Application of a stepwise rehabilitation program in ICU patients requiring mechanical ventilation
阶梯式康复训练在ICU机械通气患者中的应用研究

摘要

目的 观察规范化阶梯式康复方案在重症监护病房（ICU）机械通气患者中的应用效果，为患者康复方案的制定提供参考。方法 采用随机对照试验设计，选择 2022年10月至2023年5月在西安交通大学第一附属医院重症医学科收治的90例机械通气患者为研究对象。采用随机数字法分为试验组45例，对照组45例。对照组患者采用ICU常规康复护理，主要目的是预防卧床和关节挛缩等并发症，即病情稳定后开始每日床上主动或被动的四肢关节活动，每次20-30min，3次／d，根据病情逐渐增加活动量，至下床活动，脱机转出ICU。试验组实施基于早期康复理念的阶梯式康复方案，根据患者病情严重程度分阶段实施个体化康复训练，于患者机械通气24ｈ内生命体征稳定时，开始康复评估，实施阶梯式早期康复方案。比较两组患者干预第 3 天、第 5 天及第 7 天氧合指数，并比较ICU获得性肌无力（ICU-AW）发生率、呼吸机相关性肺炎（VAP）发生率、谵妄发生率发生率、ICU住院时间、机械通气时间与再插管率、及两组患者护理不良事件数。结果 试验组患者在第5 天及第 7 天氧合指数时间效应及交互效应有统计学意义（P<0. 05）；试验组患者机械通气时间（6.45±1.78）d低于对照组（9.17±2.09）d，试验组再插管率0低于对照组6.67%，差异均具有统计学意义（P＜0.05）；试验组患者ICU住院时间（10.78±3.48）低于对照组（15.23±3.29）d，差异具有统计学意义（P＜0.05）；试验组ICU-AW发生率2.22%低于对照组17.78%（P＜0.05）；试验组组谵妄发生率0%低于对照组13.33%（P＜0.05），两组患者在治疗期间均未发生VAP及不良事件。结论 规范化阶梯式康复方案能有效提升患者氧和指数，缩短ICU患者机械通气时间及ICU住院时间，降低患者再插管率、减少 ICU-AW及谵妄发生的风险，促进患者快速康复，临床应用疗效确切。

Abstract

Objective To evaluate the clinical efficacy of a standardized stepwise rehabilitation protocol in mechanically ventilated patients admitted to the intensive care unit (ICU) and to provide evidence for developing individualized rehabilitation strategies.
Methods Ninety mechanically ventilated patients admitted to the ICU of The First Affiliated Hospital of Xi’an Jiaotong University between October 2022 and May 2023 were enrolled. Patients were randomly assigned to either control group receiving routine lCU rehabilitation care or an experimental group receiving astandardized stepwise early-rehabilitation protocol initiated within 24 h of intubation. Control group: received routine ICU rehabilitation care aimed at preventing complications of bed rest and joint contracture. After hemodynamic stabilization, patients underwent active or passive limb joint mobilization in bed, 20–30 min per session, 3 times daily; activity was progressively increased until out-of-bed mobilization, weaning, and ICU discharge. Experimental group based on the concept of early rehabilitation therapy, patients underwent systematic assessment within 24 h of intubation once vital signs were stable, followed by implementation of a standardized stepwise early-rehabilitation protocol. Outcomes were compared between groups on intervention days 3, 5, and 7, and included: oxygenation index (PaO₂/FiO₂), incidence of ICU-acquired weakness (ICU-AW), ventilator-associated pneumonia (VAP), delirium, duration of mechanical ventilation, ICU length of stay, re-intubation rate, and nursing-related adverse events.
Results Oxygenation index: Significant time effects and interaction effects favoring the experimental group were observed on days 5 and 7 (P < 0.05). Mechanical ventilation Duration was shorter in the experimental group (6.45 ± 1.78 d) than in the control group (9.17 ± 2.09 d) (P < 0.05). Re-intubation: 0 % in the experimental group versus 6.67 % in the control group (P < 0.05). ICU stay: Length of stay was reduced in the experimental group (10.78 ± 3.48 d) compared with the control group (15.23 ± 3.29 d) (P < 0.05).Incidence of ICU-AW: 2.22 % in the experimental group versus 17.78 % in the control group (P < 0.05). Delirium: 0 % in the experimental group versus 13.33 % in the control group (P < 0.05). No cases of VAP or nursing-related adverse events occurred in either group.
Conclusion   A standardized stepwise rehabilitation protocol can effectively improve oxygenation, shorten both mechanical ventilation duration and ICU length of stay, reduce re-intubation rates, and decrease the risks of ICU-acquired weakness and delirium in mechanically ventilated ICU patients, thereby facilitating rapid recovery. The protocol is clinically effective and merits broader application.