Effectiveness of neuromuscular electrostimulation in COPD subjects on mechanical ventilation. A systematic review and meta-analysis

Gutierrez-Arias, Ruvistay; Jalil, Yorschua; Fuentes-Aspe, Rocío; Seron, Pamela

doi:10.1016/j.clinsp.2022.100108

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Review articles • Clinics 77 • 2022 • https://doi.org/10.1016/j.clinsp.2022.100108 copy

Effectiveness of neuromuscular electrostimulation in COPD subjects on mechanical ventilation. A systematic review and meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To estimate the effectiveness of Neuromuscular Electrostimulation (NMES) in adults with COPD undergoing MV.

Method:

A sensitive search was performed in MEDLINE, Embase, CENTRAL, CINAHL and other resources. Randomized Controlled Clinical Trials (RCTs) or non-RCTs that enrolled adults with COPD on MV due to an exacerbation of their disease were included. Two independent reviewers screened, extracted information, and assessed the risk of bias (RoB 2 tool) and the certainty of evidence (GRADE approach) from the included studies.

Results:

Four RCTs (144 participants) were included. Subjects who underwent NMES were able to move from bed to chair independently in less time (MD = 4.98 days less; 95% CI -8.55 to -1.47; 2 RCTs; low certainty of the evidence) and they were fewer days on MV (MD = 2.89 days less; 95% CI -4.58 to -1.21); 3 RCTs; low certainty of the evidence) than the control group. However, the effect of NMES on muscle strength is unclear (very low certainty of the evidence).

Conclusions:

NMES may improve functional independence and decrease MV time in adults with COPD; however, its effectiveness on muscle strength is uncertain. More and better RCTs are needed to determine with greater certainty the effectiveness of NMES in this population.

Keywords:
COPD; Neuromuscular electrostimulation; Mechanical ventilation; Critical illness; Systematic review; Meta-analysis

HIGHLIGHTS

NMES may improve functional independence and decrease in adults with COPD.

NMES may decrease in duration of MV in adults with COPD.

More RCTs with a better methodological design are needed.

ID	Groups		Interventions
	Experimental	Control	Experimental	Control
Zanotti 2003	n = 12 Age, y: 66.2 ± 8 Male, n (%): 8 (66.7%) BMI, kg/m²: 24.5 ± 2.4 Barthel, p: NR APACHE II, p: NR	n = 12 Age, y: 64.5 ± 4 Male, n (%): 9 (75%) BMI, kg/m²: 22.4 ± 3.7 Barthel, p: NR APACHE II, p: NR	Stimulated muscles: quadriceps and vastus glutei Device: SportTrainer; Actionfit; Forlì, Italy Dosage: 5 m at 8 Hz pulse width 250 ms and then 25 m at 35 Hz pulse width 350 ms Sessions: maximum time tolerated by the patient and gradually increasing the time of training up to 30 m; 5 d/w; 4w * In addition, the same interventions that were delivered to the control group were also applied	Active mobilization of 4 limbs as soon as possible
Akar 2015	n = 10 Age, y: 70 ± 12.3 Male, n (%): 4 (40%) BMI, kg/m²: NR Barthel, p: NR APACHE II, p: NR	n = 10 Age, y: 68 ± 17.8 Male, n (%): 5 (50%) BMI, kg/m²: NR Barthel, p: NR APACHE II, p: NR	Stimulated muscles: Deltoids and quadriceps Device: COMPEX (MI theta PRO, Switzerland) Dosage: 20‒25 mA; 50 Hz; 6 s of contraction duration, 1.5 s of increase and 0.75 s of decrease Sessions: 5 d/w; 20 sessions * In addition, the same interventions that were delivered to the control group were also applied	Active exercises of 4 limbs. If active exercise was not possible, patients underwent passive or assisted active exercise
Koçan 2015	n = 15 Age, y: 66.1 ± 13.9 Male, n (%): 14 (93.3%) BMI, kg/m²: 26.6 ± 7.4 Barthel, p: NR APACHE II, p: NR	n=15 Age, y: 69.9 ± 11 Male, n (%): 14 (93.3%) BMI, kg/m²: 25.7 ± 4.5 Barthel, p: NR APACHE II, p: NR	Stimulated muscles: pectorals major, trapezius and latissimus dorsi Device: COMPEX (MI theta PRO, Switzerland) Dosage: 20‒25 mA; 50 Hz; 6 s of contraction duration, 1.5 s of increase and 0.75 s of decrease Sessions: 20 m/d; 1d * In addition, the same interventions that were delivered to the control group were also applied	Upper extremity range-of-motion exercises and controlled breathing techniques and respiratory physiotherapy
	n = 30 Age, y: 62.4 ± 13.6 Male, n (%): 14 (51.9%) BMI, kg/m²: 22.3 ± 1.5 Barthel, p: 89.4 ± 6 APACHE II, p: 19.8 ± 4.4	n = 30 Age, y: 59.8 ± 11.8 Male, n (%): 17 (58.6%) BMI, kg/m²: 22.5 ± 1.6 Barthel, p: 90.1 ± 5.3 APACHE II, p: 19.0 ± 4.2	Stimulated muscles: Biceps, triceps, quadriceps, tibialis anterior and gastrocnemius Device: KT90A (Beijing Yaoyang Kangda Medical Co) Dosage: 30‒40 Hz Sessions: 30 m; 2/d; until the patient is transferred from ICU * In addition, the same interventions that were delivered to the control group were also applied	Usual treatment that includes etiological treatment and general symptomatic support, in addition to passive and active functional training and pulmonary rehabilitation

