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Mobility is a life-saving intervention. In this episode, Kali will discuss the lethal risks of Immobility and muscular atrophy and how mobility (even and especially on the ventilator) can help your loved one survive and thrive.
Episode Transcription
Ok, episode 9. I know this is a lot and I commend you for sticking with this podcast. This is a really important episode about mobility. This is probably not your first inclination when it comes to helping your loved one. Getting them out of bed with they’re nearly on their deathbed may feel counterintuitive. That’s ok. The belief that bedrest is best during illness is an erroneous belief that has been passed down throughout the generations and in some cultures more than others. Yet, for the past few hundred years, we have continually realized how harmful bedrest is.
Let’s first define bedrest- it is staying in bed for more than 24 hours. This can be while awake- you can lift your legs, arms, and scratch your nose- you’re still moving- you’re just not up bearing weight and leaving the bed. This can really impact outcomes such as death, infection, and physical function for patients in the hospital and especially the ICU. We have found that bedrest increases the risk of blood clots, pneumonia, and worsening illness.
The reasoning and mechanisms by which bedrest causes damage are extensive and you can listen to the listed episodes in the other podcast for deeper explanations. For now, understand that bedrest is very harmful. Muscles can break down very quickly by lack of use alone, but when patients have other things such as infection and malnutrition going on during their illness- it fuels the fire of muscle loss. Yet, being stuck in bed alone can cause significant muscle loss.
One study monitored a group of healthy young men that were not sick, were eating regular food, but stayed in bed for 1 week. They found that these young men had a 1.4 kg lean muscle loss- that is 3.08 pounds of muscle. Again- there was nothing else going besides just being in bed- but they could still sit up, lift their extremities, and move. They also became 5% more insulin resistant, which is significant to the overall outcomes of ICU patients.
Now immobility is different and far worse. Immobility is what happens when you have your arm in a cast- the arm CANNOT bend, those muscles CANNOT move. The limb is immobilized. When patients are sedated and in medically-induced comas- they are immobilized. This alone is VERY harmful and potentially lethal.
When muscles do not ignite and contract for days to weeks, they are deeply harmed. They waste away and lose the mass to function the way they usually do, but during critically illness, for many reasons, they can also lose the neuromuscular connection to be able to even move and control those muscles. Meaning, the signal from the brain through the nerves that tell the muscles to work is disrupted. So the loss of muscle mass and the connection from the brain to the muscles is called critical illness neuromyopathy. This makes it so that patients cannot move, or cannot move well.
It is ultimately a neuromuscular disorder developed in the ICU. So they turn off sedation, they takes hours to weeks to wake up, and once they’re opening their eyes, now they have physical impairments from being unable to lift a finger to being unable to sit up, stand, walk, and even breath independently. When patients develop this level of muscular weakness and dyfunction, they are 8 times more likely to die when they develop critical illness neuromyopathy.
Patients at risk of developing this are those have sepsis, multi-organ failure, have high blood sugar, being female, receiving certain medication such as steroids and paralytics, and in the research you will see that the longer a patient is on the ventilator, the more risk they have of developing critical illness neuromyopathy.
Likely this has very little to do with the ventilator itself, but rather, the treatment they receive while on the ventilator. Let’s look at sedation. When patients are deeply sedated, they cannot move. They stop using and controlling their muscles for as long as they are sedated which can be days to weeks or more. That alone can cause massive muscle loss.
Yet, the ICU community is usually unaware that the sedatives themselves affect the muscles in different ways. Propofol, for example, disrupts the sodium channels of the muscles impairing their ability to contract. Propofol also increases the blood sugar which exacerbates muscle wasting. It has also been observed to be myotoxic- or toxic to the muscles causing breakdown for unclear reasons. It is also probably an independent risk factor for diaphragm dysfunction- meaning- even without the ventilator, propofol can damage the diaphragm which affects your ability to breath without support.
