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Choi YH, Kim DH, Jeon ET, Lee HJ, Park TY, Yoon SH, Jin KN, Lee HW. Cluster analysis of thoracic muscle mass using artificial intelligence in severe pneumonia. Sci Rep 2024; 14:16912. [PMID: 39043882 PMCID: PMC11266397 DOI: 10.1038/s41598-024-67625-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024] Open
Abstract
Severe pneumonia results in high morbidity and mortality despite advanced treatments. This study investigates thoracic muscle mass from chest CT scans as a biomarker for predicting clinical outcomes in ICU patients with severe pneumonia. Analyzing electronic medical records and chest CT scans of 778 ICU patients with severe community-acquired pneumonia from January 2016 to December 2021, AI-enhanced 3D segmentation was used to assess thoracic muscle mass. Patients were categorized into clusters based on muscle mass profiles derived from CT scans, and their effects on clinical outcomes such as extubation success and in-hospital mortality were assessed. The study identified three clusters, showing that higher muscle mass (Cluster 1) correlated with lower in-hospital mortality (8% vs. 29% in Cluster 3) and improved clinical outcomes like extubation success. The model integrating muscle mass metrics outperformed conventional scores, with an AUC of 0.844 for predicting extubation success and 0.696 for predicting mortality. These findings highlight the strong predictive capacity of muscle mass evaluation over indices such as APACHE II and SOFA. Using AI to analyze thoracic muscle mass via chest CT provides a promising prognostic approach in severe pneumonia, advocating for its integration into clinical practice for better outcome predictions and personalized patient management.
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Affiliation(s)
- Yoon-Hee Choi
- Department of Physical Medicine and Rehabilitation, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Tae Jeon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Hyo Jin Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 5 gil 20, Boramae-Road, Dongjak-gu, Seoul, Republic of Korea
| | - Tae Yun Park
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 5 gil 20, Boramae-Road, Dongjak-gu, Seoul, Republic of Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kwang Nam Jin
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun Woo Lee
- Division of Respiratory and Critical Care, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 5 gil 20, Boramae-Road, Dongjak-gu, Seoul, Republic of Korea.
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Ahn S, Jin BY, Park JH, Kim S, Lee S, Moon S, Cho H. Thigh muscle mass evaluated by point-of-care ultrasound is associated with short-term mortality in patients with sepsis in the emergency department. Sci Rep 2024; 14:12776. [PMID: 38834760 PMCID: PMC11150469 DOI: 10.1038/s41598-024-63769-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 05/31/2024] [Indexed: 06/06/2024] Open
Abstract
Muscle mass depletion is associated with mortality and morbidity in various conditions including sepsis. However, few studies have evaluated muscle mass using point-of-care ultrasound in patients with sepsis. This study aimed to evaluate the association between thigh muscle mass, evaluated using point-of-care ultrasound with panoramic view in patients with sepsis in the emergency department, and mortality. From March 2021 to October 2022, this prospective observational study used sepsis registry. Adult patients who were diagnosed with sepsis at the emergency department and who underwent point-of-care ultrasounds for lower extremities were included. The thigh muscle mass was evaluated by the cross-sectional area of the quadriceps femoris (CSA-QF) on point-of-care ultrasound using panoramic view. The primary outcome was 28 day mortality. Multivariable Cox proportional hazard model was performed. Of 112 included patients with sepsis, mean CSA-QF was significantly lower in the non-surviving group than surviving group (49.6 [34.3-56.5] vs. 63.2 [46.9-79.6] cm2, p = 0.002). Each cm2 increase of mean CSA-QF was independently associated with decreased 28 day mortality (adjusted hazard ratio 0.961, 95% CI 0.928-0.995, p = 0.026) after adjustment for potential confounders. The result of other measurements of CSA-QF were similar. The muscle mass of the quadriceps femoris evaluated using point-of-care ultrasound with panoramic view was associated with mortality in patients with sepsis. It might be a promising tool for determining risk factors for mortality in sepsis patients in the early stages of emergency department.
