Can High Intensity Inspiratory Muscle Training Improve Inspiratory Muscle Strength and Accelerate Weaning in Medical Patients With Difficulty on Weaning?

Study Overview
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Brief Summary
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Introduction: It has been described that invasive mechanical ventilation leads to diaphragm weakness. The inspiratory muscle weakness is related with a difficult and prolonged weaning as well as longer duration of mechanical ventilation and increased risk of complications and death. Consequently, the duration of stay in ICU is longer and the costs in ICU increase. Objectives: To determine the effects of a high intensity inspiratory muscle training (IMT) on inspiratory muscle strength, weaning outcomes, complications and length of stay in the ICU in medical patients with difficulty on weaning and admitted in the ICU. Methodology: In a single blind randomized clinical trial, 40 tracheotomy ventilated medical patients in which spontaneous breathing trial has failed ≥ 1 time, will be selected and randomized into two equitable groups. In the intervention group, IMT will be performed at 60% of the maximum inspiratory pressure (which will increase by 10% every week) while in the control group it will be performed at 30%. In both groups, 5 sets of 6 breaths will be performed, once a day, 5 days a week, for a maximum of 28 days or until the patient is successfully weaned. The main outcome will be the maximum inspiratory pressure, while the maximum expiratory pressure, weaning duration process, weaning success, duration of mechanical ventilation, length of stay in the ICU, complications and the rapid shallow breathing index will be analyzed as secondary outcomes. t-student test for independent samples will be used to analyze quantitative outcomes. For qualitative outcomes will be used X2 test. A value of p<0.05 will be assumed as an indicator of statistically significant results. Future contributions: Our collect results can be useful for the updating of the clinical practice guidelines and promote its implementation in the clinical practice.

Official Title
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Can High Intensity Inspiratory Muscle Training Improve Inspiratory Muscle Strength and Accelerate Weaning in Medical Patients With Difficulty on Weaning Admitted in the Intensive Care Unit?

Conditions
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Weaning Failure

Intervention / Treatment
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* Procedure: Low Intensity IMT
* Procedure: High Intensity IMT


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Medical patients aged ≥ 18 years hospitalized in the ICU. Patients ventilated by tracheostomy and who have failed ≥ 1 spontaneous breathing test. Being ventilated in assisted-controlled, assisted or pressure support modes. PEEP ≤ 10 cmH2O Richmond Agitation-Sedation Scale between -1 and 0. Confusion Assessment Method for the Intensive Care Unit negative. Cardiorespiratory and hemodynamic stability in the absence of vasopressor support or with minimal requirement (dobutamine or dopamine ≤ 5 μg / kg / min, phenylephrine ≤ 1 μg / kg / min). FiO2 ≤ 0,6 PaO2/FiO2 ratio > 200 Blood lactate levels < 4 mmol/L Exclusion Criteria: Progressive neuromuscular disease Thoraco-abdominal surgery in a period <30 days from the beginning of the study. Diseases that cause hemodynamic instability (cardiac arrhythmia, decompensated heart failure, unstable ischemic heart disease). Hemoptysis Unstable chest wall. Not drained pneumothorax Phrenic nerve injury Spinal cord injury above T8 Clinical signs of respiratory distress (paradoxal breathing, use of accessory respiratory muscles) Body mass index > 40 kg / m2 Use domiciliary ventilator support prior to hospitalization. Skeletal disorder of the rib cage that impairs its biomechanics (severe kyphoscoliosis, congenital deformities). Body temperature > 38ºC Pregnancy Receive therapy with nitric oxide or nebulized prostacyclin. Medical order.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 99 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Low Intensity IMT<br> | Procedure: Low Intensity IMT<br>* The control group will get a supervised IMT with Threshold IMT device, once a day, 5 days a week for a maximum of 28 days or until the participant is weaned successfully. In each session the participant will do 5 sets of 6 repetitions with 2 minutes of rest between sets. The initial training load will be adjusted to 30% of the MIP and will be increased by 10% of the initial MIP weekly. The patient will be placed in a semi-incorporated position (head of the bed elevated 45º). The ICU physiotherapist will check before training that the cuff of the tracheal tube is correctly swollen to avoid air leaks during the training. The ICU physiotherapist will disconnect the mechanical ventilation during the IMT and will provide supplemental oxygen when required. However, between series the participant will be returned to ventilator support. Patients will be instructed to do a whole expiration and immediately inspire as forceful as possible until reaching the total lung capacity.<br>|
| Experimental: High Intensity IMT<br> | Procedure: High Intensity IMT<br>* The experimental group will get a supervised IMT with Threshold IMT device, once a day, 5 days a week for a maximum of 28 days or until the participant is weaned successfully. In each session the participant will do 5 sets of 6 repetitions with 2 minutes of rest between sets. The initial training load will be adjusted to 60% of the MIP and will be increased by 10% of the initial MIP weekly. The patient will be placed in a semi-incorporated position (head of the bed elevated 45º). The ICU physiotherapist will check before training that the cuff of the tracheal tube is correctly swollen to avoid air leaks during the training. The ICU physiotherapist will disconnect the mechanical ventilation during the IMT and will provide supplemental oxygen when required. However, between series the participant will be returned to ventilator support. Patients will be instructed to do a whole expiration and immediately inspire as forceful as possible until reaching the total lung capacity.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Inspiratory muscle strength | Measured with MIP (Maximal Inspiratory Pressure) Assessments: Baseline, after the intervention period | Through study completion, an average of 28 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Expiratory muscle strength | Measured with MEP (Maximal Expiratory Pressure) Baseline, after the intervention period | Through study completion, an average of 28 days | 
| Rapid Shallow Breathing Index | Measured with the mechanical ventilator | Through study completion, an average of 28 days | 
| Duration of the weaning period | Defined as the hours since the first attempt of spontaneous breathing (or the initiation of pressure support ≤ 7 cmH2O) to successful weaning | Through study completion, an average of 28 days | 
| Weaning success | Recorded as successfully if the patient can breathe spontaneously through tracheostomy without restart mechanical ventilation for at least 48 hours. | Through study completion, an average of 28 days | 
| Duration of mechanical ventilation | Recorded as the days since patient was connected to mechanical ventilator to successful weaning. | Through study completion, an average of 28 days | 
| Length of stay in the ICU | Measured in days. | Through study completion, an average of 28 days | 
| Complications | Defined as the patient needs to be intubated again when the patient was weaned or the death of the participant | Through study completion, an average of 28 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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mechanical ventilator weaning, mechanical ventilation, difficult weaning, intensive care unit, inspiratory muscle training, ventilator-induced diaphragmatic dysfunction, physiotherapy