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It has been claimed that ICU early mobility is a “new and temporary fad”. Is walking intubated patients really that new? Let’s start in 1970 and work our way through decades of research that continues to reaffirm that true mastery of the ABCDEF bundle gives patients the best chance to survive and thrive in and after the ICU.
Episode Transcription
To many, the concept of being awake and walking on a ventilator is unfathomable and seems new. Yet, is it really that new? In 2020, someone mentioned to me that LDS Hospital in Salt Lake City, Utah, or, the “Awake and Walking ICU” that I come from, was quote, “Cutting-edge”. The opposition to this movement claim that this is a “fictitious new fad that lacks evidence or validity”. —— but is it?
To address these claims, we are going to go back about 50 years and work our way through the history of critical care medicine. I will be walking you through a timeline of the highlights and milestone research that has been developed throughout the decades. Johns Hopkins has a library of this that has a growing reservoir of 4,000 studies. Obviously I won’t be going through every possible study, yet I will include citations to the studies I mention as well as the Johns Hopkins library for your personal reference and review.
Let’s address the assumption that walking patients on ventilators is new as this brings us to the early roots of critical care medicine and ventilator management. On the transcript of this episodes on my website, You can see a picture of a patient at San Francisco General Hospital in 1970 that is intubated and pushing her own ventilator alongside a nurse dressed in the white nurses dress. Classic.
Now, admittedly, the patients of the 1970’s were not the same patients that we care for now. For example, ARDS was only first discovered in the 1960’s, but we didn’t know how to treat it. Patients who developed ARDS or severe critical illness usually died before they became the type of complicated and high acuity patient that fills our ICUs today.
Yet, consider that 50 years ago, automatically sedating patients because of an endotracheal tube was not a common practice. Now, during the 1980’s and 1990’s, we really started to experiment with how to utilize mechanical ventilation to support patients with ARDS. The initial theory was that these stiff, fluid-filled lungs would best inflate with high lungs volumes and high PEEP- so for many years, the common practice was to give patients 12 ml per kg of tidal volume, that is 2 and 3 times higher than what we give now.
Dr. Clemmer talks about this more in episode 2 of this podcast, but Imagine these old ventilators that were without sensors, feedback mechanisms, and the ability to adjust and acclimate to patient’s breaths. Now imagine the horror of 12 ml/kg and HIGH peep with STIFF endotracheal tubes that had large and stiff tracheal balloons on them. It was the ultimate recipe for discomfort and horror for patients. There is NO WAY they could be awake, calm, and synchronous with these settings.
This is what really sparked the introduction of continuous sedatives from the operating room such as high-dose opioids, barbiturates, benzodiazepines, and paralytics into the ICU. They knew that they caused amnesia and “comfort” short-term in the OR, but the risks of prolonged use beyond a few hours were unknown.
Intensive care sedation: the past, present and the future.
What was initially observed is that with these drugs, patients magically synchronized much better with the ventilator and their oxygen saturations went up. We became enchanted by the idea that these still and motionless patients were quote, “sleeping”, and it was assumed that they were blissfully unaware of the horrors of the ICU and especially the uncomfortable device in their throat.
I suspect that it was these beliefs of patient comfort and benefit that really caused these medically-induced comas to have a wild-fire effect throughout the ICU community. We went from sedating patients with ARDS To sedating them during mechanical ventilation no matter the diagnosis or reason they were intubated. During the 1980’s and 1990’s, the memory of patients awake and walking in the 1970’s slipped into the history books and standardized medically-induced comas for all intubated patients became the common practice. The focus of the ICU was only on the “front-end” of critical illness. The numbers, lab values, acute diagnosis. Again, the big picture, long-term effects, etc. of these interventions were still very unknown.
In the 1990’s some research from NASA came out showing the similarities of impact from bedrest as being in an antigravity spaceflight for prolonged periods of time. Yet this would take decades to reach the bedside.
Now, during all of this ARDS experimentation in the 1990’s, there were other important discoveries that came into play. In 1990, Dr. Inuoye published her validated delirium screening tool called the confusion assessment method that could accurately identify delirium in the patients in the hospital.
Around the mid 1990’s, my mentor and hero, Polly Bailey was a nurse in a shock trauma ICU. They were doing all the normal things of that time- 12ml/kg, dangerous continuous sedation drips for weeks, etc. She never questioned it until she cared for Joy, a mother of young children in her early 30’s that had received this classic sedation and immobility ARDS cocktail. Back then they had primary nurses and Polly was her primary nurse and followed her horrific hospitalization course. Joy was from her community, so she ended up visiting her at home after she was scooped up off the gurney and plopped into her car and sent home. She routinely visited and was shocked to observe her struggles to use the bed pan in her bed, take a year to get up the stairs, and be unable to resume her life as a mother. She was mortified to witness the psychological and cognitive destruction she was left with.
