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REVIEW

Comprehensive physiotherapy management in ARDS

N. AMBROSINO 1, 2, D. N. MAKHABAH 1

1Pulmonary Rehabilitation and Weaning Center, Auxilium Vitae, Volterra, Pisa, Italy; 2Pulmonary Unit, University
Hospital, Pisa, Italy

ABSTRACT
Survival of critically ill patients is frequently associated with significant functional impairment and reduced health-
related quality of life. Early physiotherapy of acute respiratory distress syndrome (ARDS) patients has recently been
identified as an important therapeutical tool and has become an important evidence-based component in the man-
agement of these patients. Nevertheless, availability and quality of physiotherapy performed in intensive care units
(ICUs) is often inadequate. The aim of this review is to describe recent progresses in application of physiotherapy
in ARDS patients. The assessment and evidence-based treatment of these patients should include prevention and
reduction of adverse consequences of immobilization and weaning failure. A variety of modalities of early physi-
otherapy in ICU are suggested by clinical research and should be applied according to the stage of disease, comor-
bidities, and patient’s level of cooperation. Early ICU physiotherapy is an interdisciplinary team activity, involving
physical therapists, occupational therapists, nurses and medical staff. (Minerva Anestesiol 2013;79:554-63)
Key words: Physical therapy modalities - Respiration, artificial - Weaning - Respiratory insufficiency - Respiratory
muscles - Muscle, skeletal.

T he acute respiratory distress syndrome

(ARDS) is an important clinical and re-
source consuming problem.1Progress of medi-
cal and ventilatory therapy has substantially
improved survival of critically ill patients in
intensive care units (ICUs), nevertheless sur-
vivors of ARDS like other elderly survivors of
mechanical ventilation (MV) 2 may suffer from
long-lasting functional impairment, exercise
limitation, reduced cognitive and health-related
quality of life (HRQL) up to 2 and 5 years after
discharge.3-5 ARDS is a substantial contributor
to “Chronic critical illness” which is observed
or other proprietary information of the Publisher.
fections, and long-term steroid administration
are well known risk factors for ICU-acquired
weakness. Electrophysiological tests can identify
peripheral neuromyopathies, although the cor-
relation of these findings to weakness as meas-
ured at the bedside is not always narrow. For
routine clinical purposes, bedside assessment of
neuromuscular function can be performed but
factors such as sedative and analgesic admin-
istration may confound the picture. There is a
tight relationship between weakness and long-
term ventilator dependence.9-17 Furthermore
ARDS survivors, like survivors from sepsis 5 may

in almost half of the ICU patients with sepsis,
multiple organ failure and/or need of prolonged
MV.5-8
ICU-acquired weakness is a major deter-
minant of long-term health status and HRQL
outcomes in ARDS survivors and may last for
months, or even indefinitely. Immobility, in-
complain of depression, anxiety, memory distur-
bances, and difficulty with concentration often
unchanged at 2 and 5 years.18, 19 Less than half
of all ARDS survivors return to work within the
first year following discharge, two-thirds at two
years, and more than 70% at five years.2, 20, 21
Despite return to work most survivors continue

554 MINERVA ANESTESIOLOGICA May 2013

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to complain of functional limitation and a re-
duction in their HRQL.22
There is a growing need for recognition of
the role of physiotherapy (PT) in the short- and
long-term care of ICU patients, including those
with ARDS.23, 24 Nevertheless, availability of
physiotherapists and quality of intervention in
ICU are often insufficient.25-29 US physiothera-
pists 26 report greater involvement during the
recovery phase from critical illness. At difference
most of physiotherapists in Europe 25 Australia,27
South Africa 28 and the UK 29 work in the ICU.
A survey by Skinner et al.27 reported that in the
ICU physiotherapists used to decide when and
how to perform patients mobilization. However,
large variations were noted in the safety criteria
used to initiate and monitor exercise as well as in
the dosage of therapy reported by physiothera-
pists.27
The aims of PT programs in ARDS patients
should be to apply advanced cost-effective thera-
peutic tools to reduce complications of immo-
bilization and patient’s ventilator-dependency,
to improve residual function, to prevent new
hospitalisations and to improve health status
and HRQL.30-33 Physiotherapy in critical pa-
tients is claimed also to prevent and contribute
to treat respiratory complications such as secre-
tion retention, atelectasis, and pneumonia.34, 35
Early mobilization and maintenance of muscle
strength may reduce the risk of difficult weaning,
limited mobility and ventilator dependency.36, 37
Algorithms have been proposed as a guide in
selecting suitable patients for mobilization and
providing appropriate treatment strategies.23, 24
However, such algorithms should be tailored to
each individual patient though adaptations and
changes. Therefore, PT should start as earlier as
possible within the ICU, even while patients are
on MV in order to improve function and reduce
morbidity, as there is report that most of patients
or other proprietary information of the Publisher.
undergoing continuous MV for longer than 48
hours, will require assistance for up to one year.2
Nevertheless more studies are needed to confirm
the short term and long term responsiveness of
ARDS survivors to PT. Table I summarizes the
interventions of a PT course for ARDS patients.
Table II depicts some clinical trials of PT meth-
ods in ICU.
Vol. 79 - No. 5 MINERVA ANESTESIOLOGICA 555
Table I.—Physiotherapy-based activities and techniques in
the ICU.
Muscle weakness Passive and active-assisted mobilisation
Continuous rotational therapy
Postures
Limb exercise and peripheral muscle
training
Neuromuscular electrical stimulation
Respiratory muscle training
Airway secretions Manual hyperinflation
Percussion and vibrations
In-exsufflation
Percussive ventilation
Treatment of muscle weakness
Mobilization
Although ARDS patients’ survival is improv-
ing, patients and clinicians must be aware of
short- and long-term complications of critical
illness. Prolonged immobility is a contributing
factor of deconditioning and weakness which are
common problems in ARDS survivors requiring
MV.
Passive mobilization of upper (Figure 1) and
lower (Figure 2) limb and active mobilization
(Figure 3) may substantially contribute to the
patient’s recovery. The feasibility, safety, and
benefits of early mobilization of ICU patients
under MV have been recently reported. The
benefits of early mobilization include reductions
in ICU and Hospital length of stay, as well as
improvements in muscle function and func-
tional status.44 Such benefits can be obtained
under relevant safety condition. Passive and ac-
tive mobilization together with specific muscle
training, when possible, can improve functional
outcomes, cognitive and respiratory conditions
(Table II).45
There is agreement on the use of early mobili-
zation also in unconscious or sedated patients.24,
46 This includes the use of semi-recumbent po-
sitioning with the goal of 45o head of the bed
up and higher;23, 47 regular changes in postures
beyond the standard every two hour turning reg-
imen;48 daily passive movement of all joints,49
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Table II.—Some clinical trial of physiotherapy methods in ARDS.