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Affiliation(s)
- Sejoong Ahn
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Bo-Yeong Jin
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong-Hak Park
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Sungjin Kim
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Sukyo Lee
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Sungwoo Moon
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea
| | - Hanjin Cho
- Department of Emergency Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, Republic of Korea.
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Xue Y, Wang TT, Zhang L, Zheng S, Mu YM, Jia FY, Du L. Relationship among low baseline muscle mass, skeletal muscle quality, and mortality in critically ill children. Nutr Clin Pract 2024; 39:589-598. [PMID: 37873591 DOI: 10.1002/ncp.11084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/10/2023] [Accepted: 09/24/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Studies in adults have shown that low baseline muscle mass at intensive care unit (ICU) admission was associated with poor clinical outcomes. However, no information on the relationship between baseline muscle quality or mass and clinical outcomes in critically ill children was found. METHODS 3775 children were admitted to the pediatric ICU (PICU), 262 were eligible for inclusion. Abdominal computed tomography was performed to assess baseline skeletal muscle mass and quality. Patients were categorized to normal or low group based on the cutoff value for predicting hospital mortality of the skeletal muscle index (SMI; 30.96 cm2/m2) and skeletal muscle density (SMD; 41.21 Hounsfield units). RESULTS Body mass index (BMI) (18.07 ± 4.44 vs 15.99 ± 4.51) and BMI-for-age z score (0.46 [-0.66 to 1.74] vs -0.87 [-1.69 to 0.05]) were greater in the normal-SMI group, the length of PICU stay was longer in the low-SMI group (16.00 days [8.50-32.50] vs 13.00 days [7.50-20.00]), and the in-PICU mortality rate in the normal-SMI group (10.00%) was lower than the low-SMI group (22.6%). Children with low SMD had a higher in-PICU mortality rate (25.6% vs 7.7%), were younger (36.00 months [12.00-120.00] vs 84.00 months [47.50-147.50]) and weighed less (16.40 kg [10.93-37.25] vs 23.00 kg [16.00-45.00]). Mortality was greater in patients with lower SMD and prolonged hospital stay (log-rank, P = 0.007). SMD was an independent predictor for length of PICU stay and in-PICU mortality. CONCLUSIONS Low baseline skeletal muscle quality in critically ill children is closely tied with a higher in-PICU mortality and longer PICU stay and is an independent risk factor for unfavorable clinical outcomes.
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Affiliation(s)
- Yang Xue
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Tian-Tian Wang
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Lei Zhang
- Department of Radiology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Shuang Zheng
- Department of Radiology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Yue-Ming Mu
- Department of Dermatology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Fei-Yong Jia
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Lin Du
- Department of Developmental and Behavioral Pediatrics, The First Hospital of Jilin University, Jilin University, Changchun, China
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Peres LM, Luis-Silva F, Menegueti MG, Lovato WJ, Espirito Santo DAD, Donadel MD, Sato L, Malek-Zadeh CH, Basile-Filho A, Martins-Filho OA, Auxiliadora-Martins M. Comparison between ultrasonography and computed tomography for measuring skeletal muscle mass in critically ill patients with different body mass index. Clin Nutr ESPEN 2024; 59:214-224. [PMID: 38220379 DOI: 10.1016/j.clnesp.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND & AIM Among critical patients, there is an early onset of changes in both the quantity and quality of muscle mass. It is essential to find tools that promptly identify this muscle mass loss. The aim of this study was to compare the ultrasonography of the quadriceps femoris to the gold standard, thigh computed tomography (CT) for assessing the musculature of critically ill patients with different body mass index who have suffered traumatic brain injury. METHODS This is a prospective validation study in an Intensive Care Unit (ICU) specialized in trauma care, located at a tertiary teaching hospital. Our study involved a convenience sample of patients. Sequential ultrasound and CT scans were performed at three distinct time intervals: upon admission, between 24 and 96 h' post-admission, and