So as Polly tells in episode 21, she went to her medical director, Dr. Terry Clemmer- who shares this story in episode #2. Polly essentially said to Dr. Clemmer, “What are we working so hard and doing all this to patients if this is the life we send these survivors to?”. Dr. Clemmer told her to look into the research and report back with what information she could find to explain what Joy was experiencing. Polly dug through all the research there was and came back and reported that there was nothing. She told him she thought her psychological, cognitive, and physical impairments and suffering were because she was sedated for weeks. She proposed that they didn’t do that and instead got patients awake and moving on the ventilator.
Dr. Clemmer was not comfortable with that idea. So he sent her to search the research again to find anything about moving patients on ventilators. She again returned empty handed but still determined to try it. Dr. Clemmer said, that he trusted nurses’ instincts and knew Polly would keep her patients safe. So he let her experiment.
It worked. They immediately saw a huge difference in outcomes and started to try it on more and more patients. Yet, this Shock Trauma ICU already had settled into a set culture of sedation and immobility and nurses were really nervous to follow Polly’s lead. So it because a huge struggle to standardize this in that ICU.
In the late 1990’s, the hospital started a respiratory ICU and Polly was given charge of hiring and training new nurses. She recruited nurses from nursing homes that didn’t have any ICU experience and used their blank slates to teach them to keep patients awake and mobile- thus the Awake and Walking ICU was created.
While Polly was doing her thing in her own world… other were doing important research. Dr. Wes Ely published a spontaneous breathing trial study in 1996 that showed that when patients were routinely screened for breathing trial criteria and they turned off vent support for two hours, patients were extubated 1.5 days sooner.
In 1998, Dr. Paula Trezpacz published a study looking at the difference between dementia with delirium and delirium without dementia and found that they were almost identical. They realized that delirium alone can create severe cognitive impairments even without underlying dementia. That is going to be really important to understand as we move forward.
Consider, that during the 1990’s benzodiazepines were the primary sedatives – continuous midazolam and even lorazepam drips. Propofol was fairly new, but the main studies being done to compare these medications were measuring costs and hemodynamic impacts and propofol was 4-5 times more expensive at the time and caused hypotension. Survival and delirium were not on the radar let alone long-term outcomes.
In 1998, Christiane Perme, a physical therapist at Houston Methodist hospital published a study showing walking patients with trachs on ventilators that were unable to wean from the ventilator actually led to ventilator weaning. She talks about her journey of walking intubated patients in the 1990’s in episode 35.
In 1999, Ramona Hopkins published a really important study investigating the neuropsychological and overall health status of these ARDS survivors who were sedated for prolonged periods of time. She found that 100% had severe cognitive, psychological, and physical impairments leaving the hospital.
1 year after discharge, 30% of those survivors still had cognitive decline in terms of impaired memory, attention, concentration and/or processing speed. They weren’t sure why.
That same year of 1999, Dr. Inouye that had create the CAM tool also published a study showing that interventions like hearing aids, glasses, mobility, proper sleep, family, etc. helped decrease delirium and improved cognition at discharge.
In 2,000 the ARDS net study was published comparing tidal volumes on the ventilator of 12ml/kg and 6ml/kg. They didn’t even finish the study as they quickly noticed that death was lower in the 6ml/kg group. Both groups were sedated and I believe usually paralyzed. This brough a significant change to ventilator management. We had a new way to do less harm, but we still hadn’t arrived at how to do the most good for our patients.
In 2000, Dr. JP Kress published a study evaluating daily awakening and breathing trials and found that ventilator days decreased by 2.4 days and ICU Length of stay decreased by 3.2 days.
Around that same time, we started to see evidence that propofol decreased time on the ventilator compared to benzodiazepines.
In 2000, we learned that propofol decreases muscle excitability by inhibiting the GABA receptors and disrupting the sodium channels.
In 2001, Dr. Wes Ely published a study validating the confusion assessment method or CAM tool for the ICU now known as the CAM ICU. Finally,, there was a way to screen for delirium in the ICU.
In 2002, the first clinical practice guidelines for sedation in the ICU for the United states was published.
