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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira


ISSN: 0103-507X
Online ISSN: 1982-4335

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Skueresky AS, Forgiarini SGI, Forgiarini LA, Dias AS. Para: Extubação fora do leito: um estudo de viabilidade. Rev Bras Ter Intensiva. 2015;27(3):293-295





To: Out-of-bed extubation: a feasibility study

Para: Extubação fora do leito: um estudo de viabilidade


Conflicts of interest: None.

Corresponding author: Luiz Alberto Forgiarini Júnior, Curso de Fisioterapia do Centro Universitário Metodista, Rua Coronel Joaquim Pedro Salgado, 80 - Rio Branco, Zip code: 90420-060 - Porto Alegre (RS), Brazil. E-mail:


To the Editor,

We congratulate the authors on their article entitled “Out-of-bed extubation: a feasibility study”, which was published in this journal.(1) The issue addressed by this article is extremely important for professionals who work in intensive care units and are looking for paradigm shifts, particularly with respect to the mobilization of chronically critically ill patients.

These patients often experience muscle complications related to immobility. Puthucheary et al. evaluated 63 patients beginning 48 hours after admission to the intensive care unit (at 1, 3, 7 and 10 days) and prospectively demonstrated early changes related to both reduced muscle cross-sectional area and muscle protein metabolism. These changes in muscle, which occur early and rapidly in septic patients, are directly related to increased time on mechanical ventilation.(2)

The patient sample evaluated by Dexheimer Neto et al. consisted of septic patients; these patients were compared against patients with other pathologies (including 33 septic patients, 24 patients with cardiac insufficiency, 26 postoperative patients and 10 neurological patients), an approach that introduced bias with respect to heterogeneity.(1)

Similar to this investigation by Dexheimer Neto et al.,(1) other studies have reported the effectiveness of early mobilization for seriously ill patients with respect to not only the process of removing these patients from mechanical ventilation but also reducing their length of stay in the intensive care unit. In a systematic review, Li et al. demonstrated that active mobilization protocols for mechanically ventilated patients produce positive in-hospital outcomes; thus, this approach is a safe strategy that can increase muscle strength, providing better conditions for weaning from mechanical ventilation and promoting functional independence.(3)

Relative to the new proposal for extubating chronically critically ill patients, the article addressed in this letter appears to utilize a methodological design that limits the assessment of the examined variables.

Thus, this study adds to knowledge regarding the implementation of new strategies for removing chronically critically ill patients from mechanical ventilation and demonstrates the effectiveness of participation by multidisciplinary teams with respect to the therapeutic approaches adopted for patients.(4)

However, it behooves us to note that the study results could be enhanced by employing a new methodological design that seeks to randomize the extubation of patients who are either lying in bed or sitting in a chair and thereby avoid potential selection bias.


Amanda Soares Skueresky, Soraia Genebra Ibrahim Forgiarini and Luiz Alberto Forgiarini Júnior - Course of Physiotherapy, Centro Universitário Metodista - Porto Alegre (RS), Brazil.
Alexandre Simões Dias, Course of Physiotherapy, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),Brazil.



Dexheimer Neto FL, Vesz PS, Cremonese RV, Leães CG, Raupp AC, Rodrigues CS, et al. Extubação fora do leito: um estudo de viabilidade. Rev Bras Ter Intensiva. 2014;26(3):263-8.
Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310(15):1591-600. Link DOILink PubMed
Li Z, Peng X, Zhu B, Zhang Y, Xi X. Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil. 2013;94(3):551-61. Link DOILink PubMed
Parker AM, Liu X, Harris AD, Shanholtz CB, Smith RL, Hess DR, et al. Respiratory therapy organizational changes are associated with increased respiratory care utilization. Respiratory Care. 2013;58(3):448-9. Link DOI





Thank you for your compliments and the opportunity to discuss not only the practices of early mobilization and out-of-bed extubation but also the incorporation of these practices into the care of critically ill patients in our country.

First, we note that the benefits of early mobilization (the mobilization of patients who have received mechanical ventilation for less than 48 hours, who compose the population examined in our study) extend to patients with various clinical conditions; in particular, early mobilization can reduce delirium durations, increase patients’ functional abilities at discharge, and decrease lengths of stay in the intensive care unit and in the hospital.(1-3)

We also agree that for critically ill patients, a diagnosis of sepsis is closely linked to muscle damage and to polyneuromyopathy, a highly prevalent condition among severely ill patients that is detrimental to the process of weaning patients from mechanical ventilation.(4,5) However, because the aim of our study was to assess the effectiveness of an unprecedented practice (out-of-bed extubation), we intentionally examined a heterogeneous patient population to ensure that our findings exhibited good external validity.(6)

Similarly, a limitation of our study is its retrospective design, which restricts the interpretation of implications related to the safety of this new practice.(6) Once again, we agree that a randomized clinical trial design and better characterization of the patient groups undergoing weaning from ventilation (septic versus non-septic, for example) would provide stronger results; such findings have not yet been published in the literature.

Mechanically ventilated patients benefit from the use of less sedation (through sedation protocols and/or daily interruption) in combination with spontaneous breathing trials and early mobilization.(7-9) Because these interventions occur concurrently, we propose that early mobilization does not delay weaning (or vice versa); thus, out-of-bed extubation can be regarded as a novel approach, although this treatment still needs to be validated in specific, well-designed studies.(6)

In conclusion, we emphasize the importance of communication and the coordination of the efforts of different specialists within a multidisciplinary team (that includes members from medical, nursing, and physiotherapy fields, among others) in attempts to improve the viability of early mobilization combined with concurrent mechanical ventilation.(3,5,10,11)


Felippe Leopoldo Dexheimer Neto, Patrini Silveira Vesz, Rafael Viegas Cremonese, Clarissa Garcia Soares Leães, Ana Carolina Tabajara Raupp, Cristiano dos Santos Rodrigues, Juliana Mara Stormovski de Andrade and Raquel da Silva Townsend - Intensive Care Unit, Hospital Ernesto Dornelles - Porto Alegre (RS), Brazil.
Juçara Gasparetto Maccari and Cassiano Teixeira - Intensive Care Unit, Hospital Moinhos de Vento, Porto Alegre (RS), Brazil.



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(8):2238-43.
Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373(9678):1874-82.
Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014;18(6):658.
Fan E, Cheek F, Chlan L, Gosselink R, Hart N, Herridge MS, Hopkins RO, Hough CL, Kress JP, Latronico N, Moss M, Needham DM, Rich MM, Stevens RD, Wilson KC, Winkelman C, Zochodne DW, Ali NA; ATS Committee on ICU-acquired Weakness in Adults; American Thoracic Society. An official American Thoracic Society Clinical Practice guideline: the diagnosis of intensive care unit-acquired weakness in adults. Am J Respir Crit Care Med. 2014;190(12):1437-46.
Schweickert WD, Kress JP. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. 2011;140(6):1612-7. Review.
Dexheimer Neto FL, Vesz PS, Cremonese RV, Leães CG, Raupp AC, Rodrigues C dos S, et al. Out-of-bed extubation: a feasibility study. Rev Bras Ter Intensiva. 2014;26(3):263-8.
Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126-34.
Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-7.
Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P, Fowler R, Burns K, Jacka M, Olafson K, Skrobik Y, Hébert P, Sabri E, Meade M; SLEAP Investigators; Canadian Critical Care Trials Group. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA. 2012;308(19):1985-92.
Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, et al. Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Crit Care Med. 2014;42(5):1178-86.
Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study. BMC Anesthesiol. 2014;14:84.

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