Abstract
BACKGROUND:
Patients who have been treated with mechanical ventilation for more than 72 hours are susceptible to symptoms such as hypoxia and respiratory muscle fatigue after weaning, which may result in weaning difficulty and delay, as well as an increased incidence of negative emotions such as anxiety and depression. Correct pulmonary rehabilitation exercise technique and timing can improve the weaning success rate, reduce the disability rate, and reduce the incidence of pulmonary infection, as well as reduce medical expenses.
OBJECTIVE:
This article provides a review of pulmonary rehabilitation interventions for mechanically ventilated patients, searching relevant literature through databases such as CNKI and PubMed, aiming to provide guidance for the successful weaning of mechanically ventilated patients.
METHODS:
We selected articles related to pulmonary rehabilitation interventions for mechanically ventilated patients from CNKI (China National Knowledge Infrastructure) and PubMed over the years.
RESULTS:
This article provides a comprehensive review of the research on lung rehabilitation for patients who are mechanically ventilated during the weaning process in an effort to serve as a guide for a successful transition from mechanical ventilation.
CONCLUSION:
Early pulmonary rehabilitation training can effectively increase the pulmonary function level and ventilation function of patients and reduce the duration of mechanical ventilation and hospitalization, and is an effective, safe, and feasible treatment method.
Introduction
Mechanical ventilation is a supportive therapy that uses mechanical devices to replace or assist the respiratory muscles when patients suffer from respiratory failure [1]. Although mechanical ventilation cannot cure the primary diseases causing respiratory failure, it can help patients regain their effective ventilation and improve oxygenation, buying time and creating conditions for treating the underlying disease. Weaning is the process of discontinuing the use of a ventilator once the underlying disease is under control and the level of mechanical ventilation support is progressively decreased. This is done as the patient gradually recovers spontaneous breathing, taking into consideration relevant physiological and respiratory indicators, in order to successfully wean the patient off the ventilator [2]. Patients undergo active or passive exercise to improve respiratory muscle strength, stabilize or improve lung symptoms and function, and reduce the duration of mechanical ventilation, thereby increasing the success rate of weaning, decreasing disability rates and the incidence of lung infections, and lowering healthcare costs [3]. Traditional methods of weaning have a high rate of failure in clinical practice. Therefore, this article provides a review of pulmonary rehabilitation interventions for mechanically ventilated patients, searching relevant literature through databases such as CNKI and PubMed, aiming to provide guidance for the successful weaning of mechanically ventilated patients.
Pulmonary rehabilitation
Current status of pulmonary rehabilitation research
Pulmonary rehabilitation (PR) was first proposed by the American College of Chest Physicians and the American Cardiopulmonary Rehabilitation Association in 1997 [4]. Comprehensive pulmonary rehabilitation includes exercise training, training for the respiratory muscles, health education, psychological and behavioral intervention, and effect evaluation. Pulmonary rehabilitation focuses on exercise training as a part of a comprehensive program designed to stabilize and reverse the condition, allowing the patient to achieve maximum respiratory potential. The majority of pulmonary rehabilitation interventions for patients emphasize self-management during hospitalization and after discharge [5], but compliance is low. Relevant studies indicate that only 1.2% of patients with chronic obstructive pulmonary disease (COPD) perform pulmonary rehabilitation training [6], 50% of patients with severe COPD refuse to participate in pulmonary rehabilitation training [7], and that the dropout rate for patients undergoing pulmonary rehabilitation is significant. As a comprehensive treatment involving multiple disciplines [8], pulmonary rehabilitation can better relieve dyspnea symptoms, improve health status, exercise tolerance, and quality of life [9], reduce acute exacerbation rates, hospitalization rates, disability rates, and mortality rates [10]. However, most patients have limited understanding of rehabilitation, and the application of pulmonary rehabilitation for respiratory diseases in China needs to be popularized and improved.
The timing of pulmonary rehabilitation for patients weaned from mechanical ventilation
The timing of pulmonary rehabilitation depends on the clinical symptoms of the patients, and it should not be considered as the last line of defense for patients with severe respiratory impairment. Patients treated with mechanical ventilation for more than 72 hours experience varying degrees of decline in respiratory muscle strength, and if the inhaled oxygen concentration is less than 40% within one hour after weaning, the patient is susceptible to hypoxia and respiratory muscle fatigue, may refuse to extubate, and has a strong ventilator dependence due to the desire for mechanical ventilation [11]. As per literature, 20%–30% of mechanically ventilated patients have weaning difficulties and delayed weaning [12, 13]. During mechanical ventilation, accurately formulating a pulmonary rehabilitation training plan with ultrasound guidance can effectively improve the lung function of patients who are mechanically ventilated, increase their oxygenation index, and shorten the duration of mechanical ventilation [14]. Early pulmonary rehabilitation is vital for patients who are mechanically ventilated to recover their pulmonary function prior to weaning [15]. Three months of pulmonary rehabilitation exercise after weaning off mechanical ventilation can significantly improve the lung function index of patients and reduce the incidence of negative emotions [16]. Choosing the correct weaning time, appropriate weaning methods, and effective intervention measures can help patients wean off the ventilator safely, timely, and without complications.
Influence of pulmonary rehabilitation on the weaning of patients
According to studies [17], prolonged mechanical ventilation increases the incidence of anxiety and depression. Therefore, early weaning is a popular topic in clinical research. Currently, numerous international studies [18] have demonstrated the safety and viability of pulmonary rehabilitation in mechanical ventilation; specifically, relevant pulmonary rehabilitation interventions within 48 hours of performing mechanical ventilation are safe and effective and can reduce the patient’s mechanical ventilation time. Jenkins et al. [19] noted that early pulmonary rehabilitation exercises for patients receiving mechanical ventilation can improve their inspiratory muscle strength, lung function, weaning success rate, duration of mechanical ventilation, and related complications [20].
