Multidisciplinary rehabilitation in ventilator-dependent patients: Call for action in specialized inpatient facilities

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(A) Protein gel electrophoresis. Index case ZQ0 displays only a band corresponding to PI*Z allele. (B) Electropherogram of the index case. The arrow shows the region of the T to C mutation in codon 263." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.J. Oliveira, S. Seixas, I. Ladeira, R. Monteiro, T. Shiang, M. Guimarães, R. Lima" "autores" => array:7 [ 0 => array:2 [ "Iniciales" => "M.J." "apellidos" => "Oliveira" ] 1 => array:2 [ "Iniciales" => "S." "apellidos" => "Seixas" ] 2 => array:2 [ "Iniciales" => "I." "apellidos" => "Ladeira" ] 3 => array:2 [ "Iniciales" => "R." "apellidos" => "Monteiro" ] 4 => array:2 [ "Iniciales" => "T." "apellidos" => "Shiang" ] 5 => array:2 [ "Iniciales" => "M." "apellidos" => "Guimarães" ] 6 => array:2 [ "Iniciales" => "R." "apellidos" => "Lima" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915459735?idApp=UINPBA00004E" "url" => "/08732159/0000002100000006/v0_201604141141/X0873215915459735/v0_201604141141/en/main.assets" ] "itemAnterior" => array:16 [ "pii" => "X0873215915459719" "issn" => "08732159" "doi" => "10.1016/j.rppnen.2015.03.002" "estado" => "S300" "fechaPublicacion" => "2015-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Rev Port Pneumol. 2015;21:327-33" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6223 "formatos" => array:3 [ "EPUB" => 250 "HTML" => 4922 "PDF" => 1051 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Asthma control and exacerbations in patients with severe asthma treated with omalizumab in Portugal" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "327" "paginaFinal" => "333" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n06-90445971fig1.jpg" "Alto" => 2290 "Ancho" => 3005 "Tamanyo" => 247025 ] ] "descripcion" => array:1 [ "en" => "Distribution of the number of exacerbations (A) unscheduled healthcare utilization (B) and increases in OCS intake (C) in the 12-month follow-up period." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.S. Sousa, A.M. Pereira, J.A. Fonseca, L.F. Azevedo, C. Abreu, A. Arrobas, T. Calvo, M.J. Silvestre, L. Cunha, H. Falcão, M. Drummond, L. Geraldes, C. Loureiro" "autores" => array:13 [ 0 => array:2 [ "Iniciales" => "A.S." "apellidos" => "Sousa" ] 1 => array:2 [ "Iniciales" => "A.M." "apellidos" => "Pereira" ] 2 => array:2 [ "Iniciales" => "J.A." "apellidos" => "Fonseca" ] 3 => array:2 [ "Iniciales" => "L.F." "apellidos" => "Azevedo" ] 4 => array:2 [ "Iniciales" => "C." "apellidos" => "Abreu" ] 5 => array:2 [ "Iniciales" => "A." "apellidos" => "Arrobas" ] 6 => array:2 [ "Iniciales" => "T." "apellidos" => "Calvo" ] 7 => array:2 [ "Iniciales" => "M.J." "apellidos" => "Silvestre" ] 8 => array:2 [ "Iniciales" => "L." "apellidos" => "Cunha" ] 9 => array:2 [ "Iniciales" => "H." "apellidos" => "Falcão" ] 10 => array:2 [ "Iniciales" => "M." "apellidos" => "Drummond" ] 11 => array:2 [ "Iniciales" => "L." "apellidos" => "Geraldes" ] 12 => array:2 [ "Iniciales" => "C." "apellidos" => "Loureiro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915459719?idApp=UINPBA00004E" "url" => "/08732159/0000002100000006/v0_201604141141/X0873215915459719/v0_201604141141/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Multidisciplinary rehabilitation in ventilator-dependent patients: Call for action in specialized inpatient facilities" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "334" "paginaFinal" => "340" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Winck, R. Camacho, N. Ambrosino" "autores" => array:3 [ 0 => array:4 [ "Iniciales" => "J." "apellidos" => "Winck" "email" => array:1 [ 0 => "jcwinck@mail.telepac.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor1" ] ] ] 1 => array:3 [ "Iniciales" => "R." "apellidos" => "Camacho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "N." "apellidos" => "Ambrosino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Pulmonology, Faculdade de Medicina, Universidade do Porto, Portugal & Linde Healthcare, Pullach, Germany" "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "REMEO Program, Colombia" "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Weaning and Rehabilitation Unit, Auxilium Vitae Rehabilitation Center, Volterra, Italy" "etiqueta" => "c" "identificador" => "affc" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Corresponding author. jcwinck@mail.telepac.pt" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n06-90445972fig1.jpg" "Alto" => 1735 "Ancho" => 975 "Tamanyo" => 906284 ] ] "descripcion" => array:1 [ "en" => "A ventilator-dependent tracheostomized patient walking with assistance from the staff." ] ] ] "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a>IntroductionAccording to the NAMDRC consensus conference, prolonged mechanical ventilation (PMV) defines patients who require at least 6 h of mechanical ventilation for >21 consecutive days.<a href="#bib49" class="elsevierStyleCrossRefs">1</a> Recent estimates indicate that in the US the numbers of PMV are expected to double by the year 2020, reaching more than 600,000 patients.<a href="#bib50" class="elsevierStyleCrossRefs">2</a>The reasons for this are heterogeneous: a greater capacity of ICUs to assist severe respiratory failure; modulate systemic inflammatory response syndrome and severe sepsis in patients with a high prevalence of secondary neuromuscular dysfunction and severe physical deconditioning, all these at increasingly advanced ages. Another large group of patients is represented by those suffering from severe injuries to the central nervous system or incurable and progressive neuromuscular diseases.Currently we only have partial information about the functional outcomes and quality of life of these patients, who are now described as chronic critically ill patients.<a href="#bib51" class="elsevierStyleCrossRefs">3</a> Their life trajectories, during their stay at long-term acute care hospitals, or LTACs or after a successful ventilatory weaning, are yet to be described. Many will have severe, permanent cognitive and physical impairments and serious limitations due to their disability, which will obviously involve high psychosocial costs.<a href="#bib52" class="elsevierStyleCrossRefs">4</a>Treating these patients in specific venues with strong rehabilitative focus is normally recommended, with the cost savings and higher ventilator weaning rates.<a href="#bib53" class="elsevierStyleCrossRefs">5</a>PMV patients (also referred to as Chronically Critically Ill patients) are very demanding due to multiple systems and organs dysfunctions. Beyond prolonged dependence on mechanical ventilation, muscle, neuro-endocrine, skin and brain dysfunctions give way to a distinct and complex syndrome.<a href="#bib51" class="elsevierStyleCrossRefs">3</a>Although liberation from the ventilator will be one of the most important interventions in this setting, there is more than one type of weaning.<a name="sec0010" class="elsevierStyleCrossRefs"></a>Psychological factorsPsychological factors (like depression or delirium) may hinder ventilator weaning.<a href="#bib54" class="elsevierStyleCrossRefs">6</a> Sleep deprivation or unrecognized sleep disorders may also interfere with weaning.<a href="#bib55" class="elsevierStyleCrossRefs">7</a> So measures to improve sleep and psychological disorders can impact other outcomes.<a href="#bib56" class="elsevierStyleCrossRefs">8</a> In fact educational interventions, counseling and stress management can decrease the risk of developing psychological disorders. Moreover, effective pharmacological treatment of anxiety and depression is also mandatory.<a name="sec0015" class="elsevierStyleCrossRefs"></a>Swallowing dysfunctionOropharyngeal dysphagia (OPD) has been described in patients with PVM for three decades, and yet, has not received much attention in research addressing different subgroups of this diverse population.<a href="#bib57" class="elsevierStyleCrossRefs">9</a>, <a href="#bib58" class="elsevierStyleCrossRefs">10</a> Swallowing dysfunction is a common complication in chronic critically ill patients, which affects nearly half of the non-neurologic patients requiring percutaneous dilatational tracheostomy and almost all of those with neurologic involvement; it is well known to deteriorate outcomes, and delay the weaning and tracheostomy decannulation process.