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Xue Y, Zhang Z, Sheng CQ, Li YM, Jia FY. The predictive value of diaphragm ultrasound for weaning outcomes in critically ill children. BMC Pulm Med 2019; 19:270. [PMID: 31888586 PMCID: PMC6937936 DOI: 10.1186/s12890-019-1034-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction Multiple studies have shown that diaphragmatic ultrasound can better predict the outcome of weaning in adults. However, there are few studies focusing on children, leading to a lack of sufficient clinical evidence for the application of diaphragmatic ultrasound in children. The purpose of this study was to investigate the predictive value of diaphragm ultrasound for weaning outcomes in critically ill children. Methods The study included 50 cases whose mechanical ventilation (MV) time was > 48 h, and all eligibles were divided into either the weaning success group (n = 39) or the weaning failure group (n = 11). Diaphragm thickness, diaphragmatic excursion (DE), and diaphragmatic thickening fraction (DTF) were measured in the zone of apposition. The maximum inspiratory pressure (PImax) was also recorded. Results The ventilatory treatment time (P = 0.002) and length of PICU stay (P = 0.013) in the weaning failure group was longer than the success group. Cut-off values of diaphragmatic measures associated with successful weaning were ≥ 21% for DTF with a sensitivity of 0.82 and a specificity of 0.81, whereas it was ≥0.86 cm H2O/kg for PImax with a sensitivity of 0.51 and a specificity of 0.82. The linear correlation analysis showed that DTF had a significant positive correlation with PImax in children (P = 0.003). Conclusions Diaphragm ultrasound has potential value in predicting the weaning outcome of critically ill children. DTF and PImax presented better performance than other diaphragmatic parameters. However, DE has limited value in predicting weaning outcomes of children with MV. Trial registration Current Controlled Trials ChiCTR1800020196, (Dec 2018).
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Affiliation(s)
- Yang Xue
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China
| | - Zhen Zhang
- Department of Pediatrics Intensive Care Unit, The First Hospital of Jilin University, Changchun, China
| | - Chu-Qiao Sheng
- Department of Pediatrics Intensive Care Unit, The First Hospital of Jilin University, Changchun, China
| | - Yu-Mei Li
- Department of Pediatrics Intensive Care Unit, The First Hospital of Jilin University, Changchun, China
| | - Fei-Yong Jia
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, 71 Xinmin Street, Changchun, 130021, China.
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102
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Varón-Vega F, Hernández Á, López M, Cáceres E, Giraldo-Cadavid LF, Uribe-Hernandez AM, Crevoisier S. [Usefulness of diaphragmatic ultrasound in predicting extubation success]. Med Intensiva 2019; 45:226-233. [PMID: 31870509 DOI: 10.1016/j.medin.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/16/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of diaphragmatic ultrasound in predicting extubation success. DESIGN A diagnostic accuracy study was carried out. SCOPE Intensive Care Unit of an Academic hospital in the city of Bogotá (Colombia). PATIENTS OR PARTICIPANTS A consecutive sample of patients >18 years of age subjected to invasive mechanical ventilation for >48h. INTERVENTIONS Diaphragmatic ultrasound evaluation at the end of spontaneous ventilation testing. MAIN VARIABLES OF INTEREST Diaphragmatic excursion (DE, cm), inspiration time (TPIAdia, s), diaphragm contraction speed (DE/TPIAdia, cm/s) and total time (Ttot, s) were evaluated, together with thickening fraction (TFdi, %). RESULTS A total of 84 patients were included, 79.8% (n=67) with successful extubation and 20.2% (n=17) with failed extubation. The variable with the best discriminatory capacity in predicting extubation success was diaphragm contraction speed, with AUC-ROC 0.70 (p=0.008). CONCLUSIONS Diaphragm contraction speed exhibited acceptable discriminatory capacity. Ultrasound could be part of a multifactorial approach in the extubation process.
