Early intensive care unit mobility therapy in the treatment of acute respiratory failure* Peter E. Morris, MD; Amanda Goad, RN; Clifton Thompson, RN; Karen Taylor, MPT; Bethany Harry, MPT; Leah Passmore, MS; Amelia Ross, RN, MSN; Laura Anderson; Shirley Baker; Mary Sanchez; Lauretta Penley; April Howard, RN; Luz Dixon, RN; Susan Leach, RN; Ronald Small, MBA; R. Duncan Hite, MD; Edward Haponik, MD I mmobility, deconditioning, and weakness are common problems in mechanically ventilated pa- tients with acute respiratory fail- ure, and may contribute to prolonged hospitalization (1, 2). Although physical therapy has a theoretical appeal and may address this problem, it has not been de- termined whether physical therapy has increased benefit when initiated early during intensive care unit (ICU) treat- ment. There may be perceived barriers to the consistent delivery of passive range of motion (PROM) and physical therapy in many ICUs, namely concern over appara- tus dislodgment, integration of mobility with sedation needs, costs of physical therapists in ICUs and time restraints of both nurses and physical therapists (3). Although exercise has been shown to im- prove functional outcome in emphysema and heart failure in the outpatient set- ting, few data exist regarding whether early mobility of the medical ICU patient will improve outcomes (4, 5). Physical therapy practice in the ICU setting varies greatly from one setting to another (6). One reason for the observed variability in the delivery of physical ther- apy to ICU patients may be the lack of a uniform protocolized approach for ICU delivery of physical therapy. Such proto- cols exists for other ICU interventions: weaning from mechanical ventilation, liberation from sedation, and early goal directed therapies for severe sepsis (7–9). To our knowledge there are no previous studies that assess efficacy, cost, or hos- pital or long-term benefits of early ICU Mobility therapy in medical ICU patients. As part of a quality improvement project we developed a standard physical therapy protocol for use in medical ICU patients. In our ICUs physical therapy is part of usual care; however, delivery and admin- istration of physical therapy is often in- frequent and occurs irregularly. The mo- bility protocol was designed to provide a mechanism (i.e., the protocol and Mobil- ity Team) for standard and frequent (once every day) administration of physical *See also p. 2444. From the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases (PEM, AH, RDH, EH), and Public Health Sciences (Le.P), Wake Forest Uni- versity School of Medicine, Winston Salem, NC; De- partments of Nursing, Physical Therapy, and Hospital Administration (AG, CT, KT, BH, AR, LA, SB, MS, La.P, LD, SL, RS), North Carolina Baptist Hospital, Winston Salem, NC. Supported, in part, by The North Carolina Baptist Hospital and The Claude D. Pepper Older Americans Independence Center of Wake Forest University, NIH Grant P60AG10484. The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: pemorris@wfubmc.edu Copyright © 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e318180b90e Objective: Immobilization and subsequent weakness are conse- quences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been shown that physical therapy initiated in the intensive care unit offers benefit. Design and Setting: Prospective cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care. Patients: Medical intensive care unit patients with acute re- spiratory failure requiring mechanical ventilation on admission: Protocol, n  165; Usual Care, n  165. Interventions: An intensive care unit Mobility Team (critical care nurse, nursing assistant, physical therapist) initiated the protocol within 48 hrs of mechanical ventilation. Measurements and Main Results: The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge. Baseline characteristics were similar between groups. Outcome data are reflective of survivors. More Protocol patients received at least one physical therapy session than did Usual Care (80% vs. 47%, p < .001). Protocol patients were out of bed earlier (5 vs. 11 days, p < .001), had therapy initiated more frequently in the intensive care unit (91% vs. 13%, p < .001), and had similar low complication rates compared with Usual Care. For Protocol patients, intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care (p  .025); hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care (p  .006) (intensive care unit/hospital length of stay adjusted for body mass index, Acute Physiology and Chronic Health Evaluation II, vasopressor). There were no untoward events during an intensive care unit Mobility session and no cost differ- ence (survivors  nonsurvivors) between the two arms, including Mobility Team costs. Conclusions: A Mobility Team using a mobility protocol initi- ated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care. (Crit Care Med 2008; 36:2238 –2243) KEY WORDS: respiratory failure; mechanical ventilation; mobility; intensive care units; physical therapy; passive range of motion 2238 Crit Care Med 2008 Vol. 36, No. 8