Physiotherapists abstractsOral communicationsO79 Lung ultrasound: help to the diagnostic and the monitoring of response to physiotherapy. A case report of pneumoniaAymeric Le Neindre1, Pascal Selot1, Daniel Ferreiro,1, Maria Bonarek,1, Stépahen Henriot,1, Julie Rodriguez,1 1Physiotherapy, Hôpital Forcilles - Fondation Cognacq-Jay, Férolles-Attilly, France Correspondence: Aymeric Le Neindre - aymeric.leneindre@gmail.com Annals of Intensive Care 2017, 7(Suppl 1):O79 Introduction Lung ultrasound is widely used in intensive care, ermergency and pneumology medicine, for assessing acute respiratory pathologies. It is noninvasive, radiation free and rapidly available at the patient's bedside and provides an excellent accuracy. So, lung ultrasound may be an interesting tool for the physiotherapist as it allows to assess with more accuracy the patient improving the chest physiotherapy indication and monitoring (1).As far as we are aware, no study has evaluated the impact of lung ultrasound on clinical-decision making by physiotherapists in the use of chest physiotherapy.This case report highlights the lung ultrasound interest in chest physiotherapy in patient with lung consolidation. Patients and methods This was a case report written following the recommendations of the CARE guideline (2).The case was a 68-years-old female patient, non intubated, hospitalized in a respiratory ICU. She was hypoxemic (PaO2 = 59 mmHg and SaO2 = 89%), with dyspnoea at rest and an increasing radiological opacity at the right lung base. Hypoxemia was the indication for physiotherapist referral.At the clinical examination, the physiotherapist's findings were: decreased mobility, dullness and abolished vesicular sound at the base of right hemithorax.This clinical examination and chest x-rays analysis allowed the physiotherapist to propose several clinical hypotheses: pleural effusion, obstructive atelectasis or pneumonia.The chest physiotherapy treatment differs according to the type of lung deficiencies. For example, the physiotherapist must to refer the patient to the medical staff in case of pleural effusion or may implement hyperinflation technique in case of obstructive atelectasis. Determining the nature of lung deficiencies is essential to provide the more suitable therapeutic strategy. So, the physiotherapist decided to perform a lung ultrasound examination to retain the more likely hypothesis. Results Ultrasound examination performed by the physiotherapist highlighted the presence of a lung consolidation at the infero-lateral and posterior parts of the right lung with a pneumonia pattern: presence of tissue-like sign, shred sign, dynamic air bronchogram and fluid bronchogram.The medical staff implemented antibiotic treatment. The ultrasound findings guided the physiotherapist to choose chest physiotherapy technique improving the alveolar recruitment: nearly prone position (left side down) and continuous positive airway pressure during 45 min.The patient response to the treatment was monitored by ultrasound and showed a decrease of the lung consolidation size and apparition of B lines, meaning a gain of lung aeration. These findings were associated with SpO2 improvement but without decrease of dyspnoea. Discussion Lung ultrasound allowed the physiotherapist to precise the nature of the radiological lung opacity. As it is more accurate than clinical examination or chest x-ray, this suggests a more suitable choice of chest physiotherapy techniques than conventional clinical decision-making process.Ultrasound findings suggested a positive response to the chest physiotherapy treatment. The apparition of re-aeration signs (B lines, decreased consolidation size) showed a short-term efficacy of the chest physiotherapy treatment. This allowed the physiotherapist to continue the treatment during 1 week and obtain a substantial clinical improvement. Conclusion The use of lung ultrasound in the clinical decision-making process may help the physiotherapist to choose with more accuracy the therapeutic strategy. Moreover, it allows to monitor the treatment in real-time and assess the patient's response. The use of this tool may allow the physiotherapist to determine the optimal indications for chest physiotherapy and thus avoid unnecessary or inappropriate treatments. Competing interests None. References 1. Le Neindre A, Mongodi S, Philippart F, Bouhemad B. Thoracic ultrasound: potential new tool for physiotherapists in respiratory management. A narrative review. J Crit Care. 2016;31(1):101–9. 2. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. The CARE guidelines: consensus-based clinical case reporting guideline development. J Med Case Rep. 2013;7(223):1–6. O80 Chronic critical illness: a prospective observational study in Florence, ItalyMara Taddei1, Mauro Di Bari2 1Department of healthy profession, intensive care unit, division of cardiology, Careggi University Hospital, Firenze, Italy; 2Division of geriatric cardiology and medicine, research unit of medicine of ageing, Careggi University Hospital, Firenze, Italy Correspondence: Mara Taddei - marataddei@libero.it Annals of Intensive Care 2017, 7(Suppl 1):O80 Introduction Chronic Critical Illness (CCI) syndrome is a new condition affecting an increasing number of patients, who survived an acute critical illness but have persistent severe organ dysfunction, requiring prolonged specialized care. CCI is a iatrogenic process, reflecting the efficacy of modern life support technologies(1), and encompasses multiple organ failure, need for prolonged mechanical ventilation (MV), organ support, and palsy due to polineuromyopathy. The transition from acute to CCI is gradual: definitions are based on duration of MV, with cut-offs of 7, 14 or 21 consecutive days of MV for ≥6 h/day. CCI patients may come from either medical or surgical ICU; their health status fluctuates between improvements and deteriorations implying recurrent transitions between different levels of care (1).The risk of death is reported to be as high as 50%. Despite a relatively young age (65 years on average), functional status of CCI patients discharged is seriously impaired, thus CCI patients require long-term rehabilitation.AIM: To estimate the frequency of CCI Syndrome in Careggi, a large academic, tertiary care hospital; to describe the clinical course of CCI patients through discharge, and their functional status at discharge. Patients and methods Administrative data on admission, transfer, death and discharge of all CCI patients, consecutively admitted in one of the 56 ICU beds at Careggi Hospital from January 1 to December 31, 2014, were collected. CCI was defined with the cut off of ≥21 days of ICU stay, representing the index event (IE) without contribution of previous or subsequent hospitalization in other hospitals. Reasons for admission were grouped into the 4 broad categories of medical causes, surgery, major trauma and cardio-respiratory arrest. Patients discharged were evaluated in daily living, cognitive status, and mobility using Barthel Index. Results We identified 123 subjects who developed CCI (71 males; age 61.7 ± 1.5 years, mean ± SEM); 36 of them came from an external ICU, 87 began their CCI course within Careggi hospital (60 from the Emergency Room, 27 from a regular ward). Average duration of the IE was 36.1 ± 2.1 days. These sample developed accumulative length of ICU stay of 4440 days, corresponding to a 22% ICU bed occupation over the theoretical total of 20,440. When days of sub-intensive care and regular ward were separately added, 5500 days of highly specialized care and 6266 days of total acute hospital stay were reached. Surgical patients had longer hospitalizations (p = 0.009).CCI patients confirmed to be highly erratic: a total of 302 transitions across different services were recorded in the 123 patients, with a maximum of 9 in 6 of them. Mean age was comparable between the 27 patients who died (22%) and the remaining 95 who were discharged alive (66.9 ± 2.5 vs. 60.3 ± 1.7 years; p = 0.058).Fourteen subjects continued their ICU stay out of hospital. Only 6, whose age was lower (37.7 ± 3.7 years), were discharged home; half of the participants (n = 68, 55.2%) were admitted to a residential rehabilitation facility. Younger subjects scored better in the domains of self care (p = 0.018) and cognitive status (p = 0.008) but not in the domain of mobility, including walking ability: 45 patients required maximal assistance in performing activities of daily living and transfers, other 12 required medium/maximal assistance, with no statistical difference between DG group. Conclusion CCI is a relevant clinical condition that need to be assessed and possibly prevented, as it causes severe morbidity, long-term functional impairment and exceeding healthcare costs. Competing interests None. Reference 1. MacIntyre NR, Fan E, et al. Journal Conference on Chronic