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Affiliation(s)
- F Varón-Vega
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia; Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Departamento de Anestesiología y Cuidados Intensivos, Universidad de Navarra, Pamplona, España
| | - Á Hernández
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - M López
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - E Cáceres
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - L F Giraldo-Cadavid
- Departamento de Investigación, Fundación Neumológica Colombiana, Bogotá, Colombia; Departamento de Epidemiología y de Medicina Interna, Universidad de La Sabana, Chía, Colombia
| | - A M Uribe-Hernandez
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia; Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Departamento de Investigación, Fundación Neumológica Colombiana, Bogotá, Colombia.
| | - S Crevoisier
- Medicina Crítica y Cuidado Intensivo, Universidad de La Sabana, Chía, Colombia
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103
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Prada G, Vieillard-Baron A, Martin AK, Hernandez A, Mookadam F, Ramakrishna H, Diaz-Gomez JL. Tracheal, Lung, and Diaphragmatic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth 2019; 35:310-322. [PMID: 31883769 DOI: 10.1053/j.jvca.2019.11.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 11/11/2022]
Abstract
Today, proficiency in cardiopulmonary ultrasound is considered essential for anesthesiologists and critical care physicians. Conventional 2-dimensional images, however, do not permit optimal characterization of specific conditions (eg, diaphragmatic paralysis, major atelectasis, and pneumothorax) that may have relevant clinical implications in critical care and perioperative settings. By contrast, M-mode (motion-based) ultrasonographic imaging modality offers the highest temporal resolution in ultrasonography; this modality, therefore, can provide important information in ultrasound-driven approaches performed by anesthesiologists and intensivists for diagnosis, monitoring, and procedural guidance. Despite its practicability, M-mode has been progressively abandoned in echocardiography and is often underused in lung and diaphragmatic ultrasound. This review describes contemporary applications of M-mode ultrasonography in the practice of critical care and perioperative medicine. Information presented for each clinical application includes image acquisition and interpretation, evidence-based clinical implications in critically ill and surgical patients, and main limitations. The article focuses on tracheal, lung, and diaphragmatic ultrasound. It reviews tracheal ultrasound for procedural guidance during endotracheal intubation, confirmation of correct tube placement, and detection of esophageal intubation; lung ultrasound for the confirmation of endotracheal and endobronchial (selective) intubation and for the diagnosis of pneumothorax, alveolar-interstitial syndrome (cardiogenic v noncardiogenic pulmonary edema), pulmonary consolidation (pneumonia v major atelectasis) and pleural effusion; and diaphragmatic ultrasound for the diagnosis of diaphragmatic dysfunction and prediction of extubation success.
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Affiliation(s)
- Gabriel Prada
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne Billancourt, France; Faculty of Medicine Paris Ile de France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint Quentin En Yvelines, France; INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Phoenix, AZ.
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Abdelhafeez RM, Abumossalam AM, Arram EO, Elshafey MM, Abushehata ME. Diaphragm and weaning from mechanical ventilation: anticipation and outcome. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_13_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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105
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Preoperative Diaphragm Function Is Associated With Postoperative Pulmonary Complications After Cardiac Surgery. Crit Care Med 2019; 47:e966-e974. [DOI: 10.1097/ccm.0000000000004027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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106
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Ultrasonographic measurement of the diaphragm thickness in patients with obstructive sleep apnea syndrome. Sleep Breath 2019; 24:89-94. [PMID: 31463778 DOI: 10.1007/s11325-019-01931-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to evaluate the diaphragm thickness in patients with obstructive sleep apnea syndrome (OSAS). METHODS This prospective study included patients who underwent polysomnography evaluation for the first time with a clinical suspicion of OSAS. All patients underwent polysomnographic evaluation with a 55-channel Alice 6 computerized system (Respironics; Philips, IL). Diaphragm thickness was measured as the distance between the peritoneum and the pleura using electronic calipers with a 7-12-MHz linear probe (PHILIPS EPIQ 5G). RESULTS A total of 108 patients (67 males, 41 females) were enrolled in the current study. The mean age of the patients was 48.92 ± 11.47 years. The diaphragm thicknesses were significantly higher in OSAS patients both at end-inspirium and end-expirium compared with the normal group (p < 0.05). No significant difference was observed regarding the change level and thickening ratio (%) (p > 0.05). When the patients were allocated into OSAS subtypes; diaphragm thicknesses at the end of inspirium and expirium on both sides were significantly higher in the severe OSAS group and OSAS+OHS group compared with the other groups of normal, mild OSAS, and moderate OSAS subgroups (p < 0.05 for all). There was no significant difference between the groups regarding the thickening ratio (p > 0.05 for all). There was a positive correlation between the severity of OSAS and diaphragm thickness. CONCLUSION Diaphragm thickness seems to be increased in OSAS patients and the thickness correlates with the severity of OSAS. However, the thickness ratio of OSAS patients does not differ from that of normal subjects.
