should early mobilization be routine in mechanically

Should Early Mobilization Be Routine in MechanicallyVentilated Patients?

Ulrich H Schmidt MD PhD MBA, Lauren Knecht MD, and Neil R MacIntyre MD FAARC

IntroductionEarly Mobilization: The Case for Routine Application in Mechanically

Ventilated PatientsThe Supporting Evidence BaseHow Early, How Often, How Long?

Early Mobilization: Concerns and Reasons for CautionAre the Results of the Many Positive Trials Overstated?Early Mobility Entails Patient RiskEarly Mobility Programs Require Additional ResourcesOther Logistical Challenges

Conclusions

ICU-acquired weakness is a major complication of critical illness requiring mechanical ventilation.Early mobilization has been shown to decrease the negative consequences of ICU-acquired weak-ness. However, early mobilization might entail risks to the patient. Additional staffing needs mighthave a negative financial impact. This review examines whether early mobilization should beroutinely performed in mechanically ventilated patients. Key words: mobilization; weakness; me-chanical ventilation. [Respir Care 2016;61(6):867–875. © 2016 Daedalus Enterprises]

Introduction

Deconditioning and weakness are prevalent problems insurvivors of critical illness requiring mechanical ventila-tion. Intensive care unit (ICU) acquired weakness is char-acterized by fatigue and profound neuromuscular weak-

ness that can cause serious functional disability insurvivors.1,2 Herridge et al3 performed a prospective studyof 109 subjects with ARDS. These subjects had significantphysical disability 1 y after hospital discharge, with �50%of subjects back at work because of persistent fatigue,weakness, and poor functional status.3 The disease patho-genesis is complex and multifactorial but is known to beassociated with the inflammatory response from severesepsis and systemic inflammatory response syndrome. In-dependent of critical illness, bed rest has been shown toincrease reactive oxygen species and inflammatory medi-ators, causing muscle atrophy and protein catabolism, ul-timately leading to disuse atrophy, weakness, and func-tional disability.4 Fink et al5 showed in a preclinical ratmodel that both immobilization and inflammation causemuscle weakness and are additive in their effects. ICU-acquired weakness could therefore be described as a resultof a combination of insults leading to a cycle of inflam-mation, disuse, and muscle breakdown, ultimately leadingto functional disability (Fig. 1).

Drs Schmidt and Knecht are affiliated with the Department of Anesthe-siology, University of California, San Diego, California. Dr MacIntyre isaffiliated with the Department of Medicine, Duke University, Durham,North Carolina.

The authors have disclosed no conflicts of interest.

Dr MacIntyre presented a version of this paper at the 54th RESPIRATORY

CARE Journal conference, held June 5–6, 2015, in St. Petersburg, Florida.

Correspondence: Ulrich H Schmidt MD PhD MBA, Department of An-esthesiology, University of California, 200 West Arbor Drive, Room8770, San Diego, CA 92103-8770. E-mail: [email protected].

DOI: 10.4187/respcare.04566

RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6 867

ICU-acquired weakness is known to be associated withincreased duration of mechanical ventilation, immobilization,and increased ICU and hospital length of stay (LOS). Theincidence of ICU-acquired weakness has been reported byobservational studies to be as high as 57%, depending on theICU population studied.6 Therefore, ICU-acquired weaknessimpairs many ICU survivors and is a major public healthissue.

Given the deleterious consequences of ICU-acquired weak-ness, it is not surprising that early mobilization has beenpromoted to minimize the negative outcome of ICU-acquiredweakness.7 Early mobilization might, however, have unin-tended risks leading to negative outcomes. The followingreview as a pro-con debate will provide the reader with theinformation to judge whether early mobilization should beroutinely performed in mechanically ventilated patients.

Early Mobilization: The Case for Routine Applicationin Mechanically Ventilated Patients

The Supporting Evidence Base

The benefit of physical movement in critically ill pa-tients has been known for decades. In 1995, Griffiths et al7

documented the benefits of passive range-of-motion exer-cise in decreasing muscle atrophy in subjects with criticalillness receiving neuromuscular blockade. The authors usedcontinuous passive motion for 3-h intervals, compared witha control leg that received routine nursing care. In thecontinuous passive motion group, they reported less mus-cle atrophy and a 35% decrease in fiber area. The fact thatpassive range-of-motion exercise helps to reduce muscleatrophy led to changes in ICU protocols. ICU nurses intheir facility are now required to do passive range-of-motionexercises. However, passive stretching in the bed did notsolve the significant problem of protein catabolism.