<a href="#bib59" class="elsevierStyleCrossRefs">11</a> A number of possible specific swallowing dysfunctional conditions arise in PMV patients; to mention a few, sarcopenic dysphagia, presbyphagia, neuromuscular dysfunction related dysphagia and even with some structural swallowing disorders.<a href="#bib60" class="elsevierStyleCrossRefs">12</a> Overall evaluation measures and treatment are based on experiments with different methodologies<a href="#bib61" class="elsevierStyleCrossRefs">13</a>, <a href="#bib62" class="elsevierStyleCrossRefs">14</a> but not on controlled studies which consider the unique pathophysiology of chronic critically ill patients.<a href="#bib63" class="elsevierStyleCrossRefs">15</a> It is worth mentioning the potential role of fiberoptic endoscopic evaluation of swallowing (FEES) as an objective tool to precisely classify and guide therapeutic interventions after prolonged intubation and in tracheostomy patients. In fact, FEES with sensory testing is improving the rehabilitation designs and protocols.<a href="#bib64" class="elsevierStyleCrossRefs">16</a>The main components of a dysphagia rehabilitation program include oral health care, swallowing rehabilitative techniques, and food consistency modification. To the best of our knowledge there are no detailed studies or any evidence about the most effective strategies to improve the swallowing process in different non-invasive and invasive PMV scenarios. This role which has been suggested for FEES as an objective tool to precisely classify and guide therapeutic interventions after prolonged intubation and in tracheostomy patients should be considered.<a href="#bib65" class="elsevierStyleCrossRefs">17</a><a name="sec0020" class="elsevierStyleCrossRefs"></a>Skin integritySkin integrity is an independent determinant of survival in patients requiring prolonged mechanical ventilation and is a potentially modifiable factor.<a href="#bib66" class="elsevierStyleCrossRefs">18</a> The most important risk factors for development of pressure ulcers while in ICU are total score on Braden Scale, mobility, activity, sensory perception, moisture, friction/shear, nutrition, age, blood pressure, length of stay, APACHE II, vasopressor administration, and co-morbid conditions.<a href="#bib67" class="elsevierStyleCrossRefs">19</a> Where it is chronic, central neurological involvement and small fiber pathology (which explains chronic sensory impairment and pain in neuro-critical care survivors) are the main features.<a href="#bib68" class="elsevierStyleCrossRefs">20</a><a name="sec0025" class="elsevierStyleCrossRefs"></a>Whole body rehabilitation ( Fig. 1 )Increasing evidence supports early physiotherapy for the critically ill patient<a href="#bib69" class="elsevierStyleCrossRefs">21</a>, <a href="#bib70" class="elsevierStyleCrossRefs">22</a>.<a name="f0005" class="elsevierStyleCrossRefs"></a><img src="320v21n06-90445972fig1.jpg" alt="A ventilator-dependent tracheostomized patient walking with assistance from the staff."></img>Figure 1. A ventilator-dependent tracheostomized patient walking with assistance from the staff.RCT in ICU settings have already shown that early physical and occupational rehabilitation of mechanically ventilated patients translates into better weaning outcomes.<a href="#bib71" class="elsevierStyleCrossRefs">23</a>In weaning facilities the studies evaluating the impact of rehabilitation in prolonged mechanical ventilated patients (<a href="#t0005" class="elsevierStyleCrossRefs">Table 1</a>) show positive results, from increase in limb strength<a href="#bib72" class="elsevierStyleCrossRefs">24</a>, <a href="#bib73" class="elsevierStyleCrossRefs">25</a> to improvement in functional measures like FIM,<a href="#bib72" class="elsevierStyleCrossRefs">24</a>, <a href="#bib73" class="elsevierStyleCrossRefs">25</a>, <a href="#bib74" class="elsevierStyleCrossRefs">26</a>, <a href="#bib75" class="elsevierStyleCrossRefs">27</a>, <a href="#bib76" class="elsevierStyleCrossRefs">28</a> respiratory muscle strength<a href="#bib73" class="elsevierStyleCrossRefs">25</a> and mechanics.<a href="#bib75" class="elsevierStyleCrossRefs">27</a> A RCT study has also shown a significant survival benefit in the rehabilitation group.<a href="#bib74" class="elsevierStyleCrossRefs">26</a> In these studies mortality ranges from 12%<a href="#bib72" class="elsevierStyleCrossRefs">24</a> to 30%<a href="#bib73" class="elsevierStyleCrossRefs">25</a> and weaning rate from 47%<a href="#bib77" class="elsevierStyleCrossRefs">29</a> to 98%.<a href="#bib72" class="elsevierStyleCrossRefs">24</a> The studies include also very different sub-groups of patients from chronic respiratory diseases<a href="#bib73" class="elsevierStyleCrossRefs">25</a>, <a href="#bib74" class="elsevierStyleCrossRefs">26</a>, <a href="#bib75" class="elsevierStyleCrossRefs">27</a>, <a href="#bib76" class="elsevierStyleCrossRefs">28</a>, <a href="#bib77" class="elsevierStyleCrossRefs">29</a>, <a href="#bib78" class="elsevierStyleCrossRefs">30</a> to post-operative and acute lung injuries.<a href="#bib72" class="elsevierStyleCrossRefs">24</a>, <a href="#bib73" class="elsevierStyleCrossRefs">25</a>, <a href="#bib74" class="elsevierStyleCrossRefs">26</a> Only one study includes neuromuscular patients.<a href="#bib76" class="elsevierStyleCrossRefs">28</a> Even in RCT, rehabilitation programs are not uniform, with some studies proposing 6-week long programs<a href="#bib73" class="elsevierStyleCrossRefs">25</a>, <a href="#bib74" class="elsevierStyleCrossRefs">26</a> while others proposing shorter times<a href="#bib75" class="elsevierStyleCrossRefs">27</a>, <a href="#bib78" class="elsevierStyleCrossRefs">30</a>; some include specific inspiratory muscle training,<a href="#bib72" class="elsevierStyleCrossRefs">24</a> a few others formal cardiopulmonary endurance exercise<a href="#bib75" class="elsevierStyleCrossRefs">27</a> and the others use electrical stimulation.<a href="#bib77" class="elsevierStyleCrossRefs">29</a>Table 1. Summary of retrospective/prospective/RCT in weaning facilities.<a name="t0005" class="elsevierStyleCrossRefs"></a><table><tr align="left"><td>Article</td><td>Number of patients</td><td>Diagnosis</td><td>Design</td><td>Intervention</td><td>Outcome</td><td>Frequency of exercise sessions</td><td>Results</td></tr><tr align="left"><td>Martin 24*</td><td>49</td><td>Pneumonia, CHF, ARDS</td><td>Retrospective</td><td>Whole body Rehab, IMT</td><td>Weaning success, FIM, MRC</td><td>5days/wk 30–60 min (1–2 sessions/day)</td><td>↑ limbs strength; ability to sit to stand and supine to sit; FIM Mortality 12% Weaning rate 98%</td></tr><tr align="left"><td>Chiang 25**</td><td>39</td><td>Chronic lung disease, Post-op, ALI</td><td>RCT</td><td>Whole body Rehab, Diaphragmatic breathing</td><td>Barthel Index, FIM, ventilator free time, Pimax, Pemax, Dynamometer</td><td>5 days/wk for 6 wks</td><td>↑ limbs strength; Pimax, Pemax FIM, BI Ventilator free time Mortality 17.6% Weaning rate 47%</td></tr><tr align="left"><td>Chen 26**</td><td>34</td><td>Chronic lung disease, Post-op, ALI</td><td>RCT</td><td>Whole body Rehab, Diaphragmatic breathing</td><td>1-year Survival FIM</td><td>5days/wk for 6 wks + 1day/wk for 6 wks</td><td>↑ FIM, survival Mortality 30% Weaning rate (at 1 year) 36%</td></tr><tr align="left"><td>Clini 30*</td><td>77</td><td>COPD, Post-Op</td><td>Prospective</td><td>Whole body Rehab (including pedaling and weights holding)</td><td>ADL, survival weaning success</td><td>6days/wk for 15 sessions</td><td>↑ ADL Mortality 13% Weaning rate 74%</td></tr><tr align="left"><td>Chen 27**</td><td>27</td><td>COPD/Chronic Lung Disease, CHF, SCI, Pneumonia</td><td>RCT</td><td>Whole body Rehab, Cardiopulmonary endurance exercise</td><td>Pulmonary mechanics, Barthel Index, FIM, weaning success, mortality</td><td>10 exercise training sessions</td><td>↑ VT, RSBI, FIM Mortality 0% Weaning rate 75%</td></tr><tr align="left"><td>Montagnini 28</td><td>56</td><td>COPD, NMD, Trauma, CHF, Post-op</td><td>Retrospective</td><td>Whole body Rehab (including bed-side cycle ergometer)</td><td>FIM</td><td>6 days/wk</td><td>↑ FIM Dyspnea (MRC) PaO2/FiO2 ↓ PaCO2</td></tr><tr align="left"><td>Vitacca 29*</td><td>240</td><td>COPD, ARF, Neurological diseases, Post-op</td><td>Prospective</td><td>Whole body Rehab (including electrical stimulation)</td><td>Barthel Index, Gussago Nursing Scale, survival, weaning success</td><td>6 days/wk 1 h/day (in 1 or 2 30 min sessions)</td><td>↑ BI, GNS, DPAP PaO2/FiO2 ↓ PaCO2 ↓ Borg Mortality 13.8% Weaning rate 47%</td></tr></table>CHF, chronic heart failure; FIM, functional independence measure; IMT, inspiratory muscle training; BI, barthel index; Post-op, post-operative; ALI, acute lung injury; SCI, spinal cord injury; NMD, neuromuscular disorders; ARF, acute respiratory Failure. * Excluded NMD. ** Excluded neurological disorders. Type of intervention, frequency, duration and intensity based on Denehy et al.