Study design Physical therapy interventions
Study outcome
(N.=subjects) mobilization airway secretion
Berney 38 Crossover (N.=20) Manual
versus ventilator Improved static lung
hyperinflation compliance no difference
sputum volume
Berney 39 Crossover (N = 20) Side lying versus Head down tilt improved
side lying with head down tilt sputum and peak
manual hyperinflation expiratory flow rate
Bailey 40 Prospective Twice daily activity Increased distance
one-group pretest-posttest design session ambulated
(N.=103 patients)
Thomsen 41 Prospective Sitting at edge of Increased mobilization
One group pretest-posttest design bed and out of bed; activites within 24
(N.=104 patients, 91 survivors) ambulation hours of transfer to the
mobilization unit
Malkoc 42 Prospective Bed exercises, and Postural drainage, percussion, Physiotherapy reducing
Prospective-restropective design mobilization vibration, coughing, and the period of treatment
(N, intervention group=277, stimulation techniques, deep required in ICU
control group=233) breathing exercises, suctioning
Needham 43 Prospective Supine to sit; Able to do advanced
Case controlled (N.=57) sitting at the edge mobilization and reduced
of bed, ambulation ICU and hospital length
of stay

Figure 1.—Passive mobilization of upper limbs in a mechani- Figure 2.—Passive mobilization of lower limbs.
cally ventilated ARDS patient.

passive bed cycling 50 and electrical stimulation

as indicated.51
Scientific literature offers few studies evaluat-
ing the mobilization of critically ill (including
or other proprietary information of the Publisher.

ARDS) patients in the ICU. However, present

Figure 3.—Active mobilization during mechanical ventilation.
literature supports early mobilization as a safe
and effective intervention that can have a signifi-
cant impact on functional outcomes. Authors
usually prescribe early passive and/or active mo-
bilization in patients under MV. Nevertheless,
despite these promising observations, the poten-
tial for early mobilization to improve long-term