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107
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain
- Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Universidad Europea, Madrid, Spain
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108
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Zhang Z, Xue Y, Li HH, Li YM. [Research advances in validity of predictors for extubation outcome in children receiving invasive mechanical ventilation]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:730-734. [PMID: 31315777 PMCID: PMC7389097 DOI: 10.7499/j.issn.1008-8830.2019.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/25/2019] [Indexed: 06/10/2023]
Abstract
The development of invasive mechanical ventilation technology provides effective respiratory support for critically ill children. However, respiratory support is not the end of treatment as the ultimate goal is successful extubation in children. At present, some evaluation indicators before extubation including rapid shallow breathing index, maximal inspiratory pressure, and work of breathing are of high clinical value in predicting adult extubation outcome, but their evidence of evidence-based medicine is not sufficient in the field of pediatric intensive care. This paper reviews the current research on the validity of predictors for extubation outcomes in children. It shows that there is still a lack of indicators with good sensitivity and specificity for assessment before extubation in children. The studies are still in a small-sample size and single-center stage. Therefore, how to optimize evaluation before extubation and improve the success rate of extubation is the direction of joint efforts of doctors in the pediatric intensive care unit and rehabilitation medicine department.
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Affiliation(s)
- Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun 130021, China.
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109
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Rittayamai N, Hemvimon S, Chierakul N. The evolution of diaphragm activity and function determined by ultrasound during spontaneous breathing trials. J Crit Care 2019; 51:133-138. [DOI: 10.1016/j.jcrc.2019.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/28/2022]
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Abdelwahed WM, Abd Elghafar MS, Amr YM, Alsherif SEDI, Eltomey MA. Prospective study: Diaphragmatic thickness as a predictor index for weaning from mechanical ventilation. J Crit Care 2019; 52:10-15. [PMID: 30904733 DOI: 10.1016/j.jcrc.2019.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/08/2019] [Accepted: 03/13/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Wafaa M Abdelwahed
- Faculty of Medicine, Tanta University, Department of Anesthesia and Surgical Intensive Care, Tanta University Hospital, Tanta, Egypt.
| | - Mohamed S Abd Elghafar
- Faculty of Medicine, Tanta University, Department of Anesthesia and Surgical Intensive Care, Tanta University Hospital, Tanta, Egypt
| | - Yasser M Amr
- Faculty of Medicine, Tanta University, Department of Anesthesia and Surgical Intensive Care, Tanta University Hospital, Tanta, Egypt
| | - Salah El-Din I Alsherif
- Faculty of Medicine, Tanta University, Department of Anesthesia and Surgical Intensive Care, Tanta University Hospital, Tanta, Egypt
| | - Mohamed A Eltomey
- Faculty of Medicine, Tanta University, Department of Diagnostic Radiology, Tanta University Hospital, Tanta, Egypt
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111
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Turton P, ALAidarous S, Welters I. A narrative review of diaphragm ultrasound to predict weaning from mechanical ventilation: where are we and where are we heading? Ultrasound J 2019; 11:2. [PMID: 31359260 PMCID: PMC6638615 DOI: 10.1186/s13089-019-0117-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background The use of ultrasound to visualize the diaphragm is well established. Over the last 15 years, certain indices of diaphragm function, namely diaphragm thickness, thickening fraction and excursion have been established for mechanically ventilated patients to track changes in diaphragm size and function over time, to assess and diagnose diaphragmatic dysfunction, and to evaluate if these indices can predict successful liberation from mechanical ventilation. In the last 2 years, three meta-analyses and a systematic review have assessed the usability of diaphragmatic ultrasound to predict successful weaning. Since then, further data have been published on the topic. Conclusions The aim of this narrative review is to briefly describe the common methods of diaphragmatic function assessment using ultrasound techniques, before summarizing the major points raised by the recent reviews. A narrative summary of the most recent data will be presented, before concluding with a brief discussion of future research directions in this field.
