Diaphragm dysfunction in mechanically ventilated patients is associated with poor outcome. Maximal inspiratory pressure (MIP) can be used to evaluate inspiratory muscle function. However, it is unclear whether respiratory weakness is independently associated with long-term mortality. The aim of this study was to determine if low MIP is independently associated with one-year mortality. We conducted a prospective observational cohort study in an 18-bed ICU. Adults requiring at least 24 hours of mechanical ventilation with scheduled extubation and no evidence of pre-existing muscle weakness underwent MIP evaluation just before extubation. Patients were divided into two groups: low MIP (MIP ≤30 cmH2O) and high MIP (MIP >30 cmH2O). Mortality was recorded for one year after extubation. For the survival analysis, the effect of low MIP was assessed using the log-rank test. The independent effect of low MIP on post mechanical ventilation mortality was analyzed using a multivariable Cox regression model. One hundred and twenty-four patients underwent MIP evaluation (median age 66 years (25th–75th percentile 56–74), Simplified Acute Physiology Score (SAPS) 2 = 45 (33–57), duration of mechanical ventilation 7 days (4–10)). Fifty-four percent of patients had low MIP. One-year mortality was 31 % (95 % CI 0.21, 0.43) in the low MIP group and 7 % (95 % CI 0.02, 0.16) in the high MIP group. After adjustment for SAPS 2 score, body mass index and duration of mechanical ventilation, low MIP was independently associated with one-year mortality (hazard ratio 4.41, 95 % CI 1.5, 12.9, p = 0.007). Extubation failure was also associated with low MIP (relative risk 3.0, 95 % CI 1, -9.6; p = 0.03) but tracheostomy and ICU length of stay were not. Low MIP is frequent in patients on mechanical ventilation and is an independent risk factor for long-term mortality in ICU patients requiring mechanical ventilation. MIP is easily evaluated at the patient’s bedside. This study was retrospectively registered in www.clinicaltrials.gov (NCT02363231) in February 2015.

Background: Few studies have evaluated muscle strength in COVID-19 ICU survivors. We aimed to report the incidence of limb and respiratory muscle weakness in COVID-19 ICU survivors. Method: We performed a cross sectional study in two ICU tertiary Hospital Settings. COVID-19 ICU survivors were screened and respiratory and limb muscle strength were measured at the time of extubation. An ICU mobility scale was performed at ICU discharge and walking capacity was self-evaluated by patients 30 days after weaning from mechanical ventilation. Results: Twenty-three patients were included. Sixteen (69%) had limb muscle weakness and 6 (26%) had overlap limb and respiratory muscle weakness. Amount of physiotherapy was not associated with muscle strength. 44% of patients with limb weakness were unable to walk 100 m 30 days after weaning. Conclusion: The large majority of COVID-19 ICU survivors developed ICU acquired limb muscle weakness. 44% of patients with limb weakness still had severely limited function one-month post weaning.

In the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive. A randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle. The results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques. Most bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out. ClinicalTrials.gov, NCT02920684 . Registered on 30 September 2016. Prospectively registered.

How effective is home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) for people with chronic obstructive pulmonary disease (COPD) compared with: no exercise therapy (ET), in/outpatient ET, and home-based ET without ATT? Systematic review and meta-analysis of randomised trials. People with stable COPD referred for ET. ATT-ET. Exercise capacity, quality of life, functional dyspnoea, cost-effectiveness and various secondary outcomes. Fifteen eligible trials involved 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (four studies, 6-minute walk test MD 15 m, 95% CI 5 to 24) and probably improved quality of life (four studies, SMD 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in/outpatient ET on functional dyspnoea (two studies, SMD -0.05, 95% CI -0.39 to 0.29) and a similar or better effect on quality of life (two studies, SMD 0.23, 95% CI -0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (three studies, 6-minute walk test MD 6 m, 95% CI -26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (three studies, 6-minute walk test MD 2 m, 95% CI -16 to 19) and similar or better effects on quality of life (three studies, SMD 0.79, 95% CI -0.04 to 1.62) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator. ATT-ET improves exercise capacity, functional dyspnoea and quality of life compared with no ET, although some benefits may be small. Its benefits are generally similar to in/outpatient ET and similar to or better than home-based ET without ATT. PROSPERO CRD42020165773.

