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Eddie: Hello and welcome. You're listening to the ATS Breathe Easy Podcast with me your host, Dr. Eddie Chen. Each Tuesday of every month, ATS will welcome guests who will show the latest news in pulmonary critical care and sleep medicine. Whether you're a patient, patient advocate, or healthcare professional, the ATS Breathe Easy podcast is for you.
Joining me today is Dr. Justin Banerdt in our series of things that you may have missed when you were at the ATS International Conference 2025, there are so many great sessions going on at the same time. It's inevitable that you may miss something exciting that you're interested in, and, and that's why we're here.
Dr. Banerdt is a fellow in the division of Allergy, pulmonary and Critical Care Medicine at Vanderbilt University Medical Center. I. [00:01:00] He returned to Vanderbilt where he got his MD and MPH after his residency at Yale. We will get into more of this shortly, but his research interests include studying long-term outcomes of critical illness, identifying interventions to improve survivorship and functional status among critically ill patients and resource limited settings, and then.
Global critical care capacity building. And I suppose I, I have a disclaimer that I'm a faculty member at Vanderbilt University Medical Center, but our affiliation will not impact our discussion. Thank you so much for joining us, Justin.
Justin: Thanks so much, Eddie. It's great to be here.
Eddie: Great, great. So I, I think we should just jump right into it.
I'm really excited to talk about this. The, the title of your abstract that you presented at at ATS was characterizing critical illness recovery trajectories, exploring risk factors for post intensive care syndrome. So, I, I, I think right off the top, there's a lot of, a lot for us to unpack and digest just from there.
So [00:02:00] why don't you tell me a little bit about critical illness recovery trajectories. Tell me a little bit about post intensive care syndrome and why is this important?
Justin: Yeah, sure. So this really builds off of over a decade of, of prior research looking at. How do critically ill patients do after they've overcome their initial critical illness?
And, and you know, there, it wasn't that long ago that we thought that it was a success if, if a patient was able to survive their ICU stay, we were able to get them through and out of the ICU. But what we're realizing now is that many of these patients end up having. Long-term impairments and cognitive function, physical function, and, and, and mental health.
And those new or worsened impairments are, are referred to as post intensive care syndrome. So it's, you know, 500 or 5 million. There's 5 million admissions to ICUs every year in, in the United States alone, and many of those patients, [00:03:00] probably at least 25 to 50% of them are going to experience at least some element of post intensive care syndrome.
So it's a real, I. Real issue that as a field we're trying to better understand and, and better address and really where what we wanted to, to answer with the study was to, to figure out what do these trajectories of recovery look like in these different domains of functions? So can we identify groups of patients that have distinct.
Patterns of recovery in their physical function or in their cognitive function. And if some of those are consistent with post intensive care syndrome, can the, can we then identify risk factors that those patients may have for post intensive care syndrome?
Eddie: Yeah, no, that, that makes a lot of sense.
Explain to me a little bit. About you post intensive care syndrome and, and syndrome is just a consolation of symptoms that gives you kind of a similar phenotype, [00:04:00] so, so what kind of things are we looking for in our loved ones or in our patients that would say, Hey, you, you may have, or you may be suffering from post intensive care syndrome.
Justin: Absolutely. So there's, I'll just go by the three main buckets of symptoms or functional impairments that we think about with post intensive care syndrome. And it can look different for every patient. So with one of them is cognitive dysfunction. So when we think about that, we think about a loved one who survived critical illness, having.
Difficulty remembering things sort of brain fog, difficulty processing new information or engaging in, in certain tasks that they used to be able to, like maybe managing their finances or, or planning events and things like that. And we know from prior work that the level of cognitive impairment that ICU survivors have can be pretty significant that a [00:05:00] year after ICU admission, some of these patients have.
Cognitive impairment that's equivalent to mild Alzheimer's. And that's new impairment. So that's one thing. The other domain is, is physical impairments. So functional impairments in their ability to do things that they would typically do. And this ranges from basic activities of daily living, like bathing dressing themselves, being able to eat food to more.
Advanced activities of daily living are what we call instrumental activities of daily living, which include managing finances, being able to cook being able to manage your medications. And so if your loved one is, is experiencing problems with any of these things, then that could be a sign they're suffering from post intensive care syndrome.
And the last bucket. Problems that we think about as mental health issues. So a lot, we know a lot of survivors of critical illness suffer from post [00:06:00] intensive care syndrome because the experience in the ICU can often be very traumatic and as well as depression and anxiety. And, and that's definitely something we are, are working to better understand and, and treat as well in these survivors.