<a href="#bib79" class="elsevierStyleCrossRefs">31</a> and Hanekom et al.<a href="#bib80" class="elsevierStyleCrossRefs">32</a> is proposed in <a href="#t0010" class="elsevierStyleCrossRefs">Table 2</a>.Table 2. Type of intervention, frequency, duration and intensity.<a name="t0010" class="elsevierStyleCrossRefs"></a><table><tr align="left"><td>Frequency of exercise sessions</td><td colspan="2">15 min/day (if <4 h spontaneous breathing) 2× 15 min/day (if >4 h spontaneous breathing)</td></tr><tr align="left"><td>Type of exercise</td><td>Marching in place Moving from sitting to standing Arm and leg active and active resistance movements</td><td>Based on 34 Active range of motion exercises for all major joints, bed mobility exercises (e.g. lateral rolling, supine to sit), dangling at the edge of the bed, postural retraining, balance exercises (e.g. reaching in and out of the base support, challenges to elicit “righting” reflexes), training in ADL (eating or simulated eating, grooming, bathing, dressing, and toileting), transfer from seated to a standing position and from bed to chair or commode, standing exercises such as reaching in and out of the base of support, mini-squats, marching, and ambulation (with or without assistive devices)</td></tr><tr align="left"><td>Intensity</td><td>Target modified Borg Scale score 3–5</td><td> </td></tr></table><a name="sec0030" class="elsevierStyleCrossRefs"></a>Aims of multidisciplinary (interdisciplinary or trans-disciplinary) rehabilitationTo improve survival, diminish co-morbidities, decrease ventilator dependence, improve functional status and health related quality of life, decrease hospital re-admissions, decrease length of stay in long-term care, favor return to work and social re-integration and reduce the amount of ineffective care. Caution must be taken about potential contraindications (<a href="#t0015" class="elsevierStyleCrossRefs">Table 3</a>).Table 3. Contraindications of physical therapy in PMV.<a name="t0015" class="elsevierStyleCrossRefs"></a><table><tr align="left"><td>Hemodynamic instability (in this case the patient should be discharged to an ICU)</td></tr><tr align="left"><td>Non-controlled behavioral disorders (in this case also the patient should be discharged)</td></tr><tr align="left"><td>Severe anemia (less than Hgb 7 g/dl) or thrombocytopenia (Platelets <40–50.000/dl). In Hemato-oncologic patients levels between 20 and 30.000 can be accepted</td></tr><tr align="left"><td>HR <60 or >110/min (or >30 bpm above resting predicted HR); also consider underlying cardiac disease</td></tr><tr align="left"><td>Mean ABP <65 mmHg or >200 mmHg</td></tr><tr align="left"><td>Sepsis or persistent fever (>38 °C) (in fever of central cause or while fever cause is being investigated, between fever peaks, consider lower intensity/passive interventions)</td></tr><tr align="left"><td>End-stage patients included in palliative care</td></tr></table>Abbreviations: ICU, intensive care unit; Hgb, hemoglobin; HR, heart rate; ABP, arterial blood pressure. <a name="sec0035" class="elsevierStyleCrossRefs"></a>Evidence-based multidisciplinary rehabilitative interventionsThere has been a growing interest in different rehabilitative strategies to treat PMV patients. However most of the published studies covered non-randomized clinical trials.In <a href="#t0020" class="elsevierStyleCrossRefs">Table 4</a> we review some of the most interesting topics involved in these interventions. Cognitive training has been tested among post-ICU survivors and preliminary data are encouraging<a href="#bib81" class="elsevierStyleCrossRefs">33</a> and a new RCT is being designed.<a href="#bib82" class="elsevierStyleCrossRefs">34</a> A prospective non-randomized study has also shown that early intra-ICU clinical psychologist intervention may help critically ill trauma patients recover from post-traumatic stress disorder.<a href="#bib56" class="elsevierStyleCrossRefs">8</a>Table 4. Evidence-based multidisciplinary rehabilitative interventions.<a name="t0020" class="elsevierStyleCrossRefs"></a><table><tr align="left"><td>Cognitive rehabilitation</td><td>8,33,34</td></tr><tr align="left"><td>Feeding/nutrition and swallowing</td><td>NA</td></tr><tr align="left"><td>Sleep</td><td>35</td></tr><tr align="left"><td>Respiratory – respiratory muscle training Secretion management; Weaning/decannulation protocols</td><td>36 37 38,39</td></tr><tr align="left"><td>Physical therapy – limb exercises, exercise training, neuromuscular electrical stimulation</td><td>See Table 1 </td></tr><tr align="left"><td>Co-morbidities management (e.g. CHF, DM, COPD),</td><td>NA</td></tr><tr align="left"><td>Skin care</td><td>NA</td></tr></table>Abbreviations: CHF, chronic heart failure; DM, diabetes mellitus; COPD, chronic obstructive pulmonary disease. As mentioned before no RCT so far has analyzed swallowing dysfunction management.Disruption of sleep is very common in mechanically ventilated patients. In an observational study Koldobskyi et al. have shown that specific facilities (like LTAC's) maintain the patients’ circadian rhythm compared to the ICU environment.<a href="#bib83" class="elsevierStyleCrossRefs">35</a>In a recent meta-analysis, examining three trials involving a heterogeneous group of patients, inspiratory muscle training was found to significantly increase inspiratory muscle strength in adults undergoing mechanical ventilation.<a href="#bib84" class="elsevierStyleCrossRefs">36</a> Further research is needed including more homogeneous PMV populations and analyzing more relevant outcomes.Concerning airway secretion management, Gonçalves et al. showed in a RCT that adding mechanical in-exsufflation improved extubation outcomes, increasing the efficacy of NIV post-extubation.<a href="#bib85" class="elsevierStyleCrossRefs">37</a>There are few RCT in the context of weaning tracheostomized patients. Hernandez showed that deflating the tracheal cuff in tracheostomized patients shortens weaning, reduces respiratory infections, and probably improves swallowing.<a href="#bib86" class="elsevierStyleCrossRefs">38</a> Jubran et al. in patients requiring PMV, showed that unassisted breathing through a tracheostomy (compared with pressure support) resulted in shorter median weaning time.<a href="#bib87" class="elsevierStyleCrossRefs">39</a>Verceles et al. have shown that in patients under PMV, higher comorbidity burden is associated with increased risk of transfer to acute care.<a href="#bib88" class="elsevierStyleCrossRefs">40</a> In fact, in a retrospective study, Schulman et al. suggest that tighter glycemic control was associated with better outcomes in CCI patients. Prospective studies addressing the importance of co-morbidities treatment optimization are warranted in this setting.<a href="#bib89" class="elsevierStyleCrossRefs">41</a><a name="sec0040" class="elsevierStyleCrossRefs"></a>Members of the team and roles ( Table 5 )Teamwork has been shown to improve outcomes. In fact medical ICU nurses’ reports of collaboration were associated positively with patient outcomes.<a href="#bib90" class="elsevierStyleCrossRefs">42</a>Table 5. Members of the team and roles.<a name="t0025" class="elsevierStyleCrossRefs"></a><table><tr align="left"><td>Core team: MD, Nurse, RT</td></tr><tr align="left"><td>MD: Serve as a coordinator</td></tr><tr align="left"><td>Nurse: Liaise with RT/PT as required</td></tr><tr align="left"><td>Speech pathologist: Liaise with RT/PT as required to evaluate swallowing</td></tr><tr align="left"><td>Occupational therapist, psychologist, nutritionist/dietitian, social worker involved as required</td></tr></table>The core team is normally the medical doctor, the nurse and the respiratory therapist (or specialized physiotherapist); the sense of interdependence exists between each other to ensure workflow is efficient, effective and coordinated.<a href="#bib91" class="elsevierStyleCrossRefs">43</a> Daily multidisciplinary rounds integrate the different knowledge to promote the clinical goals and formulate a plan of interventions. Coordination between professionals is essential to make a personalized and integrated therapeutic plan.The speech pathologist has a very important role not only to facilitate speech in patients with tracheostomy but also to evaluate swallowing.