In 2007, Bailey et al8 investigated whether it was safeand feasible to exercise critically ill subjects while receiv-ing mechanical ventilation. Subjects were included whomet the following criteria: ventilated for �4 d and phys-iologically stable in 3 areas: neurologic (respond to com-mand), respiratory (FIO2

�0.6, PEEP �10 cm H20), andcirculatory (no orthostasis or catecholamine infusions).There were 3 goals of physical activity: sit on the edge ofthe bed, sit in a chair, or walk down the hall. The teamconsisted of nurses, respiratory therapists, physical thera-pists, and critical care technicians. During the study, 103subjects were enrolled, and there were 1,449 activity events:233 events were sitting on the edge of the bed, 454 weresitting in a chair, and 762 were recorded as ambulation.Forty-one percent of the events took place in intubatedsubjects, and 42% of those events were ambulation. Therewere �1% associated adverse events, which included 5falls to knees without injury, 4 systolic blood pressurereadings �90 mm Hg, 3 oxygen saturations �80%, onefeeding tube removal, and one systolic blood pressure�200 mm Hg. There were no unplanned extubations, andnone of the adverse events led to lengthened hospital staysor the need for additional therapy.

Morris et al9 performed a prospective randomizedtrial investigating whether a protocol of early mobility(within 48 h of intubation) with a mobility team versususual care improved patient outcomes and increased thefrequency of physical therapy in ICU subjects. The mo-bility team consisted of a critical care nurse, nursingassistant, and physical therapist and was dedicated toperforming the mobility protocol 7 d/week, whereas theusual care group received physical therapy at the at-tending physician’s discretion. The study included 4levels of activity, and subjects progressed through thembased on consciousness and increased strength, startingwith passive range-of-motion exercises, sitting on theedge of the bed, transfers from bed to chair, seated balanceexercises, pregait exercises, and ambulation. The results ofthis study showed decreased mortality in the protocol groupcompared with the usual care group (12% vs 18%), and therewere no deaths, near-deaths, or cardiopulmonary resuscita-tion during physical therapy. There were no adverse events,such as removal of tubes or devices. There was no differencein ventilator-free days; however, ICU LOS for the protocolgroup was significantly shorter compared with the usual caregroup (5.5 d vs 6.9 d). Similarly, the hospital LOS was alsodecreased in the protocol group (11.2 d vs 14.5 d). The costper subject was $3,000 less in the protocol group than in theusual care group.

In 2009, Schweickert et al10 published a randomizedcontrolled trial that compared scheduled early mobiliza-tion in ventilated subjects with physician-initiated mobil-ity therapy. The primary outcome was the ability of sub-jects to perform the activities of daily living (independent

Fig. 1. Mechanisms of ICU-acquired weakness. LOS � length ofstay.

EARLY MOBILIZATION IN MECHANICALLY VENTILATED PATIENTS

868 RESPIRATORY CARE • JUNE 2016 VOL 61 NO 6

functional status) by hospital discharge. In addition, theauthors included secondary outcomes, such as duration ofdelirium, number of ventilator-free days, and LOS in theICU and hospital. The intervention group started physicaltherapy on the day of trial enrollment, whereas the controlgroup received standard therapy according to physicianorder. Physical therapy progressed from passive range-of-motion exercises to more active bed exercises and furtheron to activities of daily living and walking. The interven-tion group began therapy 1.5 (range 1–2.1) d after intuba-tion, whereas the control group did not start therapy until7.4 (range 6–10.9) d after intubation. Return to indepen-dent functional status was achieved more commonly in theintervention group, 59% of subjects compared with only35% in the control group. The intervention group also hadmore ventilator-free days (23.5 d vs 21.1 d) and fewerdays of delirium (2.0 d vs 4.0 d). Serious adverse eventswere uncommon: one event in 498 physical therapy ses-sions (desaturation �80%).

