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Burns 

Burn Units

Prolonged Immobility has significant and long-term negative health consequences in physical psychomotor and quality of life domains. Burn victims experience additional psychological and physical impairments especially when the burns are extensive or involve the lower extremities and their ability to walk and perform activities of daily living. The socioeconomic costs of these impairments are high, including costs to the patient and family, to the caregiver(s) and to the healthcare facilities where the care is provided. In addition to the physical difficulty of mobilizing these patients, additional quality care and patient satisfaction considerations include protection of skin graft sites, limited tolerance for activity, and emotional trauma of working through pain that can be severe, as burned and healing tissues are stretched and moved.

Patient Recovery much Shorter than Anticipated

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Pulmonary 

Covid, ARDS, Pneumonia Risks

Gravity is the single most important factor responsible for uneven distributions of ventilation and blood flow in the healthy lung. The effect of gravity on the upright lung and the resulting gradients of ventilation and perfusion from top to bottom has been well documented.

Tidal Volume

This is the volume of air exchanged during normal breathing and is typically around 500ml. In a supine person, the weight of the body restricts the free movement of the rib cage, reducing tidal volume.

It has been estimated that, when a person is upright, 78% of tidal exchange is due to the motion of the rib cage but, in the supine position, restriction of rib cage movement reduces this to around 32%.

During prolonged bedrest, patients may develop fixed contractures of the costovertebral joints, further reducing tidal exchange and potentially leading to permanent restrictive pulmonary disease.[5]

Residual Volume

This is the air remaining in the lungs after a full forced breath out and is typically around 1.5L.
The residual volume of the lungs drops in bedridden patients, potentially increasing the risk of portions of the lung collapsing.

This reduction in residual volume appears to be due to:

•Airway obstruction, potentially due to pooled mucus.
• A shifting of the internal abdominal organs towards the thorax, which press on the diaphragm and compress the lungs.[7]

FVC & FEV1

Forced vital capacity (FVC) is the amount of air that can be forced out of the lungs after a maximum intake of breath, and is typically around 4.5L.

The supine position reduces both FVC and another measure called forced expiratory volume in one second (FEV1). It is thought these effects are due to a combination of: Movement of blood away from the lower limbs into the abdomen and thorax, increasing pulmonary blood volume.

• Increased resistance in the airways and a loss of elastic recoil as a result of structural changes within the lungs.[7]

References

1.Martin CJ, Young AC: Ventilation-perfusion variations within the lung. J Appl Physiol 11:371-376,1957

2. Glaister DH: The effect of posture on the distribution of ventilation and blood flow in the normal lung. Clin Sci 33:391-398, 1967

3. Corcoran, P.J. (1991) Use it or lose it: the hazards of bedrest and inactivity. Western Journal of Medicine; 54: 5, 536 - 538.

4. Corcoran, P.J. (1981) Disability consequences of bed rest. In: Stolov, W.C., Clowers, M.R. (eds) Handbook of Severe Disability: A Text for Rehabilitation Counselors, Other Vocational Practitioners, and Allied Health Professionals. Washington, DC: United States Government Printing.

5. Halar, E.M. (1994) Disuse syndrome: recognition and prevention. In: Hayes, R.M. et al (eds) Chronic Disease and Disability: A Contemporary Rehabilitation Approach to the Practice of Medicine. New York: Demos Medical Publishing.

6. Dean, E. (1985) Effect of body position on pulmonary function.Physical Therapy; 65: 5, 613 - 618.
7. Manning, F. et al (1999) Effects of side lying on lung function in older individuals. Physical Therapy; 79: 5, 456 - 466.

LOS cut in Half at Stanford 

What-Are-the-Functions-of-the-Cardiovasc

Standing better than sitting?

After a period of Immobilization if an individual attempts to sit or stand there is a marked pooling of blood in the lower extremities causing a decrease in circulating blood volume. Blood pressure drops and the brain is depleted of blood and oxygen, which leads to fainting.

