Felten-Barentz et al (2015), Feasibility and Safety of Hydrotherapy in Critically Ill Ventilated Patients

Early mobilization can improve outcomes in critically ill ventilated patients (1). Although preliminary data suggest that mobilization in a swimming pool (hydrotherapy) may enhance rehabilitation in very weak patients (e.g., congestive heart failure [2] and multiple sclerosis [3]) because of the reduced gravitational forces, there are challenges and potential safety issues when applied to ventilated patients. In this study, we report feasibility and safety of hydrotherapy in critically ill, ventilated patients.

CORRESPONDENCE
Feasibility and Safety of Hydrotherapy in
Critically Ill Ventilated Patients
To the Editor:
Early mobilization can improve outcomes in critically ill ventilated
patients (1). Although preliminary data suggest that mobilization
in a swimming pool (hydrotherapy) may enhance rehabilitation in
very weak patients (e.g., congestive heart failure [2] and multiple
sclerosis [3]) because of the reduced gravitational forces, there are
challenges and potential safety issues when applied to ventilated
patients. In this study, we report feasibility and safety of
hydrotherapy in critically ill, ventilated patients.
In 2010, the 35-bed adult intensive care unit (ICU) of the
Radboudumc hospital implemented a slightly modified Morris early
mobilization program (4). In 2012, a dedicated pool (maximum
depth, 1.35 m; total volume, 30 m 3 ) with a movable floor became
available. Ventilated patients admitted to the medical, surgical,
or thoracic ICU were eligible for hydrotherapy if they were
severely weak (inability to stand upright despite support by
physiotherapist) and were able to respond to verbal commands.
Exclusion criteria included high ventilator support (fractional
inspired oxygen.0.6; positive end expiratory pressure.10 cm
H 2 O; inspiratory support.15 cm H 2 O), vasopressors, large
wounds, severe agitation, and colonization with multiresistant
bacteria. Patients and primary decision makers were informed about
the novelty of the therapy and potential complications. Formal
informed consent was waived by the Radboudumc ethics committee.
Patients were screened prospectively for eligibility. Before
hydrotherapy,anycentralvenouscatheters(internaljugularvein)and
arterial catheters (radial artery) were disconnected and covered with
transparent dressing (Tegaderm; 3M, St. Paul, MN) and secured with
elasticbandage(Elastomul,Hamburg,Germany).Duringtransferand
hydrotherapy, patients were ventilated with a portable ventilator
(LTV 1000; Carefusion, San Diego, CA), using pressure support
mode. Pulse oximetry and heart rate were monitored using
a handheld device with finger clip during transport, and during
hydrotherapy the pulse oximeter was used only as needed, based on
clinical judgment. An individualized program for hydrotherapy was
designed for each patient and could include standing, walking,
moving upper extremities, and back stroke swimming. The mobility
team included two ICU nurses, a physical therapist, and a physician.
The following adverse events were reported prospectively:
tachycardia (.100 bpm), bradycardia (,60 bpm), peripheral
oxygen saturation lower than 90% while on ventilator, and
accidental removal of arterial catheters, central venous catheters, or
artificial airway. To assess water quality, samples were obtained
twice daily for biochemical analysis (chloride and pH) and at least
once per month for cultures, according to Dutch law (5).
Between July 2012 and October 2013, a total of 3,686 patients
were admitted to our ICU. After excluding patients admitted
after elective uncomplicated surgery and all patients admitted to
the neuro-ICU, 259 patients were evaluated for hydrotherapy.
Twenty-five patients received at least one hydrotherapy session in
addition to the regular early mobilization program. Reasons for
not receiving hydrotherapy were failure to meet inclusion criteria
(mostly not being severely weak) or meeting exclusion criteria
and limited availability and logistical reasons. Total duration of one
hydrotherapy session was approximately 60 minutes, including
briefing, transportation to the pool, patient preparation at poolside,
hydrotherapy, showering, and transportation back to the ICU. The
movie shows a representative patientduring hydrotherapy(see Movie
E1 in the online supplement). Reasons for ICU admission and other
patient characteristics are given in Table 1.