Morris et al11 looked at hospital readmissions within1 y, in subjects who had been discharged after hospital-ization with acute respiratory failure. They used hospitaldatabases and responses from letters mailed to 280 survi-vors to determine what factors influenced readmission.Among many variables that predicted readmission anddeath was the lack of early ICU mobility in those subjects.This supports the notion that early mobility helps to de-crease hospital costs. Hospital readmissions are a hugeburden on yearly hospital cost and an issue that hospitalstake great strides to reduce. Early mobilization protocols,if instituted nationwide, could cut readmission costs greatly,decreasing overall hospital costs.

Hodgson and co-workers12 addressed whether early mo-bilization plays a role in decreasing longer-term mortalityfollowing a stay in the ICU. These authors observed thecurrent mobilization practice in 12 Australian hospitals,looking at strength of subjects at discharge as well asoutcomes at 3- and 6-month follow-up.12 Of 192 subjectsenrolled, 147 survived to discharge, and 122 subjects(63.5%) did not receive any early mobilization. The mainreported barriers were intubation and sedation. On follow-up, subjects who had received early mobilization had highermuscle strength as measured by the Medical ResearchCouncil Manual Muscle Test Sum Score compared withsubjects who did not receive early mobilization (50 � 11vs 42 � 10, P � .003).

These studies provide substantial evidence that a proto-col for early mobilization is possible and safe, while re-ducing mortality. When begun early, patients are morelikely to return to their independent functional status, withfewer days on the ventilator and a shorter length of ICUdelirium.

How Early, How Often, How Long?

There is no consensus among experts as to the best timeto implement early mobility. Many studies have used in-clusion criteria based on a mechanical ventilation time of�48 h to �4 d (either length of time on the ventilator orlength of time anticipated on the ventilator).8,12,13 Althoughstudies looking at this issue use the duration of mechanicalventilation as an inclusion criterion, there is no common,predefined, or agreed upon time (in days from admissionor intubation) by which physical therapy must be imple-mented to classify it as early mobilization. Experts agreeupon the necessity of patients to meet appropriate physi-ologic parameters before starting physical therapy. Theseparameters include the ability to follow commands, stableventilator settings, and hemodynamic stability.14

Because early mobilization has provided benefits in theICU setting, a continuation of the therapy after transfer outof the ICU seems a logical step. However, the impact ofthis remains unknown because most studies on early mo-bilization have concentrated on the ICU setting and havenot continued the therapy to the floor.

Early Mobilization: Concerns and Reasonsfor Caution

The evidence base supporting benefits from early mobili-zation above is compelling. The following discussion is moreof a cautionary tale, things to be aware of when trying tounderstand and implement an early mobilization protocol.

Are the Results of the Many Positive TrialsOverstated?

There are several reasons to be cautious about overinter-preting the multiple positive trials. First, true equipoisewas probably lacking in many study sites that have longchampioned early mobility. This can lead to a subtle se-lection bias toward keeping “good” subjects in the treat-

Table 1. Reported Complications Associated With Early MobilityFrom 7 Trials

Sessions 8,942Desaturations 27Patient-ventilator asynchrony 19Falls/unsteadiness 15High blood pressure 13Arrhythmias 12Gastrostomy tube loss 7Low blood pressure 6Vascular access loss 3Endotracheal tube loss 1Achilles rupture 1



ment arm and removing “bad” subjects early. These stud-ies are also unblinded by necessity, and this createsadditional potential for bias. Specifically, “believers” maypush more aggressive ventilator withdrawal strategies, se-dation reduction strategies, and nutritional support and pro-vide other forms of assistance to subjects randomized toearly mobility. Indeed, some have suggested that the ma-jority of the benefits attributed to early mobility programsare really a consequence of an aggressive sedation man-agement program, a strategy well documented to facilitateventilator withdrawal.

One must also be cautious of interpreting the cost sav-ings in these kinds of studies. These purported savings areusually calculated as a reduction in resource consumptiondue to shorter LOS. Unfortunately, shorter LOS can trans-late into significant cost reductions only if personnel andinfrastructure elements are reduced or eliminated, some-thing very difficult to do in busy ICUs with fixed spacecosts. Instead, the financial benefit to lower LOS reportedin most studies must be tied to some kind of an increase inrevenue resulting from more ICU bed availability, whereadditional patients can be admitted. These studies lookingat financial benefits for early mobility programs presumethat there will be more turnover and thus more revenue,something that probably occurs but may not.