finally, between 96 and 168 h' post-admission. For all ultrasound measurements, we conducted simultaneous quadriceps CT measurements. The correlation between measurements obtained by ultrasound and computed tomography at three different times and in three BMI ranges was analyzed, in individuals with normal weight, overweight and obese. RESULTS Results: We analyzed 252 images in 49 patients in time 1, 40 patients in time 2, and 37 in time 3 to compare the thickness quadriceps muscle using US and CT. Of these, 18 patients had a BMI ≤ 24.9 kg/m2 (normal weight), 18 patients from 25 to 29.9 kg/m2 (overweight), and 8 patients had a BMI ≥ 30 kg/m2 (obese). The mean age was 37 years, the majority (94%) were male and the main comorbidities were: hypertension 12%, diabetes 4% and 14% smoking. The results revealed minor discrepancies between measurements obtained through the two methods, these changes were not influenced by the body mass index, with these variations being practically insignificant in the context of clinical application. Thus, the correlation and concordance between the values obtained found a strong positive correlation with good limits of agreement. The Spearman's correlation coefficients obtained were r = 0.89, 0.91 and 0.88, p < 0.01 at T1, T2 and T3 respectively for normal weight, r = 0.91, 0.80 and 0.81, p < 0.01 at T1, T2 and T3 respectively for overweight and r = 0.89, 0.94 and 0.84, p < 0.01 at T1, T2 and T3 respectively for obesity. In addition to a positive correlation, we observed a high agreement between the methods. The Bland & Altman analysis at time 1 showed, respectively, the bias of 1.46, 2.03 and 0.76. At time 2, the bias was 0.42, 3.11 and 2.12. At time 3, the bias was 2.26, 3.38 and 2.11 mm. CONCLUSION Our findings suggest that measure femoral quadriceps muscle thickness ultrasound-based exhibits a comparable performance to thigh CT. This conclusion stems from the excellent correlation and good agreement observed between ultrasound and CT, which is considered the gold standard for muscle assessment in critically ill patients. TRIAL REGISTRATION This clinical trial is registered at REBEC https://ensaiosclinicos.gov.br/ identifier: RBR-2bzspnz. The protocol was approved, on July 30, 2019, by the Research Ethics Committee of the Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto - Trial Registration Number: 3,475,851.
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Affiliation(s)
- Leandro Moreira Peres
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Fabio Luis-Silva
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Wilson José Lovato
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Douglas Alexandre do Espirito Santo
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Mariana Derminio Donadel
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Lucas Sato
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Carolina Hunger Malek-Zadeh
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Anibal Basile-Filho
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Maria Auxiliadora-Martins
- Division of Intensive Care Medicine, Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
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Boscolo A, Sella N, Pettenuzzo T, Pistollato E, Calabrese F, Gregori D, Cammarota G, Dres M, Rea F, Navalesi P. Diaphragm Dysfunction Predicts Weaning Outcome after Bilateral Lung Transplant. Anesthesiology 2024; 140:126-136. [PMID: 37552079 DOI: 10.1097/aln.0000000000004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuroventilatory efficiency (the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. The authors hypothesized that (1) diaphragm dysfunction, as defined by a diaphragm thickening fraction less than 29%, is more likely to occur in difficult weaning; (2) diaphragm thickening fraction and neuroventilatory efficiency predict weaning outcome; and (3) duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction. METHODS Adult bilateral-lung transplant patients admitted to the intensive care unit were screened at the time of the first spontaneous breathing trial (pressure-support of 5 cm H2O and 0 positive end-expiratory pressure). At the fifth minute, diaphragm thickening fraction and neuroventilatory efficiency were measured during three respiratory cycles. Weaning was classified as simple, difficult, or prolonged (successful extubation at the first spontaneous breathing trial, within three or after three spontaneous breathing trials, respectively). RESULTS Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%), all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both diaphragm thickening fraction (24 [20 to 