Using exoskeletons to assist intensive care personnel with ExoTurn

Intensive care units in most hospitals have recently had to cope with an increase in the number of patients with severe Covid-19-related Acute Respiratory Distress Syndrome (ARDS) who need to be placed in a specific position to improve oxygenation. Ventilation of patients in the prone position is crucial for treatment. This involves positioning patients lying on their stomach with a complicated roll-over maneuver. Each PP procedure requires approximately 6 medical staff trained in the procedure to remain with the bust bent forward for several minutes, resulting in a physical load on the lumbar area and increasing the risks of back pain and potentially injury.

Specific “PP” teams were deployed in Nancy hospitals from 23 March to 24 April 2020 in their extended intensive care unit (from 22 to 46 beds). "During this period, 75 volunteers took turns to have one to three teams of 5 people each day and carried out an average of 8 to 15 placements per day, which corresponds to a total manipulated weight of more than 30 tons", explains Prof. Bruno Chenuel, coordinating doctor of the PP teams. The kinematic analysis carried out by Loria shows that the medical staff can spend about 40% of the time with the bust bent more than 20 degrees forward when placed next to the patient, and can maintain a static posture with a significant flexion of the trunk for several minutes to secure the patient's head and avoid extubation. "We recorded the PP movements with an Xsens suit and performed a biomechanical analysis of the movement with the AnyBody software," explains Pauline Maurice, a CNRS researcher at Loria. Even without load manipulation, such postures cause pressure and potential injury to the lower back. "This is a typical situation where back support exoskeletons can be considered to improve working conditions, which is the main mission of INRS," explain Jean Theurel and Laurent Claudon, experts in physiology and biomechanics at INRS. These exoskeletons are generally deployed in the industrial sector; there are very few reports on their use in the healthcare system and no use in intensive care units

"To our knowledge, exoskeletons have never been used in intensive care units or in connection with Covid-19," explains Serena Ivaldi. "In order to study their usefulness, we first evaluated different back support exoskeletons in simulation, i.e., on caregivers performing the PP maneuver on a patient simulator, i.e., a manikin, before deploying the selected exoskeleton on two volunteers performing the PP in a real situation in an intensive care unit". The CUESim Simulation Centre at the Lorraine Virtual Hospital (HVL) provided a simulated intensive care room with a patient simulator reproducing the same conditions that doctors face in real life. "The manikin was intubated and kept alive, in order to reproduce the complicated conditions of Covid-19 patients under treatment in intensive care," explains Ms. Hind Hani, Biomedical Studies Engineer and Operational Director of the CUESim/HVL. After the first experiments at the simulation center, the ExoTurn team selected the passive exoskeleton "Laevo". The medical staff using this exoskeleton during PP maneuvers in the intensive care unit perceived a physical relief in the lower back and clearly indicated their intention to adopt such a technology.

This work is of crucial importance for the improvement of the working conditions of medical staff, and more generally for the medical and scientific community.

Prof. Jean Paysant, Head of the Rehabilitation Unit, Nancy University Hospital, Medical Director of the Regional Institute of Physical Medicine and Rehabilitation, UGECAM of the North-East of France

When innovation and research reinforce the solidarity of the health care system for the best treatment of patients in the midst of a health crisis, this is an exemplary project in many respects!

Prof. Bruno Chenuel, CHRU Nancy, Professor of Physiology, Head of Department, University Centre for Sports Medicine and Adapted Physical Activity and Department of Respiratory Function Examinations, University of Lorraine

Initially, I sought to understand the problems associated with the management of patients affected by the Covid-19 epidemic at the Nancy CHRU. My friendship with Dr. Settembre certainly helped a lot: even though our areas of knowledge and way of working are different, we understood how to work together fairly quickly. Dr. Nicla Settembre, Prof. Bruno Chenuel and Prof. Jean Paysant detailed the specificities of the management of patients with a severe form of coronavirus respiratory infection and the physical demands placed on the doctors and intensive care nurses who had to perform the prone position maneuvers on curarized patients. Given the large number of patients to be treated at the peak of the epidemic, they described a situation akin to "industrial production", resulting in a great deal of not only physical but also mental fatigue for the nursing staff, in addition to permanent stress. The situation seemed to me to be very similar to that of workers in industry, who perform tasks that are often strenuous, repetitive and exhausting. We are studying how to help them with robots and exoskeletons in our European project AnDy. On the basis of our experience, using exoskeletons to help medical staff in their physical efforts without introducing new robots seemed feasible.

So, I contacted Jean Theurel from INRS with whom we had collaborated on exoskeletons during the AnDy project. His team and his colleagues from the "Man at Work" department joined the project with great enthusiasm.
The first step was to compare a number of potential exoskeletons to find the best candidate. We carried out the tests in a simulated situation, thanks to the collaboration of the Virtual Hospital of Lorraine (CUESim). Volunteers equipped with exoskeletons performed the prone position maneuvers on a Covid-19 patient simulator. Pauline Maurice, a CNRS researcher in our team and former post-doctoral student on the AnDy project, performed an analysis of the movement without and with exoskeletons. Following the tests, we identified a passive exoskeleton as the best candidate for use in resuscitation.

The second step was the use in ICU, in real life situation. Two volunteer medical doctors used the exoskeleton during 10 PP maneuvers. Initial results were very encouraging: the two physicians who received physical support said they would adopt the technology. To our knowledge, this was the first time an exoskeleton was used in an ICU to assist medical staff!

A first scientific article describing the pilot study and the results in ICU was submitted and accepted in a medical journal.

Today, the project continues in order to more rigorously evaluate the benefits of the exoskeletons during prone positioning manuevers, with a view to future adoption of the technology in medical practice. Finally, we have acquired a new exoskeleton model that should be even more practical for physicians and therefore better integrated into their care activities.

We are delighted with the usefulness and positive outcome of this collaboration and hope that the idea can also help medical teams in other hospitals.

Dr Nicla Settembre, Vascular Surgeon at Nancy University Hospital & Virtual Hospital of Lorraine