Critical Illness. Resp. Care 2012;57(6). O81 Physical therapy during the early course of sepsis is safe and preserves skeletal muscle massCheryl Hickmann1, Diego Castanares-Zapatero1, Louise Deldicque2, Peter Van Den Bergh3, Gilles Caty4, Jean Roeseler1, Marc Francaux2, Pierre-François Laterre1 1Intensive care unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Bruxelles, Belgium; 2Institute of neuroscience, Université catholique de Louvain, Louvain-la-Neuve, Belgium; 3Neuromuscular reference centrer, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium; 4Department of physical medicine and rehabilitation, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium Correspondence: Cheryl Hickmann - cheryl.hickmann@uclouvain.be Annals of Intensive Care 2017, 7(Suppl 1):O81 Introduction Critical illness together with immobilization have deleterious effects on patients outcome, especially in the presence of sepsis. Increased muscle catabolism and membrane inexcitability reduce muscular mass and impair function within the first days after sepsis onset (1). Early mobilization could potentially limit muscle wasting and functional impairment in this population. The purpose of this study was to test whether exercise during the early phase of sepsis is safe and beneficial and to which extent it can limit skeletal muscle protein catabolism and preserve function. Patients and methods Adult patients admitted with the diagnosis of severe sepsis were included and randomly allocated to two groups; 1) Control group (Ctrl-G): manual passive/active manual mobilization twice a day or 2) Experimental group (Exp-G): additional two times 30 min of passive/active cycling exercise. Both groups benefited from a reduced sedation, adjusted nutritional intake and bed to chair transfer as soon as possible.Skeletal muscle biopsy and electrophysiological testing were realized at day-1 and day-7. Muscle histology, biochemical and molecular analyses of anabolic/catabolic and inflammatory signalling pathways were performed. A group of four healthy subjects was used to obtain non pathological values.Hemodynamic parameters and patients perception were collected during each session. Results Twenty-one patients were included, however 3 died before the second muscle biopsy. Ten patients in Ctrl-G and nine in Exp-G were finally analysed. Muscle fibre cross sectional area (µm2) was significantly preserved by exercise (relative changes were Ctrl-G: −45 ± 41% vs Exp-G:12 ± 19%, p = 0.001). Markers of catabolic systems were highly increased during sepsis compared to healthy subjects and reduced in both groups 7 days after admission. However the reduction in mRNA (relative change) tended to be more important in Exp-G: MURF-1 (Ctrl-G: −31 ± 67% vs Exp-G: −63 ± 45%, p = 0.15), MAFbx (Ctrl-G: −7 ± 138% vs Exp-G: −56 ± 37%, p = 0.23), LC3b (Ctrl-G: 5 ± 47% vs Exp-G: −21 ± 18%, p = 0.18) and Bnip3 (Ctrl-G: 27 ± 198% vs Exp-G: −59 ± 23%, p = 0.02). Anabolic and inflammatory markers were not affected by exercise.Electrophysiological testing, including direct muscular stimulation, was abnormal on Day-1 in 10 of 13 evaluated patients. Since only a limited number of patients could be reassessed a second time, comparison between groups was not possible.In general, all activities were well tolerated by patients with no adverse events. Conclusion Early mobilization during the first week of the sepsis onset was safe and preserved muscle fibre cross sectional area. Competing interests None. Reference 1. Kress JP, Jesse BH. ICU-Acquired weakness and recovery from critical illness. N Engl J Med. 2014;(370):1626–35. O82 Where should we place the stethoscope's chestpiece to hear the noise of the primary bronchi?Frédéric Duprez1, Bastien Dupuis2, Grégory Cuvelier2, Thierry Bonus1, Sandra Ollieuz1, Sharam Machayeckhi1, Gregory Reychler3 1Icu, C.H. Epicura, Hornu, Belgium; 2Laboratoire de l'effort et du mouvement, Condorcet, Tournai, Belgium; 3Service de pneumologie, Cliniques Universitaires Saint Luc, Bruxelles, Belgium Correspondence: Frédéric Duprez - dtamedical@hotmail.com Annals of Intensive Care 2017, 7(Suppl 1):O82 Introduction The pulmonary auscultation is used by respiratory therapist (RT) to evaluate the efficiency of a treatment. Listen to the noises coming from the primary bronchi (PB) is important because it is the place where secretions can be accumulated. Therefore, it is crucial to know exactly where to place the stethoscope's chestpiece