556 MINERVA ANESTESIOLOGICA May 2013

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outcomes in ARDS survivors needs further stud-
ies.44, 41, 52-54
Continuous rotational therapy
This therapeutic tool uses specialised beds to
continuously turn patients along the longitu-
dinal axis up to an angle of 60° onto each side,
with preset degree and speed of rotation. There
are few studies indicating that this tool can re-
duce the risk of airway closure, and pulmonary
atelectasis, reduce the incidence rate of lower
airways infection, and pneumonia, duration of
endotracheal intubation and length of hospital
stay but does not seem to affect mortality or the
period of mechanical ventilation.36, 37, 55-57 We
feel that despite weak evidence this manoeuvre
can be applied as additional method to prevent
or reduce infectious complication of MV.
Postures
Techniques of prone positioning may result
in short-term improvement in oxygenation,
ventilation/perfusion mismatch and in residual
lung capacity.58-60 Despite easy-to apply and
a sound physiological rationale,23 these tech-
niques are still not widely used. Furthermore it
is still discussed whether the physiological im-
provements may be translated to similar advan-
tages in stronger clinical outcomes like mortal-
ity.59 A recent systematic review concluded that
prone ventilation improves survival in severely
hypoxaemic patients.60 We agree with sugges-
tion that, given related risks, this approach
should be reserved for severely hypoxaemic pa-
tients.
Limb exercise and peripheral muscle training
Inactivity is associated to skeletal muscle
or other proprietary information of the Publisher.
dysfunction and atrophy in antigravity muscles
and aerobic exercise capacity.61, 62
Passive, active assisted, or active (against re-
sistance) limb movements may preserve or even
increase joint motion, to improve soft-tissue
length and muscle strength, decreasing the risk
of thromboembolism.63 In a randomized study
in critically ill patients a daily 20 minute exer-
Vol. 79 - No. 5 MINERVA ANESTESIOLOGICA 557
cise session of passive or active exercise train-
ing session, by means of a bedside ergometer
was added to standard physiotherapy and com-
pared to standard physiotherapy alone. Despite
at ICU discharge, quadriceps force and func-
tional status were similar between groups, at
hospital discharge, exercise capacity, isometric
quadriceps force, and sense of well-being were
significantly higher in the treatment group.52
A “Mobility Team” using a protocol within
48 hours of MV was reported to be feasible,
safe, resulting in decreased ICU and hospital
length of stay in survivors receiving PT dur-
ing ICU treatment compared with patients re-
ceiving usual care.64 Addition of a supported
arm training protocol was effective in patients
recently weaned from MV.65 In severely disa-
bled patients peripheral muscle training (lifting
weights or pushing against a resistance with the
limbs), results in increased strength and activi-
ties of daily life (ADL).33 In patients on long
term MV and those difficult to wean, a tailored
training program may be effective in shorten-
ing weaning time, in reducing hospital stay
and improving survival.66 Limb exercise and
peripheral muscle training should be routinely
included in programs leading to early mobili-
zation.
Neuromuscular electrical stimulation
Low-intensity neuromuscular electrical
stimulation (NMES) of motor nerves improves
healthy muscle performance inducing a mus-
cle contraction and is associated with increased
muscle mass, strength, and endurance of nor-
mally and abnormally innervated muscles in
several diseases. NMES delays muscle wasting
during denervation related immobilization and
maximises recovery of muscle strength without
any increase in ventilatory stress.67, 68 Patients
suffering from COPD,69 spinal cord injury,70
or congestive heart failure 71 are more likely to
benefit. NEMS is easily applied to lower limb
muscles of bed ridden patients also in the ICU
and does not require any collaboration. The
beneficial effects are mainly observed in muscle
groups directly stimulated, but also in muscle
groups not stimulated. NEMS is a promising
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means of muscle strength preservation and
early mobilization in ARDS patients.72 and
has been also considered as a means to prevent
the ICU neuromyopathy.73 Nevertheless the
NEMS timing is to be determined yet. The se-
verity of the acute illness appears also to have
an important role as benefit of NMES has been
shown in patients with sepsis but not in those
with septic shock.74, 75 ICU patients are charac-
terised by a catabolic state, whereas NEMS can
induce an anabolic stimulus in critically ill 76, 77
and postoperative patients.78 NMES is a prom-
ising tool requiring further studies. Interesting
and future development may be application to
muscle group different from limb muscle like
abdominal muscle to enhance cough function.
Respiratory muscle training
Respiratory muscle weakness, imbalance be-
tween respiratory muscle strength and load of
the respiratory system, and cardiovascular im-
pairment, are major determinants of weaning
failure. Although respiratory muscle fatigue has
not been demonstrated so far, even in patients
requiring MV,79 in ICU patients these factors
and the excessive use (especially in the past) of
controlled MV, may rapidly lead to diaphrag-
matic dysfunction.80 Positive end-expiratory
pressure can further reduce muscle strength
by adversely shifting the diaphragm length-
tension curve. Polyneuropathy is also likely to
contribute to muscle weakness, and nutritional
and drugs effects may further worsen muscle
weakness.79-82 There is recent evidence that
inspiratory muscle training is safe and feasi-
ble in selected ventilator-dependent patients,
potentially reducing the weaning length and
improving overall weaning success rates. Sev-
eral possible mechanisms have been hypoth-
esized.83 Although the rationale of respiratory
or other proprietary information of the Publisher.
muscle training in critically ill patients is still
controversial and is not part of routine practice
in many institutions,84 studies in ventilator-
dependent patients showed that such training
may be associated with a favourable weaning
outcome.85-88 We feel that this approach still
requires further validation before entering rou-
tine management of these patients.
558 MINERVA ANESTESIOLOGICA May 2013
Management of airway secretions
Patients under MV are at risk for retained