29] vs. 39 [35 to 45]%) and neuroventilatory efficiency (34 [26 to 45] vs. 55 [43 to 62] ml/µV) were lower in difficult weaning (both P < 0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 (95% CI, 0.73 to 0.99) for diaphragm thickening fraction and 0.85 (95% CI, 0.71 to 0.95) for neuroventilatory efficiency. The duration of ventilation demonstrated a linear inverse correlation with both diaphragm thickening fraction and neuroventilatory efficiency. CONCLUSIONS Diaphragm dysfunction is common after bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for diaphragm thickening fraction and neuroventilatory efficiency were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine, and Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | | | - Fiorella Calabrese
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | | | - Martin Dres
- Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Center, Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
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Dams K, De Meyer GR, Jacobs R, Schepens T, Perkisas S, Moorkens G, Jorens P. Combined ultrasound of m. quadriceps and diaphragm to determine the occurrence of sarcopenia and prolonged ventilation in a COVID-19 ICU cohort: The COVID-SARCUS trial. Nutrition 2024; 117:112250. [PMID: 37918311 DOI: 10.1016/j.nut.2023.112250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE The aim of this study was to determine the development of sarcopenia in a COVID-19 intensive care unit population by sequential quadriceps and diaphragm ultrasound and its relationship with hospital outcomes. METHODS We assessed muscle thickness, cross-sectional area, fascicle length, pennation angle, and echo intensity within 48 h after intubation, at days 5 and 10 and at discharge from the intensive care unit in 30 critically ill patients with confirmed COVID-19. RESULTS A different evolution of muscle thickness of the diaphragm and m. rectus femoris was observed; the changes between the two muscles were not correlated (Pearson's χ2 3.91, P = 0.419). The difference in muscle thickness was linked to the outcome for both m. rectus femoris and diaphragm, with the best survival seen in the group with stable muscle thickness. The greatest loss of muscle thickness occurred between days 5 and 10. The echo intensity was higher in the patients with increased muscle thickness, who also had a worse prognosis. There was a correlation between cross-sectional area on day 5 and handgrip strength (r = 0.290, P = 0.010). Only 31% of patients were able to return to their preadmission residence without any additional rehabilitation. CONCLUSIONS Muscle atrophy and decline in muscle strength appear in the earliest stages after admission to the intensive care unit and are related to functional outcome.
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Affiliation(s)
- Karolien Dams
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp, Belgium.
| | - Gregory Ra De Meyer
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp, Belgium; Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Rita Jacobs
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium
| | - Tom Schepens
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium; Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Stany Perkisas
- University Centre of Geriatrics, University of Antwerp, Antwerp, Belgium
| | - Greta Moorkens
- Department of Internal Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Philippe Jorens
- Intensive Care Department, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Paediatrics (LEMP), Faculty of Medicine and Health Sciences, Antwerp, Belgium
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Panelli A, Verfuß MA, Dres M, Brochard L, Schaller SJ. Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury. Intensive Care Med Exp 2023; 11:94. [PMID: 38109016 PMCID: PMC10728426 DOI: 10.1186/s40635-023-00577-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients' VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation.
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Affiliation(s)
- Alessandro Panelli
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Michael A Verfuß
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Martin Dres
- Sorbonne Université, INSERM UMRS 1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation, Département R3S, APHP, Sorbonne Université, Hôpital Pitie Salpêtrière, Paris, France
| | - Laurent Brochard
- Unity Health Toronto, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany.
- Technical University of Munich, School of Medicine and Health, Klinikum Rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany.