Early Mobility Entails Patient Risk

Early mobility is not without its risks, and the compli-cations are very real. One study carefully documented anumber of important changes in physiological variablesthat occur after mobility procedures.15 These range fromchanges in heart rate of up to 15 beats/min, changes inbreathing frequency of up to 6 breaths/min, changes inarterial pressure of up to 9 mm Hg, and drops in saturation�1 point. Although these are not huge numbers, they doillustrate that early mobility is associated with physiologicstress. These changes can have important implications inICU patients who already have limited reserves.

Fig. 2. Color-coded symbols for mobilization safety criteria. From Reference 14, with permission.

Fig. 3. Respiratory considerations for early mobility. For color cod-ing definitions, see Figure 2. From Reference 14, with permission.



These physiologic stresses can produce more seriousproblems, some of which have been noted above. A sum-mary of 7 studies is given in Table 1 and shows that themost common problem that terminated a mobility proce-dure was arterial hemoglobin desaturations.16,17 Other im-

portant problems were arrhythmias, ventilator asynchrony,patient falls, blood pressure changes, loss of various cath-eters, and one Achilles tendon rupture. These only occurredin a very small number of sessions (�1%), but when theyoccur, they can be significant. As a consequence, monitoring

Fig. 4. Cardiovascular considerations for early mobility. IABP � intra-aortic balloon pump, ECMO � extracorporeal membrane oxygenation,DVT � deep vein thrombosis, PE � pulmonary embolism, EKG � echocardiogram. For color coding definitions, see Figure 2. FromReference 14, with permission.



is critically important, and this must be performed by per-sonnel trained to know how to respond. As a minimum, heartrate, pulse oximetry, ventilator settings, blood pressure, andalertness/agitation in patients must be carefully monitoredduring any mobility procedure.

In 2008, the European Respiratory Society and Euro-pean Intensive Care Medicine Task Force published guide-lines for mobilization of patients in the ICU.18 These rec-ommendations were based on observational studies andexpert opinion. According to these guidelines, patientscould only undergo physical therapy after passing a verylong checklist of physiologic parameters. Therefore, if apatient falls outside of the list in one or a few areas, he orshe is excluded from physical therapy at that time. How-ever, Garzon-Serrano et al19 state that these strict barriersmight hurt patients by not allowing them to start therapy atan earlier stage in their hospital stay. These authors advo-cate for allowing the patients to participate in therapy un-der the care of a health-care provider who can observe andmaintain blood pressure, heart rate, and oxygen saturationswithin reasonable limits. They argue that patients shouldthus be evaluated on an individual basis rather than bystrict exclusion criteria. More data are required to evaluatethis.

A more recent consensus group has put together recom-mendations on safety criteria to consider before embarkingon active mobilization of mechanically ventilated, criti-cally ill patients.14 These recommendations are presentedas a series of color-coded green, yellow, and red situations(Fig. 2). Green means that the consideration should not bea major barrier to mobility, yellow means that specificmonitoring strategies should be provided, and red meansthat the patient should not be subjected to mobility proce-dures. These are summarized in Figures 3–6.

Early Mobility Programs Require AdditionalResources

Most mobility programs involve several levels of pro-gressive activity, as noted above. Level 1 is simply withthe patient lying in bed, level 2 is with the patient sittingon the bed, level 3 is standing and pivoting, and finallylevel 4 is walking. These all require various levels ofadditional caregivers. If the patient is simply lying in thebed, most activities can usually be accomplished by thebedside nurse. However, once the patient is sitting onthe bed, additional personnel are required. If the patient isstanding, there may be more than one person required, andif the person is walking, especially with a ventilator, thismay require multiple caregivers.

To address these issues, additional resources are goingto be required. Three large centers (Wake Forest Univer-sity, John Hopkins University, and the University of Cal-ifornia at San Francisco) reported the increased need for

resources for carrying out mobility programs.20 At WakeForest University, 7-d/week mobility is provided. To dothis, one additional registered nurse, one additional nurs-ing assistant, one additional physical therapist, and a man-ager were needed. At Johns Hopkins, which provides6-d/week mobility, one physical therapist, one occupa-tional therapist, one technician, one coordinator, one part-time assistant coordinator, and 2 new wheel chairs wereadded. At the University of California at San Francisco,

Fig. 5. Neurological considerations for early mobility. RASS � Rich-mond Agitation Assessment Scale, CAM-ICU � confusion assess-ment method for the ICU. For color coding definitions, see Figure2. From Reference 14, with permission.



which provided 5-d/week mobility capabilities, one phys-ical therapist and one part-time aid were added. An ICUplatform walker was also required. Thus, up to 6 addi-tional new personnel needed to be hired to carry out theseprograms, and often some additional equipment is required.The bottom line is that these programs are not free, andadministration must buy into these additional resources toallow these programs to exist.