secretions from several causes. Endotracheal in-
tubation deranges the mucociliary mechanism
enhancing the susceptibility to infections, in-
creasing the volume and tenacity of mucus. Im-
mobility of a bed ridden patient can result in
atelectasis, impaired cough, and retained secre-
tions. Expiratory muscle weakness, by reducing
the expulsive force of cough and fluid restriction
may also contribute to secretion retention.89, 90
Airway secretion management in the mechani-
cally ventilated patient includes routine methods
for maintaining mucociliary function, as well as
techniques for secretion removal (Table I).91, 92
Humidification
Management of secretions in the mechanically
ventilated patient requires adequate humidifica-
tion and suctioning. The American Association
for Respiratory Care suggested that humidifica-
tion should be performed in all patients under
invasive and also for non invasive MV, as it may
improve adherence and comfort.93
Manual hyperinflation
Manual hyperinflation (MH), is commonly
applied in intubated and mechanically venti-
lated patients. It may simulate cough in order
to move airway secretions towards the larger air-
ways, from where they can be easily suctioned.
Manual hyperinflation can prevent airway plug-
ging and pulmonary collapse, improve oxygena-
tion and lung compliance.94 A survey indicated
that MH is widely used although the practice
for the application of MH vary across different
ICU.95 The possible physiological side effects of
delivered air volume, flow rates and airway pres-
sure must be carefully considered especially in
patients under MV.96-98
A systematic review 99 concluded that MH
induced short-term improvements in lung
compliance, oxygenation and secretion clear-
ance, but no change in clinical outcomes. On
the other side when performed by experienced
and trained physioterapists in stable, critically
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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
ill patients, MH was reported to be associated
with short-term and probably non relevant side-
effects. like reduction in cardiac output, altera-
tions of heart rates and increased central venous
pressure. Therefore the conclusions were that
studies failed to show MH benefits in intubated
and mechanically ventilated patients.100 Another
study reported that PT using ventilator hyperin-
flation cleared a comparable amount of sputum
and was as safe as MH.101 Before definitive re-
search can be developed, standards for the MH
procedure should be established.102
Percussion and vibrations
The literature on percussion and postural
drainage in mechanically ventilated patients is
poor. The use of percussion and postural drain-
age in mechanically ventilated patients is anedoc-
tal. In patients under MV with retained secre-
tions, chest clapping is supposed to mechanically
loosen secretions. Percussion and postural drain-
age are often used to treat or prevent atelectasis in
the absence of secretion retention, but there is no
known mechanism besides mucus plug removal.
In fact, more papers have described complications
from percussion and postural drainage (pain,
anxiety, atelectasis, elevated oxygen consump-
tion) than those reporting any positive effects. At
present, in mechanically ventilated patients the
usefulness of percussion and postural drainage,
or chest physiotherapy, or other external vibra-
tion methods is still to be demonstrated.26, 103-105
Intrapulmonary percussive ventilation
High-frequency devices for airway clearance
generate either positive or negative pressure
swings resulting in high-frequency, small-volume
oscillations in the airways. Intrapulmonary per-
cussive ventilation (IPV) is a high-frequency ven-
or other proprietary information of the Publisher.
tilation modality that can be superimposed on
spontaneous breathing. IPV may reduce respira-
tory muscle load and help to move airway secre-
tions. This device creates a percussive effect in the
airways thus enhancing mucus clearance through
a direct high-frequency oscillatory ventilation
able to help the alveolar recruitment. Positive
effects from this technique have been shown in
Vol. 79 - No. 5 MINERVA ANESTESIOLOGICA 559
patients with respiratory distress, neuromuscular
diseases, and pulmonary atelectasis.106 In trache-
ostomised patients recently weaned from MV the
addition of IPV to routine chest physiotherapy
was associated with improvement in oxygenation
and expiratory muscle performance with a sub-
stantial reduction in the risk of late onset pneu-
monia.107 It has been suggested that IPV may be
an alternative to non invasive ventilation (NIV)
in patients at risk for post-extubation respiratory
failure. Both NIV and IPV were shown to reduce
respiratory rate and work of breathing, but IPV
was less effective in increasing alveolar ventila-
tion.108 Despite potential benefits of IPV in dif-
ferent respiratory diseases, the impact of setting
parameters on the mechanical effects produced
by IPV in the lungs is unknown. A study sug-
gested that modifying the parameters resulted in
important modulation of the mechanical effects
produced in the lungs.109
Mechanical insufflator-exsufflator
When manually assisted coughing is not
enough, the most effective alternative is me-
chanically assisted coughing. The combination
of mechanical in-exsufflation with an abdomi-
nal thrust is a mechanically assisted cough.110
Mechanical in-exsufflation delivers deep insuf-
flations followed immediately by deep exsuffla-
tions. Inspiratory–expiratory pressures delivered
via oronasal interface or adult tracheostomy with
the cuff inflated are usually the most effective.
Independent of delivered pressures, the impor-
tance is to fully expand and then fully and quick-
ly empty the lungs. The Cough Assist is a me-
chanical insufflator-exsufflator designed to assist
airway secretion clearance in patients with inef-
fective cough. The device may benefit intubated
and tracheotomized patients.111, 112 The risk of
pneumothorax has been reported.113 Neverthe-
less no literature is available for ARDS patients
in ICU. This approach must be considered as ex-
perimental in this pathology.
Conclusions
ICU admissions and with related risk of sub-
sequent complications and mortality will in-
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
crease in the next years.3, 114 As a consequence
comprehensive programs including PT should
be developed to speed-up functional recovery   
and to prevent the complications of prolonged
immobilization especially in ventilator-depend-
  