Outcomes	Illustrative comparative risks^* * The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group.		N° of participants (studies)	Certainty	Comments
Outcomes	Assumed risk Control	Corresponding risk NMES (95% CI)	N° of participants (studies)	Certainty	Comments
Functional independence (Time to move from bed to chair) ‒ days	The mean range of time across the control groups was from 12.6 to 14.33	MD 4.86 lower (8.55 to 1.47 lower)	44 (2 studies)	⊕⊕⊝⊝ Low^a a The certainty of the evidence was downgraded by the risk of bias of the included studies and by imprecision (sample size less than the optimal information size).	A third study reported no difference in the FIM scale between the groups, and the fourth study reported a higher Barthel index score in the intervention group
Muscular strength (manual evaluation) ‒ points	1 study reported no difference between the groups and 2 studies reported greater muscle strength in the intervention group		104 (3 studies)	⊕⊝⊝⊝ Very low^b b The certainty of the evidence was downgraded by the risk of bias of the included studies, by imprecision (sample size less than the optimal information size), and by inconsistency.95%CI, Confidence Interval 95%; FIM, Functional Independence Measure; MD, Mean Difference; MV, Mechanical Ventilation; NMES, Neuromuscular Electrostimulation; SGRQ, Saint George’s Respiratory Questionnaire; SF-36, Short Form 36 Health Survey Questionnaire.GRADE Working Group grades of evidence:⊕⊕⊕⊕ High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.⊕⊕⊕⊝ Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.⊕⊕⊝⊝ Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.⊕⊝⊝⊝ Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.	One study also reported greater grip strength in the intervention group. Due to the way in which the results were reported it was not possible to perform a meta-analysis
Duration of MV ‒ days	The mean range of time across the control groups was from 6.75 to 18.13	MD 2.89 lower (4.58 to 1.21 lower)	96 (3 studies)	⊕⊕⊝⊝ Low^a a The certainty of the evidence was downgraded by the risk of bias of the included studies and by imprecision (sample size less than the optimal information size).	One study reported that one-third of all patients were unable to wean from MV
Quality of life (SGRQ and SF-36) ‒ points	1 study reported no difference between the groups		30 (1 study)	⊕⊕⊝⊝ Low^a a The certainty of the evidence was downgraded by the risk of bias of the included studies and by imprecision (sample size less than the optimal information size).	The study does not report the scores of the questionnaires, and the graphs of the SGRQ tool do not allow to extract the information
Length of ICU stay ‒ days	The mean range of time across the control groups was from 7.5 to 10.45	MD 4.2 higher (9.1 lower to 17.5 higher)	69 (2 studies)	⊕⊝⊝⊝ Very low^b b The certainty of the evidence was downgraded by the risk of bias of the included studies, by imprecision (sample size less than the optimal information size), and by inconsistency.95%CI, Confidence Interval 95%; FIM, Functional Independence Measure; MD, Mean Difference; MV, Mechanical Ventilation; NMES, Neuromuscular Electrostimulation; SGRQ, Saint George’s Respiratory Questionnaire; SF-36, Short Form 36 Health Survey Questionnaire.GRADE Working Group grades of evidence:⊕⊕⊕⊕ High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.⊕⊕⊕⊝ Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.⊕⊕⊝⊝ Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.⊕⊝⊝⊝ Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.	One study reported that one third of all patients were unable to be discharged from ICU
Length of hospital stay ‒ days	The main of the control group was 15.38	MD 2.17 lower (3.74 to 0.6 lower)	60 (1 study)	⊕⊕⊝⊝ Low^a a The certainty of the evidence was downgraded by the risk of bias of the included studies and by imprecision (sample size less than the optimal information size).
Adverse effects	1 study reported that the interventions were well tolerated by both groups		24 (1 study)	⊕⊕⊝⊝ Low^a a The certainty of the evidence was downgraded by the risk of bias of the included studies and by imprecision (sample size less than the optimal information size).	The remaining 3 studies make no mention of the safety or tolerability of NMES and the control intervention.

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[1] * Corresponding author. E-mail address: pamela.seron@ufrontera.cl (P. Seron).