Critical Illness Neuromyopathy and the Role of Physical Therapy and Rehabilitation in Critically Ill Patients
Critical Illness Neuromyopathy and the Role of Physical Therapy and Rehabilitation in Critically Ill Patients
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DOI：
10.4187/respcare.01634
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发表时间：
2012-06-01
期刊：
影响因子：
2.5
通讯作者：
Fan, Eddy
中科院分区：
文献类型：
--
作者：
Fan, Eddy
危重病的神经肌肉并发症很常见，可以是严重的和持续的，对身体功能和长期生活质量有实质性的损害。虽然ICU获得性虚弱(ICUAW)的病因是多因素的，但危重病的直接并发症(如重症神经肌病)和间接并发症(如静止/废止萎缩)都是导致ICU获得性虚弱的原因。ICUAW在危重疾病的急性期往往很难临床诊断，因为经常使用深度镇静、脑病和精神错乱，这损害了患者体力的体检。尽管体检有其局限性，但在合作患者中，体检仍是鉴定ICUAW的起点。考虑到相对成本、侵袭性和对专业知识的需求，电生理测试和/或肌肉活组织检查可能保留给在系列临床检查中改善慢于预期的虚弱患者。目前预防或治疗ICUAW的干预措施有限，严格的血糖控制具有最大的支持性证据。评估早期康复在慢性危重病患者中的具体作用的临床试验很少。然而，许多研究支持在接受慢性机械通气的患者中进行强化康复的好处。此外，新出现的数据表明危重患者早期活动的安全性、可行性和潜在益处，需要多中心随机试验来评估早期活动的潜在短期和长期好处，包括防止需要长时间机械通气和/或发展慢性危重疾病的可能性，以及其他对患者肌肉力量、身体功能、生活质量和资源利用的新治疗。最后，早期活动在内科和其他ICU(如外科、神经科、儿科)以及慢性危重病人中的障碍、可行性和有效性尚未得到正式评估，需要在未来的临床试验中进行探索。
Neuromuscular complications of critical illness are common, and can be severe and persistent, with substantial impairment in physical function and long-term quality of life. While the etiology of ICU-acquired weakness (ICUAW) is multifactorial, both direct (ie, critical illness neuromyopathy) and indirect (ie, immobility/disuse atrophy) complications of critical illness contribute to it. ICUAW is often difficult to diagnose clinically during the acute phase of critical illness, due to the frequent use of deep sedation, encephalopathy, and delirium, which impair physical examination for patient strength. Despite its limitations, physical examination is the starting point for identification of ICUAW in the cooperative patient. Given the relative cost, invasiveness, and need for expertise, electrophysiological testing and/or muscle biopsy may be reserved for weak patients with slower than expected improvement on serial clinical examination. Currently there are limited interventions to prevent or treat ICUAW, with tight glycemic control having the greatest supporting evidence. There is a paucity of clinical trials evaluating the specific role of early rehabilitation in the chronic critically ill. However, a number of studies support the benefit of intensive rehabilitation in patients receiving chronic mechanical ventilation. Furthermore, emerging data demonstrate the safety, feasibility, and potential benefit of early mobility in critically ill patients, with the need for multicenter randomized trials to evaluate potential short- and long-term benefits of early mobility, including the potential to prevent the need for prolonged mechanical ventilation and/or the development of chronic critical illness, and other novel treatments on patients' muscle strength, physical function, quality of life, and resource utilization. Finally, the barriers, feasibility, and efficacy of early mobility in both medical and other ICUs (eg, surgical, neurological, pediatric), as well as in the chronic critically ill, have not been formally evaluated and require exploration in future clinical trials.