ent or difficult-to-wean patients. Indeed, there is
still a limited scientific evidence to support such
a comprehensive approach to all ARDS patients.  
Therefore, despite the ethical difficulties experi-
enced with randomized control trials and other  
reasons making such studies difficult we need
randomized studies with solid clinical short- and  
long-term outcome measures.115
 
Key messages
 
—— Survival of ARDS patients is frequent-
ly associated with significant functional im-
pairment and reduced health-related quality  
of life.  
—— Early physiotherapy of ARDS patients
has recently been proposed as an important  
therapeutical tool in the management of
these patients.
—— The assessment and treatment of these  
patients should include prevention and re-
duction of adverse consequences of immobi-
lization and weaning failure.  
—— Early ICU physiotherapy is an inter-
disciplinary team activity, involving physical
therapists, occupational therapists, nurses  
and medical staff.
 
References
   1. Hall JB, Kress JP. The burden of functional recovery from  
ARDS. N Engl J Med 2011;364:1358-9.
   2. Barnato AE, Albert SM, Angus DC, Lave JR, Degenholtz
HB. Disability among elderly survivors of mechanical ven-  
tilation. Am J Respir Crit Care Med. 2011;183:1037-42.
   3. Cheung AM, Tansey CM, Tomlinson G, Diaz-Granados
N, Matté A, Barr A et al. Two-year outcomes, health care
use, and costs of survivors of acute respiratory distress syn-
or other proprietary information of the Publisher.
drome. Am J Respir Crit Care Med 2006;174:538-44.
   4. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-  
Granados N, Cooper A et al. Functional disability 5 years
after acute respiratory distress syndrome. N Engl J Med
2011;364:1293-304.
   5. Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term
cognitive impairment and functional disability among sur-
vivors of severe sepsis. JAMA 2010;304:1787-94  
   6. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical
illness. Am J Respir Crit Care Med 2010;182:446-54.
   7. Adhikari NK, McAndrews MP, Tansey CM, Matte A,  
560 MINERVA ANESTESIOLOGICA May 2013
Pinto R, Cheung AM et al. Self-reported symptoms of de-
pression and memory dysfunction in survivors of ARDS.
Chest 2009, 135:678-87.
8. Lee CM, Herridge MS, Gabor JY, Tansey CM, Matte
A, Hanly PJ. Chronic sleep disorders in survivors of the
acute respiratory distress syndrome. Intensive Care Med.
2009;35:314-20.
9. Puthucheary Z, Harridge S, Hart N. Skeletal muscle dys-
function in critical care: wasting, weakness, and rehabilita-
tion strategies. Crit Care Med 2010;38:Suppl:S676-S682.
10. Wilcox ME, Herridge MS. Lung function and quality of
life in survivors of the acute respiratory distress syndrome
(ARDS) Presse Med 2011;40:e595–603.
11. Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna
TJ. Long-term acute care hospital utilization after critical
illness. JAMA 2010;303:2253-9.
12. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Per-
rin G, Loundou A et al. Neuromuscular blockers in
early acute respiratory distress syndrome. N Engl J Med
2010;363:1107-16.
13. Hraiech S, Forel JM, Papazian L. The role of neuromus-
cular blockers in ARDS:benefits and risks. Curr Opin Crit
Care 2012;18:495-502.
14. Hough CL, Steinberg KP, Taylor Thompson B, Ruben-
feld GD, Hudson LD. Intensive care unit-acquired neu-
romyopathy and corticosteroids in survivors of persistent
ARDS. Intensive Care Med 2009;35:63-8.
15. Griffiths RD, Hall JB. Intensive care unit-acquired weak-
ness. Crit Care Med 2010;38:779-87.
16. Ambrosino N, Gabbrielli L. The difficult-to-wean patient.
Expert Rev Respir Med 2010;4:685-92.
17. Puthucheary Z, Rawal J, Ratnayake G, Harridge S, Mont-
gomery H, Hart N. Neuromuscular blockade and skeletal
muscle weakness in critically ill patients: time to rethink
the evidence? Am J Respir Crit Care Med. 2012;185:911-
7.
18. Adhikari NK, Tansey CM, McAndrews MP, Matté A,
Pinto R, Cheung AM et al. Self-reported depressive symp-
toms and memory complaints in survivors five years after
ARDS. Chest. 2011;140:1484-93.
19. Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, Dinglas
VD, Shanholtz C, Husain N et al. Depressive symptoms
and impaired physical function after acute lung injury:a
2-year longitudinal study. Am J Respir Crit Care Med
2012;185:517-24.
20. Herridge MS, Cheung AM, Tansey CM, Matte-Martyn
A, Diaz-Granados N, Al-Saidi F et al. One-year outcomes
in survivors of the acute respiratory distress syndrome. N
Engl Med 2003;348:683-93.
21. Kress JP, Herridge MS. Medical and economic implica-
tions of physical disability of survivorship. Semin Respir
Crit Care Med 2012;33:339-47.
22. Skinner EH, Warrillow S, Denehy L. Health-related quali-
ty of life in Australian survivors of critical illness. Crit Care
Med. 2011;39:1896-905.
23. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Nor-
renberg M et al. Physiotherapy for adult patients with criti-
cal illness: recommendations of the European Respiratory
Society and European Society of Intensive Care Medicine
Task Force on Physiotherapy for Critically Ill Patients. In-
tensive Care Med 2008;34:1188-99.
24. Hanekom S, Gosselink R, Dean E, van Aswegen H, Roos
R, Ambrosino N et al. The development of a clinical man-
agement algorithm for early physical activity and mobiliza-
tion of critically ill patients: synthesis of evidence and ex-
pert opinion and its translation into practice. Clin Rehabil
2011;25:771-87.
25. Norrenberg M, Vincent JL. A profile of European in-
tensive care unit physiotherapists. Intensive Care Med
2000;26:988-94.
26. Hodgin KE, Nordon-Craft A, McFann KK, Mealer
 ©
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ML, Moss M. Physical therapy utilization in intensive
care units: results from a national survey. Crit Care Med
2009;37:561-6.  
  27. Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilita-
tion and exercise prescription in Australian intensive care
units. Physiotherapy 2008;94:220-229.  
