Muscle Recruitment During Neck Flexion and Inspiratory Muscle Training

Official title

Muscle Recruitment During Neck Flexion and Inspiratory Muscle Training in Difficult and Prolonged Weaning Patients: a Physiological Study - The FLEX Study

Overview

Respiratory muscle dysfunction is highly prevalent in patients with prolonged weaning from mechanical ventilation and is strongly associated with weaning failure. Efforts to strengthen the respiratory muscles, aimed at reversing or minimizing the impact of respiratory muscle weakness on clinical outcomes, have generally focused on the diaphragm with specific inspiratory muscle training (IMT) exercises. However, the effectiveness of these exercises and impact on clinical outcomes are not current practice in the majority of ICUs, as they are hardly feasible in ICU patients who often cannot be disconnected from the ventilator and cannot fully cooperate. Promising results have been published concerning non-respiratory training techniques, which can also target the accessory muscles, particularly important in the presence of increased load to the respiratory system, as in the case of the weaning phase. These non-respiratory training techniques would have the advantage of not entailing disconnection of the patient from the ventilator. In particular, in healthy subjects, a quasi-isometric neck contraction, called neck flexion, appeared to generate greater or comparable recruitment of some principal and accessory muscles of respiration, when compared to conventional IMT. However, this has not been studied in patients requiring prolonged mechanical ventilation, for whom IMT with threshold loading devices remains the primary recommended rehabilitation strategy. Therefore, the primary aim of the investigators is to assess the feasibility, tolerability, and safety of neck flexion and to compare them with IMT technique in patients with difficult and prolonged weaning from mechanical ventilation. Secondary aims are: i) to characterize which respiratory muscles are recruited and their level of activation at different levels of ventilatory assistance and ii) to assess which respiratory muscles are recruited and their level of activation during the two techniques and to compare these findings. The hypothesis of the investigators is that neck flexion will be feasible (more than conventional IMT), well tolerated, and safe in patients with difficult and prolonged weaning. The investigators also hypothesize that, reducing the level of assistance and during unassisted breathing, a progressively increasing activation of the diaphragm, neck and trunk respiratory muscles, reflecting increased ventilatory load, will be fund. Finally, the hypothesis of the investigators is that the level of muscle activation/recruitment during neck flexion will be comparable or even greater to that occurring during IMT, as found in healthy subjects. Finding a new and highly feasible rehabilitative technique, able to recruit and train the respiratory muscles (including accessory muscles), will have the potential to promote patients' weaning and improve all related clinical outcomes, and therefore to dramatically shift the paradigm about the role of rehabilitation in ICU.

Detailed description

The investigators will conduct a prospective longitudinal pilot study in patients receiving mechanical ventilation via endotracheal tube or tracheostomy.

The investigators will perform a set of baseline measurements (as early as possible after the patient reaches the ability to spontaneously trigger the ventilator).These measurements include: I) ultrasound measurements (thickness and thickening fraction) of the diaphragm, parasternal intercostals, sternocleidomastoid and of the abdominal muscles; II) surface electromyography (sEMG) of the diaphragm, sternocleidomastoid, scalene, and of the abdominal muscles. Ultrasound and sEMG measurements will be performed during the current level of ventilation (decided by the clinical team), during minimal level of ventilatory support and/or during unassisted breathing; III) maximal inspiratory pressure (MIP); IV) maximal voluntary contraction (MVC) of neck flexion.

As soon as patients can be disconnected from the ventilator I) IMT maneuvers and II) neck flexion maneuvers, will be started and performed once a week (each time in a randomized order), until patients are successfully weaned or for a maximum of 4 weeks. The investigators will also perform: III) ultrasound measurements; IV) surface electromyography of the muscles above specified during each IMT and neck flexion maneuver; V) MIP and MVC; these latter measurements will be repeated weekly and inspiratory muscle training and neck flexion intensity level targeted accordingly.

Interventions

• Other Quasi-Isometric Neck Flexion
  Patients will be asked to minimally lift their head from the pillow generating a quasi-isometric neck contraction (2 sets of 6-10 flexions).
• Other Inspiratory Muscle Training
  Patients will be asked to complete 2 sets of 6-10 breaths through a POWERbreathe device, which applies a variable resistance provided by an electronically controlled valve (variable flow resistive load). During each IMT and neck flexion maneuver ultrasound measurements will be performed (measurements of the diaphragm, sternocleidomastoid, parasternal intercostal, internal oblique \[IO\], external oblique \[EO\], transversus abdominis \[TrA\] and rectus abdominis \[RA\] will be taken) and, durin

Primary outcome measures

• Adherence to the training techniques [Time frame: Baseline measurements assessed ≤ 72 hours from admission and once a week until successfully weaned or up to maximum of 4 weeks.]
• Incidence of Treatment-Emergent Adverse Events [Time frame: Baseline measurements assessed ≤ 72 hours from admission and once a week until successfully weaned or up to maximum of 4 weeks.]