<a href="#bib92" class="elsevierStyleCrossRefs">44</a>Due to the high resource use and costs involved in supporting ventilator-dependent patients, social workers are indispensable to assure effective integration of health, social, education and employment services and voluntary and independent sectors when pertinent.<a href="#bib93" class="elsevierStyleCrossRefs">45</a> It also plays a fundamental role avoiding any possible discrimination that may rise from the disability surrounding PMV. Frequent communication with the family with discussion about realistic versus futile goals is also an important goal.<a name="sec0045" class="elsevierStyleCrossRefs"></a>Evaluation of efficacyThe traditional severity-of-illness scoring systems like the SOFA (Sepsis-related organ failure Assessment) score or the APACHE III were developed in the acute Intensive care Unit (ICU) population.<a href="#bib94" class="elsevierStyleCrossRefs">46</a> These systems were not established or validated using populations of patients under PMV (or also referred to as Chronically Critically Ill patients), as a result caution should be used when interpreting such data.<a href="#bib95" class="elsevierStyleCrossRefs">47</a>Therefore the development of adequately performing severity-of-illness measures appropriate to this patient population is highly needed.In the absence of newer multidimensional tools, the majority of authors use the Functional Independence Measure (FIM) to evaluate the efficacy of a rehabilitation program.<a href="#bib72" class="elsevierStyleCrossRefs">24</a>, <a href="#bib73" class="elsevierStyleCrossRefs">25</a>, <a href="#bib75" class="elsevierStyleCrossRefs">27</a>, <a href="#bib76" class="elsevierStyleCrossRefs">28</a> They evaluate the functional status of the patient at admission, after half the length of the program, at the end of the program and at discharge. If the results are not improving significantly the program/interventions should be adjusted on a regular basis, decreasing/increasing or maintaining intensity based on the eventual resolution of contraindications/significant improvement/deterioration/plateauing. To make this choice the Minimal Detectable Change (MDC) or Minimal Clinically Important Difference (MCID) of the disability scoring system being used should be considered.<a href="#bib96" class="elsevierStyleCrossRefs">48</a> For stroke patients the MCID for total FIM score was 22 points.<a href="#bib96" class="elsevierStyleCrossRefs">48</a> In studies including PMV patients the improvement in total FIM score ranged from 11<a href="#bib73" class="elsevierStyleCrossRefs">25</a> at 6 weeks to 44 points at 1 year.<a href="#bib74" class="elsevierStyleCrossRefs">26</a>Eventually after >1 month of structured multidisciplinary approach, consider transferring the patient to another setting (home or nursing home) if no improvement is gained.<a name="sec0050" class="elsevierStyleCrossRefs"></a>ChallengesIn one facility with more than 30 patients with heterogeneous diagnosis, the logistics of tailored therapeutic interventions can be very complex, from timing and chronobiology to coordination. To maintain a constant flow of interventions a highly flexible team is needed.The role of the family/non-professional caregivers to support and assist in the rehabilitation program can have a role in improving functional outcomes and potentiate team interventions.It is possible that some subgroups of PMV/CCI benefit more from whole body rehabilitation than others. A challenge for the future will be identifying which subgroups of PMV/CCI benefit most from these programs.<a name="sec0055" class="elsevierStyleCrossRefs"></a>ConclusionsUntil now, post-ICU patients have not had a recognized rehabilitation program and the care process is still fragmented. There is a clear need to establish guidelines to define the optimal rehabilitation program in this setting. Integrated, multidisciplinary rehabilitation programs for ventilator-dependent chronic critically ill patients should be urgently defined. Randomized studies for this situation are welcomed.<a name="sec0060" class="elsevierStyleCrossRefs"></a>Ethical disclosures<a name="sec0065" class="elsevierStyleCrossRefs"></a>Protection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.<a name="sec0070" class="elsevierStyleCrossRefs"></a>Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data.<a name="sec0075" class="elsevierStyleCrossRefs"></a>Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.<a name="sec0080" class="elsevierStyleCrossRefs"></a>Conflicts of interestThe authors have no conflicts of interest to declare.Received 18 March 2015 Accepted 24 March 2015 Corresponding author. jcwinck@mail.telepac.pt" "pdfFichero" => "320v21n06a90445972pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec640967" "palabras" => array:3 [ 0 => "Rehabilitation" 1 => "Ventilator-dependent patients" 2 => "Weaning facilities" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:1 [ "resumen" => " Abstract The numbers of patients needing prolonged mechanical ventilation are growing. The rehabilitation programs to be implemented in specialized inpatient facilities are ill defined. There is a clear need to establish guidelines to define the optimal rehabilitation program in this setting. In this article we review the current evidence and propose some guidance." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n06-90445972fig1.jpg" "Alto" => 1735 "Ancho" => 975 "Tamanyo" => 906284 ] ] "descripcion" => array:1 [ "en" => "A ventilator-dependent tracheostomized patient walking with assistance from the staff." ] ] 1 => array:6 [ "identificador" => "fig2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "A ventilator-dependent tracheostomized patient walking with assistance from the staff." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:48 [ 0 => array:3 [ "identificador" => "bib49" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. 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J.. Wincka,

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jcwinck@mail.telepac.pt

Corresponding author. jcwinck@mail.telepac.pt

, R.. Camachob, N.. Ambrosinoc

a Department of Pulmonology, Faculdade de Medicina, Universidade do Porto, Portugal & Linde Healthcare, Pullach, Germany

b REMEO Program, Colombia

c Weaning and Rehabilitation Unit, Auxilium Vitae Rehabilitation Center, Volterra, Italy

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    "textoCompleto" => "<a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Introduction</span><p class="elsevierStylePara">According to the NAMDRC consensus conference&#44; prolonged mechanical ventilation &#40;PMV&#41; defines patients who require at least 6&#160;h of mechanical ventilation for &#62;21 consecutive days&#46;<a href="&#35;bib49" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a> Recent estimates indicate that in the US the numbers of PMV are expected to double by the year 2020&#44; reaching more than 600&#44;000 patients&#46;<a href="&#35;bib50" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a></p><p class="elsevierStylePara">The reasons for this are heterogeneous&#58; a greater capacity of ICUs to assist severe respiratory failure&#59; modulate systemic inflammatory response syndrome and severe sepsis in patients with a high prevalence of secondary neuromuscular dysfunction and severe physical deconditioning&#44; all these at increasingly advanced ages&#46; Another large group of patients is represented by those suffering from severe injuries to the central nervous system or incurable and progressive neuromuscular diseases&#46;</p><p class="elsevierStylePara">Currently we only have partial information about the functional outcomes and quality of life of these patients&#44; who are now described as chronic critically ill patients&#46;<a href="&#35;bib51" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> Their life trajectories&#44; during their stay at long-term acute care hospitals&#44; or LTACs or after a successful ventilatory weaning&#44; are yet to be described&#46; Many will have severe&#44; permanent cognitive and physical impairments and serious limitations due to their disability&#44; which will obviously involve high psychosocial costs&#46;<a