  28. Van Aswegen H, Potterton J. A pilot survey of the current
scope of practice of South African physiotherapist in inten-
sive care units. South Afr J Physiotherapy 2005;61:17-22.  
  29. Lewis M. Intensive care unit rehabilitation within the
United Kingdom. Physiotherapy 2003;89:531-8.
  30. Scala R, Corrado A, Confalonieri M, Marchese S, Ambro-
sino N. Increased number and expertise of italian respira-  
tory high-dependency care units: the second national sur-
vey. Respir Care 2011;56:1100-7.
  31. Novoa N, Ballesteros E, Jiménez MF, Aranda JL, Varela G.
Chest physiotherapy revisited: evaluation of its influence  
on the pulmonary morbidity after pulmonary resection.
Eur J Cardiothorac Surg 2011;40:130-4.
  32. Carpenè N, Vagheggini G, Panait E, Gabbrielli L, Ambro-
sino N. A proposal of a new model for long-term weaning:  
respiratory intensive care unit and weaning center. Respir
Med 2010;104:1505-11.
  33. Montagnani G, Vagheggini G, Panait Vlad E, Berrighi
D, Pantani L, Ambrosino N. Use of the functional inde-
pendence measure following a weaning program from me-  
chanical ventilation in difficult to wean patients. Phys Ther
2011;9:1109-15.
  34. Ambrosino N, Gabbrielli L. Physiotherapy in the peri-  
operative period. Best Pract Res Clin Anaesthesiol.
2010;24:283-9.
  35. Ambrosino N, Janah N, Vagheggini G. Physioterapy in
critically ill patients. Rev Port Pneumol, 2011;17:283-8.  
  36. Ambrosino N, Venturelli E, Vagheggini G, Clini E. Reha-
bilitation, weaning and physical therapy strategies in the
chronic critically ill patients. Eur Resp J 2012;39:487-92.
  37. Clini E, Ambrosino N. Early physiotherapy in the respira-  
tory intensive care unit. Respir Med 2005;99:1096-104.
  38. Berney S, Denehy L. A comparison of the effects of manual
and ventilator hyperinflation on static lung compliance
and sputum production in intubated and ventilated inten-  
sive care patients. Physiother Res Int 2002;7:100-8.
  39. Berney S, Denehy L, Pretto J. Head down tilt and manual
hyperinflation enhance sputum clearance in patients who
are intubated and ventilated. Aust J Physiother 2004;50:9-  
14.
  40. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bez-
djian L et al. Early activity is feasible and safe in respiratory
failure patients. Crit Care Med 2007;35:139-45.  
  41. Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Pa-
tients with respiratory failure increase ambulation after
transfer to an intensive care unit where early activity is a
priority. Crit Care Med 2008;36:1119-24.
  42. Malkoc M, Karadibak D, Yildrim Y. The effect of physi-  
otherapy in ventilatory dependency and the length of stay
in an intensive care unit. International Journal of Rehabili-
tation Research 2009;32:85-8.  
  43. Needham DM, Korupolu R, Zanni JM, Pradhan P, Col-
antuoni E, Palmer JB et al. Early physical medicine and
rehabilitation for patients with acute respiratory failure:a  
or other proprietary information of the Publisher.
quality improvement project. Arch Phys Med Rehabil.
2010;91:536-42.
  44. Adler J, Daniel Malone D. Early mobilization in the inten-  
sive care unit: a systematic review. Cardiopulm Phys Ther J
2012;23:5-13.
  45. Thomas AJ. Physiotherapy led early rehabilitation of the
patient with critical illness. Phys Ther Rev 2011;16:46-57.  
  46. Kress JP. Clinical trials of early mobilization of critically ill
patients. Crit Care Med 2009;37:S442-S447.
  47. Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand  
L et al. Evidence-based clinical practice guideline for the
Vol. 79 - No. 5 MINERVA ANESTESIOLOGICA 561
prevention of ventilator-associated pneumonia. Ann In-
tern Med 2004;14:305-13.
48. Krishnagopalan S, Johnson EW, Low LL, Kaufman LJ.
Body positioning of intensive care patients: clinical prac-
tice versus standards. Crit Care Med 2002;30:2588-92.
49. Clavet H, Hebert PC, Fergusson D, Doucette S, Trudel G.
Joint contracture following prolonged stay in the intensive
care unit. CMAJ 2008;178:691-7.
50. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer
D, Troosters T et al. Early exercise in critically ill patients
enhances short-term functional recovery. Crit Care Med
2009;37:2499-505.
51. Gerovasili V, Stefanidis K, Vitzilaios K, Karatzanos E,
Politis P, Koroneos A et al. Electrical muscle stimulation
preserves the muscle mass of critically ill patients:a rand-
omized study. Crit Care 2009;13:R161.
52. Pohlman MC, Schweickert WD, Pohlman AS, Nigos C,
Pawlik AJ, Esbrook CL et al. Feasibility of physical and oc-
cupational therapy beginning from initiation of mechani-
cal ventilation. Crit Care Med 2010;38:2089-94.
53. Schweickert WD, Pohlman MC, Pohlman AS, Nigos
C, Pawlik AJ, Esbrook CL et al. Early physical and oc-
cupational therapy in mechanically ventilated, criti-
cally ill patients:a randomized controlled trial. Lancet
2009;373:1874-82.
54. Schweickert WD, Kress JP. Implementing early mobiliza-
tion interventions in mechanically ventilated patients in
the ICU. Chest. 2011;140:1612-7.
55. Raoof S, Chowdhrey N, Raoof S, Feuerman M, King A,
Sriraman R et al. Effect of combined kinetic therapy and
percussion therapy on the resolution of atelectasis in criti-
cally ill patients. Chest 1999;7:1658-66.
56. deBoisblanc BP, Castro M, Everret B, Grender J, Walker
CD, Summer WR. Effect of air-supported, continuous,
postural oscillation on the risk of early ICU pneumonia in
non-traumatic critical illness. Chest 1993;103:1543-7.
57. Kirschenbaum L, Azzi E, Sfeir T, Tietjen P, Astiz M. Effect
of continuous rotational therapy on the prevalence of ven-
tilator-associated pneumonia in patients requiring long-
term ventilatory care. Crit Care Med 2002;30:1983–6.
58. Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni
D, Labarta V et al. Effect of prone positioning on the sur-
vival of patients with acute respiratory failure. N Engl J
Med 2001;345:568-73.
59. Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto
C et al. Prone positioning in patients with moderate and
