One of the largest and most influential critical care meetings took place in Montreal. CHEST 2015, led by the American College of Chest Physicians, brought together expert faculty, offering the latest advances in pulmonary, critical care, and sleep medicine. Topics included early mobilisation, interventional pulmonary procedures, and end-of-life decision-making.
Couldn’t make it to CHEST this year? Here were some of the key topics.
What are the risks and benefits of early mobility?1
Immobility in the ICU can contribute to a number of negative side effects: muscle wasting, neuromyopathy, delirium, and ICU psychosis. Dr Kyle Rehder from Duke University School of Medicine stated that activity within 2-5 days after the onset of a critical illness, whether passive or active, has several benefits and risks.
Benefits
- Improved functional status: Muscle strength, ambulation distance at discharge, functional ability and muscle strength, and ambulation and functional status scores
- Fewer days until the patient is out of bed
- Reduced delirium
- Reduced pain
- Decreased ventilator days
- Decreased ICU length of stay
- Decreased hospital length of stay
Risks
- Haemodynamic instability
- Hypoxaemia
- Device dislodgement
- Falls
- Pain
- Cost
Although there are risks, a 2014 study suggests a low adverse event incidence. Dr Rehder concluded that patient safety must be the first priority, and that early mobility is likely the safest thing for patients.
Early management of massive haemoptysis: What if you can’t control the bleeding?2, 3
Several highly attended sessions at CHEST highlighted massive haemoptysis. Doctors explored how to isolate bleeding to an affected lung when conventional therapeutic measures have failed.
Techniques ranged from simple manoeuvres, such as proper patient positioning, to the interventional use of endobronchial blockers. Once bleeding is controlled with one of these techniques, the patient can then be transferred to surgery or interventional radiology for more advanced interventions.
Dr Carla Lamb from Lahey Hospital and Medical Center reminded the audience that massive haemoptysis is an airway code and that every cart should have a cricothyrotomy device for worst-case situations.
Improving sleep in the ICU: How can each stakeholder contribute?4
ICU sleep is often short, poor quality, frequently interrupted, and incorrectly timed. So, how can the ICU team encourage more sleep opportunities and support the body’s natural sleep cycles? Dr Melissa Knauert from Yale School of Medicine provided guidance for each stakeholder:
- Physician: Avoid diagnostic testing, procedures, and medications during the sleep period.
- Nurse: Avoid non-urgent bedside care during the sleep period.
- Respiratory therapist: Avoid routine ventilator checks and suctioning during the sleep period.
- Pharmacist: Change pharmacy ordering protocols and retime medications.
- Nutrition: Avoid 24-hour scheduling.
- Physical therapist and occupational therapist: Provide daytime exercise.
- Hospital administration: Increase staffing during day shifts.
- Facilities: Avoid overnight maintenance and overnight trash and laundry pickup.
- Lab and diagnostic radiology: Increase staffing during day shifts.
ICU protocols for delirium: What are the current recommendations, evidence, and adherence data?5
Dr Margaret Pisani from Yale University School of Medicine discussed ICU protocols for delirium. Here are the key takeaways from her lecture.
- Delirium is extremely prevalent in ICU patients.
- It can be an indicator of organ dysfunction and a determinant of clinical outcomes, including mortality.
- Delirium assessment should be performed routinely in all ICU patients. Nurses and physicians can reliably detect delirium in critically ill patients using validated screening methods like the Confusion Assessment Method and the Intensive Care Delirium Screening Checklist.
- Protocols for sedation, sleep, and mobility are all important for delirium.
Check out our key insights from Anesthesiology 2015.
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Dr Melissa Knauert, Dr Carla Lamb, Dr Margaret Pisani, and Dr Kyle Rehder are not paid consultants of Cook Medical.
Citations
1 Rehder K. Rehabilitating our most critically ill patients: Is it worth the effort? Presented at: CHEST 2015; October 24-28, 2015; Montreal, QC.
2 Argento A. Definition and etiology of massive hemoptysis with a review of diagnostic approaches. Presented at: CHEST 2015; October 24-28, 2015; Montreal, QC.
3 Lamb C. Treatment strategies of massive hemoptysis, review of a systematic approach. Presented at: CHEST 2015; October 24-28, 2015; Montreal, QC.
4 Knauert M. Sleep in the ICU: Protocol development and implementation. Presented at: CHEST 2015; October 24-28, 2015; Montreal, QC.
5 Pisani M. ICU delirium protocols. Presented at: CHEST 2015; October 24-28, 2015; Montreal, QC.
Resources
The following are some of the articles cited by the doctors in their presentations.
Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310(15):1591-1600.
Apostolakis E, Papakonstantinou NA, Baikoussis NG, et al. Intensive care unit-related generalized neuromuscular weakness due to critical illness polyneuropathy/myopathy in critically ill patients. J Anesth. 2015;29(1):112-121.
Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316.
Trogrlić Z, van der Jagt M, Bakker J, et al. A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes. Crit Care. 2015;19:157.
Jackson P, Khan A. Delirium in Critically Ill Patients. Crit Care Clin. 2015;31(3):589-603.
Cameron S, Ball I, Cepinskas G, et al. Early mobilization in the critical care unit: A review of adult and pediatric literature. J Crit Care. 2015;30(4):664-672.
Amidei C, Sole ML. Physiological responses to passive exercise in adults receiving mechanical ventilation. Am J Crit Care. 2013;22(4):337-348.
Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145.
Fan E, Ciesla ND, Truong AD, et al. Inter-rater reliability of manual muscle strength testing in ICU survivors and simulated patients. Intensive Care Med. 2010;36(6):1038-1043.
Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37(9):2499-2505.
Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243.
Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-1882.
Titsworth WL, Hester J, Correia T, et al. The effect of increased mobility on morbidity in the neurointensive care unit: Clinical article. J Neurosurg. 2012;116(6):1379-1388.
Klein KE, Bena JF, Albert NM. Impact of early mobilization on mechanical ventilation and cost in neurological ICU. Am J Respir Crit Care Med. 2015;191:A2293.
Sricharoenchai T, Parker AM, Zanni JM, et al. Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care. 2014;29(3):395-400.
Elliott R, McKinley S, Cistulli P, et al. Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study. Crit Care. 2013;17(2):R46.
Knauert, MP, Yaggi HK, Redeker NS, et al. Feasibility study of unattended polysomnography in medical intensive care unit patients. Heart Lung. 2014;43(5):445-452.
Knauert MP, Haspel JA, Pisani MA. Sleep loss and circadian rhythm disruption in the intensive care unit. Clin Chest Med. 2015;36(3):419-429.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.