href="&#35;bib52" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a></p><p class="elsevierStylePara">Treating these patients in specific venues with strong rehabilitative focus is normally recommended&#44; with the cost savings and higher ventilator weaning rates&#46;<a href="&#35;bib53" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a></p><p class="elsevierStylePara">PMV patients &#40;also referred to as Chronically Critically Ill patients&#41; are very demanding due to multiple systems and organs dysfunctions&#46; Beyond prolonged dependence on mechanical ventilation&#44; muscle&#44; neuro-endocrine&#44; skin and brain dysfunctions give way to a distinct and complex syndrome&#46;<a href="&#35;bib51" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a></p><p class="elsevierStylePara">Although liberation from the ventilator will be one of the most important interventions in this setting&#44; there is more than one type of weaning&#46;</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Psychological factors</span><p class="elsevierStylePara">Psychological factors &#40;like depression or delirium&#41; may hinder ventilator weaning&#46;<a href="&#35;bib54" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a> Sleep deprivation or unrecognized sleep disorders may also interfere with weaning&#46;<a href="&#35;bib55" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> So measures to improve sleep and psychological disorders can impact other outcomes&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a> In fact educational interventions&#44; counseling and stress management can decrease the risk of developing psychological disorders&#46; Moreover&#44; effective pharmacological treatment of anxiety and depression is also mandatory&#46;</p><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Swallowing dysfunction</span><p class="elsevierStylePara">Oropharyngeal dysphagia &#40;OPD&#41; has been described in patients with PVM for three decades&#44; and yet&#44; has not received much attention in research addressing different subgroups of this diverse population&#46;<a href="&#35;bib57" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib58" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">10</span></a> Swallowing dysfunction is a common complication in chronic critically ill patients&#44; which affects nearly half of the non-neurologic patients requiring percutaneous dilatational tracheostomy and almost all of those with neurologic involvement&#59; it is well known to deteriorate outcomes&#44; and delay the weaning and tracheostomy decannulation process&#46;<a href="&#35;bib59" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">11</span></a> A number of possible specific swallowing dysfunctional conditions arise in PMV patients&#59; to mention a few&#44; sarcopenic dysphagia&#44; presbyphagia&#44; neuromuscular dysfunction related dysphagia and even with some structural swallowing disorders&#46;<a href="&#35;bib60" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">12</span></a> Overall evaluation measures and treatment are based on experiments with different methodologies<a href="&#35;bib61" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib62" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">14</span></a> but not on controlled studies which consider the unique pathophysiology of chronic critically ill patients&#46;<a href="&#35;bib63" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">15</span></a> It is worth mentioning the potential role of fiberoptic endoscopic evaluation of swallowing &#40;FEES&#41; as an objective tool to precisely classify and guide therapeutic interventions after prolonged intubation and in tracheostomy patients&#46; In fact&#44; FEES with sensory testing is improving the rehabilitation designs and protocols&#46;<a href="&#35;bib64" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">16</span></a></p><p class="elsevierStylePara">The main components of a dysphagia rehabilitation program include oral health care&#44; swallowing rehabilitative techniques&#44; and food consistency modification&#46; To the best of our knowledge there are no detailed studies or any evidence about the most effective strategies to improve the swallowing process in different non-invasive and invasive PMV scenarios&#46; This role which has been suggested for FEES as an objective tool to precisely classify and guide therapeutic interventions after prolonged intubation and in tracheostomy patients should be considered&#46;<a href="&#35;bib65" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">17</span></a></p><a name="sec0020" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Skin integrity</span><p class="elsevierStylePara">Skin integrity is an independent determinant of survival in patients requiring prolonged mechanical ventilation and is a potentially modifiable factor&#46;<a href="&#35;bib66" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">18</span></a> The most important risk factors for development of pressure ulcers while in ICU are total score on Braden Scale&#44; mobility&#44; activity&#44; sensory perception&#44; moisture&#44; friction&#47;shear&#44; nutrition&#44; age&#44; blood pressure&#44; length of stay&#44; APACHE II&#44; vasopressor administration&#44; and co-morbid conditions&#46;<a href="&#35;bib67" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">19</span></a> Where it is chronic&#44; central neurological involvement and small fiber pathology &#40;which explains chronic sensory impairment and pain in neuro-critical care survivors&#41; are the main features&#46;<a href="&#35;bib68" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">20</span></a></p><a name="sec0025" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Whole body rehabilitation &#40;  Fig&#46; 1 &#41;</span><p class="elsevierStylePara">Increasing evidence supports early physiotherapy for the critically ill patient<a href="&#35;bib69" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib70" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">22</span></a>&#46;</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n06-90445972fig1.jpg" alt="A ventilator-dependent tracheostomized patient walking with assistance from the staff&#46;"></img></p><p class="elsevierStylePara">Figure 1&#46; A ventilator-dependent tracheostomized patient walking with assistance from the staff&#46;</p><p class="elsevierStylePara">RCT in ICU settings have already shown that early physical and occupational rehabilitation of mechanically ventilated patients translates into better weaning outcomes&#46;<a href="&#35;bib71" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">23</span></a></p><p class="elsevierStylePara">In weaning facilities the studies evaluating the impact of rehabilitation in prolonged mechanical ventilated patients &#40;<a href="&#35;t0005" class="elsevierStyleCrossRefs">Table 1</a>&#41; show positive results&#44; from increase in limb strength<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a> to improvement in functional measures like FIM&#44;<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib74" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib75" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib76" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> respiratory muscle strength<a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a> and mechanics&#46;<a href="&#35;bib75" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> A RCT study has also shown a significant survival benefit in the rehabilitation group&#46;<a href="&#35;bib74" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> In these studies mortality ranges from 12&#37;<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> to 30&#37;<a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a> and weaning rate from 47&#37;<a href="&#35;bib77" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a> to 98&#37;&#46;<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> The studies include also very different sub-groups of patients from chronic respiratory diseases<a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib74" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib75" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib76" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib77" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib78" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">30</span></a> to post-operative and acute lung