Response to the Letter to the Editor

We would like to thank the authors who showed interest in our article. The authors raised very interesting points. To summarize, this network meta-analysis (NMA) focused on comparing the effects of different types of physical therapy treatments, including conventional physical therapy (CPT), inspiratory muscle training (IMT), and early mobilization (EM), on the duration of mechanical ventilation (MV) and weaning. These treatments have been used in critically ill patients who underwent MV. Mechanical unloading induces skeletal muscle atrophy in critically ill patients. Biopsy specimens from subjects who underwent MV for 18 to 69 hours had decreased the cross-sectional area of slow- and fast-type of diaphragm muscle fibers. Although IMT and EM are different in treatment protocol details, the effects of each treatment is not totally different. During EM, body systems are stimulated, especially the respiratory and cardiovascular systems. A higher level of EM causes a greater load on skeletal muscles and, inconsequently, more work of the respiratory and limb muscles. Dantas et al reported that EM gains significant increases in maximal inspiratory pressure in patients who are critically ill and mechanically ventilated. Yang et al found that EM can delay diaphragmatic atrophy in patients with MV. Functional training of the respiratory muscles, IMT with body movements, has been shown to help healthy people gain more respiratory muscle strength and endurance. Additionally, our pairwise comparison using meta-analyses (supplemental fig S3 in the supplementary data of the NMA study) showed that EM reduced MV duration when compared with CPT. Together, EM can induce the function of the inspiratory muscle. However, it is difficult to measure a load on the respiratory muscle during EM treatment. Regarding patients’ statuses included in this NMA, we excluded the studies mentioned by the authors. The results of NMA were presented the same way as previously reported in our recent publication.