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Panelli A, Grunow JJ, VERFUß MA, Bartels HG, Brass Z, Schaller SJ. Outcomes in critically ill patients after diaphragmatic stimulation on ventilator-induced diaphragmatic dysfunction: a systematic review. Eur J Phys Rehabil Med 2023; 59:772-781. [PMID: 38214045 PMCID: PMC10794987 DOI: 10.23736/s1973-9087.23.08031-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/11/2023] [Accepted: 10/09/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Mechanical ventilation (MV) is a lifesaving procedure for critically ill patients. Diaphragm activation and stimulation may counteract side effects, such as ventilator-induced diaphragm dysfunction (VIDD). The effects of stimulation on diaphragm atrophy and patient outcomes are reported in this systematic review. EVIDENCE ACQUISITION Studies investigating diaphragmatic stimulation versus standard of care in critically ill patients and evaluating clinical outcomes were extracted from a Medline database last on January 23, 2023, after registration in Prospero (CRD42021259353). Selected studies included the investigation of diaphragmatic stimulation versus standard of care in critically ill patients, an evaluation of the clinical outcomes. These included muscle atrophy, VIDD, weaning failure, mortality, quality of life, ventilation time, diaphragmatic function, length of stay in the Intensive Care Unit (ICU), and length of hospital stay. All articles were independently evaluated by two reviewers according to their abstract and title and, secondly, a full texts evaluation by two independent reviewers was performed. To resolve diverging evaluations, a third reviewer was consulted to reach a final decision. Data were extracted by the reviewers following the Oxford 2011 levels of evidence guidelines and summarized accordingly. EVIDENCE SYNTHESIS Seven studies were extracted and descriptively synthesized, since a metanalysis was not feasible. Patients undergoing diaphragm stimulation had moderate evidence of higher maximal inspiratory pressure (MIP), less atrophy, less mitochondrial respiratory dysfunction, less oxidative stress, less molecular atrophy, shorter MV time, shorter ICU length of stay, longer survival, and better SF-36 scores than control. CONCLUSIONS Evidence of the molecular and histological benefits of diaphragmatic stimulation is limited. The results indicate positive clinical effects of diaphragm activation with a moderate level of evidence for MIP and a low level of evidence for other outcomes. Diaphragm activation could be a therapeutic solution to avoid diaphragm atrophy, accelerate weaning, shorten MV time, and counteract VIDD; however, better-powered studies are needed to increase the level of evidence.
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Affiliation(s)
- Alessandro Panelli
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Michael A VERFUß
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Hermann G Bartels
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany
| | - Zarina Brass
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Stefan J Schaller
- Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin, Berlin, Germany -
- School of Medicine, Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar Hospital, School of Medicine and Health, Technical University of Munich, Munich, Germany
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Catikkas NM, Binay Safer V. Biceps brachii muscle cross-sectional area measured by ultrasonography is independently associated with one-month mortality: A prospective observational study. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1512-1521. [PMID: 37787651 DOI: 10.1002/jcu.23571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE Studies examining mortality in palliative care units are limited. We aimed to investigate the mortality and associated factors including ultrasonographic muscle parameters in hospitalized palliative patients with a subgroup analysis of older patients. METHODS A prospective-observational study. We recorded the demographics, number of diseases, diagnoses, and the Charlson comorbidity index (CCI), palliative performance scale (PPS), and nutritional risk screening-2002 (NRS-2002) scores. We noted the nutritional parameters and mortality. We measured the subcutaneous fat thickness (SFT), muscle thickness (MT), and cross-sectional area (CSA) of the rectus femoris and biceps brachii using ultrasonography. RESULTS We enrolled 100 patients (mean age: 73.2 ± 16.4 years, 53%: female). One-month mortality was 42%. The non-survivors had significantly higher malignancy, increased CCI and NRS-2002 scores, lower required energy intake, calorie sufficiency rate, and biceps brachii SFT, MT, and CSA than the survivors. The independent mortality predictors were malignancy and biceps brachii CSA while the PPS score and malignancy were significantly associated with mortality in the older subgroup. CONCLUSION The malignancy and biceps brachii CSA might have prognostic value in predicting mortality in palliative patients. This was the first study investigating the mortality-associated factors including ultrasonographic muscle measurements of both the lower and upper limbs in a palliative care center.
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Affiliation(s)
- Nezahat Muge Catikkas
- Department of Internal Medicine, Division of Geriatrics, Sancaktepe Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Vildan Binay Safer
- Department of Physical Medicine and Rehabilitation, Sancaktepe Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkey
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10
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Medrinal C, Machefert M, Lamia B, Bonnevie T, Gravier FE, Hilfiker R, Prieur G, Combret Y. Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study. Crit Care 2023; 27:338. [PMID: 37649092 PMCID: PMC10469422 DOI: 10.1186/s13054-023-04597-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. METHODS We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. RESULTS Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. CONCLUSION TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. TRIAL REGISTRATION Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.