Background: The relationship between muscle function in critically ill patients assessed using bedside techniques and clinical outcomes has not been systematically described. We aimed to evaluate the association between muscle weakness assessed by bedside evaluation and mortality or weaning from mechanical ventilation, and the capacity of each evaluation tool to predict outcomes.Methods: Five databases (PubMed, Embase, CINAHL, Cochrane Library, Science Direct) were searched from January 2000 to December 2018. Data were extracted and random effects meta-analyses were performed.Results: 60 studies were analysed, including 4382 patients. Intensive care unit (ICU)-related muscle weakness was associated with an increase in overall mortality with odds ratios ranging from 1.2 (95% CI 0.60–2.40) to 4.48 (95% CI 1.49–13.42). Transdiaphragmatic twitch pressure had the highest predictive capacity for overall mortality, with a sensitivity of 0.87 (95% CI 0.76–0.93) and a specificity of 0.36 (95% CI 0.27–0.43). The area under the curve (AUC) was 0.74 (95% CI 0.70–0.78). Muscle weakness was associated with an increase in mechanical ventilation weaning failure rate with an odds ratio ranging from 2.64 (95% CI 0.72–9.64) to 19.07 (95% CI 9.35–38.9). Diaphragm thickening fraction had the highest predictive capacity for weaning failure with a sensitivity of 0.76 (95% CI 0.67–0.83) and a specificity of 0.86 (95% CI 0.78–0.92). The AUC was 0.86 (95% CI 0.83–0.89).Conclusion: ICU-related muscle weakness detected by bedside techniques is a serious issue associated with a high risk of death or prolonged mechanical ventilation. Evaluating diaphragm function should be a clinical priority in the ICU.

In people with non-small cell lung cancer, what is the effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen? Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of the primary outcome. People with diagnosed or suspected non-small cell lung cancer and moderate-to-high risk of postoperative complications. Fifteen supervised prehabilitation sessions delivered with either a dense regimen of five sessions/week for 3 weeks (experimental group) or a non-dense regimen of three sessions/week for 5 weeks (control group). The primary outcome was the change in cardiorespiratory fitness measured by the V̇O_2peak in ml/kg/min. The secondary outcomes were the change in other variables of interest measured during cardiopulmonary exercise testing, non-invasive nutritional markers, quadriceps maximal voluntary isometric contractions, maximal inspiratory pressure, quality of life, adherence and postoperative complications. Changes with the experimental regimen were similar to or better than changes with the control regimen for: V̇O_2peak (MD 1.2 ml/kg/min, 95% CI -0.1 to 2.6); V̇E/V̇CO₂ slope (MD -3.6 points, 95% CI -8.7 to 1.5); and work rate at ventilatory threshold (MD 3.7 W, 95% CI -5.6 to 13.0). The two regimens had similar effects on: peak work rate (MD 1.3 W, 95% CI -6.4 to 9.0), V̇O₂ at ventilatory threshold (MD 0.0 ml/kg/min, 95% CI -1.4 to 1.4); body mass index (MD -0.2 kg/m², 95% CI -0.5 to 0.1); and maximal inspiratory pressure (MD -0.7 cmH₂O, 95% CI -9.8 to 8.4). The relative effect was uncertain for quadriceps maximal voluntary isometric contractions, quality of life and complications. Condensing prehabilitation sessions led to similar or better improvement in cardiorespiratory fitness and did not decrease adherence or increase adverse events. This could increase the number of patients who can be referred for prehabilitation, despite short presurgical periods. NCT03936764.