on the chest. Few studies have analyzed the chest area where the PB were located. Our hypothesis is that PB are localized on a line that joins axillary fossa (Bi-Axillary line: BAL). The aim of our study is to evaluate the probability to find the primary bronchi by analysis of chest radiography. Patients and methods A retrospective study was performed by analysis of chest X-Ray using the software: TM reception®, which allows precise measures to the tenth of millimeter. All the X-Rays were made on confined to bed patients hospitalized within intensive care unit, internal medicine and abdominal surgery rooms.The following measures (in mm) were made between: a) Lowered perpendicular (LP) of: • Bi-Axillary Line (BAL) and the sternal carina (SC) • BAL's and the position of right and left PB • Middle of the body-sternum (BS) and the perpendicular middle of right and left PB. b) Hyoid bone and the SC The exclusion criteria were: BMI < 18.5 kg/m2 and BMI > 30 kg/m2, scoliosis, minor patient, lack of visibility of one of the axillary fossa, lack of visibility of PB, clavicular asymmetry, kyphosis, lack of symmetry in the shot, atelectasis and pneumothorax.Statistics: Normality test: KS. Mean values are expressed with their SD and 95% CI. Results Discussion In this study, we performed analysis of chest x-Rays of bedridden patients and we demonstrated that it is possible to localize easily, on either side of the BS, the right and left PB at ± 25 mm distance (LP) above a line joining axillary fossa. This study constitutes a new tool for the RT who, by using stethoscope with a chestpiece of 10 cm2 surface area, will be able to listen to noise coming from PB. Conclusion The data presented herein (Fig. 31) show that right and left PB are located at a mean distance of 25 (±5) mm and 27 (±6) mm above the BAL, on both sides of the BS. The BAL represents thus an easy and precise mode to detect right and left PB by bedridden. Finally, the distance between the hyoid bone and the SC is about 12 cm. As the PB are located after the bifurcation, this information constitutes another useful way for the localization the right and left PB by bedridden patient.Fig. 3150 X-Rays (Men = 26, women = 24) have been analyzed. Normality test passed. LP lower perpendicular, BAL bi-axillary lineFull size image Competing interests None.O83 Study of efficacy on ICU acquired weakness of early standing with the assistance of a tilt table in critically ill patientsCeline Sarfati1, Alex Moore1, Paula Mendialdua1, Emilie Rodet1, Catherine Pilorge2, Francois Stephan2, Saida Rezaiguia-Delclaux2 1Physiotherapy department, Surgical Center Marie Lannelongue, Le Plessis-Robinson, France; 2Réanimation adulte, Surgical Center Marie Lannelongue, Le Plessis-Robinson, France Correspondence: Celine Sarfati - celine.sarfati@yahoo.com Annals of Intensive Care 2017, 7(Suppl 1):O83 Introduction Critically ill patients frequently develop muscle weakness, which is associated with prolonged intensive care unit and hospital stay (1). This randomized controlled trial (Clinical Trials NCT02047617) was designed to investigate whether a daily training session using a tilt table, started early in stable critically ill patients with an expected prolonged ICU stay, could improve strength at ICU and hospital discharge compared to a standard physiotherapy program. Patients and methods The study protocol was approved by an ethics committee and informed consent was obtained from all patients. Patients admitted in adult ICU of Marie Lannelongue hospital, France, who were mechanically ventilated for at least 3 days were included. Exclusion criteria were cerebral or spinal injury, pelvic or lower limb fracture. Patients were assessed each day for temporary contraindications for mobilization out of bed (RASS score <−2 or >1; hemodynamic instability; a continuous intravenous dose of epinephrine/norepinephrine >2 mg/h; continuous renal replacement; ECMO). Interventions for patients assigned to the standard physiotherapy group (Std) included sitting in armchair for at least 2 h per day. In addition to the standard physiotherapy mobilization protocol, patients assigned to the Tilt table physiotherapy group (Tilt) were positioned on a tilt table for 1 h per day. The primary outcome was the muscles strength evaluated using the Medical Research Council (MRC) score (range 0 = no muscle contraction, to 5 = normal strength), scoring 3 muscle groups in each limb, at ICU