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Affiliation(s)
- Clément Medrinal
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France.
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France.
| | - Margaux Machefert
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Physiotherapy Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Bouchra Lamia
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology, Respiratory Department, Rouen University Hospital, Rouen, France
| | - Tristan Bonnevie
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Adir Association, 76230, Bois Guillaume, France
| | - Francis-Edouard Gravier
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Adir Association, 76230, Bois Guillaume, France
| | - Roger Hilfiker
- Research and Independent Studies in Private Physiotherapy (RISE), 3902, Brig, Switzerland
| | - Guillaume Prieur
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Yann Combret
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
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11
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Formiga MF, Dosbaba F, Hartman M, Batalik L, Senkyr V, Radkovcova I, Richter S, Brat K, Cahalin LP. Role of the Inspiratory Muscles on Functional Performance From Critical Care to Hospital Discharge and Beyond in Patients With COVID-19. Phys Ther 2023; 103:pzad051. [PMID: 37247250 DOI: 10.1093/ptj/pzad051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 01/04/2023] [Accepted: 02/19/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The role of inspiratory muscle performance in functional performance in patients with coronavirus disease 2019 (COVID-19) is poorly understood. The purpose of this study was to perform a longitudinal examination of inspiratory and functional performance from intensive care unit (ICU) discharge (ICUD) to hospital discharge (HD) and symptoms at HD and 1 month after HD in patients with COVID-19. METHODS Thirty patients (19 men, 11 women) with COVID-19 were included. Examination of inspiratory muscle performance at ICUD and HD was performed with an electronic manometer, which provided the maximal inspiratory pressure (MIP) and several other inspiratory measures. Examination of dyspnea and functional performance was performed at ICUD and HD with the Modified Borg Dyspnea Scale and the 1-minute sit-to-stand test (1MSST), respectively. RESULTS The mean age was 71 (SD = 11) years, the mean length of ICU stay was 9 (SD = 6) days, and the mean length of hospital stay was 26 (SD = 16) days. Most of the patients were diagnosed with severe COVID-19 (76.7%) and had a mean Charlson Comorbidity Index of 4.4 (SD = 1.9), reflecting high comorbidity. The mean MIP of the entire cohort increased minimally from ICUD to HD (from 36 [SD = 21] to 40 [SD = 20] cm H2O), reflecting predicted values for men and women at ICUD and HD of 46 (25%) to 51 (23%) and 37 (24%) to 37 (20%), respectively. The 1MSTS score increased significantly from ICUD to HD (9.9 [SD = 7.1] vs 17.7 [SD = 11.1]) for the entire cohort but remained far below population-based reference values (2.5th percentile) for the majority of patients at ICUD and HD. At ICUD, MIP was found to be a significant predictor of a favorable change in 1MSTS performance (β = 0.308; odds ratio = 1.36) at HD. CONCLUSION A significant reduction in inspiratory and functional performance exists in patients with COVID-19 at both ICUD and HD, with a greater MIP at ICUD being a significant predictor of a greater 1MSTS score at HD. IMPACT This study shows that inspiratory muscle training may be an important adjunct after COVID-19.