Pulmonary rehabilitation intervention for patients weaned from mechanical ventilation
Abdominal lifting and compressing training
This is a rehabilitation maneuver designed to exercise the diaphragm-based respiratory muscles, simulating the process of abdominal breathing by pressing and elevating the abdomen to increase airway flow rate during respiration and enhance airway clearance ability, which is conducive to early weaning [21]. In patients with long-term mechanical ventilation, diaphragm atrophy and weakness are the primary causes of respiratory muscle weakness [22]. By lifting and pressing the abdomen, the change in abdominal pressure causes the diaphragm to move up and down, which in turn causes the thoracic pressure to change, Specifically, when the diaphragm is moved downward, the negative pressure of the thoracic cavity increases, which is favorable for the entry of air into the lungs; while, when the diaphragm is moved upward, it is favorable for the exhaustion of lung gases. This process functions as artificial respiration [23], thus slowing down diaphragmatic atrophy. The application of abdominal lifting and compressing training for pulmonary rehabilitation in mechanically ventilated patients does not result in significant changes in the hemodynamics of patients and aids patients in achieving weaning standards and subsequently, successful weaning, according to the findings of a study [24].
Respiratory muscle training
In China, respiratory muscle training is one of the earliest clinical treatments used in pulmonary rehabilitation, including chest tremor and tap, balloon blowing, abdominal breathing, pursed lip breathing, and active circular breathing training, to enhance the inspiratory muscle endurance and muscle strength of patients. Pulmonary rehabilitation can enhance the performance ability of respiratory muscles and increase pulmonary ventilation volumes. Correct breathing training can enhance muscle strength, endurance, and coordination of respiratory muscles, expand the thoracic range of motion, increase the muscle strength of the diaphragm, and improve the respiratory function, thereby facilitating the removal of secretions from the airway, keeping the airway open, preventing infections and other complications, and enhancing the cardiopulmonary function of patients. Studies have demonstrated that strengthening respiratory muscle training with abdominal breathing can improve the symptoms of hypoxia in patients [25], which is of great significance given the dependence of respiratory muscles. Through long-term exercise, the respiratory muscles, particularly the diaphragm, can be strengthened, breathing can be improved, breathing efficiency can be enhanced, and sputum excretion can be encouraged, so as to restore the decreased lung function and prevent further decline [26].
Traditional Chinese medicine treatment for pulmonary rehabilitation
Pulmonary rehabilitation in traditional Chinese medicine emphasizes holistic rehabilitation, syndrome differentiation rehabilitation, functional rehabilitation, and prevention rehabilitation. It is characterized by the combination of prevention and rehabilitation, external and internal treatments, and medicinal and dietary treatments. Chinese medicine treatment can promote the remodeling of the cough reflex and the recovery of respiratory function in patients who are mechanically ventilated, in addition to regulating the viscera, qi, and blood of patients. According to a study [27], electroacupuncture stimulation can strengthen the muscles of patients who are mechanically ventilated and prevent muscle atrophy and weakness. Tapping acupoints on the back combined with the plucking method to expel sputum is beneficial for patients who are mechanically ventilated, to expel sputum [28]. According to research, traditional Chinese medicine pulmonary rehabilitation gymnastics can increase the oxygenation index of patients, reduce carbon dioxide retention, and decrease the duration of mechanical ventilation [29]. Increasingly conspicuous is the effect of traditional Chinese medicine treatment in the pulmonary rehabilitation of patients who are mechanically ventilated; however, standard operating procedures and multidisciplinary teamwork are required.
Electrostimulation technique
Electrical stimulation technology involves the use of electrical currents to stimulate respiratory muscle motor neurons, thereby activating muscle fibers to improve respiratory muscle function [30]. Research has confirmed that respiratory electrical stimulation technology significantly improves pulmonary rehabilitation outcomes in patients with chronic obstructive pulmonary disease (COPD), spinal cord injury, and other conditions [31]. Studies have indicated that abdominal electrical stimulation technology, by synchronously stimulating nerves with respiration to induce rhythmic contractions of abdominal muscles, can slow down muscle atrophy, improve clinical outcomes, and reduce mechanical ventilation time and ICU stay [32, 33]. In recent years, electrical stimulation technology has been gradually integrated into early pulmonary rehabilitation for mechanically ventilated patients. This personalized approach based on individual patient needs has shown to enhance treatment compliance and improve outcomes.
Limitations
One limitation of the review is the potential bias in the selection of studies included in the analysis. The review may have focused on specific types of pulmonary rehabilitation interventions or certain patient populations, which could limit the generalizability of the findings to a broader range of patients undergoing mechanical ventilation weaning. Additionally, the review may not have considered potential confounding variables or factors that could influence the outcomes of pulmonary rehabilitation interventions, such as comorbidities or concurrent treatments. This lack of comprehensive analysis could impact the overall conclusions drawn from the review. Furthermore, the review may not have addressed variations in healthcare systems and practices across different regions, which could affect the implementation and effectiveness of pulmonary rehabilitation programs for mechanically ventilated patients. Future reviews should aim to address these limitations by including a more diverse range of studies, considering potential confounders, and accounting for regional differences in healthcare delivery when evaluating the impact of pulmonary rehabilitation on patients weaned from mechanical ventilation.
Conclusion
Pulmonary rehabilitation is crucial for patients who are mechanically ventilated, and experts and scholars have clinically confirmed its safety and efficacy. Early pulmonary rehabilitation training can effectively increase the pulmonary function level and ventilation function of patients and reduce the duration of mechanical ventilation and hospitalization, and is an effective, safe, and feasible treatment method.
Footnotes
Conflict of interest
None to report.