injuries&#46;<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib74" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> Only one study includes neuromuscular patients&#46;<a href="&#35;bib76" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> Even in RCT&#44; rehabilitation programs are not uniform&#44; with some studies proposing 6-week long programs<a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib74" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a> while others proposing shorter times<a href="&#35;bib75" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib78" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">30</span></a>&#59; some include specific inspiratory muscle training&#44;<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a> a few others formal cardiopulmonary endurance exercise<a href="&#35;bib75" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a> and the others use electrical stimulation&#46;<a href="&#35;bib77" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">29</span></a></p><p class="elsevierStylePara">Table 1&#46; Summary of retrospective&#47;prospective&#47;RCT in weaning facilities&#46;</p><a name="t0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Article</td><td>Number of patients</td><td>Diagnosis</td><td>Design</td><td>Intervention</td><td>Outcome</td><td>Frequency of exercise sessions</td><td>Results</td></tr><tr align="left"><td>Martin  <span class="elsevierStyleSup">24</span><span class="elsevierStyleSup">&#42;</span></td><td>49</td><td>Pneumonia&#44; CHF&#44; ARDS</td><td>Retrospective</td><td>Whole body Rehab&#44; IMT</td><td>Weaning success&#44; FIM&#44; MRC</td><td>5days&#47;wk 30&#8211;60&#160;min &#40;1&#8211;2 sessions&#47;day&#41;</td><td>&#8593; limbs strength&#59; ability to sit to stand and supine to sit&#59; FIM<br></br>Mortality 12&#37;<br></br>Weaning rate 98&#37;</td></tr><tr align="left"><td>Chiang  <span class="elsevierStyleSup">25</span><span class="elsevierStyleSup">&#42;&#42;</span></td><td>39</td><td>Chronic lung disease&#44; Post-op&#44; ALI</td><td>RCT</td><td>Whole body Rehab&#44; Diaphragmatic breathing</td><td>Barthel Index&#44; FIM&#44; ventilator free time&#44; Pi<span class="elsevierStyleInf">max</span>&#44; Pe<span class="elsevierStyleInf">max</span>&#44; Dynamometer</td><td>5 days&#47;wk for 6 wks</td><td>&#8593; limbs strength&#59; Pimax&#44; Pemax FIM&#44; BI<br></br>Ventilator free time<br></br>Mortality 17&#46;6&#37;<br></br>Weaning rate 47&#37;</td></tr><tr align="left"><td>Chen  <span class="elsevierStyleSup">26</span><span class="elsevierStyleSup">&#42;&#42;</span></td><td>34</td><td>Chronic lung disease&#44; Post-op&#44; ALI</td><td>RCT</td><td>Whole body Rehab&#44; Diaphragmatic breathing</td><td>1-year Survival<br></br>FIM</td><td>5days&#47;wk for 6 wks&#160;&#43;&#160;1day&#47;wk for 6 wks</td><td>&#8593; FIM&#44; survival<br></br>Mortality 30&#37;<br></br>Weaning rate &#40;at 1 year&#41; 36&#37;</td></tr><tr align="left"><td>Clini  <span class="elsevierStyleSup">30</span><span class="elsevierStyleSup">&#42;</span></td><td>77</td><td>COPD&#44; Post-Op</td><td>Prospective</td><td>Whole body Rehab &#40;including pedaling and weights holding&#41;</td><td>ADL&#44; survival weaning success</td><td>6days&#47;wk for 15 sessions</td><td>&#8593; ADL<br></br>Mortality 13&#37;<br></br>Weaning rate 74&#37;</td></tr><tr align="left"><td>Chen  <span class="elsevierStyleSup">27</span><span class="elsevierStyleSup">&#42;&#42;</span></td><td>27</td><td>COPD&#47;Chronic Lung Disease&#44; CHF&#44; SCI&#44; Pneumonia</td><td>RCT</td><td>Whole body Rehab&#44; Cardiopulmonary endurance exercise</td><td>Pulmonary mechanics&#44; Barthel Index&#44; FIM&#44; weaning success&#44; mortality</td><td>10 exercise training sessions</td><td>&#8593; VT&#44; RSBI&#44; FIM<br></br>Mortality 0&#37;<br></br>Weaning rate 75&#37;</td></tr><tr align="left"><td>Montagnini  <span class="elsevierStyleSup">28</span></td><td>56</td><td>COPD&#44; NMD&#44; Trauma&#44; CHF&#44; Post-op</td><td>Retrospective</td><td>Whole body Rehab &#40;including bed-side cycle ergometer&#41;</td><td>FIM</td><td>6 days&#47;wk</td><td>&#8593; FIM Dyspnea &#40;MRC&#41;<br></br>PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><br></br>&#8595; PaCO<span class="elsevierStyleInf">2</span></td></tr><tr align="left"><td>Vitacca  <span class="elsevierStyleSup">29</span><span class="elsevierStyleSup">&#42;</span></td><td>240</td><td>COPD&#44; ARF&#44; Neurological diseases&#44; Post-op</td><td>Prospective</td><td>Whole body Rehab &#40;including electrical stimulation&#41;</td><td>Barthel Index&#44; Gussago Nursing Scale&#44; survival&#44; weaning success</td><td>6 days&#47;wk 1&#160;h&#47;day &#40;in 1 or 2 30&#160;min sessions&#41;</td><td>&#8593; BI&#44; GNS&#44; DPAP<br></br>PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><br></br>&#8595; PaCO<span class="elsevierStyleInf">2</span><br></br>&#8595; Borg<br></br>Mortality 13&#46;8&#37;<br></br>Weaning rate 47&#37;</td></tr></table><p class="elsevierStylePara">CHF&#44; chronic heart failure&#59; FIM&#44; functional independence measure&#59; IMT&#44; inspiratory muscle training&#59; BI&#44; barthel index&#59; Post-op&#44; post-operative&#59; ALI&#44; acute lung injury&#59; SCI&#44; spinal cord injury&#59; NMD&#44; neuromuscular disorders&#59; ARF&#44; acute respiratory Failure&#46;<br></br></p><p class="elsevierStylePara">&#42; Excluded NMD&#46;<br></br>&#42;&#42; Excluded neurological disorders&#46;<br></br></p><p class="elsevierStylePara">Type of intervention&#44; frequency&#44; duration and intensity based on Denehy et al&#46;<a href="&#35;bib79" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">31</span></a> and Hanekom et al&#46;<a href="&#35;bib80" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">32</span></a> is proposed in <a href="&#35;t0010" class="elsevierStyleCrossRefs">Table 2</a>&#46;</p><p class="elsevierStylePara">Table 2&#46; Type of intervention&#44; frequency&#44; duration and intensity&#46;</p><a name="t0010" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Frequency of exercise sessions</td><td colspan="2">15&#160;min&#47;day &#40;if &#60;4&#160;h spontaneous breathing&#41;<br></br>2&#215; 15&#160;min&#47;day &#40;if &#62;4&#160;h spontaneous breathing&#41;</td></tr><tr align="left"><td>Type of exercise</td><td>Marching in place<br></br>Moving from sitting to standing<br></br>Arm and leg active and active resistance movements</td><td>Based on  <span class="elsevierStyleSup">34</span>  Active range of motion exercises for all major joints&#44; bed mobility exercises &#40;e&#46;g&#46; lateral rolling&#44; supine to sit&#41;&#44; dangling at the edge of the bed&#44; postural retraining&#44; balance exercises &#40;e&#46;g&#46; reaching in and out of the base support&#44; challenges to elicit &#8220;righting&#8221; reflexes&#41;&#44; training in ADL &#40;eating or simulated eating&#44; grooming&#44; bathing&#44; dressing&#44; and toileting&#41;&#44; transfer from seated to a standing position and from bed to chair or commode&#44; standing exercises such as reaching in and out of the base of support&#44; mini-squats&#44; marching&#44; and ambulation &#40;with or without assistive devices&#41;</td></tr><tr align="left"><td>Intensity</td><td>Target modified Borg Scale score 3&#8211;5</td><td>&#160;</td></tr></table><a name="sec0030" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Aims of multidisciplinary &#40;interdisciplinary or trans-disciplinary&#41; rehabilitation</span><p class="elsevierStylePara">To improve survival&#44; diminish co-morbidities&#44; decrease ventilator dependence&#44; improve functional status and health related quality of life&#44; decrease hospital re-admissions&#44; decrease length of stay in long-term care&#44; favor return to work and social re-integration and reduce the amount of ineffective care&#46; Caution must be taken about potential contraindications &#40;<a href="&#35;t0015" class="elsevierStyleCrossRefs">Table 3</a>&#41;&#46;</p><p class="elsevierStylePara">Table 3&#46; Contraindications of physical therapy in PMV&#46;</p><a name="t0015" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Hemodynamic instability &#40;in this case the patient should be discharged to an ICU&#41;</td></tr><tr align="left"><td>Non-controlled behavioral disorders &#40;in this case also the patient should be discharged&#41;</td></tr><tr align="left"><td>Severe anemia &#40;less than Hgb 7&#160;g&#47;dl&#41; or thrombocytopenia &#40;Platelets &#60;40&#8211;50&#46;000&#47;dl&#41;&#46; In