Other sedatives can do a lot of the same things, and versed, for example can be even harder on the diaphragm. Among many causes of muscle loss such as casts and bedrest, sedation causes the most detectable muscle loss the quickest- in less than 7 days. Limb weakness is strongly associated with diaphragm weakness. If your loved one comes out of a medically-induced coma and cannot give you a good high-five, chances are much higher that they will not be able to take big and consistent breaths on their own without wearing out due to this critical illness neuropathy and diaphragm dysfunction they have acquired during their time under sedation and stuck in bed. To be honest, 2 year survival rate for ICU survivors that have this ICU acquired weakness and diaphragm dysfunction is only 36%.
This is a significant reason intubated patients on the ventilator and that receive these medications for so long then need tracheostomies. A tracheostomy is a hole cut into their wind pipes with a little tube that connects to the ventilator- because they’re going to needs weeks to months of rehabilitation to be able to have the muscular strength to take their own breaths. This is often a consequence of the muscular weakness developed as a result of sedation and immobility.
I am embarrassed to admit, that this is “normal” in the ICU community. It has been accepted- especially during COVID, that a high portion of our patients on ventilators will automatically need a tracheostomy and PEG feeding tube and then be sent to another care facility to rehabilitate. They don’t know any other way. They’ve never seen anything different. They usually don’t even understand what is causing this. For example, as I’ve worked with COVID families, the teams will tell families their loved one’s lungs are still too sick to be off of the ventilator and yet, the support from the ventilator is at the most minimal – 40% oxygen and a PEEP (or pressure) of 5. The inability to be off the ventilator is not primarily from sick lungs in that scenario, it is from weakness. They are too weak to breath, and the COVID is probably not the main culprit of that. The sedation and immobility will do that even to a perfectly healthy person that is down and given those medications for that long.
“Awake and Walking ICUs” have the goal of treating the initial problem that brought a patient to the ICU without causing a downfall of other complications that will keep them there and plague them the rest of their lives. They recognize that they can either keep them awake and moving on the ventilator and get them better sooner, off the ventilator quicker, and straight back home to resume life, or they can sedate and immobilize them, allow their muscles to waste away, keep them on the ventilator for days to weeks longer, and sent them to a care facility for weeks to months after that, and let them face the mental, psychological ,and physical damage of their treatment for the rest of their lives.
Whether or not to sedate or to mobilize a patient is often that black and white. The normal approach is, “They’re sick, we’d better keep not move them”, yet the Awake and Walking ICU approach is usually, “They’re sick, they could get sicker if we DON’T move them. We have to get them going!”- As long as they’re oxygenating and tolerating mobility- they are rolling. The patient can tell them what they’re feeling, what they need, when they need a break.
They use mobility as a tool for delirium. If a patient is getting confused and wild, they don’t rush to grab sedation to mask it. They urgently treat it with mobility as well as family and sleep. They will do whatever mobility the patient is capable of. Sometimes delirium makes patients so confused and unable to control their bodies that they can barely stand let alone walk. Even sitting at the edge of the bed and holding their own core and head up can stimulate them to reconnect with their environment. You can see the lights come on as they start to make eye contact, answer questions, and follow commands.
You can see the agitation and terror start to melt away. Often even sitting there will wear them out and they will lay back down after 15 minutes or and really sleep. It is more effective and safer than most sedatives. Sedatives will usually make patients wake back up later as a danger to themselves since they’re still delirious. If we allow them to exercise instead of sedating them, then they are far more likely to wake up a little more calm and oriented than before. They will mobilize them every night to facilitate sleep. They literally walk them to sleep. Research has shown that walking patients at night improves sleep and prevents delirium. This is a process and expertise.
The decisions in the those early moments after intubation are pivotal. Why? Why is it so important to avoid sedation and keep patients moving when they are often requiring a lot of ventilator support and really sick? Why not just sedate the at let them “rest” as most are inclined to do?
