|Year : 2017 | Volume
| Issue : 2 | Page : 813-819
Role of physiotherapy in weaning of patients from mechanical ventilation in the Intensive Care Unit
Anup Bhat1, Lenny T Vasanthan2, Abraham Samuel Babu1
1 Department of Physiotherapy, School of Allied Health Sciences, Faculty of Health Sciences, Manipal University, Manipal, Karnataka, India
2 Department of Physical Medicine and Rehabilitation, Physiotherapy Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
|Date of Web Publication||8-Aug-2017|
Abraham Samuel Babu
Department of Physiotherapy, School of Allied Health Sciences, Faculty of Health Sciences, Manipal University, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
Admission to an Intensive Care Unit (ICU) initiates an interprofessional and interdisciplinary approach to bring the patient back to health with normal or near normal function. Physiotherapists play a vital role in restoring function to the patient. The role of physiotherapy (PT) in the ICU has moved from primarily being one of only respiratory care to one that also encompasses early rehabilitation and exercise training. Early mobilization in the ICU has gained prominence in the recent years and is becoming standard practice across many centers. However, the impact on weaning with these interventions is not known. This review highlights the dysfunctions from an ICU admission and the rationale for instituting early PT in the ICU. In addition, evidence from systematic reviews and meta-analysis is reviewed to determine the impact of PT interventions on weaning. Evidence suggests the benefit of active mobilization and inspiratory muscle training in facilitating weaning. In addition, these interventions along with neuromuscular electrical stimulation further improve physical function and reduce the risk of critical illness polyneuromyopathy. Therefore, early PT does have significant functional benefits to ICU patients. However, more studies are required to determine how various interventions and intensities of exercise training improve weaning outcomes.
Keywords: Critical illness polyneuropathy, exercise, rehabilitation, targeted mobility, ventilator-induced diaphragmatic dysfunction
|How to cite this article:|
Bhat A, Vasanthan LT, Babu AS. Role of physiotherapy in weaning of patients from mechanical ventilation in the Intensive Care Unit. Indian J Respir Care 2017;6:813-9
|How to cite this URL:|
Bhat A, Vasanthan LT, Babu AS. Role of physiotherapy in weaning of patients from mechanical ventilation in the Intensive Care Unit. Indian J Respir Care [serial online] 2017 [cited 2019 Jun 18];6:813-9. Available from: http://www.ijrconline.org/text.asp?2017/6/2/813/212429
| Introduction|| |
Surviving a critical illness has now become the efforts of an interdisciplinary and interprofessional team approach. This team includes critical care physicians, nurses, dieticians, physiotherapists, respiratory therapists, and psychologists, to name a few. The growing emphasis on rehabilitation for patients in the Intensive Care Unit (ICU) has created a greater role of the physiotherapist from what was traditionally thought of, being restricted to only respiratory care. However, over the last decade, there has been an expansion in the role of the PT in the ICU toward rehabilitation and not only respiratory care. The reason for this major change has been the establishment of definitive musculoskeletal dysfunctions seen in the critically ill patient. With the definitions of critical illness polyneuromyopathy (CIPNM) and ventilatory-induced diaphragmatic dysfunctions (VIDD) finding its way into part of the problems that ICU patients suffer from, there has been a great need to address these dysfunctions. Recent studies have demonstrated how CIPNM and VIDD affect outcomes with respect to weaning, extubation, and length of stay (LOS).,,, Therefore, targeting these dysfunctions to better improve outcomes has now become a priority for critically ill patients.
Admission to an ICU results in significant decrease in peripheral muscle strength and poor quality of life among ICU survivors., Within 7 days, a reduction in peripheral muscle strength by 11.3% has been observed with greater reductions in deltoid (13% reduction) and least reduction in ankle, plantar, and dorsiflexor muscle strength (10%). Considering the impact of ICU stay on the peripheral muscles, rehabilitation strategies have now focused greatly on early mobilization and exercises targeting peripheral muscles and respiratory muscles. Despite evidence showing benefits with rehabilitation and exercises, it continues to remain underutilized in the ICU, especially in India.,
This review will, therefore, focus on the various mechanisms resulting in various dysfunctions in ICU patients and will describe the various PT interventions used to promote weaning through a systematic review of systematic reviews.