Other Logistical Challenges

In 2011, Garzon-Serrano et al19 identified some impor-tant barriers to physical therapy in the ICU. The mostcommonly identified barriers were continuous renal re-

placement therapy, hemodynamic instability, and neuro-logic impairment. This is in accordance with other studiesin naming hemodynamic and respiratory instability andsedation as major barriers to initiating physical therapy inthe ICU.8-10 These barriers must be addressed for a mo-bility program to be successful.

Conclusions

Functional disability after critical illness can be a majorproblem for patients.21 Although survival from the ICUhas improved greatly in the last 30 y, these patients con-tinue to have poor long-term physical outcomes. ICU-acquired weakness is implicated in causing many patients’poor physical outcomes. Multiple studies have shown thatimmobility during bed rest and the inflammatory responseduring critical illness are associated with the developmentof ICU-acquired weakness. Unfortunately, in most ICUsacross the world, patients who require prolonged mechan-ical ventilation are still kept on bed rest while recovering.

This article outlines the argument in favor of imple-menting early mobilization as a candidate for reducingICU-acquired weakness. When performed in the right pa-tient population, early physical mobility is both safe andfeasible. Early mobility has been shown to reduce hospitalcosts by reducing the stay in both the ICU and hospital andreducing chronic debilitation and health complications.Early mobilization arguably may require increased re-sources but can be cost-effective if implemented correctlywith a specific mobility team. Concerns and cautions toearly mobility exist, and careful thought should go into pa-tient selection and monitoring, given these concerns. Despitethese cautions, however, there seems to be very little downside to early mobilization in mechanically ventilated patientsin the ICU, and its implementation could change the face ofpost-critical illness life for patients worldwide.

REFERENCES

1. Fan E, Cheek F, Chlan L, Gosselink R, Hart N, Herridge MS, et al.An official American Thoracic Society Clinical Practice guideline:the diagnosis of intensive care unit-acquired weakness in adults.Am J Respir Crit Care Med 2014;190(12):1437-1446.

2. Lipshutz AK, Gropper MA. Acquired neuromuscular weakness andearly mobilization in the intensive care unit. Anesthesiology 2013;118(1):202-215.

3. Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Grana-dos N, Al-Saidi F, et al. One-year outcomes in survivors of the acuterespiratory distress syndrome. N Engl J Med 2003;348(8):683-693.

4. Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedsidereview: mobilizing patients in the intensive care unit–from patho-physiology to clinical trials. Crit Care 2009;13(4):216.

5. Fink H, Helming M, Unterbuchner C, Lenz A, Neff F, Martyn JA,Blobner M. Systemic inflammatory response syndrome increasesimmobility-induced neuromuscular weakness. Crit Care Med 2008;36(3):910-916.

Fig. 6. Other considerations for early mobility. For color codingdefinitions, see Figure 2. From Reference 14, with permission.



6. De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-ZaleskiI, Boussarsar M, et al. Paresis acquired in the intensive care unit: aprospective multicenter study. Jama 2002;288(22):2859-2867.

7. Griffiths RD, Palmer TE, Helliwell T, MacLennan P, MacMillanRR. Effect of passive stretching on the wasting of muscle in thecritically ill. Nutrition 1995;11(5):428-432.

8. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L,et al. Early activity is feasible and safe in respiratory failure patients.Crit Care Med 2007;35(1):139-145.

9. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L,et al. Early intensive care unit mobility therapy in the treatment ofacute respiratory failure. Crit Care Med 2008;36(8):2238-2243.

10. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ,Esbrook CL, et al. Early physical and occupational therapy in me-chanically ventilated, critically ill patients: a randomised controlledtrial. Lancet 2009;373(9678):1874-1882.