Eddie: Yeah. No, that makes a lot of sense. Thanks for explaining all that. Justin. I think post intensive care syndrome is, as you've already said, is something that's growing in our consciousness as providers is something we recognize that is happening to our patients. And you're right, it's, it's not, it's still a success if someone survives ICU, but it's not the only success that we can have.
And so I think the work that you're doing is, is really interesting and great there. And we could talk. We could talk an entire hour on post-test care syndrome, but let's talk a little bit about what you guys were doing with your recovery trajectories. Tell me a little bit about how you went about and what you were doing to try to answer this question.
Justin: Sure. So the, the basic [00:07:00] underlying hypothesis we had was that. If you take patients who survive the ICU as a whole, they, they won't likely have all the same recovery trajectory. That there's gonna be certain groups of patients who do better, certain groups of patients who do worse, and they may also have different recoveries in those different, um domains of functional impairments.
So they may have different cognitive recovery or, or physical recovery. And we wanted to get a better understanding of that so we could uh oh. Hopefully better understand their, their overall recovery and how best to help them. So what we did was we took a couple data sets that already exist the brain ICU and the Mind ICU dataset, which was two studies that were done a little over a decade ago looking at long-term outcomes for patients who survive critical illness.
And the. The initial results of that actually showed [00:08:00] that delirium was an independent predictor of cognitive impairment after critical illness. So but we use that really rich data set. And looked at a couple important patient outcomes at up to 12 months after their ICU stay. And those included the mini mental state exam which is a well-validated tool for looking at cognitive impairment as well as the CATT A DL tool and the FAQ score, which both look at
impairment in activities of daily living, which are sort of the basic activities of, of feeding moving, dressing oneself, bathing toileting, those just very basic stuff. And then the instrumental activities of daily living which are, you know, things like managing your finances, medications cooking, cleaning, things like that.
So we wanted to get a more sort of [00:09:00] holistic picture of how these patients are recovering in these different important domains of, of, um of life. So we measured those outcomes at baseline three months after admission and 12 months after admission. So, and we went pretty far out in terms of after their ICU admission.
And we used a form of analysis, which we don't need to get into, you know, the, the nuts and bolts of, but it's called latent trajectory modeling. And basically it's just a way of identifying groups of patients that had similar trajectories of recovery within that group, but our goal was to identify different groups that had different trajectories of recovery between the groups.
And so what we, we ended up doing that and we ended up finding two different groups of patients that had very different recovery [00:10:00] trajectories after their ICU admission.
Eddie: Yeah, no, this is, this is, this is all really interesting, fascinating stuff. The, correct me if I'm wrong, Justin, the brain, ICU and Mind ICU studies were completed and they had.
Done these functional status scores or otherwise. And so you were able to, to utilize the data that was already collected and, and repackage it in a, in a new analysis. Is that right?
Justin: That's right. It was a, it was a secondary analysis of,
Eddie: yeah, I, I, I just wanted to, you know, highlight for everybody. I mean, this is one of the importance things about what we do as doing, doing medical research and everything from that perspective is this kind of robust research is.
The reach is well beyond just original studies to fuel more interesting analyses and cutting things in different ways. And so this is all really, really great from that perspective. So it really seems like you've kind of taken these data sets. You've [00:11:00] taken these. Scores for mental and functional impairments, and it seems like you did find a couple of differences there.
I'd love to to get into that, but we will be right back after a short break.
non: Did you miss the ATS 2025 International Conference in San Francisco? We've got you covered with the ATS conference Highlights package. You can access inspiring presentations as well as valuable clinical insights from Pullman.
Critical Care and sleep sessions, members get a discount. So become an at s member or renew your membership. To take advantage of these savings, go to conference.thoracic.org today.
Eddie: Welcome back to the podcast. We're gonna talk a little bit about what you all found Justin, so, so tell me a little bit about this recovery trajectories and the two different groups that you teased for us before the break.
Justin: Yeah. So so our total group of [00:12:00] patients in the dataset was 804 patients. We identified two different groups of patients that had very different recovery trajectories after their ICU admissions. So, and I'll, I'll just call them group one and group two for now. So group one was the larger group.
It had about 620 patients in it, and they overall did better. They, they had better recovery of their cognitive function. Over one year of follow-up and lower impairment in their activities of daily living and their instrumental activities of daily living compared to group two, which had about 184 patients those patients globally did worse.
