Mechanical Ventilation Modulates Pro-Inflammatory Cytokine Expression in Spinal Cord Tissue After Injury in Rats

Rationale: Spinal cord injury (SCI) may induce significant respiratory muscle weakness and paralysis, which in turn may cause a patient to require ventilator support. Central nervous system alterations can also exacerbate local inflammatory responses with immune cell infiltration leading to additional risk of inflammation at the injury site. Although mechanical ventilation is the traditional treatment for respiratory insufficiency, evidence has shown that it may directly affect distant organs through systemic inflammation. Objectives: This study aimed to better understand the impact of invasive mechanical ventilation on local spinal cord inflammatory responses following cervical or thoracic SCI. Methods: Five groups of female Sprague-Dawley rats were anesthetised for 24 h. Three groups received mechanical ventilation: seven rats without SCI, seven rats with cervical injury (C4-C5), and seven rats with thoracic injury (T10); whereas, two groups were non-ventilated: six rats without SCI; and six rats with thoracic injury (T10). Changes in inflammatory responses were determined in the spinal cord tissues collected at the local site of injury. Cytokines were measured using ELISA. Main results: SCI induced local pro-inflammatory cytokine IL-6 expression for all groups. Mechanical ventilation also had effects on pro-inflammatory cytokines and independently increased TNF-α and decreased IL-1β levels in the spinal cords of anesthetized rats. Conclusion: These data provide the first evidence that mechanical ventilation contributes to local inflammation after SCI and in the absence of direct tissue injury