- Email: [email protected]
The Authors Respond
Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2017;98:1490-1
DEPARTMENTS Letters to the Editor Ahmet Cemal Pazarli, MD Department of Chest Diseases Elbistan State Hospital Kahramanmaras‚, Turkey
Early Mobilization After Mechanical Ventilation: A Question of Details and Time We read with great interest the article by Lai et al1 in Archives of Physical Medicine and Rehabilitation which evaluated the effects of a quality improvement program to introduce early mobilization on the outcome of patients on mechanical ventilation in the intensive care unit. We congratulate the authors for a successful study that focused on an important issue. However, we have a few remarkable key practical points for the article. First, the authors compared the data before and after the protocol. However, it is not clear if the patients in the before protocol group received any rehabilitation (pulmonary rehabilitation and/or any other exercises). We think it is important to compare the rehabilitation methodology that the authors administered with the method in the before protocol group. Second, the authors stated that the data had been collected retrospectively. However, the methodology written in the article seems confusing. For instance, the authors presented education, intervention, and postintervention phases that need more clear determinations and associations. We would be interested in knowing why the authors required education and intervention phases in their clinics. They should clarify this to provide greater understanding and practical implications. Third, the groups seem to be very heterogeneous and lack sufficient data. For instance, the study lacks the stage/level of cancer (eg, lung, melanoma, brain metastasis), the Brunnstrom stage of motor recovery in patients with stroke, which kind of operation in postoperation, and the level of uremia (eg, acute, chronic), all which have important clinical practice implications.2,3 Finally, the authors did not assess the functional status and mobility of the patients by a specific scale. Also of note, this study lacks the rehabilitation levels of the patients in the before treatment group. We think that defining the study group more homogeneously and using more valid and reliable scales would be helpful to achieve more valid results for rehabilitation physicians.4 Further clinical trials considering the outcomes of early mobilization in intensive care unit patients are awaited. Timur Ekiz, MD Department of Physical Medicine and Rehabilitation Elbistan State Hospital Kahramanmaras‚, Turkey
Antonio M. Esquinas, MD Intensive Care and Non Invasive Ventilatory Unit Hospital Morales Meseguer Murcia, Spain Disclosures: none.
References 1. Lai CC, Chou W, Chan KS, et al. Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients with acute respiratory failure. Arch Phys Med Rehabil 2017;98:931-9. 2. Olkowski BF, Shah SO. Early mobilization in the neuro-ICU: how far can we go? Neurocrit Care. 2016 Dec 20. [Epub ahead of print]. 3. Ferreira NA, Lopes AJ, Ferreira AS, Ntoumenopoulos G, Dias J, Guimaraes FS. Determination of functional prognosis in hospitalized patients following an intensive care admission. World J Crit Care Med 2016;5:219-27. 4. Ku¨c¸u¨kdeveci AA, Tennant A, Grimby G, Franchignoni F. Strategies for assessment and outcome measurement in physical and rehabilitation medicine: an educational review. J Rehabil Med 2011;43:661-72. http://dx.doi.org/10.1016/j.apmr.2017.02.012
The Authors Respond Thank you for the comments on our article, “Early Mobilization Reduces Duration of Mechanical Ventilation and Intensive Care Unit Stay in Patients With Acute Respiratory Failure,” in Archives of Physical Medicine and Rehabilitation,1 which evaluated the effects of a quality improvement program to introduce early mobilization on the outcome of patients on mechanical ventilation (MV) in the intensive care unit (ICU). Our reply and explanation to the comments are as follows. First, regarding whether the patients in the before protocol group received rehabilitation (pulmonary rehabilitation and/or any other exercises) or not, this was shown in table 2, which displayed there was not any rehabilitation in the before protocol group. Second, regarding the methodology written in the article, we stated the data were collected retrospectively, even though we presented education, intervention, and postintervention phases.