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Affiliation(s)
- Magno F Formiga
- Programa Pós-Graduação em Fisioterapia e Funcionalidade, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - Filip Dosbaba
- Department of Rehabilitation, University Hospital Brno, Brno, South Moravia, Czech Republic
| | - Martin Hartman
- Department of Rehabilitation, University Hospital Brno, Brno, South Moravia, Czech Republic
- Department of Rehabilitation and Sports Medicine, 2nd Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic
| | - Ladislav Batalik
- Department of Rehabilitation, University Hospital Brno, Brno, South Moravia, Czech Republic
- Department of Public Health, Faculty of Medicine, Masaryk University Brno, Brno, South Moravia, Czech Republic
| | - Vojtech Senkyr
- Department of Rehabilitation, University Hospital Brno, Brno, South Moravia, Czech Republic
| | - Ivana Radkovcova
- Department of Rehabilitation, University Hospital Brno, Brno, South Moravia, Czech Republic
| | - Svatopluk Richter
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, South Moravia, Czech Republic
| | - Kristian Brat
- Department of Respiratory Diseases, University Hospital Brno, Brno South Moravia, Czech Republic
| | - Lawrence P Cahalin
- Department of Physical Therapy, University of Miami Miller School of Medicine, Coral Gables, Florida, USA
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12
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Jenkins TO, MacBean V, Poulsen MK, Karbing DS, Rees SE, Patel BV, Polkey MI. The metabolic cost of inspiratory muscle training in mechanically ventilated patients in critical care. Intensive Care Med Exp 2023; 11:41. [PMID: 37415048 DOI: 10.1186/s40635-023-00522-6] [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: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Diaphragmatic dysfunction is well documented in patients receiving mechanical ventilation. Inspiratory muscle training (IMT) has been used to facilitate weaning by strengthening the inspiratory muscles, yet the optimal approach remains uncertain. Whilst some data on the metabolic response to whole body exercise in critical care exist, the metabolic response to IMT in critical care is yet to be investigated. This study aimed to quantify the metabolic response to IMT in critical care and its relationship to physiological variables. METHODS We conducted a prospective observational study on mechanically ventilated patients ventilated for ≥ 72 h and able to participate in IMT in a medical, surgical, and cardiothoracic intensive care unit. 76 measurements were taken on 26 patients performing IMT using an inspiratory threshold loading device at 4 cmH2O, and at 30, 50 and 80% of their negative inspiratory force (NIF). Oxygen consumption (VO2) was measured continuously using indirect calorimetry. RESULTS First session mean (SD) VO2 was 276 (86) ml/min at baseline, significantly increasing to 321 (93) ml/min, 333 (92) ml/min, 351(101) ml/min and 388 (98) ml/min after IMT at 4 cmH2O and 30, 50 and 80% NIF, respectively (p = 0.003). Post hoc comparisons revealed significant differences in VO2 between baseline and 50% NIF and baseline and 80% NIF (p = 0.048 and p = 0.001, respectively). VO2 increased by 9.3 ml/min for every 1 cmH2O increase in inspiratory load from IMT. Every increase in P/F ratio of 1 decreased the intercept VO2 by 0.41 ml/min (CI - 0.58 to - 0.24 p < 0.001). NIF had a significant effect on the intercept and slope, with every 1 cmH2O increase in NIF increasing intercept VO2 by 3.28 ml/min (CI 1.98-4.59 p < 0.001) and decreasing the dose-response slope by 0.15 ml/min/cmH2O (CI - 0.24 to - 0.05 p = 0.002). CONCLUSIONS IMT causes a significant load-dependent increase in VO2. P/F ratio and NIF impact baseline VO2. The dose-response relationship of the applied respiratory load during IMT is modulated by respiratory strength. These data may offer a novel approach to prescription of IMT. TAKE HOME MESSAGE The optimal approach to IMT in ICU is uncertain; we measured VO2 at different applied respiratory loads to assess whether VO2 increased proportionally with load and found VO2 increased by 9.3 ml/min for every 1 cmH2O increase in inspiratory load from IMT. Baseline NIF has a significant effect on the intercept and slope, participants with a higher baseline NIF have a higher resting VO2 but a less pronounced increase in VO2 as the inspiratory load increases; this may offer a novel approach to IMT prescription. Trial registration ClinicalTrials.gov, registration number: NCT05101850. Registered on 28 September 2021, https://clinicaltrials.gov/ct2/show/NCT05101850.