severe acute respiratory distress syndrome:a randomized
controlled trial. JAMA. 2009;302:1977-84.
60. Sud S, Friedrich JO, Taccone P, Polli F, Adhikari NK,
Latini R et al. Prone ventilation reduces mortality in pa-
tients with acute respiratory failure and severe hypoxemia:
systematic review and meta-analysis. Intensive Care Med
2010;36:585-99.
61. Bloomfield SA. Changes in musculoskeletal structure and
function with prolonged bed rest. Med Sci Sport Exerc
1997;29:197-206.
62. Coyle EF, Martin WH 3rd, Bloomfield SA, Lowry OH,
Holloszy JO. Effects of detraining on response to sub max-
imal exercise. J Appl Physiol 1985;59:853-9.
63. Koch SM, Fogarty S, Signorino C, Parmley L, Mehlhorn
U. Effect of passive range motion on intracranial pressure
in neurosurgical patients. J Crit Care 1996;11:176-9.
64. Morris PE, Goad A, Thompson C, Taylor K, Harry B,
Passmore L et al. Early intensive care unit mobility therapy
in the treatment of acute respiratory failure. Crit Care Med
2008;36:2238-43.
65. Porta R, Vitacca M, Gilè LS, Clini E, Bianchi L, Zanotti E,
et al. Supported arm training in patients recently weaned
from mechanical ventilation. Chest 2005;128:2511-20.
66. Clini EM, Crisafulli E, Antoni FD, Beneventi C, Trianni
L, Costi S et al. Functional recovery following physical
 ©
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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training in tracheotomized and chronically ventilated pa-
tients. Respir Care 2011;56:306-13.
  67. Ambrosino N, Strambi S. New strategies to improve ex-
ercise tolerance in chronic obstructive pulmonary disease.
Eur Resp J 2004;24:313-22.
  68. Ambrosino N, Palmiero G, Strambi S. New approaches in
pulmonary rehabilitation. Clin Chest Med 2007;28:629-
38.
  69. Vivodtzev I, Pépin JL, Vottero G, Mayer V, Porsin B, Lévy
P et al. Improvement in quadriceps strength and dyspnea
in daily tasks after 1 month of electrical stimulation in
severely deconditioned and malnourished COPD. Chest
2006;129:1540-8.
  70. Langbein WE, Maloney C, Kandare F et al. Pulmonary
function testing in spinal cord injury: effects of abdominal
muscle stimulation. J Rehabil Res Dev 2001;38:591-7.
  71. Nuhr MJ, Pette D, Berger R, Quittan M, Crevenna R,
Huelsman M et al. Beneficial effects of chronic low-fre-
quency stimulation of thigh muscle in patients with ad-
vanced chronic heart failure. Eur Heart J 2004;25:136-43.
  72. Karatzanos E, Gerovasili V, Zervakis D, Tripodaki ES, Ap-
ostolou K, Vasileiadis I et al. Electrical muscle stimulation:
an effective form of exercise and early mobilization to pre-
serve muscle strength in critically ill patients. Crit Care Res
Pract 2012;2012:432752.
  73. Routsi C, Gerovasili V, Vasileiadis I, Karatzanos E, Pitsolis
T, Tripodaki E et al. Electrical muscle stimulation prevents
critical illness polyneuromyopathy:a randomized parallel
intervention trial. Crit Care 2010;14:R74.
  74. Poulsen JB, Møller K, Jensen CV, Weisdorf S, Kehlet H,
Perner A. Effect of transcutaneous electrical muscle stimu-
lation on muscle volume in patients with septic shock. Crit
Care Med 2011;39:456-61.
  75. Rodriguez PO, Setten M, Maskin LP, Bonelli I, Vidom-
lansky SR, Attie S et al. Muscle weakness in septic patients
requiring mechanical ventilation:Protective effect of tran-
scutaneous neuromuscular electrical stimulation. J Crit
Care. 2012;27:319 e1-8.
  76. Bouletreau P, Patricot MC, Saudin F, Guiraud M, Mathian
B. Effects of intermittent electrical stimulations on mus-
cle catabolism in intensive care patients. J Parenter Enteral
Nutr 1987;11:552-5.
  77. Gerovasili V, Stefanidis K, Vitzilaios K, Karatzanos E, Poli-
tis P, Koroneos A. Electrical muscle stimulation preserves
the muscle mass of critically ill patients:a randomized
study. Crit Care 2009;13:R161.
  78. Strasser EM, Stättner S, Karner J, Klimpfinger M, Freynho-
fer M, Zaller V et al. Neuromuscular electrical stimulation
reduces skeletalmuscle protein degradation and stimulates
insulin-like growth factors in an age- and current depend-
ent manner:a randomized, controlled clinical trial in major
abdominal surgical patients. Ann Surg 2009;249:738-43.
  79. Laghi F, Cattapan SE, Jubran A, Parthasarathy S, War-
shawsky P, Choi YS et al. Is weaning failure caused by low-
frequency fatigue of the diaphragm? Am J Respir Crit Care
Med 2003;167:120-7.
  80. Le Bourdelles G, Viires N, Boczkowski J, Seta N, Pavlovic
D, Aubier M. Effects of mechanical ventilation on dia-
phragmatic contractile properties in rats. Am J Respir Crit
Care Med 1994;149:1539-44.
or other proprietary information of the Publisher.
  81. Tobin MJ, Laghi F, Brochard L. Role of respiratory mus-
cles in acute respiratory failure of COPD: lessons from
weaning failure. J Appl Physiol. 2009;107:962-70.
  82. Carlucci A, Ceriana P, Prinianakis G, Fanfulla F, Co-
lombo R, Nava S. Determinants of weaning success in
patients with prolonged mechanical ventilation. Crit Care
2009;13:R97.
  83. Bissett B, Leditschke IA, Paratz JD, Boots RJ. Respiratory
dysfunction in ventilated patients: can inspiratory muscle
training help? Anaesth Intensive Care. 2012;40:236-46.
  84. Ambrosino N. Weaning and Respiratory Mus-
562 MINERVA ANESTESIOLOGICA May 2013
cle Dysfunction:The Egg-Chicken Dilemma. Chest
2005;128;481-3.
  85. Martin AD, Davenport PD, Franceschi AC, Harman E.
Use of inspiratory muscle strength training to facilitate
ventilator weaning. Chest 2002;122:192-6.
  86. Aldrich TK, Karpel JP, Uhrlass RM, Sparapani MA, Eramo
D, Ferranti R. Weaning from mechanical ventilation: ad-
junctive use of inspiratory muscle training. Crit Care Med
1989;17:14-9.
  87. Moodie L, Reeve J, Elkins M. Inspiratory muscle training
increases inspiratory muscle strength in patients weaning
from mechanical ventilation: a systematic review. J Physi-
other 2011;57:213-21.
  88. Martin DA, Smith BK, Davenport P, Harman E, Gonzal-
ez-Rothi RJ, Baz M et al. Inspiratory muscles strength
training improves the outcome in failure to wean patients:a