11. Morris PE, Griffin L, Berry M, Thompson C, Hite RD, WinkelmanC, et al. Receiving early mobility during an intensive care unit ad-mission is a predictor of improved outcomes in acute respiratoryfailure. Am J Med Sci 2011;341(5):373-377.

12. TEAM Study Investigators, Hodgson C, Bellomo R, Berney S, Bai-ley M, Buhr H, et al. Early mobilization and recovery in mechani-cally ventilated patients in the ICU: a bi-national, multi-centre, pro-spective cohort study. Crit Care 2015;19:81.

13. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients withrespiratory failure increase ambulation after transfer to an intensivecare unit where early activity is a priority. Crit Care Med 2008;36(4):1119-1124.

14. Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Bald-win CE, et al. Expert consensus and recommendations on safetycriteria for active mobilization of mechanically ventilated criticallyill adults. Crit Care 2014;18(6):658.

15. Bourdin G, Barbier J, Burle JF, Durante G, Passant S, Vincent B,et al. The feasibility of early physical activity in intensive care unitpatients: a prospective observational one-center study. Respir Care2010;55(4):400-407.

16. Adler J, Malone D. Early mobilization in the intensive care unit: asystematic review. Cardiopulm Phys Ther J 2012;23(1):5-13.

17. Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD,Needham DM. Safety of physical therapy interventions in criticallyill patients: a single-center prospective evaluation of 1110 intensivecare unit admissions. J Crit Care 2014;29(3):395-400.

18. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M,et al. Physiotherapy for adult patients with critical illness: recom-mendations of the European Respiratory Society and European So-ciety of Intensive Care Medicine Task Force on Physiotherapy forCritically Ill Patients. Intensive Care Med 2008;34(7):1188-1199.

19. Garzon-Serrano J, Ryan C, Waak K, Hirschberg R, Tully S, BittnerEA, et al. Early mobilization in critically ill patients: patients’ mo-bilization level depends on health care provider’s profession. PM R2011;3(4):307-313.

20. Engel HJ, Needham DM, Morris PE, Gropper MA. ICU early mo-bilization: from recommendation to implementation at three medicalcenters. Crit Care Med 2013;41(9 Suppl 1):S69-S80.

21. Herridge MS, Tansey CM, Matte A, Tomlinson G, Diaz-GranadosN, Cooper A, et al. Functional disability 5 years after acute respira-tory distress syndrome. N Engl J Med 2011;364(14):1293-1304.

Discussion

Berra: I have a couple of comments,one is that in our institution we do alot of early mobilization especially inthe surgical and medical units. At thebeginning we started with a few peo-ple interested in the topic: a few phy-sicians, some nurses and physicaltherapists (PTs). Sometimes a fewresidents joined the team in mobi-lizing patients out of bed. Histori-cally for us, it was crucial to iden-tify a team interested in earlymobilization. Over time it becamenatural for other people to join theearly mobilization efforts, othernurses, PTs and respiratory therapists(RTs) in the unit. I was surprised tosee how many people joined thatstudy, and how large the team be-came. I have a question for those ofyou who do randomized controlledtrials (RCTs). As noted it is crucialto have education in this type of in-tervention. In my opinion an RCT,blinded or not, will not capture the

benefit of an intervention such asthis one (mostly educational).

MacIntyre: It’s impossible in thatarena to do a real outcomes study.Those who do it are believers, theyare convinced they’re doing the rightthing and don’t have the equipoise toput patients into a control group thatdoesn’t get the intervention. And I’mnot sure we should be arguing formore RCTs, I really do think it makessense and we ought to be doing thesethings. The studies need to be moreon how to do it safely, effectively,and cost-effectively. Selection, mon-itoring, keeping it as safe as possi-ble, and as inexpensive as possibleis where I think the need for moreresearch is.