So they had greater impairment of their cognitive function compared to group one that was. Persistent throughout the one year of follow up. And then even more striking was that they had progressive worsening of their [00:13:00] dependency in, in their activities of daily living and instrumental activities of daily living.
So over that one year. They just progressively actually got worse in terms of their, their functional status and doing things like, you know, bathing, dressing, eating, or managing their finances, managing their medications. So that, yep. Oh,
Eddie: sorry. I was gonna say, so on the one hand, it's. It's reassurance to doing some quick math there.
It's about 75 to 80% of patients after they recover from the ICU, their critical illness that they will continue to improve in their cognitive function and improve in their functional status. But it's still a sizable proportion of patients who will not only not get better, but you're saying actually gets worse here.
Justin: Right. Right. And I think that's definitely one of the, the take home messages from our study is that there is a [00:14:00] group of patients up to maybe 25% in our cohort that, that actually not only did they not show evidence of recovery, but they actually got worse through that one year follow-up. Which is why we're trying to better understand why that's the case and what the risk factors are.
Eddie: Yeah. So what, so what are some of those risk factors for either way, doing better or not doing better? Or what, what kind of things can we learn from this?
Justin: Yeah, so I think this is this was really the next step in our, in our study that we really wanted to focus on was. Sure we've identified a, a class of patients that do worse.
But is, is there a way that we can predict which of those patients are going to end up having that worse trajectory? Which would be really helpful for us as clinicians when we're taking care of them initially. And that a
Eddie: lot of you know, large medical centers have clinics, multidisciplinary clinics for post [00:15:00] intensive care syndrome.
That can help out. But it's only helpful we can if we can know who to send there.
Justin: Right. So. Right, right. And that's such a great point, Eddie. And you know, there, there is this growing, um movement of developing post ICU clinics, which provide great multidisciplinary care to these patients. But oftentimes we don't know which of those patients are really gonna need the clinics when they're first discharged from the hospital.
So. Results from our study like this will help us better identify which of those patients really could benefit from that kind of support. So we, we looked at a, a variety of different factors. And through multi-variable regression analysis, we identified that there were. A couple important factors that had that were significant risk factors for developing that post intensive care syndrome trajectory.
And those [00:16:00] were older age worse baseline cognitive function as assessed by one of the patient's caregivers when they were first admitted and finally baseline frailty. And it was actually frailty that had the highest that was the highest risk factor for predicting the post intensive care syndrome.
Patients who had increased baseline frailty were over four times more likely to develop that post intensive care syndrome trajectory. Which really emphasizes the importance of evaluating. How frail someone is when they first present to the ICU because those patients most are, are far more likely to develop post intensive care syndrome afterwards.
Eddie: Yeah. Talk, talk to me a little bit about frailty. Justin. I think this is a word that ma many of us and many of the listeners can define again, [00:17:00] but it's, it's actually quite complex actually to, to actually say quantify how, how frail someone is.
Justin: Yeah. Frailty is something that is, is a concept that, like you said, I think a lot of us may be sort of.
Vaguely, subjectively familiar with, but from a clinical and research standpoint, we're really trying to better understand what is frailty and how can we assess it. So the, the tool that we used was so it was the, the Rockwell tool the CSHA frailty index, which essentially is a global subjective assessment of how functional or not functional a patient is coming into the hospital.
And it's been validated. There's, there are other measures that look at accumulation of prior [00:18:00] health conditions. And there's the, there's another group of researchers who have tried to understand frailty more from a a multi-system dysfunction perspective that think thinking of the, the human body as, as a, as a set of, of complex systems and frailty is just basically those symptoms globally dysfunctioning.
And assessing that more through aspects of like physical strength and um walking speed and things like that. So it, it is a, a very interesting. Complex topic and something that we're still trying to better understand, like how do we actually assess frailty and how does that predict long-term outcomes for those patients.
Eddie: Yeah. But, but at a minimum, it seems like from your work here, that frailty [00:19:00] seems to be highly associated with a worsening clinical trajectory after survival from the ICU. I I, I'm gonna, so when I was, when I was reading your abstracts, Justin there was a, there was one thing that surprised me. I'm gonna put you on the spot here a little bit, if that's okay.
When I think about critical illness, and I think about who may or may not do well after the ICU. I, I would be thinking about those patients who reached, you know, higher degrees or higher severity of illness during their course. And so that was one thing that I was surprised to see that that wasn't associated.
