The addition of respiratory muscle strength training to facilitate swallow and pulmonary rehabilitation following massive tissue loss and severe deconditioning: A case series |
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| Institution: | 1. Speech Pathology, Concord Repatriation General Hospital, NSW, Australia;2. Burns Unit, Concord Repatriation General Hospital, NSW, Australia;3. Intensive Care Unit, Concord Repatriation General Hospital, NSW, Australia;4. School of Health and Rehabilitation Sciences, University of Queensland, QLD, Australia;5. Faculty of Health Sciences, University of Sydney, NSW, Australia;6. Centre for Functioning and Health Research, Queensland Health, QLD, Australia;7. Department of Nutrition and Dietetics, Concord Repatriation General Hospital, NSW, Australia;8. Physiotherapy Department, Concord Repatriation General Hospital, NSW, Australia;9. Department of Nursing, Concord Repatriation General Hospital, NSW, Australia;10. Faculty of Medicine, University of Sydney, NSW, Australia;1. Intensive Care Clinical Unit, University Hospital Virgen Macarena, Dr. Fedriani St., 3, 41009, Seville, Spain;2. Department of Nursing, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Avenzoar St., 6, 41009, Seville, Spain;1. Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, NSW 2006, Australia;2. Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong Hospital, Crown St, Wollongong NSW, Australia;3. Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Northfields Avenue, Wollongong NSW, Australia;4. Emergency Department, St George Hospital, Kogarah, NSW, Australia;5. St George Clinical School, Faculty of Medicine, University of New South Wales, NSW, Australia;6. School of Medicine, Medicine and Health, University of Wollongong, Wollongong 2522, NSW, Australia;7. School of Nursing and Midwifery and Centre for Quality and Patient Safety Experience in the Institute for Health Transformation, Deakin University, Geelong, VIC, Australia;8. Centre for Quality and Patient Safety Experience – Eastern Health Partnership, Box Hill, VIC, Australia;9. University of Technology Sydney Faculty of Health, NSW, Australia;10. Northern Sydney Local Health District, NSW, Australia;11. Nursing Research Institute, St Vincent''s Health Network Sydney, St Vincent''s Hospital Melbourne and Australian Catholic University, NSW Australia;12. Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2113;13. Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW 2006, Australia;14. Department of Infection Prevention and Control, Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, 2145, Australia;15. New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, NSW, 2145, Australia;p. South West Sydney Clinical School, Faculty of Medicine, University of New South Wales, NSW 2006, Australia;1. Department of Nutrition and Dietetics, Royal Adelaide Hospital, South Australia, Australia;2. Intensive Care Unit, Royal Adelaide Hospital, South Australia, Australia;3. Discipline of Acute Care Medicine, The University of Adelaide, South Australia, Australia;4. Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, South Australia, Australia;5. Allied and Scientific Health Office (ASHO), Department for Health & Wellbeing, Adelaide, South Australia, Australia;1. Department of Intensive Care, Nambour General Hospital, 26 Hospital Road, Nambour, Sunshine Coast, Queensland, 4560, Australia;2. Department of Intensive Care, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, Sunshine Coast, Queensland, 4575, Australia;3. School of Medicine Griffith University, 170 Kessels Road, Brisbane, Queensland, 4111, Australia;4. Faculty of Medicine, University of Queensland, St Lucia, Queensland, 4072, Australia;5. Sunshine Coast Research Institute Research Activity Group, Sunshine Coast University Hospital, 6 Doherty Street, Birtinya, Sunshine Coast, Queensland, 4575, Australia |
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| Abstract: | IntroductionImpaired respiratory and swallow function in patients with intensive care unit–acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation.AimThe aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss.MethodsCase 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale NZSS]), and functional diet (Functional Oral Intake Scale FOIS]) via endoscopy.Results/discussionAt baseline, the PEF score of case 1 was 41% (predicted age–height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively.ConclusionThe addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required. |
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| Keywords: | Respiratory muscle strength training Rehabilitation Dysphagia Pulmonary Deconditioning Speech pathology |
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