Kallet: I think the appropriate levelof evidence would be a before andafter study. I agree that if you try todo an RCT there will be the “JohnHenry effect”–you see someone who’sgetting early mobility and you’re go-

ing to do something that mimics itwith patients assigned to the controlgroup. I think it’s only human natureto do that. But a before-and-after studydone in an institution within a shortperiod of time, practices aren’t likelyto change that much. So I think you’llget enough persuasive data. The othercomment I’d like to make is I sensethat with the enthusiasm for this we’regoing to have some problems with fa-naticism. In one of the local hospitals,they were boasting that they took apatient on 30 cm H2O of PEEP andgot them sitting in a chair and thatwas considered progress in the pa-tient’s recovery! I had to have my jawreattached from the floor for that one.They always show a picture of mobi-lizing someone on a ventilator–we didthis back in the early ‘80s. But patientselection was huge then (as it is now)and I think it’s false promotion to con-stantly show those images of walkinga patient on a ventilator down the hall.We need to focus more on real thingslike passive range of motion, getting



them sitting up in a chair or danglingon the side of the bed. This wouldprobably be much more accurate ofwhat can be done realistically. Andnot sensationalizing the therapy andinappropriately pushing acutely ill pa-tients to the limit.

MacIntyre: The biggest study1 Ishowed only got 11% actually walk-ing. But that’s OK. I think just gettingthem to sit up and move around isgood. I’ll go back to my earlier point,I think this may just be a good prod toreduce sedation.

Kallet: I agree. I suspect the otherwith asynchrony, is that clinicians justare not thinking things through. Youget someone mobilized and they’re go-ing to need increased ventilatory sup-port: their minute ventilation demandand work of breathing are going to goup, their sense of dyspnea is going togo up. And this would actually be theperfect segue to proportional assistventilation. You can’t just keep some-one on standard spontaneous breath-ing trial settings and have them get-ting out of bed or walking up and downthe hallway; they’ll need a lot moresupport, initially.

Kacmarek: We do walk patients onextracorporeal membrane oxygen-ation (ECMO).

MacIntyre: I think mobility withECMO is often easier than with a ven-tilator.

Kacmarek: Yes. We’ve walkedthem on ECMO and mechanical ven-tilation. We tried to extubate them but

we’ve had transplant patients wherewe’ve still provided ventilator supportduring ECMO and have walked them.But mostly it’s after we’ve extubatedthem.

Hess: We talk about this as thoughwe’re implementing a new practice,and I guess for many it is a new prac-tice. Back in the 1970s I recall we hada device in our ICU we called the Bird-mobile. It was a walker that was out-fitted with wheels. It had a Bird Mark7 on it, it had places on the sides toput O2 tanks, and we would get pa-tients out of bed and manage them onthe ventilator wide awake and walkthem in the hallway. And then alongcame pancuronium and propofol andmidazolam. Now we talk about howwe wake up patients and ambulatethem. It’s back to the future.

Marini: Can I open up the discus-sion a little? Why do we think mobi-lization works? We all believe that itis good for people and most of us saythat gravitational forces on the vascu-lature and muscles would increase tonein both systems, and that’s a usefulthing. But I think there’s somethingdeeper than that. The connection be-tween the perception of getting stron-ger and healing may be subtle and morepowerful than we understand. Whenpatients sense that they’re makingprogress–they’re getting out of bed andtheir family sees them and encouragesthem–a lot of crosstalk goes on be-tween the brain, muscles, and otherbody systems. I’m wondering if we’realmost putting training wheels backon the whole system, so to speak. Get-ting them out of the supine position,

putting gravitational forces back ontheir muscles and vascular systems andgetting the benefits of variation, beingupright and moving. Giving the pa-tient the mental picture of makingprogress is perhaps encouraging themin a way we don’t quite understandyet. Secondly, we have better equip-ment to get people upright; advancedbeds can be adjusted to encourage get-ting the patient up these days. The la-bor involved in getting them uprightis a lot less and it is less dangerous.I’m an advocate, but I realize thereare dangers.

MacIntyre: Going back to my re-hab experience, it’s very similar towhat you just said, John. It’s morethan making them walk around thetrack. Yes, that probably does haveconditioning effects on both the heartand the skeletal muscles. But the men-tal encouragement of realizing ‘by GodI can do this’ is as important, if notmore important, than the physicaltraining.

Marini: The will to live and encour-agement to stop being depressive abouttheir situation. These people often havebeen knocked flat on their butts bytheir illnesses, and they need to feeloptimism and progress toward a goal.Such mental signals might be morepowerful than I previously believed.And early mobilization might helpsend those.

REFERENCE

1. Adler J, Malone D. Early mobilization inthe ICU: a systematic review. CardiopulmPhys Ther J 2012; 23:1:4-44.



should early mobilization be routine in mechanically

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