Affiliations: Memphis, TN
Dr. Wunderink is Director, Research Department, Methodist Healthcare Memphis.
Correspondence to: Richard G. Wunderink, MD, FCCP, Director, Research Department, Methodist Healthcare Memphis, 1265 Union Ave, Suite 501 Crews, Memphis, TN 38104; e-mail: wunderiR@methodisthealth.org
In the era of electronic ICUs, computer-assisted decision making, and robotic surgical assistants, the words of this classic American hymn are a good reminder to not forget the value of basic, simple maneuvers to improve the care of our patients. In this issue of CHEST (see page 883), Mundy and coworkers have elegantly demonstrated this approach with their study on a simple maneuver—getting patients with community-acquired pneumonia (CAP) out of bed, either into a chair or ambulating within 24 h of admission. The result was an impressive average 1.1-day decrease in the length of hospitalization. The most impressive difference in length of stay for the early ambulation group was in patients with a pneumonia severity index (PSI) class III.1
Average hospital length of stay in this group decreased from a mean of approximately 7.5 days to a mean of 5 days. The lack of benefit in the lower acuity PSI classes probably results from the primarily psychological and social reasons for hospital admission.1–2
This article adds to the complementary group of studies suggesting simple procedures, such as patient positioning, decrease the risk of developing respiratory infections or hasten the recovery from them. Drakulovic et al3–
demonstrated that keeping the head of the bed elevated in patients receiving mechanical ventilation significantly decreased the incidence of ventilator-associated pneumonia. Multiple studies have demonstrated that early ambulation or at least getting up into a chair decreases the risk of postoperative pneumonia and atelectasis.4
Several physiologic benefits of early upright posture can be hypothesized. Gravitational changes may improve drainage from upper-lobe pneumonias, while greater diaphragm excursion and increased volume changes in lower lobes may improve secretion clearance in lower-lobe pneumonias. The improved cough efficacy in the upright position due to a greater ability to increase intra-abdominal pressure may also contribute. Ambulation will amplify all of these changes. The net benefit may be earlier improvement in oxygenation, a major criteria in the discharge decision.5–6
It is tempting to attribute the decrease in average length of stay with early mobilization to physiologic benefits; however, other factors may play an equal or more important role. The significant variability in physician practice regarding the discharge decision for CAP is well documented but poorly understood. PSI class III patients are generally bimodal—either younger patients with significant physiologic abnormalities or elderly patients with underlying comorbidities. The latter group is where the most benefit is most likely occurring. The attending physician who sees an afebrile elderly CAP patient walking the hall or sitting up eating a meal is more likely to consider discharge than if the same patient is seen still supine in bed. Conversely, the benefit may be on the patient’s psyche. If they realize they are well enough to get out of bed, patients may be more likely to press their physician for early discharge or at least not resist when the physician suggests discharge.
No matter what the reason, the findings are compelling enough to recommend early mobilization as a part of any standard admit orders or clinical pathway for hospitalized patients with CAP.7–8
Compliance with an order for early mobilization will be the major issue; however, the cost savings clearly suggest that the time spent encouraging and assisting early mobilization will result in both improved outcomes and significant cost savings.
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