| Physiological Dysfunctions Contributing to Weaning Difficulty in the Intensive Care Unit Patient|| |
Immobilization has severe deleterious effects on the human body. The changes that occur in the various organ systems are summarized in [Table 1]. Immobilization along with severe infection and a critical illness further compounds these physiological dysfunctions. Poor cardiovascular endurance seen in these patients greatly affects oxygen uptake of the exercising muscles and therefore results in early onset of fatigue. Similar changes also occur to the diaphragm which inevitably results in VIDD. Other postulated theories attributing the neuromuscular changes have been inflammatory axonal injury, muscle breakdown, reduced nerve excitability from sodium channelopathy, and bioenergetic failure. It is these factors that probably have the greatest impact by preventing extubation and prolonging the duration of ventilation and stay in ICU.
Inactivity and bed rest are the most common things that are seen in patients which can promote weakness besides the primary disease process. Muscles are less frequently activated and for shorter periods as compared to normal living, leading to increased muscle catabolism and depressed contractile function termed as mechanical unloading. Other contributing factors, apart from the systemic illness, to muscle weakness include nutritional status and myotoxic and neurotoxic side effects of pharmacological agents.
| Rationale for Physiotherapy in the Intensive Care Unit|| |
Exercise training, through either aerobic or resistance training, has been shown to have great physiological impact on the various systems of the body. The effects of both acute and chronic responses to exercise have been used as the foundation for prescription of exercise in the prevention and control of various noncommunicable diseases. Details of the effects of exercise on the various systems of the body are beyond the scope of this paper. Briefly, acute and chronic exposure to exercise stimulus results in various adaptations in the various physiological systems that, in turn, result in protective effects with respect to cardiovascular, pulmonary, and musculoskeletal health [Table 2]. In addition, effects on the various inflammatory pathways and endothelial function cannot be disregarded.,, With these wide ranges of benefits with exercise training, the role of exercise training in the ICU cannot be undermined.
Earlier, rehabilitation (described as the third phase of medicine) was earlier implemented after a period of critical illness where strategies were deferred until the patient was medically and surgically stable. Studies done with early rehabilitation starting at a point where the patient is physiologically stable and continuing through the critical care stay had a positive impact in improved physical functioning and thereby contributed to early discharge from critical care. Considering the various physiological dysfunctions in the ICU and the way they have potential to respond to exercises, it is no surprise that there is a strong rationale for early mobilization and exercise training for critically ill patients. Early initiation of rehabilitation has been found to reduce health-care costs by reducing dependence, nursing care, LOS, and preventing disability. Therefore, interventions should be initiated as soon as possible after the critically ill patient is admitted in the ICU; the interventions should include exercises to maintain the range of motion and muscle strength, proper positioning to prevent pressure ulcers, compression neuropathies, and pulmonary care. A simple yet effective algorithm put forward a few years ago by Hanekom et al. provided a clear overview of how to sequentially assess, plan, and progress mobilization in the ICU patient.
| Role of Various Physiotherapy Interventions to Facilitate Weaning|| |
Having various options to facilitate early mobilization and exercise requires an evidence-based approach to choosing appropriate interventions. Till date, most of the studies on critical care rehabilitation have been from high-income countries and have made use of various exercises and technologies to promote early mobilization and exercise training. To better understand what interventions will provide better results with respect to weaning and its related outcomes, we performed a systematic search of various reviews in PubMed. All human trials studying the effects of various physiotherapy interventions in adult ICU patients and reporting outcomes on weaning and related measures (i.e., duration on mechanical ventilation, LOS in ICU, cost, mortality, incidence of ventilator-associated pneumonia, and success of extubation) where provided were extracted from the reviews. For interventions not covered in the systematic or narrative reviews, results from well-controlled randomized controlled trials have been reported. All articles were screened independently for inclusion by two authors (AB, LTV), and any conflict was arbitrated by the third author (ASB) using the web application Rayyan. The search in PubMed retrieved 63 articles, of which 15 were screened for inclusion with full texts. From these 15, only eight were systematic reviews while all the rest were narrative reviews. The narrative reviews have also been summarized in [Table 3].