And the other thing that I was a little bit surprised to see is that you mentioned in the original mind ICU and Brain ICU studies, that that delirium was a factor here, but it didn't seem to play a factor in your analysis. What, what kind of things would you say to a, a interested clinician like me?
Justin: Yeah, I think those, those findings were frankly surprising to us too [00:20:00] at face value. But there's been some. Growing recognition in recent studies that acute severity of illness is certainly very important for short term outcomes. So, if a patient if you take two patients, one who's, you know, much sicker than the other patient
that sicker patient is, is likely gonna have a higher chance of mortality in the ICU. They're, they're likely gonna have worse short-term outcomes. But what we're, what we're starting to find with, with some recent studies in our study supports this is that it's. Someone's baseline, frailty, and level of function that is more predictive of their long-term outcomes.
So you can think of it as the initial sort of insult of the critical illness certainly has a major impact. But [00:21:00] that the impact of that begins to, to lessen as you progress to maybe more than a month out from admission. And then at that point, their baseline chronic health issues, their baseline frailty begins to play more importance.
And there was actually a real, a very interesting study that was done that was published a few years ago, which showed that your pre illness trajectory. Actually was predictive of your post illness trajectory. So if patients were, you know, progressively more disabled, progressively more frail, leading up to their ICU admission, that tend to predict worse long-term outcomes as well, which is what our data suggests with severity of illness.
So it's not that severity of illness doesn't matter, it certainly does. But what our findings really point to is that it's. The sort of global health and [00:22:00] level of function of the patient prior to admission that really has a strong predictive that that's strongly predictive of how they're gonna do, you know, months and years after their admission.
Yeah,
Eddie: yeah. No, that, that's really, that's really interesting. I think between, between the analysis that you guys did and the study that you referenced, it seems like that. When we get, when we get people in ICU who are critically ill, that our goal is to kind of get them back on track, but that, that track, that trajectory, pre ICU, pre-critical illness may have, may already have been a downward trajectory.
I.
Justin: Yeah, I think that's, that's definitely what what you know, our findings suggest as well. And going back to your question about delirium, so that's, that's another great question, another surprise. So I. I think what's happening here is that we've clearly shown both our research group, but also other [00:23:00] groups around the world that delirium is very much a strong predictor of long-term cognitive impairment in a, you know, dose dependent way, the more delirium you have, the more long-term cognitive impairment you're at risk for.
But in this study, we're not just looking at long-term cognitive impairment, we're looking at physical functional impairments. So impairments in activities of daily living, you know, bathing, dressing, or managing your finances, et cetera. And what I think is happening here is that we're losing the signal of delirium being predictive of cognitive impairment because we're including those other functional measures.
So it suggests that yes, probably delirium is still. And I'm quite sure that delirium still is quite predict is predictive of cognitive impairment, but it may not be particularly predictive of impairment in ADLs or instrumental activities of daily living. And that other [00:24:00] factors like frailty for example may be more predictive of those physical deficits that patients experience after their illness.
Eddie: No, this, this is all really fascinating and I'm glad you've gotten a chance to share these results with us here. And then at the ATS International Conference, what, what are some next steps for you here in this, in this space? What kind of future directions, what, what should I be anticipating seeing from, to coming down the pipeline as it relates to this topic?
Justin: Sure. So I think there's a couple things. One is. Can we develop a, a prediction tool that we can use for all patients coming into the ICU. That can predict whether they're going to or predict their risk, I should say, of developing post intensive care syndrome and then using that to help guide us in terms of directing them towards more targeted [00:25:00] therapies and interventions to help prevent post intensive care syndrome from developing.
So, for example, targeted physical therapy or cognitive therapy or, um post intensive care clinics post ICU clinics. Those all could be very impactful interventions. But we need to know which patients really need them and which patients might benefit from them from the start even before developing a.
A validated tool. I think our data suggests that it probably is worthwhile to, to assess someone's baseline level of frailty when they come into the ICU, and that should certainly help guide their, their post ICU care that if a patient comes in and they're very frail and they're discharged from the ICU, the team should be thinking about this patient may be at risk for post intensive [00:26:00] care syndrome, and, and we really should try to get them into a post ICU clinic or get them the, the physical or cognitive therapy that they might need.
And it also raises the question of what kinds of interventions would actually help these patients and developing a, a evidence-based for that. So we've done, over the last decade, we've done a great job as a field of I, of developing evidence-based interventions that improve patient care within the ICU.