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Affiliation(s)
- Peter Turton
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK. .,Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Sondus ALAidarous
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
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Naito Y, Shimizu Y, Hatachi T, Inata Y, Moon K, Tachibana K, Takeuchi M. Predicting extubation readiness by monitoring the electrical activity of the diaphragm after prolonged mechanical ventilation: a pediatric case report. JA Clin Rep 2018; 4:76. [PMID: 32026039 PMCID: PMC6967200 DOI: 10.1186/s40981-018-0213-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 10/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The intensity of the electrical activity of the diaphragm (Edi) correlates with inspiratory effort. The ratio of tidal volume to the Edi is known as neuroventilatory efficiency (NVE) and is used as an index for ventilation efficiency. Here, we present a case showing that Edi and NVE may be effective parameters to predict successful extubation. CASE PRESENTATION A 6-month-old female infant required prolonged mechanical ventilation after cardiac surgery. Fifty-two days after surgery, her trachea was extubated but required reintubation. Edi monitoring was initiated to assess diaphragm function. The Edi was > 70 mcV just after the reintubation, and her NVE was 1.0 mL/mcV, but gradually decreased. On day 59, her Edi values during the spontaneous breathing trials were 13 mcV with the improvement of NVE (2.5 mL/mcV) and her trachea was extubated without complications. CONCLUSIONS The Edi and NVE were valuable for deciding the extubation readiness in a long-term mechanically ventilated patient.
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Affiliation(s)
- Yusuke Naito
- Department of Anesthesiology, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan.
| | - Yoshiyuki Shimizu
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Takeshi Hatachi
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Yu Inata
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Kazue Moon
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Kazuya Tachibana
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
| | - Muneyuki Takeuchi
- Department of Critical Care, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi, Osaka, Japan
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Crimi C, Heffler E, Augelletti T, Campisi R, Noto A, Vancheri C, Crimi N. Utility of ultrasound assessment of diaphragmatic function before and after pulmonary rehabilitation in COPD patients. Int J Chron Obstruct Pulmon Dis 2018; 13:3131-3139. [PMID: 30349221 PMCID: PMC6183592 DOI: 10.2147/copd.s171134] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Pulmonary rehabilitation (PR) may improve respiratory symptoms and skeletal muscle strength in patients with COPD. We aimed to evaluate changes in ultrasound (US) measurements of diaphragmatic mobility and thickness after PR in COPD patients and to test its correlation with PR outcomes. Methods Twenty-five COPD patients were enrolled and underwent a diaphragm US assessment before and after a 12-week PR program. Results We found a correlation between the intraindividual percentage of change in the diaphragmatic length of zone of apposition at functional residual capacity (ΔLzapp%) and the change in 6-minute walking distance (6MWD) after PR (rho=0.49, P=0.02). ΔLzapp% was significantly higher in patients with improved 6MWD and COPD Assessment Test (CAT) score (mean rank=12.03±2.57 vs 6.88±4.37; P=0.02). A ΔLzapp% of ≥10% was able to discriminate among patients with improved 6MWD, with a sensitivity of 83% and a specificity of 74%. The area under the receiver operating characteristic curve for ΔLzapp% was 0.83. A cutoff value of ≥9% of ΔLzapp% had a positive predictive value in discriminating a reduction in ≥2 points of CAT score after PR, with a sensitivity and a specificity of 80% and 62%, respectively. Conclusion Diaphragm US assessment represents a useful prognostic marker of PR outcomes in COPD patients.