In 2003, Dr. JP Kress studied the survivors of the his 2000 SAT SBT study and found PTSD decreased from 32% in the continuous sedation group to 0% in the SAT/SBT group and their overall psychological status was better than the group that didn’t have SATs and SBTs. This really challenged beliefs that sedation would prevent PTSD.
In that same year of 2003, Dr. Wes Ely published a study validated the Richmond agitation sedation scale or the RASS. Finally, there was a way to measure and monitor sedation depth over time in the ICU.
Another study in 2003 was from Dr. Margaret Herridge published a study showing that even 1 year after discharge, ARDS survivors have poor functional status primarily involving muscle weakness and fatigue.
2004, a study from Dr. Wes Ely revealed for the first time that not only is delirium difficult to care for and patients are cognitively altered during the stay and upon admission- it is LETHAL. He discovered that delirium is an independent predictor of death and that for every 1 day of delirium there is a 10% increased risk of death. Patients with delirium are 3xs more likely to be dead 6 months after discharge.
Around 2005, there started to be more research and discussion about the role of sleep deprivation in the development of delirium and the role sedatives in sleep deprivation in the ICU.
Then, in 2006, Dr. Pandariphande published a study showing that Ativan is an independent risk factor for delirium. That for every 1 mg, the risk of delirium in the next 24 hours increased risk by 20%.
That same year, Ramona Hopkins and Dr. Jim Jackson published a study showing that survivors of critical illness can have long-lasting neurocognitive impairments that impact their daily function, quality of life, return to work, etc.
In 2007, Polly Bailey and company published a study from LDS Hospital proved that it was safe and feasible to walk intubated patients with a median PF ratio of 89 with an adverse event rate of 0.6%.
Dr. Wes Ely shares in his book, “Every Deep Drawn Breath”, that around this time of delirium discoveries in his career and ICU, he went to visit Polly’s Awake and Walking ICU in Salt Lake City, Utah. He was astonished to find that while his team at Vanderbilt was working on awakening and breathing trials, Polly’s team had almost all their patients awake and walking in the halls. This really impacted his perception of what can and should be for patients in the ICU.
This nurse practitioner, Polly Bailey, was invited to visit Vanderbilt and Johns Hopkins to help them with their early mobility programs. As she walked the halls, they would ask, “What would you do with this patient? And this one?” and each time the answer was the same, “I would turn sedation off.”
These interactions really laid the groundwork for the ABCDEF Bundle and future early mobility studies that would come for years later.
In 2008, a Dr. Weinart published a study showing that the more awake patients were and the more real memories they had of the their actual ICU experience, the less PTSD they had. Patients that had delirious memories had worse PTSD. There was no association between real recall of reality and PTSD. — in 2024, this continues to be a myth that being present during critical illness rather than sedated will cause PTSD.
In 2008, Dr. Girard published another SAT and SBT study. SAT and SBT group had 3 days less on the ventilator and in the ICU and hospital. During the following year, patients in the intervention group were less likely to die. For every 7 patients, 1 life was saved.
They later studied those survivors and found that the SAT and SBT group had less cognitive impairments 3 months after discharge than the continuous sedation group. They found that PTSD did not increase with SATs and SBTs.
In 2009, Dr. Schweikert studied the impact of mobilizing patients 48 hours after intubation. He found that those who were awake and mobile were 24% more likely be at their baseline functional status leaving the hospital, delirium and ventilator days decreased by 2. This was also proven to be safe and feasible.
In 2010, Dr. Dale Needham at Johns Hopkins published a study showing that early mobility program decreased sedation use by 25%, increased rehab session per patient by 7 times, and increased functional mobility by 22%. This decrease length of stay in the ICU by 2.1 days and 3.1 days in the hospital.
The same year of 2010, Dr. Thomas Strom in Denmark published a no-sedation vs. daily sedation interruption study. He found that time on the ventilator decreased by 4.2 days and time in the ICU decreased by 1.52 to 9.09 days. He talks about this more in episode 91.
https://pubmed.ncbi.nlm.nih.gov/20116842/
https://www.thebottomline.org.uk/summaries/icm/strom/
The next year they published another study with those patients and found that the no-sedation protocol did not increase the low rates of PTSD.
In 2010 as well, Dr. Girard published a study showing that delirium is a predictor of cognitive impairments and increases the risks of long-term cognitive impairments by 120 times.
In 2011, Dr. Morris looked at the long-term outcomes of a study he did in 2008 evaluating the impact of sitting intubated patients up 6 days sooner than the control group. He found that a lack of early mobility is an independent predictor of readmission and mortality.
