This is a journal article critique on a research which is entitled " INSPIRATORY MUSCLE TRAINING TO ENHANCE RECOVERY FROM MECHANICAL VENTILATION; A RANDOMIZED TRIAL"

2.  BRIEF INFORMATION ON RESPIRATORY MUSCLE TRAINING
 ARTICLE OBJECTIVE
 METHODOLOGY
 INTERVENTION
 MEASURES
 RESULTS
 DISCUSSION
 CONCLUSION
 STRONG POINTS
 LIMITATIONS
 REFERENCES

3. RESPIRATORY MUSCLE TRAINING
 A technique that aims to improve
function of the respiratory muscles
using specific exercises.
 Normally aimed at people who have
Asthma, Bronchitis, Emphysema
and COPD

4. RESPIRATORY MUSCLE TRAINING
 Consist of Inspiratory Muscle
Training (IMT) or Expiratory Muscle
Training (EMT) or a combination of
both

5. RESPIRATORY MUSCLE TRAINING
Responses to RMT includes:
 Changes in muscle fiber type
 Improvements in strength, speed,
power, endurance performance MIP
and MEP

6. RESPIRATORY MUSCLE TRAINING
Training Principles
 Overload
 Specificity
 Reversibility

7. INSPIRATORY MUSCLE TRAINING TO ENHANCE
RECOVERY FROM MECHANICAL VENTILATION;
A RANDOMIZED TRIAL
AUTHORS: Bernie M Bisset, Anne Leditschke,
Teresa
Neeman, Robert Boots, Jennifer Paratz
Published on June 2, 2016

8. ARTICLE OBJECTIVE
 The objective of this research was
to see if IMT improves inspiratory
muscle strength and quality of life
(QOL) in patients recently weaned
from invasive ( mechanical)
ventilation

9. METHODOLOGY
 Participants were selected by
computer – generated random
number sequence, managed by off-
site administrative staff
 The study was conducted at the
Canberra Hospital ( located in
Australia)

10. METHODOLOGY
 A second hospital was also
included (Calvary Hospital) but no
patients were recruited due to
failure to meet requirements

11.  With 48 hours of successful
weaning, 70 participants (
mechanically ventilated ≥ 7days)
were randomized to receive IMT
once daily 5 days/ week for 2
weeks with usual care or just usual
care ( control group)

12. METHODOLOGY
IMT Group Control Group
Inspiratory muscle training ( 2
weeks)
Usual physiotherapy ( respiratory
treatment and mobilization)
Usual physiotherapy ( respiratory
treatment and mobilization)

13. METHODOLOGY
Inclusion Criteria :
 Patients who are successfully weaned
from the mechanical ventilation ( > 48 hrs)
and within the 7 days following the
successful weaning
 Patients aged ≥ 16 years who are able to
provide informed consent
 Patients who are alert and able to train
with a Riker score of 4

14. METHODOLOGY
EXCLUSION CRITERIA
Low neurological status
Pregnant
Participation in IMT while ventilated
Delirium/ agitation
Medically unstable
Declined to participate
Imminent Palliation
Intellectual disability
Unable to communicate
Facial Fractures

15. INTERVENTION
 Participants were randomized to
receive either usual care (control
group) or IMT with usual care
 IMT was performed using a threshold
IMT – Inspiratory Muscle Trainer (
threshold IMT device
HS730,Respironics, New Jersey, USA)

16. INTERVENTION

17. INTERVENTION
 This device was used with the
mouthpiece, or flexible connector
to attach to the tracheostomy
 Once a tracheostomy in situ, IMT
was always performed with the cuff
inflated to ensure accurate loading

18. INTERVENTION

19. INTERVENTION
 The physiotherapist gave an
intensity of 50% MIP for the first
training set
 Then quickly increase it to a
tolerable intensity that allowed for
the pt to complete 6th breath in a set
of six breaths with 5 sets of six
breaths completed each session

20. INTERVENTION
 The intensity was increased daily
by the physiotherapist by
manually increasing the threshold
resistance by 1-2 cm H2O
 Training started on the day of
enrolment and was done once daily
for 2 weeks (weekdays only)

21. MEASURES
 Primary Endpoints- inspiratory
muscle strength and Inspiratory
Muscle Fatigue
 Secondary Endpoints- Dyspnoea,
physical function and quality of
life, post intensive care length of
stay and in- hospital mortality

22. RESULTS
 MIP improved in both groups with a
greater increase in the IMT group
than the control group – 17% in the
IMT group compared to 6 % in
control, p= 0.024.
 No statistical value change in FRI
was observed in both groups (0.03 vs
0.02, p=0.81)

23. RESULTS
 Quality of Life was greater in the IMT
group
 Changes in dyspnoea scores at rest
and during exercise were not
statistically significant.
 No significant difference in post –
ICU length of stay, reintubation rate
or ICU readmission

24. RESULTS
 There was a difference in hospital
mortality which was higher in the
IMT group (p=0.051) with four
deaths.

25. DISCUSSION
 Participants who completed 2
weeks of IMT have greater
improvement in respiratory muscle
strength than their counterparts
 IMT group expressed improved
quality of life using the EQ5D

26. DISCUSSION
 In COPD patients IMT has longer
term effects including lower rates
of hospitalization over a 12 month
period
 The maximum setting on the
device is 41cmH2O and it was
impossible for 2 participants to
achieve greater than 50% MIP

27. DISCUSSION
 The reasons for improved QOL
in the absence of a
demonstrated effect on
respiratory endurance,
dyspnoea or functional level
remained unclear

28. CONCLUSIONS
 IMT following successful weaning
increases IMT strength and QOL .
 The researchers cannot confidently
rule out an associated increase risk
of in- hospital mortality

29. STRONG POINTS
 The study was approved by the Australian
Capital Territory Health Human Ethics
Committee and the University of Queensland
Medical Research Ethics Committee
 This study was the first to demonstrate the
value of IMT for patients in the
postextubation period
 Clear and concise Inclusion Criteria

30. STRONG POINTS
 Good reliability , inter – rater
reliability and validity of most
research tools used in the research
 There was researcher blinding to
group allocation for MIP, QOL,
Dyspnoea and physical function
measurements

31. LIMITATIONS
 The physiotherapists could not be
blinded in administering IMT training
to patients
 Inability to demonstrate an
improvement in Inspiratory Muscle
Endurance in the IMT group
A lack of follow-up of primary
outcomes beyond 2 weeks

32. LIMITATIONS
Not all participants achieved greater
than 50% MIP which
underestimated the effect of IMT in
this research

33. LIMITATIONS
In assessing QOL the researchers
also used SF36 questionnaire which
is a lengthy questionnaire.

34. THE IMPORTANCE OF THIS RESEARCH
 This research can let PTs
understand how this specific
regime of IMT may be useful
adjunct to the medical
management pts in post weaning
period

35. REFERENCES
 Buxton, S . Cotton, L. Lowe, R. Respiratory
Muscle Training. Retrieved from http://
www.physio-pedia.com/Respiratory
_Muscle_Training
 Bissett, B., Boots, R., Leditschke, A., Neeman,
T., Paratz. (2016). Inspiratory Muscle training
to enhance recovery from mechanical
ventilation : a randomized trial. Thorax Online
First. 71(9)
http://thorax.bmj.com/content/71/9/812.short?
g=w_thorax_current_tab

36. THE END
ANY QUESTIONS??