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Affiliation(s)
- Claudia Crimi
- Respiratory Medicine Unit, AOU "Policlinico-Vittorio Emanuele", Catania, Italy,
| | - Enrico Heffler
- Respiratory Medicine Unit, Department of Clinical and Experimental Medicine, AOU "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Teresa Augelletti
- Respiratory Medicine Unit, Department of Clinical and Experimental Medicine, AOU "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Raffaele Campisi
- Respiratory Medicine Unit, AOU "Policlinico-Vittorio Emanuele", Catania, Italy,
| | - Alberto Noto
- Anesthesia and Intensive Care Unit, AOU Policinico "G. Martino", Messina, Italy
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, A.O.U. "Policlinico-Vittorio Emanuele", Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Nunzio Crimi
- Respiratory Medicine Unit, Department of Clinical and Experimental Medicine, AOU "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
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Qian Z, Yang M, Li L, Chen Y. Ultrasound assessment of diaphragmatic dysfunction as a predictor of weaning outcome from mechanical ventilation: a systematic review and meta-analysis. BMJ Open 2018; 8:e021189. [PMID: 30287605 PMCID: PMC6173234 DOI: 10.1136/bmjopen-2017-021189] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The aim of this systematic review was to assess the diaphragmatic dysfunction (DD) as a predictor of weaning outcome. BACKGROUND Successful weaning depends on several factors: muscle strength, cardiac, respiratory and metabolic. Acquired weakness in mechanical ventilation is a growing important cause of weaning failure. With the development of ultrasonography, DD can be evaluated with ultrasound in weakness patients to predict weaning outcomes. METHODS The Cochrane Library, PubMed, Embase, Ovid Medline, WanFang Data and CNKI were systematically searched from the inception to September 2017. Ultrasound assessment of DD in adult mechanical ventilation patients was included. Two independent investigators assessed study quality in accordance with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The primary outcome was diaphragmatic thickness and excursion in the weaning success and failure group. The secondary outcome was the influence of DD on weaning outcome. RESULTS Eleven studies involving a total of 436 patients were included. There were eight studies comparing diaphragmatic excursion (DE), five comparing the diaphragmatic thickening fraction (DTF) and two comparing DD between groups with and without successful weaning. Overall, the DE or DTF had a pooled sensitivity of 0.85 (95% CI 0.77 to 0.91) and a pooled specificity of 0.74 (95% CI 0.66 to 0.80) for predicting weaning success. There was high heterogeneity among the included studies (I2=80%; p=0.0006). The rate of weaning failure was significantly increased in patients with DD (OR 8.82; 95% CI 3.51 to 22.13; p<0.00001). CONCLUSIONS Both DE and DTF showed good diagnostic performance to predict weaning outcomes in spite of limitations included high heterogeneity among the studies. DD was found to be a predictor of weaning failure in critically ill patients.
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Affiliation(s)
- Zhicheng Qian
- Department of Intensive Care Unit, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ming Yang
- Department of Pharmacy, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Lin Li
- Department of Ultrasonography, Suining People’s Hospital, Suining, China
| | - Yaolong Chen
- Department of Evidence-based Medicine, Center of Lanzhou University, Lanzhou, China
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Keim-Malpass J, Enfield KB, Calland JF, Lake DE, Clark MT. Dynamic data monitoring improves predictive analytics for failed extubation in the ICU. Physiol Meas 2018; 39:075005. [PMID: 29932430 DOI: 10.1088/1361-6579/aace95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Predictive analytics monitoring that informs clinicians of the risk for failed extubation would help minimize both the duration of mechanical ventilation and the risk of emergency re-intubation in ICU patients. We hypothesized that dynamic monitoring of cardiorespiratory data, vital signs, and lab test results would add information to standard clinical risk factors. METHODS We report model development in a retrospective observational cohort admitted to either the medical or surgical/trauma ICU that were intubated during their ICU stay and had available physiologic monitoring data (n = 1202). The primary outcome was removal of endotracheal intubation (i.e. extubation) followed within 48 h by reintubation or death (i.e. failed extubation). We developed a standard risk marker model based on demographic and clinical data. We also developed a novel risk marker model using dynamic data elements-continuous cardiorespiratory monitoring, vital signs, and lab values. RESULTS Risk estimates from multivariate predictive models in the 24 h preceding extubation were significantly higher for patients that failed. Combined standard and novel risk markers demonstrated good predictive performance in leave-one-out validation: AUC of 0.64 (95% CI: 0.57-0.69) and 1.6 alerts per week to identify 32% of extubations that will fail. Novel risk factors added significantly to the standard model. CONCLUSION Predictive analytics monitoring models can detect changes in vital signs, continuous cardiorespiratory monitoring, and laboratory measurements in both the hours preceding and following extubation for those patients destined for extubation failure.