Secondary outcome measures (4)

• Level of activation of the different respiratory muscles at different levels of ventilatory assistance through surface EMG [Time frame: As early as possible after reaching the ability to spontaneously trigger the ventilator and tolerate a pressure support value of 10 cmH2O or below for at least 15 minutes until successfully weaned or a maximum of 4 weeks]
• Level of activation of the different respiratory muscles at different levels of ventilatory assistance through ultrasound [Time frame: As early as possible after reaching the ability to spontaneously trigger the ventilator and tolerate a pressure support value of 10 cmH2O or below for at least 15 minutes until successfully weaned or a maximum of 4 weeks]
• Level of activation of the different respiratory muscles during the two training techniques (quasi-isometric neck flexion and IMT) through surface EMG [Time frame: As early as possible after reaching the ability to spontaneously trigger the ventilator and tolerate a pressure support value of 10 cmH2O or below for at least 15 minutes until successfully weaned or a maximum of 4 weeks]
• Level of activation of the different respiratory muscles during the two training techniques (quasi-isometric neck flexion and IMT) through ultrasound [Time frame: As early as possible after reaching the ability to spontaneously trigger the ventilator and tolerate a pressure support value of 10 cmH2O or below for at least 15 minutes until successfully weaned or a maximum of 4 weeks]

Eligibility criteria

Inclusion criteria

• Patients receiving invasive MV via endotracheal tube who had failed a planned extubation or failed at least three spontaneous breathing trials (SBTs) or receiving MV via tracheostomy (who required tracheostomy because of difficult or prolonged weaning, failed extubation and/or prolonged ventilation) and able to spontaneously trigger the ventilator.
• Over or equal to 16 years of age
• Tolerating levels of pressure support of 10 cmH2O or lower (or equivalent support in NAVA or PAV+) for at least 15 minutes
• In stable clinical and hemodynamic conditions and adequate level of oxygenation (cardiac frequency ≤ 140 beats/minute, systolic blood pressure 90-160 mmHg, no or minimal vasopressors, PaO2/FiO2 over or equal to 150 mmHg)
• Able to understand and follow simple verbal instructions

Exclusion criteria

• Patients with a previously diagnosed severe neuromuscular disorder (such as amyotrophic lateral sclerosis, muscular dystrophy, multiple sclerosis, myasthenia gravis or spinal cord injury)
• Patients with chronic respiratory failure already ventilated before ICU admission
• Patients unable to collaborate or understand instructions

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Crossover

Masking

Single blind

Primary purpose

Other

Study locations

Canada · 1 center

• St. Michael's Hospital — Toronto

Publications

• Beduneau G, Pham T, Schortgen F, Piquilloud L, Zogheib E, Jonas M, Grelon F, Runge I, Nicolas Terzi, Grange S, Barberet G, Guitard PG, Frat JP, Constan A, Chretien JM, Mancebo J, Mercat A, Richard JM, Brochard L; WIND (Weaning according to a New Definition) Study Group and the REVA (Reseau Europeen de Recherche en Ventilation Artificielle) Network double dagger. Epidemiology of Weaning Outcome acc PMID 27626706
• Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H, Stanchina M, Vieillard-Baron A, Welte T. Weaning from mechanical ventilation. Eur Respir J. 2007 May;29(5):1033-56. doi: 10.1183/09031936.00010206. PMID 17470624
• Funk GC, Anders S, Breyer MK, Burghuber OC, Edelmann G, Heindl W, Hinterholzer G, Kohansal R, Schuster R, Schwarzmaier-D'Assie A, Valentin A, Hartl S. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J. 2010 Jan;35(1):88-94. doi: 10.1183/09031936.00056909. Epub 2009 Jun 18. PMID 19541716
• Herridge MS, Chu LM, Matte A, Tomlinson G, Chan L, Thomas C, Friedrich JO, Mehta S, Lamontagne F, Levasseur M, Ferguson ND, Adhikari NK, Rudkowski JC, Meggison H, Skrobik Y, Flannery J, Bayley M, Batt J, Santos CD, Abbey SE, Tan A, Lo V, Mathur S, Parotto M, Morris D, Flockhart L, Fan E, Lee CM, Wilcox ME, Ayas N, Choong K, Fowler R, Scales DC, Sinuff T, Cuthbertson BH, Rose L, Robles P, Burns S, PMID 26974173
• Unroe M, Kahn JM, Carson SS, Govert JA, Martinu T, Sathy SJ, Clay AS, Chia J, Gray A, Tulsky JA, Cox CE. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med. 2010 Aug 3;153(3):167-75. doi: 10.7326/0003-4819-153-3-201008030-00007. PMID 20679561
• Damuth E, Mitchell JA, Bartock JL, Roberts BW, Trzeciak S. Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med. 2015 Jul;3(7):544-53. doi: 10.1016/S2213-2600(15)00150-2. Epub 2015 May 20. PMID 26003390
• Claxton AR, Wong DT, Chung F, Fehlings MG. Predictors of hospital mortality and mechanical ventilation in patients with cervical spinal cord injury. Can J Anaesth. 1998 Feb;45(2):144-9. doi: 10.1007/BF03013253. PMID 9512849
• Dres M, Dube BP, Mayaux J, Delemazure J, Reuter D, Brochard L, Similowski T, Demoule A. Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients. Am J Respir Crit Care Med. 2017 Jan 1;195(1):57-66. doi: 10.1164/rccm.201602-0367OC. PMID 27310484

Identifiers

NCT: NCT05710432 · 22-185

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