And many of those interventions have shown long-term benefits. So now I'll mention one, the HF bundle that was developed by our research group in collaboration with a bunch of others which really focuses on preventing and treating delirium in the ICU early mobility in the ICU minimizing harmful sedation in the ICU that we've, that we've shown can, can have long-term negative impacts on patients.
[00:27:00] And and that's been. You know, very successful and I is being deployed in ICUs all around the country and the world. We need to develop bundles of care like that with a strong evidence base for patients after they've left the ICU. We need to figure out what are interventions that can, that can bend the curve of, of that recovery trajectory towards more meaningful recovery for patients after their ICU stay.
So there's ongoing research into this, um you know, around the country and, and it's definitely something that we're interested in too. There's. A couple studies actually ongoing in our, in the, the critical illness, brain dysfunction and survivorship center here. Um one looking at whether measures of mitochondrial dysfunction might be associated with these physical, long-term physical impairments, and is that something we can intervene on, or whether using a, a [00:28:00] cognitive a virtual cognitive rehabilitation.
Game on an iPad after admission can help prevent the cognitive dysfunction that these patients are at risk of developing. So there's a lot of innovative work being done both here and elsewhere to try to figure out what interventions can, can help prevent. Treat post intensive care syndrome.
And then finally you know, I think you mentioned in the introduction, I have an interest in global health as well. And, and this is really a global problem. We did a study in, in Zambia and Africa that showed that, um post intensive care syndrome and cognitive impairment. And functional impairment is, is just as big of an issue there as it is here.
And thinking about how do we develop evidence-based interventions that apply there as well? How do we better support patients all around the world who are recovering from critical [00:29:00] illness in a, in a. A compassionate evidence-based way. And we're really committed to the idea of walking beside patients as they.
As they recover and, and trying to, to help them get back to being able to live the lives that they, that they want to live and, and being able to, to do meaningful things. So it's, it's a, it's an ongoing journey. And this is just a small, this paper is just a abstract, is just a small little part in that story.
But it's, it's it, some people have referred to it as a survivorship movement, thinking about that survivorship doesn't equal recovery and, and thinking about these survivors as a group of patients who really need our support and who need evidence-based. Interventions that can improve their quality of life and help prevent the devastating [00:30:00] consequences of post intensive care syndrome.
So those are some of the things we're looking into. It's it's a huge area for a lot of possibility and we're, we're excited to continue the journey.
Eddie: Yeah, no, this, this, this has been a really great discussion and I, I would even say that I wouldn't sell yourself short there, that this is not just a, just an abstract this.
It seems like it has the potential to be very foundational in this field, and well, we can talk about all we want about different types of things that we can do to help post intensive care syndrome. But it, it's really difficult to do that research. It's really difficult to implement that in real practice if we have no idea and no means of figuring out who, who are the patients who would benefit.
So I, I think that this is potentially really foundational. I really appreciate you taking the time to share this with us here, Justin, what, what kind of or anything that you may have wanted to [00:31:00] talk about that we, we didn't, we didn't get to or any take home points for the listeners here?
Justin: Yeah, I think, you know, this is, this is about, you know, shining a light in the darkness and, and showing that patients who have significant frailty coming into the hospital, they're at significant risk of, of having post intensive care syndrome of, of really struggling with deficits in, in multiple areas of, of function that can have a profound impact on their lives, their family, and how do we.
Identify those patients and get them to the care that they need. And then I think the other real take home message is that the, the group of patients who had that post intensive care syndrome trajectory, they continued to worsen that. And that was a, a sizable portion of our cohort and likely of
globally, patients who've, who've survived their ICU stay, and, and that's really a call to [00:32:00] action that this is likely millions of patients around the world are, are not only not improving after their ICU state, but they're actually worsening. And that as a, as a field medical professionals, the community family members, we need to all come together to, to figure out how to help these patients and prevent that from happening.
Eddie: Yeah. No, that's, that's really great. I think that's a really nice way to tie it all together. So, but, but like I said, thank you Justin for spending the time with us to explain all your complicated work and how important it is. Thank you to all the listeners for joining us today on today's ATS Breathe Easy podcast episode.
Please subscribe and share this episode with your colleagues and if you are interested in hearing about all this interested work and other new work.
But we will [00:33:00] see you guys next time. Thank y'all.
non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ATS Breathe Easy podcasts on transistor, YouTube, apple podcasts, and Spotify. Don't forget to like, comment, and subscribe, so you never miss a show.