Five patients died while in the ICU. In four patients, active
treatment was withdrawn on the patient’s request. In one patient,
further treatment was deemed futile because of metastatic
carcinoma not responding to chemotherapy. No complications
as defined here were reported during transport or hydrotherapy.
In the study period, microbiological analysis was performed 17
times. Biochemical and microbiological analysis of pool water
demonstrated that water quality met standards as dictated by the
Dutch law at all times (Table 2) (5).
The duration of each hydrotherapy session was determined by
the physiotherapist, based on the development of fatigue. None
of the sessions was discontinued because of safety issues or adverse
events. Although not systematically analyzed, patients and
their loved ones highly appreciated the hydrotherapy sessions.
None of the patients refused subsequent hydrotherapy sessions.
This is the first report describing the feasibility and safety
of hydrotherapy in critically ill mechanically ventilated patients.
The most important finding is that hydrotherapy appears to be safe
inaselectedgroupofventilatedICUpatients.Itshouldbeacknowledged
Table 1. Patient Characteristics at Admission and during First
Hydrotherapy Session
N 25
Male, % 72
Age, yr 61 616
Body mass index, kg/m 2 26 65
Cardiovascular failure, % 16
Septic shock, % 16
Mean APACHE-2 19 65
Mortality, % 20
First hydrotherapy session
Time on ventilator, d 33 625
Tracheostomy, % 76
PEEP, cm H 2 O 6.761.7
F I O 2 0.40 60.03
Sp O 2 , % 97.8 61.9*
Pa O 2 /F I O 2 ratio, mm Hg 260672 †
Arterial catheter, % 80
Central venous catheter, % 16
Foley catheter, % 100
Definition of abbreviations: APACHE = Acute Physiology and Chronic
Health Evaluation; F I O 2 =fractional inspired oxygen; Pa O 2 =partial pressure
of oxygen in arterial blood; PEEP=positive end expiratory pressure; Sp O 2 =
pulse oximeter oxygen saturation.
Variables are mean6SD. Cardiovascular failure was defined as cardiac
failure as primary reason for intensive care unit admission. Septic shock
was defined as meeting the systemic inflammatory response syndrome
criteria, evidence for infection, hypotension despite adequate fluid
administration, and organ failure.
*Missing value: 1.
† Missing value: 6.
This letter has an online supplement, which is accessible from this issue’s
table of contents at www.atsjournals.org
476 American Journal of Respiratory and Critical Care Medicine Volume 191 Number 4 | February 15 2015
thathydrotherapy wasperformedinauniversity hospitalwithextensive
experience with early mobilization in ICU patients. No patient reported
discomfort or exhibited severe oxygen desaturation or hemodynamic
instability. No interventions were needed to improve hemodynamics.
In addition to immediate complications, transmission of
infections through contaminated water was an initial concern.
However, microbiological screening of pool water did not reveal any
relevant contamination.
In conclusion, hydrotherapy appears to be a feasible and safe
interventioninselectedcriticallyillventilatedpatients.Futurestudiesare
needed to evaluate potential clinical benefits and cost-effectiveness. n
Author disclosures are available with the text of this letter at
www.atsjournals.org.
Acknowledgment: The authors thank Peterpaul Mazure, P.T. (Radboud
University Medical Centre, Nijmegen, The Netherlands) and his colleagues
for the application of the hydrotherapy. They did not receive compensation
for their contribution. The authors also thank Joanne Postma for the
voiceover in the video.
Karin M. Felten-Barentsz, P.T., M.Sc.
Antonius J. C. Haans, R.T.
Radboud University Medical Centre
Nijmegen, The Netherlands
Arthur S. Slutsky, M.D.
St. Michael’s Hospital
Toronto, Ontario, Canada
and
University of Toronto
Toronto, Ontario, Canada
Leo M. A. Heunks, M.D., Ph.D.
Johannes G. van der Hoeven, M.D., Ph.D.