Hemato-oncologic patients levels between 20 and 30&#46;000 can be accepted</td></tr><tr align="left"><td>HR &#60;60 or &#62;110&#47;min &#40;or &#62;30&#160;bpm above resting predicted HR&#41;&#59; also consider underlying cardiac disease</td></tr><tr align="left"><td>Mean ABP &#60;65&#160;mmHg or &#62;200&#160;mmHg</td></tr><tr align="left"><td>Sepsis or persistent fever &#40;&#62;38&#160;&#176;C&#41; &#40;in fever of central cause or while fever cause is being investigated&#44; between fever peaks&#44; consider lower intensity&#47;passive interventions&#41;</td></tr><tr align="left"><td>End-stage patients included in palliative care</td></tr></table><p class="elsevierStylePara"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ICU&#44; intensive care unit&#59; Hgb&#44; hemoglobin&#59; HR&#44; heart rate&#59; ABP&#44; arterial blood pressure&#46;<br></br></p><a name="sec0035" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Evidence-based multidisciplinary rehabilitative interventions</span><p class="elsevierStylePara">There has been a growing interest in different rehabilitative strategies to treat PMV patients&#46; However most of the published studies covered non-randomized clinical trials&#46;</p><p class="elsevierStylePara">In <a href="&#35;t0020" class="elsevierStyleCrossRefs">Table 4</a> we review some of the most interesting topics involved in these interventions&#46; Cognitive training has been tested among post-ICU survivors and preliminary data are encouraging<a href="&#35;bib81" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">33</span></a> and a new RCT is being designed&#46;<a href="&#35;bib82" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">34</span></a> A prospective non-randomized study has also shown that early intra-ICU clinical psychologist intervention may help critically ill trauma patients recover from post-traumatic stress disorder&#46;<a href="&#35;bib56" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">8</span></a></p><p class="elsevierStylePara">Table 4&#46; Evidence-based multidisciplinary rehabilitative interventions&#46;</p><a name="t0020" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Cognitive rehabilitation</td><td><span class="elsevierStyleSup">8&#44;33&#44;34</span></td></tr><tr align="left"><td>Feeding&#47;nutrition and swallowing</td><td>NA</td></tr><tr align="left"><td>Sleep</td><td><span class="elsevierStyleSup">35</span></td></tr><tr align="left"><td>Respiratory &#8211; respiratory muscle training<br></br>Secretion management&#59; Weaning&#47;decannulation protocols</td><td><span class="elsevierStyleSup">36</span><br></br><span class="elsevierStyleSup">37</span><br></br><span class="elsevierStyleSup">38&#44;39</span></td></tr><tr align="left"><td>Physical therapy &#8211; limb exercises&#44; exercise training&#44; neuromuscular electrical stimulation</td><td>See  Table 1 </td></tr><tr align="left"><td>Co-morbidities management &#40;e&#46;g&#46; CHF&#44; DM&#44; COPD&#41;&#44;</td><td>NA</td></tr><tr align="left"><td>Skin care</td><td>NA</td></tr></table><p class="elsevierStylePara"><span class="elsevierStyleItalic">Abbreviations</span>&#58; CHF&#44; chronic heart failure&#59; DM&#44; diabetes mellitus&#59; COPD&#44; chronic obstructive pulmonary disease&#46;<br></br></p><p class="elsevierStylePara">As mentioned before no RCT so far has analyzed swallowing dysfunction management&#46;</p><p class="elsevierStylePara">Disruption of sleep is very common in mechanically ventilated patients&#46; In an observational study Koldobskyi et al&#46; have shown that specific facilities &#40;like LTAC&#39;s&#41; maintain the patients&#8217; circadian rhythm compared to the ICU environment&#46;<a href="&#35;bib83" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">35</span></a></p><p class="elsevierStylePara">In a recent meta-analysis&#44; examining three trials involving a heterogeneous group of patients&#44; inspiratory muscle training was found to significantly increase inspiratory muscle strength in adults undergoing mechanical ventilation&#46;<a href="&#35;bib84" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">36</span></a> Further research is needed including more homogeneous PMV populations and analyzing more relevant outcomes&#46;</p><p class="elsevierStylePara">Concerning airway secretion management&#44; Gon&#231;alves et al&#46; showed in a RCT that adding mechanical in-exsufflation improved extubation outcomes&#44; increasing the efficacy of NIV post-extubation&#46;<a href="&#35;bib85" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">37</span></a></p><p class="elsevierStylePara">There are few RCT in the context of weaning tracheostomized patients&#46; Hernandez showed that deflating the tracheal cuff in tracheostomized patients shortens weaning&#44; reduces respiratory infections&#44; and probably improves swallowing&#46;<a href="&#35;bib86" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">38</span></a> Jubran et al&#46; in patients requiring PMV&#44; showed that unassisted breathing through a tracheostomy &#40;compared with pressure support&#41; resulted in shorter median weaning time&#46;<a href="&#35;bib87" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">39</span></a></p><p class="elsevierStylePara">Verceles et al&#46; have shown that in patients under PMV&#44; higher comorbidity burden is associated with increased risk of transfer to acute care&#46;<a href="&#35;bib88" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">40</span></a> In fact&#44; in a retrospective study&#44; Schulman et al&#46; suggest that tighter glycemic control was associated with better outcomes in CCI patients&#46; Prospective studies addressing the importance of co-morbidities treatment optimization are warranted in this setting&#46;<a href="&#35;bib89" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">41</span></a></p><a name="sec0040" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Members of the team and roles &#40;  Table 5 &#41;</span><p class="elsevierStylePara">Teamwork has been shown to improve outcomes&#46; In fact medical ICU nurses&#8217; reports of collaboration were associated positively with patient outcomes&#46;<a href="&#35;bib90" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">42</span></a></p><p class="elsevierStylePara">Table 5&#46; Members of the team and roles&#46;</p><a name="t0025" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"></p><table><tr align="left"><td>Core team&#58; MD&#44; Nurse&#44; RT</td></tr><tr align="left"><td>MD&#58; Serve as a coordinator</td></tr><tr align="left"><td>Nurse&#58; Liaise with RT&#47;PT as required</td></tr><tr align="left"><td>Speech pathologist&#58; Liaise with RT&#47;PT as required to evaluate swallowing</td></tr><tr align="left"><td>Occupational therapist&#44; psychologist&#44; nutritionist&#47;dietitian&#44; social worker involved as required</td></tr></table><p class="elsevierStylePara">The core team is normally the <span class="elsevierStyleItalic">medical doctor</span>&#44; the <span class="elsevierStyleItalic">nurse</span> and the <span class="elsevierStyleItalic">respiratory therapist</span> &#40;or <span class="elsevierStyleItalic">specialized physiotherapist</span>&#41;&#59; the sense of interdependence exists between each other to ensure workflow is efficient&#44; effective and coordinated&#46;<a href="&#35;bib91" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">43</span></a> Daily multidisciplinary rounds integrate the different knowledge to promote the clinical goals and formulate a plan of interventions&#46; Coordination between professionals is essential to make a personalized and integrated therapeutic plan&#46;</p><p class="elsevierStylePara">The <span class="elsevierStyleItalic">speech pathologist</span> has a very important role not only to facilitate speech in patients with tracheostomy but also to evaluate swallowing&#46;<a href="&#35;bib92" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">44</span></a></p><p class="elsevierStylePara">Due to the high resource use and costs involved in supporting ventilator-dependent patients&#44; <span class="elsevierStyleItalic">social workers</span> are indispensable to assure effective integration of health&#44; social&#44; education and employment services and voluntary and independent sectors when pertinent&#46;<a href="&#35;bib93" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">45</span></a> It also plays a fundamental role avoiding any