randomized trial. Crit Care 2011;15:R84.
  89. Ntoumenopoulos G, Shannon H, Main E. Do commonly
used ventilator settings for mechanically ventilated adults
have the potential to embed secretions or promote clear-
ance? Respir Care 2011;56:1887-92.
  90. Osadnik CR, McDonald CF, Jones AP, Holland AE.
Airway clearance techniques for chronic obstructive pul-
monary disease. Cochrane Database Syst Rev. 2012 Mar
14;3:CD008328.
  91. Branson RD. Secretion management in the mechanically
ventilated patient. Respir Care 2007;52:1328-42.
  92. Venturelli E, Crisafulli E, Debiase A, Righi D, Berrighi
D, Cavicchioli PP et al. Efficacy of temporary positive ex-
piratory pressure (TPEP) in patients with lung diseases and
chronic mucus hypersecretion. The UNIKO (R) project:a
multicentre randomized controlled trial. Clin Rehabil.
2012 Sep 11 [Epub ahead of print]
  93. American Association for Respiratory Care, Restrepo
RD, Walsh BK. Humidification during invasive and
noninvasive mechanical ventilation:2012. Respir Care
2012;57:782-8.
  94. Paulus F, Veelo DP, de Nijs SB, Beenen LF, Bresser P, de
Mol BA et al. Manual hyperinflation partly prevents re-
ductions of functional residual capacity in cardiac surgi-
cal patients--a randomized controlled trial. Crit Care
2011;15:R187.
  95. Paulus F, Binnekade JM, Middelhoek P, Schuitz MJ,
Vroom MB. Manual hyperinflation of intubated and
mechanically ventilated patients in Dutch intensive care
units--a survey into current practice and knowledge. In-
tensive Crit Care Nurs. 2009;25:199-207.
  96. Clarke RC, Kelly BE, Convery PN, Fee JP. Ventilatory
characteristics in mechanically ventilated patients during
manual hyperventilation for chest physiotherapy. Anesthe-
sia 1999;54:936-40.
  97. Singer M, Vermaat J, Hall G, Latter G, Patel M. Hemo-
dynamic effects of manual hyperinflation in critically ill
mechanically ventilated patients. Chest 1994;106:1182-7.
  98. Turki M, Young MP, Wagers SS, Bates JH. Peak pressures
during manual ventilation. Respir Care 2005;50:340-4.
  99. Paulus F, Binnekade JM, Vroom MB, Schultz MJ. Benefits
and risks of manual hyperinflation in intubated and me-
chanically ventilated intensive care unit-patients:a system-
atic review. Crit Care 2012;16:R145.
100. Dennis D, Jacob W, Budgeon C. Ventilator versus manual
hyperinflation in clearing sputum in ventilated intensive
care unit patients. Anaesth Intensive Care 2012;40:142-9.
101. Paulus F, Binnekade JM, Vermeulen M, Vroom MB,
Schultz MJ. Manual hyperinflation is associated with a low
rate of adverse events when performed by experienced and
trained nurses in stable critically ill patients--a prospective
observational study. Minerva Anestesiol 2010;76:1036-42.
102. Savian C, Paratz J, Davies A.Comparison of the effective-
ness of manual and ventilator hyperinflation at different
levels of positive end-expiratory pressure in artificially ven-
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tilated and intubated intensive care patients. Heart Lung.
2006;35:334-41.
103. Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF.
Chest Physiotherapy for the prevention of ventilator-asso-
ciated pneumonia. Intensive Care Med 2002;28:850-6.
104. Barker M, Adams S. An evaluation of a single chest physi-
otherapy treatment on mechanically ventilated patients
with acute lung injury. Physiother Res Int 2002;7:157-
69.
105. Chen YC, Wu LF, Mu PF, Lin LH, Chou SS, Shie HG.
Using chest vibration nursing intervention to improve ex-
pectoration of airway secretions and prevent lung collapse
in ventilated ICU patients:a randomized controlled trial. J
Chin Med Assoc. 2009;72:316-22.
106. Chatburn RL. High-frequency assisted airway clearance.
Respir Care. 2007;52:1224-35.
107. Clini EM, Antoni FD, Vitacca M, Crisafulli E, Paneroni
M, Chezzi-Silva S et al. Intrapulmonary percussive ventila-
tion in tracheostomized patients:a randomized controlled
trial. Intensive Care Med. 2006;32:1994-01.
108. Dimassi S, Vargas F, Lyazidi A, Roche-Campo F, Della-
monica J, Brochard L. Intrapulmonary percussive ventila-
tion superimposed on spontaneous breathing:a physiologi-
cal study in patients at risk for extubation failure. Intensive
Care Med. 2011;37:1269-76.
109. Toussaint M, Guillet MC, Paternotte S, Soudon P, Haan
J. Intrapulmonary effects of setting parameters in portable
intrapulmonary percussive ventilation devices. Respir Care
2012;57:735-42.
110. Winck JC, Gonçalves MR, Lourenço C, Viana P, Almeida
J, Bach JR. Effects of mechanical insufflation-exsufflation
on respiratory parameters for patients with chronic airway
secretion encumbrance. Chest 2004;126:774-80.
111. Guérin C, Bourdin G, Leray V, Delannoy B, Bayle F, Ger-
main M et al. Performance of the cough assist insufflation-
exsufflation device in the presence of an endotracheal
tube or tracheostomy tube:a bench study. Respir Care
2011;56:1108-14.
112. Gonçalves MR, Honrado T, Winck JC, Paiva JA Effects of
mechanical insufflation-exsufflation in preventing respira-
tory failure after extubation:a randomized controlled trial.
Crit Care 2012;16:R48.
113. Suri P, Burns SP, Bach JR. Pneumothorax associated with
mechanical insufflation-exsufflation and related factors.
Am J Phys Med Rehabil 2008;87:951-5.
114. Martin UJ, Hincapie L, Nimchuk M, Gaughan J, Criner
GJ. Impact of whole-body rehabilitation in patients re-
ceiving chronic mechanical ventilation. Crit Care Med
2005;33:2259-65.
115. Gosselink R, Needham D, Hermans G. ICU-based reha-
bilitation and its appropriate metrics. Curr Opin Crit Care
2012;18:533-39.

Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed
in the manuscript.
Received on October 22, 2012 - Accepted for publication on January 8, 2013.
Corresponding author: Prof. N. Ambrosino, Cardiothoraco-Vascular Department, Pulmonary Unit, University Hospital, Pisa. Ed 13,
56128 Cisanello, Pisa, Italy. E-mail: n.ambrosino@ao-pisa.toscana.it
or other proprietary information of the Publisher.

Vol. 79 - No. 5 MINERVA ANESTESIOLOGICA 563