Table 1.  Early mobilization protocol of the Nagoya Medical Center.

Level 1 Respiratory RASS −5 to −3	Level 2 HOB RASS ≥ −3	Level 3 Sitting RASS ≥ −1	Level 4 Standing RASS ≥0	Level 5 Walking RASS ≥0
Physical therapy □Passive ROM exercise □Respiratory physical therapy	Physical therapy □Positioning □Passive ROM exercise □Active ROM exercise □Respiratory physical therapy □Continuous lateral rotation therapy	Physical therapy □Positioning □Passive ROM exercise □Active ROM exercise □Sitting at side of bed □Rising from the supine position	Physical therapy □Positioning □Passive ROM exercise □Active ROM exercise □Standing at side of bed □Stand and pivot to a chair	Physical therapy □Positioning □Passive ROM exercise □Active ROM exercise □Walk with assistance □Walk independently
Positioning □Posture change □HOB ≤45°	Positioning □Posture change □HOB ≥60°	Positioning □Posture change □HOB ≥60°	Positioning □Posture change □HOB ≥60°	Positioning □Posture change □HOB ≥60°
Step up criteria □Oxygenation/ hemodynamic stability □Can withstand posture change □Can withstand HOB ≤45°	Step up criteria □Can withstand supplementary motion of physical therapy □Can withstand HOB ≤60° □Anti-gravity movement possible	Step up criteria □Can endure the active movement of physical therapy □Can withstand HOB ≤60° □Can withstand sitting at side of bed	Step up criteria □All exercise can be carried out □Can withstand partial weight standing	Step up criterion □Increase walking distance gradually
Step up criterion to level 3 or higher are defined as □RASS: −2 to +1, □BPS ≤3 or NRS ≤5, □SpO2 ≥90%, □FIO2 <0.6, □PEEP <10 cmH2O, □Respiratory rate: <35 times/min, □Mean blood pressure ≥65 mmHg, □Heart rate: 50 to 120 beats/min, □There were no new arrhythmias, □No additional administration of vasopressors, □No bleeding, no wound with the possibility of separation, □No unstable fracture.

ROM, range of motion; HOB, head of bed; BPS, behavioral pain scale; NRS, numeric rating scale; PEEP, positive end expiratory pressure.

The EM protocol includes 5 levels: Level 1: head of bed elevation ≤45° and passive ROM; Level 2: head of bed elevation ≥60°, active ROM, and continuous lateral rotation therapy; Level 3: sitting on the side of the bed and rising from the supine position; Level 4: standing at the side of the bed, and standing and pivoting to a chair; and Level 5: walking with assistance and walking independently.

From Watanabe et al.²¹⁾