|Table 3: Summary of articles assessing the effects of physiotherapy interventions on weaning and related outcomes|
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Inspiratory muscle training
Inspiratory muscle training (IMT) makes the use of devices for improving the strength of the diaphragm and other respiratory muscles. Devices make the use of varying narrow apertures, through which the patient has to inspire, thereby increasing the demand on the respiratory muscles. Threshold devices are the most commonly used in IMT, and varying levels of maximal inspiratory pressure (PImax) targets can be set with this device. IMT has been used successfully in various cardiopulmonary conditions such as chronic obstructive pulmonary disease and in heart failure., In the ICU setting, for patients on mechanical ventilation, an alternate option is by altering the pressure trigger sensitivity by 20% of the first PImax., The data were conflicting from both these studies with the study by Elbouhy et al. demonstrating a significant improvement in weaning success with IMT using the ventilator. The findings were similar to anecdotal observations where the use of the ventilator to train difficult to wean patients has facilitated weaning and extubation from the author's institute (Babu, Unnikrishnan, Shanbagh; Manipal, India; 2014). Altering sensitivity of the trigger to achieve at least 70% of the spontaneous tidal volume 5 times per se ssion, 4 times a day, had been used to improve endurance and strength of the inspiratory muscles in difficult to wean individuals resulting in favorable outcomes. Progression of training was by increasing the number of repetitions per se ssion and later even reducing the pressure support. When using other methods of IMT, such as threshold devices, studies have shown favorable benefits. A previous systematic review by Moodie et al. did not find any change in weaning outcomes and LOS in the ICU. However, a more recent review by Elkins and Denticefound that the results are in favor of IMT when it comes to improving rapid shallow breathing index, PImax, and weaning success. An updated review on IMT using threshold devices by Volpe et al. in 2016 found that they were better at facilitating weaning by improving inspiratory muscle strength. Thus, there appears to be a greater thrust toward the benefits of IMT to facilitate liberation from mechanical ventilation.
Active mobilization is a general term used in rehabilitation and PT. However, with respect to critical care rehabilitation, along with active mobilization, early initiation of this program is vital. A previous study has defined early mobilization as “the intensification and early application (within the first 2–5 days of critical illness) of the physical therapy that is administered to critically ill patients.” The evidence reviewed describes the early initiation of various physiotherapy interventions such as active exercises and mobilization out of bed. The evidence from systematic reviews and meta-analysis suggests that active mobilization improves the weaning rate (relative risk [RR] 3.56 [0.44–28.61] P = 0.230) and reduces the duration of mechanical ventilation (RR is −6.0 [−7.1-–5.0]). In addition, the review also found improvements in physical function with early initiation of physiotherapy. Thus, the physiotherapist plays a vital role in the ICU team to help improve the function of critically ill patients. This has been observed in a study by Garzan-Serrano in 2011, where it was seen that physiotherapists were able to mobilize patients to higher levels when compared to nurses. Furthermore, routine involvement of physiotherapists would help patients achieve better levels of mobility. Although there is evidence to prove that active mobilization is helpful in patients in ICU. The point prevalence of mobilized patients, according to a study conducted in Germany, among people on mechanical ventilation and those with an endotracheal tube was 24% and 8%, respectively. Therefore, even though the utilization of active mobilization is common, its application and the reduced prevalence of patients being mobilized suggest that there is a greater need to promote the use of early mobilization in the ICU.
Neuromuscular electrical stimulation
Neuromuscular electrical stimulation (NMES) makes the use of low-intensity electrical currents which stimulate a contraction in the skeletal muscles. This involves placing electrodes over the belly of the muscle and adjusting the intensity to obtain a visible contraction of the muscle. This prevents unwanted loss of muscle strength and bulk. The recent evidence from Wageck et al. shows that there were differences in outcomes between groups receiving NMES and those not receiving it [Table 3]. However, even though the outcomes on weaning were not statistically significant, they did observe significant risk reductions in the development of critical illness polyneuropathy (odds ratio [OR]: 0.22, 95% confidence interval [CI] = 0.05–0.92; P = 0.04). A Cochrane review further supported these findings in that there were no significant changes to weaning and its related outcomes. However, Burke et al. found that NMES did have an impact on physical function, which still suggests potential for NMES to have a functional impact. This area of study, however, lacks good quality evidence and requires more intensive research to explore how the use of NMES will facilitate early mobilization and also weaning.