0003-9993/17/$36 - see front matter Ó 2017 by the American Congress of Rehabilitation Medicine
Letters to the Editor We did a quality improvement intervention from January 1, 2014, to December 31, 2014, with 3 divided phases as phase 1 (preintervention period: January 1, 2014, to March 31, 2014), phase 2 (intervention period: July 1, 2014, to October 31, 2014), and phase 3 (maintenance period: November 1, 2014 to December 31, 2014). Additionally, we conducted a quality improvement education program from April 1, 2014, to June 30, 2014. Phase 1 was called the before protocol group, and phases 2 and 3 were the after protocol group. After finishing the intervention, we collected all the clinical and laboratory data retrospectively and studied whether a rehabilitation program can reduce MV duration or other outcomes. Because we previously did not have an advanced rehabilitation program in our ICUs or hospital, we needed education and intervention phases in our clinics. Third, regarding the heterogeneous population in our study, we admit that it is a study limitation. Regarding the underlying comorbidity of cancer, we did not list the stage and pathologic data to compare each group. We only made sure that all cancers were inactive, without any intervention during enrollment. Further prospective study should be conducted to confirm the effect of early mobilization. Finally, we did not assess the functional status and mobility of the patients by a specific scale, which was listed in our study limitations. Of course, further prospective clinical trials are still warranted to confirm our findings. Chih-Cheng Lai, MD Department of Intensive Care Medicine, Chi Mei Medical Center Liouying, Tainan, Taiwan Willy Chou, MD Department of Recreation and Health-Care Management Chia Nan University of Pharmacy and Science Tainan, Taiwan Khee-Siang Chan, PhD Department of Intensive Care Medicine, Chi Mei Medical Center Tainan, Taiwan
www.archives-pmr.org
1491 Kuo-Chen Cheng, MD Department of Internal Medicine, Chi Mei Medical Center Tainan, Taiwan Department of Safety, Health and Environment Chung Hwa University of Medical Technology Tainan, Taiwan Kuo-Shu Yuan, PhD Department of Medical Research, Chei Mei Medical Center Tainan, Taiwan Department of Business Management National Sun Yat-Sen University Kaohsiung, Taiwan Chien-Ming Chao, MD Department of Intensive Care Medicine Chi Mei Medical Center, Liouying Tainan, Taiwan Chin-Ming Chen, MD Department of Recreation and Health-Care Management Chia Nan University of Pharmacy and Science Tainan, Taiwan Department of Intensive Care Medicine, Chi Mei Medical Center Tainan, Taiwan Disclosures: none.
Reference 1. Lai CC, Chou W, Chan KS, et al. Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients with acute respiratory failure. Arch Phys Med Rehabil 2017;98:931-9. http://dx.doi.org/10.1016/j.apmr.2017.03.001
DEPARTMENTS Letters to the Editor Ahmet Cemal Pazarli, MD Department of Chest Diseases Elbistan State Hospital Kahramanmaras‚, Turkey
Early Mobilization After Mechanical Ventilation: A Question of Details and Time We read with great interest the article by Lai et al1 in Archives of Physical Medicine and Rehabilitation which evaluated the effects of a quality improvement program to introduce early mobilization on the outcome of patients on mechanical ventilation in the intensive care unit. We congratulate the authors for a successful study that focused on an important issue. However, we have a few remarkable key practical points for the article. First, the authors compared the data before and after the protocol. However, it is not clear if the patients in the before protocol group received any rehabilitation (pulmonary rehabilitation and/or any other exercises). We think it is important to compare the rehabilitation methodology that the authors administered with the method in the before protocol group. Second, the authors stated that the data had been collected retrospectively. However, the methodology written in the article seems confusing. For instance, the authors presented education, intervention, and postintervention phases that need more clear determinations and associations. We would be interested in knowing why the authors required education and intervention phases in their clinics. They should clarify this to provide greater understanding and practical implications. Third, the groups seem to be very heterogeneous and lack sufficient data. For instance, the study lacks the stage/level of cancer (eg, lung, melanoma, brain metastasis), the Brunnstrom stage of motor recovery in patients with stroke, which kind of operation in postoperation, and the level of uremia (eg, acute, chronic), all which have important clinical practice implications.2,3 Finally, the authors did not assess the functional status and mobility of the patients by a specific scale. Also of note, this study lacks the rehabilitation levels of the patients in the before treatment group. We think that defining the study group more homogeneously and using more valid and reliable scales would be helpful to achieve more valid results for rehabilitation physicians.4 Further clinical trials considering the outcomes of early mobilization in intensive care unit patients are awaited. Timur Ekiz, MD Department of Physical Medicine and Rehabilitation Elbistan State Hospital Kahramanmaras‚, Turkey
Antonio M. Esquinas, MD Intensive Care and Non Invasive Ventilatory Unit Hospital Morales Meseguer Murcia, Spain Disclosures: none.