Because sedation is NOT sleep, and immobility is NOT rest- it is ROT. The sicker they are the more quickly their muscles are going to break down- so we need to get them up to prevent or alleviate multi-organ failure, ICU acquired weakness, and delirium. Mobility is key in preventing delirium.
Yet, if we start sedation, then we take away their ability to move, communicate and connect with family, and sleep. We sign them up for delirium. Then, a few days or a week plus later when we try to do a sedation vacation and wean down the sedation, then they come out delirious, agitated, making the ventilator alarm, and everyone panics and turns sedation back on and this probably signs them up for a at least a few more days on the ventilator.
The longer they’re sedated, the more delirious and weak they’re going to get, and the longer they’re going to be on the ventilator. It is a terrible cycle to lock patients into. Then, once they’ve been sedated and immobilized, if the team does want to rehabilitate them and get them off the ventilator, it is a huge effort and danger. When a 200 pound adult loses the core strength to sit up, hold their head up, or stand, then it requires many people, a special lift, and a lot of work to get them to rebuild that capacity over many days to weeks. It is very painful and exhausting for the patient too. Check out my other podcast to hear it from those that have lived it.
I wish the ICU community understood how much easier it is to help a patient get out of bed shortly after intubation when they still have their muscles. It is less work to preserve muscles and physical function than to rebuild it. I promise.
Again, this is not always an option- if someone has a massive trauma and/or brain bleed- mobility may not be an option. Yet as soon as they can move- they need to be hustled. For patients with pneumonia, sepsis, COVID19, different traumas, and so forth, mobility is much safer than is commonly believed. Various studies have shown a less than 1% harm rate that happened to ICU patients during mobility during many thousands of activity sessions. The difficulty and danger increase the longer we wait to do it.
Ok, now I’ve worried you. Now you’re concerned- but what can you do? Don’t go turning off IV pumps and pushing your loved one out of bed. Yet, work with your ICU team. Support and encourage them to implement best practices into your loved one’s care. If needed, gently educate. Ask if they have a physical and occupational therapy consultation ordered. If they are intubated, ask why they’re sedated. If the team says, “to rest” or “to let them sleep”, or “to prevent PTSD”, tactfully ask if sedation is sleep, if immobility rejuvenates the muscles, or where in the literature does it show that sedation and delirium prevent PTSD. Don’t be hostile, don’t be accusatory, just open up the conversation. Gently guide their thought process past what is “normal” to what is “right”. Understand their perspective and deeply rooted culture and training in this.
If they are intubated and they tell you they can’t order physical therapy until your loved one is off of the ventilator, ask them “why?” or “How will they get off the ventilator if they don’t move and become so weak?”. If they say, “It’s not safe to move them”, ask them when it will be safe and what research demonstrates those parameters. Again, don’t be obnoxious, but you have every right to understand their rationale and have honest discussion about the plan of care. This may be an opportunity to help them learn and change the lives of thousands of future patients as you help them get your loved one awake and moving.
Even if your loved one is not on the ventilator, mobility is key to helping prevent the need for the ventilator or shortening the duration of time on the ventilator if they reach that point. Even breathing on their own, they need to keep moving all throughout their hospitalization so that they can walk themselves out of the hospital and go directly home.
Mobility in the ICU has proven to decrease:
- The need for intubation
- Ventilator associated pneumonia
- Hospital acquired pneumonia
- Pressure injuries
- Falls
- Delirium
- Aspiration
- Constipation/ileus
- Death
- Intubation
- Re-intubation
- Tracheostomy and PEG tube placements
- Discharges to care facilities
- Hospital and ICU readmissions
- delirium
- time: on ventilator, in the ICU, in hospital
Improves:
- How the oxygen moves throughout the lungs
- the ability to get mucous out of the lungs
- Diaphragm function
- Successful extubation
- Discharges from ICU
- Survival
- Quality of life
I tell my patients- “walk like your life depends on it- because it very well may” and “Stay in bed, and that is where you will stay.”