Traditionally, physiotherapists have been involved in the respiratory care of patients on mechanical ventilation in ICU. The respiratory care involves optimization of ventilation, airway clearance, prevention of pulmonary complications, and hastening weaning from mechanical ventilation. Although respiratory care is empirically provided to all the patients on mechanical ventilation, there is limited evidence to support this. Since no systematic reviews on respiratory care and weaning were retrieved, a scoping search of randomized controlled trials was performed. This yielded five randomized controlled trials,,,,, of which four studies showed that respiratory care by physiotherapists has beneficial effects on weaning outcomes, length of ICU, and hospital stay. However, the findings from the study conducted by Templeton and Palazzodo not support these, thus highlighting a continuing conundrum. Well-designed prospective randomized controlled trials in the area are warranted at this moment.
Positioning and kinetic therapy
Positioning is an important part of physiotherapy interventions and is been widely used in the ICU. Lateral positioning has been used as a method to overcome the adverse effects of immobilization. One review did identify improvements in pulmonary function with no impact on weaning reported. Another form of positioning has been the use of continuous rotating frames or kinetic therapy. Kinetic therapy utilizes continuous rotation with a specific rotational bed to help reduce the pulmonary complications and other complications of immobilization. The review on this did not show a demonstrable impact on weaning though it did show an improvement in reduction in pneumonia (OR 0.38, 95% CI 0.28–0.53, P < 0.001). However, there was no effect on LOS in the ICU or in hospital.
| Clinical Implications|| |
The findings from the review of reviews suggest that early physiotherapy (active mobilization, IMT, and NMES) in the ICU has numerous benefits. Although positioning is used routinely and has its effects on pulmonary system, there is no evidence of its beneficial effect on weaning. With respect to facilitating weaning, active and early mobilization and IMT need to be instituted early in the ICU. Institution of these techniques will facilitate weaning from mechanical ventilation. However, the success of these interventions will also depend on the underlying condition and the prognosis of the patient. Therefore, the authors believe that a concept of “Targeted mobility therapy” or TMT would be a novel idea to adopt [Figure 1]. This concept will provide holistic care and will be a part of all ICU therapies and management strategies for critically ill patients. This concept will work as a scientifically driven, dynamic bundle of rehabilitation interventions and will include providing respiratory care and hygiene as required along with various evidence-based interventions (namely, active mobilization and strengthening including IMT) to ensure best outcomes for critically ill individuals admitted to the ICU. This concept, however, is purely speculative at this juncture and will need to be tested prospectively in the future.
| Future Scope|| |
This review has highlighted the various gaps in critical care research with respect to how various physiotherapy interventions have an impact on weaning outcomes. Although it is now becoming standard practice to initiate early physiotherapy in the ICU, there is still a need for more rigorous studies on the effects of these interventions on weaning and its related outcomes. The use of ventilator-targeted IMT, though ineffective in the individual studies, does demonstrate to be a feasible method of training. More rigorous trials in this area hold potential to initiate IMT in ventilated patients who are conscious and able to respond to commands.
| Conclusions|| |
Early initiation of physiotherapy through early mobilization and IMT facilitates faster weaning of patients from ventilator. However, more high-quality evidence is required to be able to provide strong clinical recommendations for the use of these interventions as a guideline-based recommendation. Nevertheless, the clinical benefits observed from various studies with early physiotherapy suggest the need to implement early physiotherapy to all critically ill patients admitted to the ICU.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Stiller K. Physiotherapy in intensive care: Towards an evidence-based practice. Chest 2000;118:1801-13.
Stiller K. Physiotherapy in intensive care: An updated systematic review. Chest 2013;144:825-47.
Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, et al.
Coexistence and impact of limb muscle and diaphragm weakness at time of liberation from mechanical ventilation in medical Intensive Care Unit patients. Am J Respir Crit Care Med 2017;195:57-66.
Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, et al.
Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med 2016;42:853-61.
De Jonghe B, Bastuji-Garin S, Durand MC, Malissin I, Rodrigues P, Cerf C, et al.
Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med 2007;35:2007-15.
Doherty N, Steen CD. Critical illness polyneuromyopathy (CIPNM); rehabilitation during critical illness. Therapeutic options in nursing to promote recovery: A review of the literature. Intensive Crit Care Nurs 2010;26:353-62.
Samosawala NR, Vaishali K, Kalyana BC. Measurement of muscle strength with handheld dynamometer in Intensive Care Unit. Indian J Crit Care Med 2016;20:21-6.
] [Full text]
Angus DC, Carlet J; Brussels Roundtable Participants. Surviving intensive care: A report from the 2002 Brussels Roundtable. Intensive Care Med 2003;29:368-77.
Babu AS. Critical care rehabilitation: A neglected part of ICU care. Oman Med J 2012;27:268.
Kumar JA, Maiya AG, Pereira D. Role of physiotherapists in Intensive Care Units of India: A multicenter survey. Indian J Crit Care Med 2008;11:198-203.
Thomas DC, Kreizman IJ, Melchiorre P, Ragnarsson KT. Rehabilitation of the patient with chronic critical illness. Crit Care Clin 2002;18:695-715.
Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extrem Physiol Med 2015;4:16.
Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med 2011;39:371-9.
Petrof BJ, Jaber S, Matecki S. Ventilator-induced diaphragmatic dysfunction. Curr Opin Crit Care 2010;16:19-25.
Chambers MA, Moylan JS, Reid MB. Physical inactivity and muscle weakness in the critically ill. Crit Care Med 2009;37 10 Suppl:S337-46.
Truong AD, Fan E, Brower RG, Needham DM. Bench-to-bedside review: Mobilizing patients in the Intensive Care Unit – From pathophysiology to clinical trials. Crit Care 2009;13:216.
Heinonen I, Kalliokoski KK, Hannukainen JC, Duncker DJ, Nuutila P, Knuuti J. Organ-specific physiological responses to acute physical exercise and long-term training in humans. Physiology (Bethesda) 2014;29:421-36.
Ahmadizad S, Avansar AS, Ebrahim K, Avandi M, Ghasemikaram M. The effects of short-term high-intensity interval training vs. moderate-intensity continuous training on plasma levels of nesfatin-1 and inflammatory markers. Horm Mol Biol Clin Investig 2015;21:165-73.
Swardfager W, Herrmann N, Cornish S, Mazereeuw G, Marzolini S, Sham L, et al.
Exercise intervention and inflammatory markers in coronary artery disease: A meta-analysis. Am Heart J 2012;163:666-76.e1-3.
Pearson MJ, Smart NA. Aerobic training intensity for improved endothelial function in heart failure patients: A systematic review and meta-analysis. Cardiol Res Pract 2017;2017:2450202.
National Institute for Health and Clinical Excellence. Rehabilitation After Critical Illness. London: National Institute for Health and Clinical Excellence; 2009.
Babu AS, Shanbhag V, Maiya AG. Mobilization in ICU. In: Gurujar M, editor. Manual of ICU Procedures. 1st
ed., Ch. 57. Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2016. p. 574-86.
Hanekom S, Gosselink R, Dean E, van Aswegen H, Roos R, Ambrosino N, et al.
The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients: Synthesis of evidence and expert opinion and its translation into practice. Clin Rehabil 2011;25:771-87.
Ghosh G, Bhat A, Babu AS. Current trend of research in critical care physiotherapy. Manipal: Manipal University; 2017. [Unpublished].
Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016;5:210.
Delaney A, Gray H, Laupland KB, Zuege DJ. Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients: A systematic review and meta-analysis. Crit Care 2006;10:R70.
Moodie L, Reeve J, Elkins M. Inspiratory muscle training increases inspiratory muscle strength in patients weaning from mechanical ventilation: A systematic review. J Physiother 2011;57:213-21.