References 1. Lai CC, Chou W, Chan KS, et al. Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients with acute respiratory failure. Arch Phys Med Rehabil 2017;98:931-9. 2. Olkowski BF, Shah SO. Early mobilization in the neuro-ICU: how far can we go? Neurocrit Care. 2016 Dec 20. [Epub ahead of print]. 3. Ferreira NA, Lopes AJ, Ferreira AS, Ntoumenopoulos G, Dias J, Guimaraes FS. Determination of functional prognosis in hospitalized patients following an intensive care admission. World J Crit Care Med 2016;5:219-27. 4. Ku¨c¸u¨kdeveci AA, Tennant A, Grimby G, Franchignoni F. Strategies for assessment and outcome measurement in physical and rehabilitation medicine: an educational review. J Rehabil Med 2011;43:661-72. http://dx.doi.org/10.1016/j.apmr.2017.02.012
The Authors Respond Thank you for the comments on our article, “Early Mobilization Reduces Duration of Mechanical Ventilation and Intensive Care Unit Stay in Patients With Acute Respiratory Failure,” in Archives of Physical Medicine and Rehabilitation,1 which evaluated the effects of a quality improvement program to introduce early mobilization on the outcome of patients on mechanical ventilation (MV) in the intensive care unit (ICU). Our reply and explanation to the comments are as follows. First, regarding whether the patients in the before protocol group received rehabilitation (pulmonary rehabilitation and/or any other exercises) or not, this was shown in table 2, which displayed there was not any rehabilitation in the before protocol group. Second, regarding the methodology written in the article, we stated the data were collected retrospectively, even though we presented education, intervention, and postintervention phases.
0003-9993/17/$36 - see front matter Ó 2017 by the American Congress of Rehabilitation Medicine
Letters to the Editor We did a quality improvement intervention from January 1, 2014, to December 31, 2014, with 3 divided phases as phase 1 (preintervention period: January 1, 2014, to March 31, 2014), phase 2 (intervention period: July 1, 2014, to October 31, 2014), and phase 3 (maintenance period: November 1, 2014 to December 31, 2014). Additionally, we conducted a quality improvement education program from April 1, 2014, to June 30, 2014. Phase 1 was called the before protocol group, and phases 2 and 3 were the after protocol group. After finishing the intervention, we collected all the clinical and laboratory data retrospectively and studied whether a rehabilitation program can reduce MV duration or other outcomes. Because we previously did not have an advanced rehabilitation program in our ICUs or hospital, we needed education and intervention phases in our clinics. Third, regarding the heterogeneous population in our study, we admit that it is a study limitation. Regarding the underlying comorbidity of cancer, we did not list the stage and pathologic data to compare each group. We only made sure that all cancers were inactive, without any intervention during enrollment. Further prospective study should be conducted to confirm the effect of early mobilization. Finally, we did not assess the functional status and mobility of the patients by a specific scale, which was listed in our study limitations. Of course, further prospective clinical trials are still warranted to confirm our findings. Chih-Cheng Lai, MD Department of Intensive Care Medicine, Chi Mei Medical Center Liouying, Tainan, Taiwan Willy Chou, MD Department of Recreation and Health-Care Management Chia Nan University of Pharmacy and Science Tainan, Taiwan Khee-Siang Chan, PhD Department of Intensive Care Medicine, Chi Mei Medical Center Tainan, Taiwan
www.archives-pmr.org
1491 Kuo-Chen Cheng, MD Department of Internal Medicine, Chi Mei Medical Center Tainan, Taiwan Department of Safety, Health and Environment Chung Hwa University of Medical Technology Tainan, Taiwan Kuo-Shu Yuan, PhD Department of Medical Research, Chei Mei Medical Center Tainan, Taiwan Department of Business Management National Sun Yat-Sen University Kaohsiung, Taiwan Chien-Ming Chao, MD Department of Intensive Care Medicine Chi Mei Medical Center, Liouying Tainan, Taiwan Chin-Ming Chen, MD Department of Recreation and Health-Care Management Chia Nan University of Pharmacy and Science Tainan, Taiwan Department of Intensive Care Medicine, Chi Mei Medical Center Tainan, Taiwan Disclosures: none.
Reference 1. Lai CC, Chou W, Chan KS, et al. Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients with acute respiratory failure. Arch Phys Med Rehabil 2017;98:931-9. http://dx.doi.org/10.1016/j.apmr.2017.03.001