possible discrimination that may rise from the disability surrounding PMV&#46; Frequent communication with the family with discussion about realistic versus futile goals is also an important goal&#46;</p><a name="sec0045" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Evaluation of efficacy</span><p class="elsevierStylePara">The traditional severity-of-illness scoring systems like the SOFA &#40;Sepsis-related organ failure Assessment&#41; score or the APACHE III were developed in the acute Intensive care Unit &#40;ICU&#41; population&#46;<a href="&#35;bib94" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">46</span></a> These systems were not established or validated using populations of patients under PMV &#40;or also referred to as Chronically Critically Ill patients&#41;&#44; as a result caution should be used when interpreting such data&#46;<a href="&#35;bib95" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">47</span></a></p><p class="elsevierStylePara">Therefore the development of adequately performing severity-of-illness measures appropriate to this patient population is highly needed&#46;</p><p class="elsevierStylePara">In the absence of newer multidimensional tools&#44; the majority of authors use the Functional Independence Measure &#40;FIM&#41; to evaluate the efficacy of a rehabilitation program&#46;<a href="&#35;bib72" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib75" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleSup">&#44; </span><a href="&#35;bib76" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">28</span></a> They evaluate the functional status of the patient at admission&#44; after half the length of the program&#44; at the end of the program and at discharge&#46; If the results are not improving significantly the program&#47;interventions should be adjusted on a regular basis&#44; decreasing&#47;increasing or maintaining intensity based on the eventual resolution of contraindications&#47;significant improvement&#47;deterioration&#47;plateauing&#46; To make this choice the Minimal Detectable Change &#40;MDC&#41; or Minimal Clinically Important Difference &#40;MCID&#41; of the disability scoring system being used should be considered&#46;<a href="&#35;bib96" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">48</span></a> For stroke patients the MCID for total FIM score was 22 points&#46;<a href="&#35;bib96" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">48</span></a> In studies including PMV patients the improvement in total FIM score ranged from 11<a href="&#35;bib73" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">25</span></a> at 6 weeks to 44 points at 1 year&#46;<a href="&#35;bib74" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">26</span></a></p><p class="elsevierStylePara">Eventually after &#62;1 month of structured multidisciplinary approach&#44; consider transferring the patient to another setting &#40;home or nursing home&#41; if no improvement is gained&#46;</p><a name="sec0050" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Challenges</span><p class="elsevierStylePara">In one facility with more than 30 patients with heterogeneous diagnosis&#44; the logistics of tailored therapeutic interventions can be very complex&#44; from timing and chronobiology to coordination&#46; To maintain a constant flow of interventions a highly flexible team is needed&#46;</p><p class="elsevierStylePara">The role of the family&#47;non-professional caregivers to support and assist in the rehabilitation program can have a role in improving functional outcomes and potentiate team interventions&#46;</p><p class="elsevierStylePara">It is possible that some subgroups of PMV&#47;CCI benefit more from whole body rehabilitation than others&#46; A challenge for the future will be identifying which subgroups of PMV&#47;CCI benefit most from these programs&#46;</p><a name="sec0055" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStylePara">Until now&#44; post-ICU patients have not had a recognized rehabilitation program and the care process is still fragmented&#46; There is a clear need to establish guidelines to define the optimal rehabilitation program in this setting&#46; Integrated&#44; multidisciplinary rehabilitation programs for ventilator-dependent chronic critically ill patients should be urgently defined&#46; Randomized studies for this situation are welcomed&#46;</p><a name="sec0060" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Ethical disclosures</span><a name="sec0065" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Protection of human and animal subjects</span><p class="elsevierStylePara">The authors declare that no experiments were performed on humans or animals for this study&#46;</p><a name="sec0070" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Confidentiality of data</span><p class="elsevierStylePara">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p><a name="sec0075" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Right to privacy and informed consent</span><p class="elsevierStylePara">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p><a name="sec0080" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara">Received 18 March 2015 <br></br>Accepted 24 March 2015 </p><p class="elsevierStylePara">Corresponding author&#46; jcwinck&#64;mail&#46;telepac&#46;pt</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle"> Abstract</span><br/><p class="elsevierStylePara"> The numbers of patients needing prolonged mechanical ventilation are growing&#46; The rehabilitation programs to be implemented in specialized inpatient facilities are ill defined&#46; There is a clear need to establish guidelines to define the optimal rehabilitation program in this setting&#46; In this article we review the current evidence and propose some guidance&#46;</p>"
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Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppnen.2015.03.005

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Year/Month	Html	Pdf	Total

2024 November	21	7	28
2024 October	202	39	241
2024 September	228	39	267
2024 August	246	70	316
2024 July	271	54	325
2024 June	193	51	244
2024 May	246	64	310
2024 April	177	63	240
2024 March	172	43	215
2024 February	111	32	143
2024 January	141	30	171
2023 December	115	40	155
2023 November	133	51	184
2023 October	135	65	200
2023 September	145	53	198
2023 August	152	83	235
2023 July	127	60	187
2023 June	149	59	208
2023 May	213	31	244
2023 April	171	52	223
2023 March	218	38	256
2023 February	158	34	192
2023 January	123	39	162
2022 December	171	35	206
2022 November	196	50	246
2022 October	149	48	197
2022 September	158	34	192
2022 August	139	44	183
2022 July	124	49	173
2022 June	104	41	145
2022 May	128	58	186
2022 April	103	50	153
2022 March	120	62	182
2022 February	88	33	121
2022 January	132	30	162
2021 December	105	49	154
2021 November	93	52	145
2021 October	102	53	155
2021 September	120	47	167
2021 August	111	35	146
2021 July	104	41	145
2021 June	108	25	133
2021 May	156	49	205
2021 April	255	106	361
2021 March	200	41	241
2021 February	156	27	183
2021 January	163	34	197
2020 December	104	26	130
2020 November	108	34	142
2020 October	144	29	173
2020 September	126	29	155
2020 August	118	33	151
2020 July	178	35	213
2020 June	153	47	200
2020 May	176	46	222
2020 April	218	31	249
2020 March	191	41	232
2020 February	114	39	153
2020 January	141	28	169
2019 December	121	26	147
2019 November	158	29	187
2019 October	141	22	163
2019 September	166	36	202
2019 August	551	40	591
2019 July	598	42	640
2019 June	633	35	668
2019 May	649	50	699
2019 April	585	68	653
2019 March	520	35	555
2019 February	234	14	248
2019 January	257	32	289
2018 December	170	12	182
2018 November	141	1	142
2018 October	155	9	164
2018 September	53	10	63
2018 August	58	30	88
2018 July	86	14	100
2018 June	92	16	108
2018 May	119	20	139
2018 April	67	17	84
2018 March	220	24	244
2018 February	34	10	44
2018 January	32	19	51
2017 December	34	21	55
2017 November	35	22	57
2017 October	25	19	44
2017 September	36	26	62
2017 August	48	17	65
2017 July	41	16	57
2017 June	49	8	57
2017 May	47	15	62
2017 April	38	13	51
2017 March	33	19	52
2017 February	9	6	15
2017 January	19	13	32
2016 December	26	14	40
2016 November	43	13	56
2016 October	57	16	73
2016 September	92	21	113
2016 August	22	20	42
2016 July	36	55	91
2016 June	10	0	10
2016 April	30	2	32
2016 March	50	19	69
2016 February	48	35	83
2016 January	80	52	132
2015 December	80	81	161

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