The TLB allows for a caregiver to gradually increase the patients standing angle with full control while being able to monitor blood pressure. It's not an all or nothing approach that often results in fainting thus leading to falls and injuries. The problem of Orthostatic Hypotension can be improved by repeated standing.

Cardiovascular 

Balloon Pump Patients LOS sees drastic reductions

Extracorporeal-Membrane-Oxygenation-ECMO

Ecmo

Extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is in-creasingly being used in patients with respiratory failure[12,13]. Patients receiving venovenous or venoarterialECMO have traditionally been considered too unstablefor active physical therapy, frequently are heavily sedated,and occasionally are administered neuromuscular blockingagents. However, the ability to ambulate while receivingECMO support has been facilitated by advances in extra- corporeal technology and cannulation techniques [14-17].Additionally, mobilization may be facilitated when ECMOallows for weaning from invasive mechanical ventilation[18].

Although patients receiving ECMO as bridge totransplantation (BTT) are obvious targets for early re-habilitation to maintain their transplant candidacy, thoserequiring ECMO as a bridge to recovery (BTR) from acute respiratory failure should theoretically benefit similarlyfrom early mobilization, though there are few publishedreports of success in such populations [18-21]. We de-scribe our center’s experience with a multidisciplinary ap- proach to early physical therapy, including ambulation, inpatients requiring ECMO as either BTR from acute re-spiratory failure or BTT in cases of end-stage lung disease.

References

Total Lift Bed ~ ECMO

More Patient Inclusion: Don't let tradional barriers keep you forom including patients in your Early Mobility Program. This graph is an example from Colombia as to how they increases patient inclusion over time.

1. Early mobilization of patients receivingextracorporeal membrane oxygenation: aretrospective cohort studyDarryl Abrams1, Jeffrey Javidfar2, Erica Farrand3, Linda B Mongero4, Cara L Agerstrand1, Patrick Ryan5,David Zemmel6, Keri Galuskin6, Theresa M Morrone6, Paul Boerem1, Matthew Bacchetta7†and Daniel Brodie1*†

2. Brodie D, Bacchetta M: Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 1905–1914, 2011:365
3. Paden ML, Conrad SA, Rycus PT, Thiagarajan RR: Extracorporeal life support organization registry report 2012. ASAIO J 2013, 59:202–210.

4. Wang D, Zhou X, Liu X, Sidor B, Lynch J, Zwischenberger JB: Wang-Zwischedouble lumen cannula-toward a percutaneous and ambulatoryparacorporeal artificial lung. ASAIO J 2008, 54:606–611

5. Javidfar J, Brodie D, Wang D, Ibrahimiye AN, Yang J, Zwischenberger JB,Sonett J, Bacchetta M: Use of bicaval dual-lumen catheter for adultvenovenous extracorporeal membrane oxygenation. Ann Thorac Surg2011, 91:1763–1768.

6. Khoshbin E, Roberts N, Harvey C, Machin D, Killer H, Peek GJ, Sosnowski AW,Firmin RK: Poly-methyl pentene oxygenators have improved gasexchange capability and reduced transfusion requirements in adultextracorporeal membrane oxygenation. ASAIO J 2005, 51:281–287.

7. Javidfar J, Brodie D, Costa J, Miller J, Jurrado J, LaVelle M, Newmark A,Takayama H, Sonett JR, Bacchetta M: Subclavian artery cannulation forvenoarterial extracorporeal membrane oxygenation.

8. Abrams D, Brenner K, Burkart KM, Agerstrand C, Thomashow B, Bacchetta M,Brodie D: Pilot study of extracorporeal carbon dioxide removal tofacilitate extubation and ambulation in COPD exacerbations. Ann AmThorac Soc 2013, 10:307–314

Hospital's ELSO scores go from 0 to 4!

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Eventhough we are growing fast and our technology is used in many of the world's most prestigious hospitals, it's still not the standard of care for most.  Please share your clinical success stories with the world so all patients can be mobile.  

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