Morris Peter E, Berry Michael J, Files D Clark, Thompson J Clifton, Hauser Jordan, Flores Lori, Dhar Sanjay, Chmelo Elizabeth, Lovato James, Case L Douglas, Bakhru Rita N, Sarwal Aarti, Parry Selina M, Campbell Pamela, Mote Arthur, Winkelman Chris, Hite Robert D, Nicklas Barbara, Chatterjee Arjun, Young Michael P
Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington.
Department of Health and Exercise Science, Wake Forest University, Winston Salem, North Carolina.
JAMA. 2016 Jun 28;315(24):2694-702. doi: 10.1001/jama.2016.7201.
Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure.
To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure.
DESIGN, SETTING, AND PARTICIPANTS: Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up.
Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0).
Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength.
Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, -1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, -2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, -0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, -1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, -0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02).
Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS.
clinicaltrials.gov Identifier: NCT00976833.
重症监护病房（ICU）中的物理康复可能会改善急性呼吸衰竭患者的预后。
比较标准化康复治疗（SRT）与急性呼吸衰竭患者的常规ICU护理。
设计、设置和参与者：北卡罗来纳州韦克福里斯特浸礼会医学中心的单中心随机临床试验。2009年10月至2014年5月期间，因急性呼吸衰竭需要机械通气而入住ICU的成年患者（平均年龄58岁；女性占55%）被随机分为SRT组（n = 150）或常规护理组（n = 150），并进行6个月的随访。
SRT组患者在出院前每天接受治疗，包括被动关节活动度训练、物理治疗和渐进性抗阻运动。常规护理组在临床团队下达医嘱时接受工作日的物理治疗。对于SRT组，被动关节活动度训练的治疗天数中位数（四分位间距[IQR]）为8.0（5.0 - 14.0）天，物理治疗为5.0（3.0 - 8.0）天，渐进性抗阻运动为3.0（1.0 - 5.0）天。常规护理组物理治疗的天数中位数为1.0（IQR，0.0 - 8.0）天。
两组在ICU、出院时以及2、4和6个月时均接受了评估者盲法测试。主要结局是住院时间（LOS）。次要结局包括机械通气天数、ICU天数、简短体能状况量表（SPPB）评分、36项简明健康调查问卷（SF - 36）的生理和心理健康及身体功能量表评分、功能表现量表（FPI）评分、简易精神状态检查表（MMSE）评分以及握力和手持测力计力量。
在300名随机分组的患者中，SRT组的住院LOS中位数为10天（IQR，6至17天），常规护理组为10天（IQR，7至16天）（中位数差异为0 [95% CI，-1.5至3]，P = 0.41）。机械通气时间或ICU护理时间无差异。6个月时，握力（差异为2.0 kg [95% CI，-1.3至5.4]，P = 0.23）和手持测力计力量（差异为0.4 lb [95% CI，-2.9至3.7]，P = 0.82）、SF - 36生理健康评分（差异为3.4 [95% CI，-0.02至7.0]，P = 0.05）、SF - 36心理健康评分（差异为2.4 [95% CI，-1.2至6.0]，P = 0.19）或MMSE评分（差异为0.6 [95% CI，-0.2至1.4]，P = 0.17）均无影响。SRT组在6个月时的SPPB评分（差异为1.1 [95% CI，0.04至2.1，P = 0.04]）、SF - 36身体功能量表评分（差异为12.2 [95% CI，3.8至20.7]，P = 0.001）和FPI评分（差异为0.2 [95% CI，0.04至0.4]，P = 0.02）更高。
在因急性呼吸衰竭住院的患者中，与常规护理相比，SRT并未缩短住院时间。
clinicaltrials.gov标识符：NCT00976833。