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Affiliation(s)
- Jessica Keim-Malpass
- School of Nursing, University of Virginia, Charlottesville, VA, United States of America. School of Medicine, University of Virginia, Charlottesville, VA, United States of America
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Wallbridge P, Steinfort D, Tay TR, Irving L, Hew M. Diagnostic chest ultrasound for acute respiratory failure. Respir Med 2018; 141:26-36. [PMID: 30053969 DOI: 10.1016/j.rmed.2018.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/19/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023]
Abstract
Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying aetiologies. Diagnostic chest ultrasound provides accurate diagnosis of conditions that commonly cause ARF, and may improve overall diagnostic accuracy in critical care settings as compared to standard diagnostic approaches. Respiratory physicians are becoming increasingly familiar with ultrasound as a part of routine clinical practice, although the majority of data to date has focused on the emergency and intensive care settings. This review will examine the evidence for the use of diagnostic chest ultrasound, focusing on different levels of imaging efficacy; specifically ultrasound test attributes, impacts on clinician behaviour and impact on health outcomes. The evidence behind use of multi-modality ultrasound examinations in ARF will be reviewed. It is hoped that readers will become familiar with the advantages and potential issues with chest ultrasound, as well as evidence gaps in the field.
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Affiliation(s)
- Peter Wallbridge
- Department of Respiratory & Sleep Medicine, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.
| | - Daniel Steinfort
- Department of Respiratory & Sleep Medicine, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Louis Irving
- Department of Respiratory & Sleep Medicine, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Mark Hew
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
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Tenza-Lozano E, Llamas-Alvarez A, Jaimez-Navarro E, Fernández-Sánchez J. Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation. Crit Ultrasound J 2018; 10:12. [PMID: 29911284 PMCID: PMC6004341 DOI: 10.1186/s13089-018-0094-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lung and diaphragm ultrasound methods have recently been introduced to predict the outcome of weaning from mechanical ventilation (MV). The aim of this study is to assess the reliability and accuracy of these techniques for predicting successful weaning in critically ill adults. METHODS We conducted two studies: a cross-sectional interobserver agreement study between two sonographers and a prospective cohort study to assess the accuracy of lung and diaphragm ultrasound for predicting weaning and extubation outcome. For the interobserver agreement study, we included 50 general critical care patients who were consecutively admitted to the ICU. For the predictive accuracy study, we included consecutively 69 patients on MV who were ready for weaning. We assessed interobserver agreement of ultrasound measurements, using the weighted kappa coefficient for LUSm score (modified lung ultrasound score) and the intraclass correlation coefficient (ICC) and Bland-Altman method for TI (diaphragm thickening index). We assessed the predictive value of LUSm and TI in weaning outcome by plotting the corresponding ROC curves. RESULTS We found adequate interobserver agreement for both LUSm (weighted kappa 0.95) and TI (ICC 0.78, difference according to Bland-Altman analysis ± 12.5%). LUSm showed good-moderate discriminative power for successful weaning and extubation (area under the ROC curve (AUC) for successful weaning 0.80, and sensitivity and specificity at optimal cut-off point 0.76 and 0.73, respectively; AUC for successful extubation 0.78, and optimal sensitivity and specificity 0.76 and 0.47, respectively. TI was more sensitive but less specific for predicting successful weaning (AUC 0.71, optimal sensitivity and specificity 0.93 and 0.48) and successful extubation (AUC 0.76, optimal sensitivity and specificity 0.93 and 0.58). The area under the ROC curve for predicting weaning success was 0.83 for both ultrasound measurements together. CONCLUSIONS Interobserver agreement was excellent for LUSm and moderate-good for TI. A low TI value or high LUSm value indicates high risk of weaning failure.