If a patient is refuses, we explain, “It is your right to refuse to get up. Yet that is like refusing an antibiotic. Mobility is a life saving intervention. If you do not want this treatment, then we need to discuss goals of care to better understand what you ultimately want to happen here. “
As their loved one and advocate, you are also their cheerleader. They may not be really motivated to get up and move. Many- even those on the ventilators- actually are. Hospital beds are terrible and it does not feel good to sit in the same spot for days straight. I’ve seen countless patient write on the board asking to get in the chair and/or go on a walk. They want to feel human, they want to use the toilet and wipe their own backside to preserve their own dignity- even on the ventilator.
Granted, I am referring to a utopia- a team that has the culture and expertise to move patients with all of this equipment. Yet any level of mobility you can bring to your loved one will be of great benefit. If they are awake and sitting at the side of the bed- that alone may spare them from a tracheostomy. If they’re walking, You can help push an IV pole or wheelchair, carry a urinary catheter bag, or just cheer them on as they go. You will see their delirium and/or anxiety improve, they will be exhausted, but then get real sleep after. Mobility is magic. It truly is a life-saving intervention.
Do whatever the team is able and willing to do. Understand their perspectives – that this may be a really new concept to them, that they are short staffed, they are terrified of your loved one pulling their tube out or falling, they deeply believe it is endangers the lungs, so many things that inexperience and misinformation make difficult to push this along. Be patient with them, but apply this knowledge and these principles to help get your loved one home. I want to give you all the tools to be able to advocate. I want you to be able to start preventing delirium with mobility, your involvement, keeping your loved one awake during the day and helping them sleep at night, and protecting them from sedation. I want you to be able to have productive collaboration with your ICU team so that everyone is on the same page about how to get your loved one better back to their lives ASAP.
Keep going, hang in there.
Impact of propofol:
Trapani G, et al. (2000). Propofol in anesthesia. mechanism of action, structure-activity relationships, and drug delivery. Current Medical Chemistry, 7(2):249–71.
Yasuda, Y. et al. (2012). Anesthesia with propofol induces insulin resistance systemically in skeletal and cardiac muscles and liver of rats. Biochemistry Biophysiology Respiratory Community, 431(1).
Lonngvist, et al. (2020) Does prolonged propofol sedation of mechanically ventilated covid19 patients contribute to critical illness myopathy? British Journal of Anaesthesia, 125(3).
Bruells, et al. (2014) Sedation using proprofol induces similar diaphragm dysfunction and atrophy during spontaneous breathing and mechanical ventilation in rats. Anesthesiology, 120(3).
Safety and benefit of mobility during mechanical ventilation:
Sricharoenchai, et al. (2014). Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. Journal of Critical Care, 29(3). https://pubmed.ncbi.nlm.nih.gov/24508202/
Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., Veale, K., Rodriguez, L., & Hopkins, R. (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine.
Nydahl, et al. (2017) Safety of patient mobilization and rehabilitation in the intensive care unit. Systematic review with meta-analysis. American Thoracic Society, 14(5).
Hickmann, et al. (2021) Acute effects of sitting out of bed and exercise on lung aeration and oxygenation in critically ill subjects. Respiratory Care, 66(2).
Impact of Immobility:
Dirks, M, et al. (2016). One week of bed rest leads to substantial muscle atrophy and induces whole-body insulin resistance in the absence of skeletal muscle lipid accumulation. Diabetes, 65(10).
Saccheri, C et al. (2020). Icu-acquired weakness, diaphragm dysfunction and long-term outcomes of critically ill patients. Annals of Intensive Care, 10(1).
Parry, S., & Puthucheary, Z. (2015). The impact of extended bedrest on the musculoskeletal system in the critical care environment. Extreme Physiology Medicine, 4(16).
Other episodes on impact of bedrest and immobility:
Survivor testimonials about immobility:
Episodes on the importance of mobility:
Impact of sedation:
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