and hospital discharge, compared to MRC score evaluated in ICU before the implementation of the physiotherapy program. Secondary outcome variables included ICU and hospital length of stay. Results The flow chart of the study, conducted between October 2013 and October 2014, is presented in the Fig. 32.Fig. 32See text for descriptionFull size image Both groups (Std vs Tilt) are comparable for age (63 ± 16 vs 60 ± 15, p = 0.37), gender (21 Females vs 26 F and 52 Males vs 46 M, p = 0.34) and the SAPSII (43 ± 13 vs 42 ± 12, p = 0.65). No significant difference was observed in terms of MRC score or in terms of pts with or without weakness (MRC > 48) at ICU or hospital discharge. However, the number of pts with weakness was significantly higher in the group before Tilt mobilization, suggesting a more rapid improvement in the tilt group. The ICU and hospital lengths of stay were not different between groups. Discussion The prevalence of muscle weakness in our population is high before mobilization (90.6%, 95% CI 85.2–95.6), is still 48.6% at ICU discharge but represents only ~ 1% at hospital discharge. This low hospital discharge prevalence is probably related to the early and intense physiotherapy in both groups, which may explain our inability to demonstrate superiority of the addition of tilt table positioning, although a faster recovery is suggested. Conclusion Training sessions using a tilt table, in addition to early and intense physiotherapy did not improve muscle strength evaluated using MRC score in surgical ICU patients with muscle weakness. Competing interests None. Reference 1. Am J Respir Crit Care Med. 2007;175:480–9. O84 Aerosol delivery using two nebulizers through high flow nasal cannula: a randomized cross-over SPECT-CT studyJonathan Dugernier1, Michel Hesse2, Thibaud Jumetz1, Emilie Bialais1, Jean Roeseler1, Virginie Depoortere2, Jean Bernard Michotte3, Xavier Wittebole1, Pierre-François Laterre1, François Jamar4, Gregory Reychler5 1Sevice des soins intensifs, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium; 2 Médecine nucléaire, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium; 3Respiratory, Haute École de Santé Vaud, Lausanne, Switzerland; 4Service de médecine nucléaire, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium; 5Service de pneumologie, Cliniques Universitaires Saint Luc, Bruxelles, Belgium Correspondence: Jonathan Dugernier - jonathan.dugernier@uclouvain.be Annals of Intensive Care 2017, 7(Suppl 1):O84 Introduction Patients with high flow nasal cannula may benefit from combined aerosol therapy. Clinical efficacy depends on pulmonary deposition which is related to the type of nebulizer. All new nebulizers or delivery methods require rigorous evaluation. The aim of this study was to compare lung deposition between two nebulizers (jet nebulizer vs vibrating-mesh nebulizer) through high flow nasal cannula in healthy subjects. Patients and methods Aerosol delivery of diethylenetriaminepentaacetic acid labelled with technetium-99m (99mTc-DTPA, 4 mCi/4 mL) to the lungs using a vibrating-mesh nebulizer (Aerogen Solo®, Aerogen Ltd., Galway, Ireland) and a constant-output jet nebulizer (Opti-Mist Plus Nebulizer®, ConvaTec, Bridgewater, NJ) through high flow nasal cannula (Optiflow®, Fisher & Paykel, New Zealand) was compared in 6 healthy subjects. Flow rate was set at 30 L/min through the heated humidified circuit. Pulmonary and extrapulmonary deposition were measured by single photon emission computed tomography combined with a low dose CT-scan (SPECT-CT) and by planar scintigraphy. Results Lung deposition was only 3.3 ± 1.3 and 1.2 ± 0.8% of the nominal dose with the vibrating-mesh nebulizer and the jet nebulizer, respectively (p < 0.05). Dose lost in the high flow circuit, humidification chamber and nasal cannula was higher with the vibrating-mesh nebulizer as compared to the jet nebulizer (75.2 ± 8.2 vs 45.0 ± 6.2% of the nominal dose, p = 0.001). Expressed as percentage of emitted dose, lung deposition was similar with both nebulizers. Conclusion This study demonstrated that aerosol delivery through HFNC is poor in the specific conditions of the study despite the higher efficiency of the vibrating-mesh nebulizer as compared to the jet nebulizer. Placing the nebulizer on the HFNC circuit at 30 L/min induces high aerosol loss on the circuit and the oropharynx. Competing interests J. Dugernier: unrestricted grant by Aerogen Ltd. (Galway, Ireland).
