Increased ICU Early Active Mobilization of Patients on MV May Not Be Beneficial

Apr 17, 2023

Increased early active mobilization in the intensive care unit (ICU) leads to a significant increase in adverse events among adults undergoing mechanical ventilation and does not improve mortality, according to study findings published in The New England Journal of Medicine.

Early active mobilization (ie, sedation minimization and an increase in daily physiotherapy) is aimed at mitigating ICU-acquired weakness. Researchers sought to determine whether early active mobilization for adult patients undergoing mechanical ventilation would increase the number of days patients were alive and out of the hospital.

The Treatment of Mechanically Ventilated Adults with Early Activity and Mobilization (TEAM) clinical trial, (ClinicalTrials.gov Identifier: NCT03133377) analyzed data collected from 733 adult patients who underwent invasive mechanical ventilation in the ICU at 49 hospitals in 6 countries from the end of February 2018 through mid-November 2021. Participants were randomly assigned to receive sedation minimization and daily physiotherapy (n=369; 34.5% women) or usual care (n=364; 39.5% women). Acute primary brain or spinal injury, rest-in-bed orders, and dependency in any daily living activity in the month prior to hospitalization represented a key exclusion criteria.

The primary outcome was the number of days that patients were alive and out of the hospital, which was evaluated 180 days post treatment. The secondary outcome was the number of deaths reported by day 180. Researchers ultimately found no significant difference between groups in the median number of days patients were alive and out of the hospital (early-mobilization, 143 days [IQR 21-161] vs usual care, 145 days [IQR 51-164]; absolute difference, -2.0 days; 95% CI, -10 to 6; P =.62). Death occurred in 22.5% of patients in early-mobilization by day 180 compared with 19.5% in usual care (odds ratio, 1.15; 95% CI, 0.81-1.65).

Researchers noted 7 serious adverse events in the early-mobilization cohort and 1 in the usual care cohort. Altered blood pressure, desaturation, and arrhythmias possibly due to mobilization occurred in 34 patients in the early-mobilization cohort vs 15 patients in the usual care cohort (P =.005). No between group differences were noted in cognitive function, psychological function, disability, activities of daily living, or quality of life among survivors.

The mean (SD) daily duration of active mobilization in the early-mobilization group was 20.8 (14.6) minutes and in usual care it was 8.8 (9.0) minutes (difference, 12.0 minutes/day; 95% CI, 10.4-13.6). Among all patients, 77% were able to stand by a median interval of 3 days in early-mobilization and 5 days in usual care (difference, -2 days; 95% CI, -3.4 to -0.6). The number of ICU-free days and ventilator-free days at day 28 were similar between groups. The number of days per patient when physiotherapy assessment occurred was not equal (early-mobilization, 0.94 [0.11]; usual care, 0.81 [0.24]).

Study limitations include missing data related to patient-reported outcomes at day 180, an inconsistent level of mobilization therapy among patients receiving usual care, the absence of mobilization therapy among some patients, missing details pertaining to rehabilitation beyond the ICU, surveillance bias due to lack of blinding of treatment assignments, and possible overestimation of relative risk.

"Among adults undergoing mechanical ventilation in the ICU, an increase in early active mobilization did not result in a significantly greater number of days that patients were alive and out of the hospital than did the usual level of mobilization in the ICU," researchers concluded. They added that an increase in adverse events was significantly associated with the increase in active mobilization.

TEAM Study Investigators and the ANZICS Clinical Trials Group, Hodgson CL, Bailey M, Bellomo R, et al. Early active mobilization during mechanical ventilation in the ICU. N Engl J Med. November 10, 2022;387(19):1747-1758. doi:10.1056/NEJMoa2209083