Hermans G, De Jonghe B, Bruyninckx F, Van den Berghe G. Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database of Systematic Reviews 2014;(1):CD006832. DOI: 10.1002/14651858.CD006832.pub3.
Wageck B, Nunes GS, Silva FL, Damasceno MC, de Noronha M. Application and effects of neuromuscular electrical stimulation in critically ill patients: Systematic review. Med Intensiva 2014;38:444-54.
Elkins M, Dentice R. Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the Intensive Care Unit: A systematic review. J Physiother 2015;61:125-34.
Burke D, Gorman E, Stokes D, Lennon O. An evaluation of neuromuscular electrical stimulation in critical care using the ICF framework: A systematic review and meta-analysis. Clin Respir J 2016;10:407-20.
Li Z, Peng X, Zhu B, Zhang Y, Xi X. Active mobilization for mechanically ventilated patients: A systematic review. Arch Phys Med Rehabil 2013;94:551-61.
Volpe MS, Aleixo AA, Almeida PR. Influence of inspiratory muscle training on weaning patients from mechanical ventilation: A systematic review. Fisioter Mov 2016;29:173-82.
Geddes EL, Reid WD, Crowe J, O'Brien K, Brooks D. Inspiratory muscle training in adults with chronic obstructive pulmonary disease: A systematic review. Respir Med 2005;99:1440-58.
Lin SJ, McElfresh J, Hall B, Bloom R, Farrell K. Inspiratory muscle training in patients with heart failure: A systematic review. Cardiopulm Phys Ther J 2012;23:29-36.
Caruso P, Denari SD, Ruiz SA, Bernal KG, Manfrin GM, Friedrich C, et al.
Inspiratory muscle training is ineffective in mechanically ventilated critically ill patients. Clinics (Sao Paulo) 2005;60:479-84.
Elbouhy MS, AbdelHalim HA, Hashem AM. Effect of respiratory muscles training in weaning of mechanically ventilated COPD patients. Egypt J Chest Dis Tuberc 2014;63:679-87.
Hodgson CL, Berney S, Harrold M, Saxena M, Bellomo R. Clinical review: Early patient mobilization in the ICU. Crit Care 2013;17:207.
Garzon-Serrano J, Ryan C, Waak K, Hirschberg R, Tully S, Bittner EA, et al.
Early mobilization in critically ill patients: Patients' mobilization level depends on health care provider's profession. PM R 2011;3:307-13.
Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, et al.
Early mobilization of mechanically ventilated patients: A 1-day point-prevalence study in Germany. Crit Care Med 2014;42:1178-86.
Strickland SL, Rubin BK, Drescher GS, Haas CF, O'Malley CA, Volsko TA, et al.
AARC clinical practice guideline: Effectiveness of nonpharmacologic airway clearance therapies in hospitalized patients. Respir Care 2013;58:2187-93.
Ntoumenopoulos G, Gild A, Cooper DJ. The effect of manual lung hyperinflation and postural drainage on pulmonary complications in mechanically ventilated trauma patients. Anaesth Intensive Care 1998;26:492-6.
Pattanshetty RB, Gaude GS. Effect of multimodality chest physiotherapy in prevention of ventilator-associated pneumonia: A randomized clinical trial. Indian J Crit Care Med 2010;14:70-6.
] [Full text]
Berti JS, Tonon E, Ronchi CF, Berti HW, Stefano LM, Gut AL, et al.
Manual hyperinflation combined with expiratory rib cage compression for reduction of length of ICU stay in critically ill patients on mechanical ventilation. J Bras Pneumol 2012;38:477-86.
Gutierrez CJ, Stevens C, Merritt J, Pope C, Tanasescu M, Curtiss G. Trendelenburg chest optimization prolongs spontaneous breathing trials in ventilator-dependent patients with low cervical spinal cord injury. J Rehabil Res Dev 2010;47:261-72.
Templeton M, Palazzo MG. Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours. Intensive Care Med 2007;33:1938-45.
Hewitt N, Bucknall T, Faraone NM. Lateral positioning for critically ill adult patients. Cochrane Database of Systematic Reviews 2016;(5):CD007205. DOI: 10.1002/14651858.CD007205.pub2.
[Table 1], [Table 2], [Table 3]