Key principles for rehabilitation of critically ill patients with obesity

Intensive Care Medicine: Published: 17 July 2026

Purpose

Patients with obesity who are admitted to an ICU bring specific challenges for rehabilitation during and after critical illness. This narrative review explores impact of differences in body compositions and pathophysiology on outcomes to summarise interprofessional, patient-centred rehabilitation strategies across the trajectory of recovery.

Methods

The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence.

Results

Three distinct phenotypes potentially influence outcomes for survivors. Whilst patients with preserved muscle mass may have a survival advantage, the phenotypes characterised by ectopic visceral fat or sarcopenia are frequently complicated by multimorbidity and polypharmacy, likely increasing the risk of adverse effects such as suboptimal sedation, prolonged ventilation and immobilisation, malnutrition, and impaired recovery. Targeted respiratory interventions, including secretion-clearance techniques and appropriate patient positioning to prevent atelectasis, reduce the work of breathing. Optimisation of communication and swallowing function is an essential component for facilitating safe oral intake and promoting active patient participation in rehabilitation. Concurrently, targeted nutrition strategies combined with early, targeted, progressive mobilisation might mitigate ICU acquired weakness and support functional recovery. The availability of appropriate weight‑based equipment is fundamental to ensuring safe mobilisation for both patients and healthcare professionals.

Conclusion

Interprofessional collaboration is central to optimising outcomes and should extend beyond the ICU to structured post-ICU follow-up to address persistent, worsening, or newly emerging health impairments. Early rehabilitation in critically ill patients with obesity should integrate physiological, logistical, and psychosocial considerations to support equitable and functional recovery.

 

 

 

Standard of care for rehabilitation in critical illness

Intensive Care Medicine: Published: 30 April 2026

Background

Rehabilitation is recognised as a cornerstone of intensive care, essential for optimising functional recovery and reducing long-term disability. Contemporary ICU populations, characterised by advanced age, multimorbidity, and prolonged stays, are at heightened risk of muscle wasting, immobility, frailty, cognitive decline, and functional dependence. Mitigation of these sequelae requires careful interprofessional collaboration for person-centred rehabilitation across the care continuum.

Content

This review synthesises evidence from randomised controlled trials, meta-analyses, and clinical practice guidelines on rehabilitation during and after intensive care. Best practice within the ICU begins with early awakening and mobilisation with evidence demonstrating that physical rehabilitation is safe, with low adverse-event rates. Furthermore, multiprofessional strategies that span across ICU, ward, and community are required to address complex problems including physical, cognitive, and psychological sequelae of critical illness.

Future directions

Research priorities include detailed reporting of intervention dose (timing, intensity, duration) for both usual care and rehabilitation provided within clinical trials, and development of intervention implementation strategies that enhance uptake and fidelity in routine practice.

Conclusion

Rehabilitation is integral to contemporary ICU care, spanning the trajectory of recovery into the community. Within the ICU, it requires interprofessional, experienced healthcare personnel to assess clinical status for safe rehabilitation and to identify an individual’s anticipated recovery trajectory. Standardised intervention reporting and implementation-focussed research are essential to advance evidence and improve outcomes for critically ill patients.

 

 

Critical Care Bulletin - July 2024

 

Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis

 

by Ben R. Richardson, Maxens Decavèle, Alexandre Demoule, Fliss E. M. Murtagh and Miriam J. Johnson 

 

Annals of Intensive Care volume 14, Article number: 107, Published: 05 July 2024

 

Background

Adults in the intensive care unit (ICU) commonly experience distressing symptoms and other concerns such as pain, delirium, and breathlessness. Breathlessness management is not supported by any ICU guidelines, unlike other symptoms.

Aim

To review the literature relating to (i) prevalence, intensity, assessment, and management of breathlessness in critically ill adults in the ICU receiving invasive and non-invasive mechanical ventilation (NIV) and high-flow oxygen therapy, (HFOT), (ii) the impact of breathlessness on ICU patients with regard to engagement with rehabilitation.

Methods

A rapid review and narrative synthesis using the Cochrane Methods Group Recommendations was conducted and reported in accordance with PRISMA. All study designs investigating breathlessness in adult ICU patients receiving either invasive mechanical ventilation (IMV), NIV or HFOT were eligible. PubMed, MEDLINE, The Cochrane Library and CINAHL databased were searched from June 2013 to June 2023. Studies were quality appraised.