In 2011, Dr. Margaret Herridge published a study looking at the 5 year outcomes of ARDS survivors with ICU- acquired cognitive and functional disability. She found that though their pulmonary function had returned to normal, they still had not returned to normal physical function and continued to have psychological problems 5 years after discharge.
In 2012, Dr. Dale Needham and company published a consensus defining post-ICU syndrome as a new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization in a survivor or family member.
In 2012 as well, Dr. Shahabi published a study proving that early deep sedation- or, when sedated patients are unable to respond to voice- is an independent predictor of death.
In that same year, Dr. Titsworth published a study showing that a 300% increase in early mobility in a neuro ICU resulted in a 60% decrease in hospital-acquired infections.
In 2012, Dr. Jakob also published a study showing that dexmedetomidine had a lower risk of delirium than propofol.
In 2013, Dr. Yasuda discovered that propofol increases insulin resistance and hyperglycemia.
2013 was the year that the first PAD – or pain, agitation, delirium guidelines were published by the Society of Critical Care Medicine. The lead author, Dr. Juli Barr talks about this in episode 136. This was the big declaration saying that we need to focusing on pain management before sedation. That delirium should be a top priority in the ICU and that benzodiazepines are a nearly-never medication. This is wild to talk about in 2024 since midazolam is still back in vogue. Early mobility was only briefly mentioned in a delirium section.
Ironically, in 2013, Dr. Pandharipande published a study showing that 74% of ICU patients had delirium and that 1 year after discharge, 40% had cognitive impairments 1.5 SD below population mean and 25% had 2 SD below population mean – similar scores to those with mild alzheimers and moderate traumatic brain injuries– in old and young survivors. The longer the duration of their delirium, the worse their global and executive function 3 and 12 months after discharge.
This is when we realized that patients were suffering brain injuries in the hospital and went on to live lives similar to dementia and TBI survivors.
Now we are realizing that not only is delirium deadly inside the hospital but can result in life-altering cognitive and psychological changes for those that survive it. Now we were faced with a difficult dichotomy of knowing that avoiding sedation and mobilizing patients improves outcomes in and after the ICU, but we weren’t yet doing it.
In 2014, Dr. Bruells, published a study suggesting that even without mechanical ventilation, propofol is an independent predictor of diaphragm dysfunction.
Alright… so now that we knew that standard sedation and immobility practices were hurting and even killing vulnerable patients in the ICU, we started to buckle down on actually doing something about it.
In 2016, the Society of Critical Care Medicine and Critical Illness, Brain dysfunction, and Survivorship Center at Vanderbilt initiated the ICU Liberation Campaign to implement the ABCDEF bundle in 75 ICUs.
In 2017, Mary Ann Barnes Daly studied the implementation of the PAD guildelines through the ABCDEF bundle in 6,064 patients across 7 hospitals. This was a new concept and so the ABCDEF bundle was not mastered and the degree of compliance with the bundle greatly varied. She found that for every 10% increase in bundle compliance, there was a 15% improvement in hospital survival. There was also a dose-dependent improvement in coma and delirium rates.
In 2018, new PAD guidelines were published and updated to PADIS for pain, agitation, delirium, immobility, and sleep. Further reinforcing the prioritization of keeping patients as free of sedation and mobile as possible.
In 2019, Society of Critical Care Medicine published the results of their big roll-out in over 15,000 patients in 68 facilities. Again, it was a new thing, so 100% compliance with the bundle was accomplished in only 8% of the patients. Only 12% of them were out of bed bearing weight- mobilty levels were still pitifully low compared to the previous Bailey, Needham, and Schweikert trials.
Nonetheless, even among this huge spectrum of compliance, the average decrease in 7-day mortality was 68%. Coma and delirium decreased by 50%. Patients were less like to be on and stay on mechanical ventilation, restraint use decreased by over 60%, patients were 46% less likely to come back to the ICU and were 36% more likely to discharge home from the hospital rather than to a care facility.
They found AGAIN a dose-dependent relationship. The more elements of the bundle patients received- the less sedation used, the more patients were mobilized- the better all of these outcomes were- death, delirium, discharge home, readmission, restraints, improved.
This shook the ICU community as we realized we had discovered a powerful way to survive and thrive in and after the ICU.
https://pubmed.ncbi.nlm.nih.gov/30339549/
So during the late 2010’s, the ABCDEF bundle had gained traction and many teams were making some progress. In 2019, Dr. Hseih showed that the bundle decrease healthcare costs by 30%- so surely this these discoveries meant no more excuses. The ABCDEF bundle save lives and money, so it was time to get patients awake and moving.