Radboud University Medical Centre
Nijmegen, The Netherlands
References
1. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ,
Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, et al.
Early physical and occupational therapy in mechanically ventilated,
critically ill patients: a randomised controlled trial. Lancet 2009;373:
1874–1882.
2. Cider A, Schaufelberger M, Sunnerhagen KS, Andersson B.
Hydrotherapy—a new approach to improve function in the
older patient with chronic heart failure. Eur J Heart Fail 2003;5:
527–535.
3. Kargarfard M, Etemadifar M, Baker P, Mehrabi M, Hayatbakhsh R. Effect
of aquatic exercise training on fatigue and health-related quality of life
in patients with multiple sclerosis. Arch Phys Med Rehabil 2012;93:
1701–1708.
4. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross
A, Anderson L, Baker S, Sanchez M, et al. Early intensive care unit
mobility therapy in the treatment of acute respiratory failure. Crit Care
Med 2008;36:2238–2243.
5. Overheid.nl. Besluit hygiëne en veiligheid badinrichtingen en
zwemgelegenheden [accessed 2014 Oct 13]. Available from: http://
wetten.overheid.nl/BWBR0003716/geldigheidsdatum_13-10-2014
Copyright © 2015 by the American Thoracic Society
Early Peripheral Perfusion–guided Fluid
Therapy in Patients with Septic Shock
To the Editor:
Septic shock remains the most frequent cause of death in patients
admitted to the intensive care unit (ICU) (1). Careful titration
of therapy is essential; undertreatment results in persistence of
impaired tissue oxygenation, whereas overtreatment leads to
a positive fluid balance that can result in pulmonary edema,
prolonged mechanical ventilation, and finally death (2–6).
Although peripheral perfusion alterations are stronger predictors
of outcome than systemic hemodynamic variables in patients
with septic shock, end points to guide volume resuscitation are
still based on systemic parameters, and little is known about
resuscitation guided by endpoints of peripheral tissue perfusion
(7–9). We therefore undertook a proof-of-concept randomized
controlled study comparing early goal-directed fluid resuscitation
based on clinical assessment of peripheral perfusion with
standard fluid therapy to investigate whether peripheral
perfusion–guided resuscitation is feasible and would lead to less
fluid administration in patients with septic shock. Some of the
results of these studies have been previously reported in the form
of an abstract (10).
Clinical trial registered with www.clinicaltrials.gov (NCT
01397474).
Table 2. Characteristics of the Hydrotherapy Sessions and
Water Quality
Duration per session, mean (range), min 29.6 (15–40)
Type of exercises*
Movements in supine position 72%
Swimming (back stroke) 12%
Seated position 36%
Standing position 64%
Walking 56%
Rate of complications (95%
confidence interval)
0% (0–4.1%)
Number of sessions during intensive
care unit stay
Total 88
Median (interquartile range) 2 (1–3)
Mean (range) 3.5 (1–20)
Microbiological screening of pool
water (17 samples in 15 mo)
Coagulase-negative Staphylococcus 2 (1 and 2 cfu)
Gram-negative rods, not Pseudomonas 2 (43 and 27 cfu)
Nonfermative gram-negative rods 3 (51, 22, and 55 cfu)
*Exercises could be combined during one session.
Author Contributions: M.E.v.G. conducted the study, analyzed and
interpreted the data, and drafted the manuscript. N.E. assisted in conducting
the study. R.J.P.v.d.V. assisted in analyzing the data and reviewed the final
data. A.L. assisted in the design of the study and assisted in conducting the
study and participated in data interpretation and statistical analysis. E.K.
assisted in the design of the study and data interpretation. J.B. assisted
with study design and manuscript preparation. J.v.B. conceived the study,
participated in its design and coordination, and reviewed the manuscript. All
authors read and approved the final manuscript.
This letter has an online supplement, which is accessible from this issue’s
table of contents at www.atsjournals.org
CORRESPONDENCE
Correspondence 477
Caught exception: Object list not found. Possible secured file.

Latest Video