Results

19 studies representing 2822 ICU patients were included (participants mean age 48 years to 71 years; proportion of males 43–100%). The weighted mean prevalence of breathlessness in ICU patients receiving IMV was 49% (range 34–66%). The proportion of patients receiving NIV self-reporting moderate to severe dyspnoea was 55% prior to initiation. Breathlessness assessment tools included visual analogue scale, (VAS), numerical rating scale, (NRS) and modified BORG scale, (mBORG). In patients receiving NIV the highest reported median (interquartile range [IQR]) VAS, NRS and mBORG scores were 6.2cm (0–10 cm), 5 (2–7) and 6 (2.3–7) respectively (moderate to severe breathlessness). In patients receiving either NIV or HFOT the highest reported median (IQR) VAS, NRS and mBORG scores were 3 cm (0–6 cm), 8 (5–10) and 4 (3–5) respectively.

Conclusion

Breathlessness in adults receiving IMV, NIV or HFOT in the ICU is prevalent and clinically important with median intensity ratings indicating the presence of moderate to severe symptoms.

Reading between the lines, the key to successfully implementing early rehabilitation in critical care

Reading between the lines, the key to successfully implementing early rehabilitation in critical care

McWilliams DJ
Intensive and Critical Care Nursing , October 2017 Volume 42, Pages 5–7

The number of critically ill individuals, complexity of illness, and cost of critical care has continued to increase over time (Bauman and Hyzy, 2014). Although this represents an older critical care population than previously seen, presenting with a variety of pre-existing comorbidities, improvements in intensive care services and delivery have meant survival rates have improved in recent years (Esteban et al., 2013; Kaukonen et al., 2014). When considering successful outcomes from critical illness, it is now acknowledged that it is no longer sufficient or appropriate to consider survival alone (Desai et al., 2011).

Rehabilitation during mechanical ventilation

Rehabilitation during mechanical ventilation: Review of the recent literature. Intensive and Critical Care Nursing, 2015 [in press]

Ntoumenopoulos, G.

http://www.intensivecriticalcarenursing.com/article/S0964-3397(15)00006-3/abstract?rss=yes

Mechanically ventilated patients are at increased risk of developing physical and psychological complications that are associated with prolonged weaning from mechanical ventilation, increased morbidity and mortality. These complications include intensive care unit acquired weakness, delirium and a loss of physical function that may persist well beyond ICU and hospital discharge. 

Physical rehabilitation of the critically ill trauma patient in the ICU

Physical rehabilitation of the critically ill trauma patient in the ICU. Critical care medicine, July 2013, Vol. 41(7), p. 1790-1801.

Engels, P.T., et al.

http://journals.lww.com/ccmjournal/Abstract/2013/07000/Physical_Rehabilitation_of_the_Critically_Ill.24.aspx

Objectives: To review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; summarize the evidence for early mobilization in each anatomic area; and provide recommendations for the mobilization of these patients.

Re-building life after ICU

Re-building life after ICU: A qualitative study of the patients' perspective. Intensive and critical care nursing, April 2012, Vol. 28(2), p.114-122.

Deacon, K.S.

http://www.intensivecriticalcarenursing.com/article/S0964-3397(11)00127-3/fulltext

Healthcare professionals in ICU, acute ward and community settings need to be aware of the broad array of physical and psychological challenges faced by patients who have been critically ill. Healthcare professionals need to ensure a holistic approach is implemented to coordinate and facilitate rehabilitation, to address identified patients’ needs.

Critical care rehabilitation and early mobilisation

Critical care rehabilitation and early mobilisation: An emerging standard of care. Intensive and critical care nursing, April 2012, Vol. 28(2), p. 55-57.

Grapp, M.J. & McFetridge, B.

http://www.intensivecriticalcarenursing.com/article/S0964-3397(12)00015-8/fulltext

Critical care rehabilitation across the trajectory of recovery, beginning in the critical care unit and ending with recovery to an optimal level of health is presently a major focus of health care and research. After discharge from the critical care unit, rehabilitation is often begun in earnest. Although the focus of critical care is appropriately on stabilisation and survival, rehabilitation must also be a major part of the plan of care during these initial stages of care.

Improving rehabilitation following transfer from ICU.

Intensive Crit Care Nurs. 2008 May 8. [Epub ahead of print]
Links
Au: Ball C.
Royal Free Hampstead NHS Trust, Pond St, London NW3 2QN, United Kingdom; City Community and Health Sciences, City University, Northampton Square, London EC1V 0HB, United Kingdom.
PMID: 18472264 [PubMed - as supplied by publisher]