In 2020, Dr. Ludwig Scheffenbichler published a report demonstrating increased mobility is more dependent on ICU culture than patient acuity and that more ICU mobility leads to more functional independence after discharge.
Then COVID happened. I don’t need to tell you how horrific the situation was. I was working in an Awake and Walking COVID unit. Admist all the unknown with this new virus, that unit decided to continue to stick 25+ years of knowledge and practices doing the things like being mobile that helped patients survive mechanical ventilation and critical illness.
At the same time, I was also working telecritical care and helping manage COVID patients in other hospitals throughout the region. It was amazing for me to watching COVID patients sitting in chairs and walking in their rooms with PT on high ventilator settings and then review charts and zoom into rooms of patients of patients that were often younger, on lower ventilator settings, and on 3-5 different sedatives and opioids.
There were concerns raised about propofol being used during COVID due to It being a mitochondrial toxin and the high risk of critical illness myopathy.
The research says that 64% of COVID patients were on continuous benzodiazepines, though the studies benzodiazepines carry the highest risk of delirium and even death.
Mobility during COVID across the globe was extremely low. We also saw that 100% compliance with the bundle was at 0%.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994035/
One study showed that 70% of COVID patients were sedated deeper than a RASS of -3 despite the orders for 0- (-3) which was again an independent predictor of delirium and even death.
Obviously diverting from the ABCDEF bundle was rooted in various things such as fear, staffing crisis, no family at the bedside, the loss of experienced clinicians that knew how to practice the bundle and the quick adaptation of deep sedation for those new clinicians that now only know automatic these antiquated practices.
We saw from this study that early mobilization was not without challenges, but was safe and feasible for COVID patients.
Nonetheless, across the board, much of the progress gained during 2010’s was largely lost during COVID.
In 2021, Dr. Girard published again a report showing the relationship between sedatives and long-term cognitive impairments.
In 2022, the TEAM trial was published showing that a 12 minute increase in early mobility after 6 days of sedation and immobility did not improve outcomes.
Walking Home From The ICU Episode 138: Early Mobility in the ICU Improves Cognitive Function 1 Year After Discharge
This is discussed at length with the author, Carol Hodgson as well as Dr. Wes Ely and Heidi Engel in episode 117.
In 2023, Dr. Bahkti Patel published a study showing that mobility- usually walking- patients within 48 hours after intubation improved cognitive function by 20% 1 year after discharge.
She discusses this more in episode 138 of the podcast.
In 2023, Dr. Margaret Herridge published a beautiful article articulating the reality of post-ICU syndrome. It was not necessary new information, but brought a reminder to seasoned ICU clinicians and a wake-up call to those that are new to the field.
In 2023, Ayaka Matsuoka published a report revealing that early mobility timing within 72 hours of ICU admission is needed for PICS prevention.
In 2024, Anna Jenkins and company published a retrospective study that showed that for every additional 10 minutes of ICU early mobility, there was a 1.2 day decrease in hospital length of stay.
Just this month, a study was published showing that for every unit of out-of-bed mobility for intubated patients, there was a 10% decrease in time on the ventilator.
I know that was a lot of information, but in reality, it was a superficial skim through decades that brought thousands of studies to the table.
Despite all of the studies we do have, we are still in need of higher quality and randomized control trials with teams that are truly applying the evidence and guidance we have compiled over the decades to become Awake and Walking ICUs. We have enough research with patients being sedated for a few days or more and THEN being mobilized at lower and variable levels.
We know how to do a little less harm, but have we fully captured how to do the most good?
We know the damage sedation does to the body and brain. We know less than 20% of patients in the ICU have actual indications for sedation. Yet, we continue to conveyor belt that sets patients up for increases risk of death and long-term physical, cognitive, and psychological damage.
It is discouraging for me to look over this vast data having worked for many years in an Awake and Walking ICU and then to get calls like one I received 2 weeks ago. A 25 year old young man called me after finding the podcast. His girlfriend had pulmonary embolisms and had been intubated and sedated for almost 4 weeks on 9-10 of midazolam and 200-300 mcg/hr of fentanyl. She had a tracheostomy and remained sedated. She was in her early 20’s brilliant in tech and coding and in grad school. All of this data repeatedly proves that the care she is receiving is lethal and damaging to her body and brain. Yet here we are in 2024, and he is struggling to beg and beg for awakening trials, early mobility, tools for communication, etc.
As we understand our past, we can better comprehend our present and most importantly, build a better future founded in the evidence and humanity for all patients in the ICU.
Transcribed by https://otter.ai
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