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Affiliation(s)
- Eva Tenza-Lozano
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain.
| | - Ana Llamas-Alvarez
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain
| | - Enrique Jaimez-Navarro
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain
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Li C, Li X, Han H, Cui H, Wang G, Wang Z. Diaphragmatic ultrasonography for predicting ventilator weaning: A meta-analysis. Medicine (Baltimore) 2018; 97:e10968. [PMID: 29851847 PMCID: PMC6392953 DOI: 10.1097/md.0000000000010968] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/10/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Weaning failure is common in mechanically ventilated patients. Whether ultrasound can predict weaning outcome remains controversial. This meta-analysis was performed to assess the accuracy of diaphragmatic ultrasonography for predicting reintubation within 48 hours of extubation. METHODS Literature search was performed in PubMed, Embase, and Cochrane Library to identify all the relevant papers, published in English up to July 16, 2017. Eligible studies were included if data were in adequate details to rebuild 2 × 2 contingency tables. Methodological quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) in Review Manager 5.3. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curve were pooled using the fixed or random effects model, meanwhile, the heterogeneity was evaluated using Cochran Q test and I statistics in Meta-DiSc 1.4. Publication bias was assessed using Deeks funnel plot in Stata 12.0. RESULTS Thirteen studies with 742 subjects were included in this meta-analysis. The pooled sensitivities for diaphragm excursion (DE) and diaphragm thickness fraction (DTF) were 0.786 and 0.893, and the pooled specificities were 0.711 and 0.796, respectively. The area under curve (AUC) for DE and DTF were 0.8590 and 0.8381. The DORs for DE and DTF were 10.623 and 32.521. No publication bias was observed among these studies. CONCLUSIONS Diaphragmatic ultrasonography is a promising tool for predicting reintubation within 48 hours of extubation. However, due to heterogeneities among the included studies, large-scale studies are warranted to confirm our findings.
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Affiliation(s)
| | - Xin Li
- Department of Cardiothoracic Surgery
| | - Hongqiu Han
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Ntoumenopoulos G, Parry SM, Neindre AL. Impact of an intensive education programme of diagnostic lung and lower limb ultrasound on physiotherapist knowledge: A pilot study. Australas J Ultrasound Med 2018; 21:104-114. [PMID: 34760510 PMCID: PMC8409815 DOI: 10.1002/ajum.12089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION/PURPOSE Diagnostic ultrasound of the respiratory system and peripheral muscular systems is increasingly being used by clinicians. The aim of this study was to evaluate the knowledge outcomes of a bespoke one-day curriculum for physiotherapists that incorporated lung, diaphragm and lower limb muscle diagnostic ultrasound theory and practical training in image acquisition and analysis. METHODS A one-day course comprised of three instructors and 32 participants on key diagnostic ultrasound findings of the lungs, diaphragm and lower limb musculature included didactic lectures combined with expert-led hands-on training in practical sessions. Participants undertook pre- and post-course knowledge questionnaire covering key ultrasound findings for normal lungs, pleural/pulmonary pathologies and normal and abnormal findings for the diaphragm and key lower limb muscle groups. The pre-test and post-test questionnaire and survey results were reported using parametric descriptive statistics (means SD) as the data were normally distributed. RESULTS Of the 32 physiotherapists who undertook the one-day training, 25 (78%) completed the pre- and post-course questionnaires. The pre-course knowledge scores (mean percentage, SD) were 63% (21), and the post-course scores were 62% (20) after training. DISCUSSION This novel diagnostic ultrasound course led to limited improvements of ultrasound knowledge in the specific areas of the key ultrasound findings pulmonary system and lower limb muscle anatomy. The pre-reading material and course structure may have been too burdensome for the participants. CONCLUSION Combined lung and muscle diagnostic ultrasound course may require more than the standard one-day training for appropriate knowledge acquisition, and use of online pre-course video lectures may facilitate learning.
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Affiliation(s)
- George Ntoumenopoulos
- Physiotherapy DepartmentSt Vincent's Hospital390 Victoria Street, DarlinghurstNew South Wales 2010Australia
| | - Selina M. Parry
- Department Of PhysiotherapyMelbourne School of Health SciencesThe University of MelbourneAlan Gilbert Building161 Barry StreetCarltonVictoria 3053Australia
| | - Aymeric Le Neindre
- Lieu‐Dit ForcillesFerolles‐Attilly77150, Ile‐de‐FranceFrance
- University of BurgundyEsplanade Erasme, BP 27877 ‐ 21078DIJON CedexFrance
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