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Affiliation(s)
- Timothy O Jenkins
- Rehabilitation and Therapies Department, Royal Brompton and Harefield Clinical Group, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- College of Health, Medicine and Life Sciences, Department of Health Sciences, Brunel University London, London, UK.
| | - Vicky MacBean
- College of Health, Medicine and Life Sciences, Department of Health Sciences, Brunel University London, London, UK
| | - Mathias Krogh Poulsen
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Brijesh V Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
- Department of Critical Care, Royal Brompton Hospital, Royal Brompton and Harefield Clinical Group, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Michael I Polkey
- Department of Respiratory Medicine, Royal Brompton and Harefield Clinical Group, Guy's and St Thomas' NHS Foundation Trust, London, UK
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13
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Dianti J, Morris IS, Urner M, Schmidt M, Tomlinson G, Amato MBP, Blanch L, Rubenfeld G, Goligher EC. Linking Acute Physiology to Outcomes in the ICU: Challenges and Solutions for Research. Am J Respir Crit Care Med 2023; 207:1441-1450. [PMID: 36705985 DOI: 10.1164/rccm.202206-1216ci] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
ICU clinicians rely on bedside physiological measurements to inform many routine clinical decisions. Because deranged physiology is usually associated with poor clinical outcomes, it is tempting to hypothesize that manipulating and intervening on physiological parameters might improve outcomes for patients. However, testing these hypotheses through mathematical models of the relationship between physiology and outcomes presents a number of important methodological challenges. These models reflect the theories of the researcher and can therefore be heavily influenced by one's assumptions and background beliefs. Model building must therefore be approached with great care and forethought, because failure to consider relevant sources of measurement error, confounding, coupling, and time dependency or failure to assess the direction of causality for associations of interest before modeling may give rise to spurious results. This paper outlines the main challenges in analyzing and interpreting these models and offers potential solutions to address these challenges.
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Affiliation(s)
- Jose Dianti
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
| | - Idunn S Morris
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesiology and Pain Medicine
| | | | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Lluis Blanch
- Critical Care Center, Institut d'Investigacio i Innovacio Parc Taulí I3PT-CERCA, Parc Taulí Hospital Universitari, Universitat Autonoma de Barcelona, Sabadell, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Universitat Autonoma de Barcelona, Parc Taulí 1, Sabadell, Spain
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine
- University Health Network/Sinai Health System
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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14
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Güngör Ş, Doğan A. Diaphragm thickness by ultrasound in pediatric patients with primary malnutrition. Eur J Pediatr 2023:10.1007/s00431-023-05024-x. [PMID: 37178359 PMCID: PMC10182341 DOI: 10.1007/s00431-023-05024-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/15/2023]
Abstract
Skeletal muscle atrophy is known to be a marker for nutritional deficiency. The diaphragm is both a skeletal muscle and a respiratory muscle. There is not enough data in the literature about the change in diaphragm thickness (DT) in children with malnutrition. We think that malnutrition may have negative effects on diaphragm thickness. Therefore, in this study, we aimed to compare the diaphragm thicknesses of pediatric patients with primary malnutrition and a healthy control group. The DT of pediatric patients diagnosed with primary malnutrition by a pediatric gastroenterologist was prospectively evaluated by a radiology specialist by ultrasonography (USG). The obtained data were statistically compared with the data of the healthy control group. There was no statistically significant difference between the groups in terms of age and gender (p = 0.244, p = 0.494). We found that right and left diaphragm thicknesses were significantly thinner in the malnourished group than in the healthy control group (p = 0.001, p = 0.009, respectively). We found that right and left diaphragm thicknesses were thinner in those with moderate and severe malnutrition compared to the normal group (p < 0.001, p = 0.003, respectively). We found a significant weak positive correlation between weight and height Z score and right and left diaphragm thickness (respectively, r: 0.297, p < 0.001; r: 0.301, p < 0.001). Conclusion: Malnutrition is a disease that affects all systems. Our study shows that the DT is thinner in patients with malnutrition. What is Known: •Malnutrition causes skeletal muscle atrophy. What is New: •Diaphragm muscle thickness decreases in malnutrition. •There is a significant positive correlation between diaphragm muscle thickness and height, weight and BMI z scores.
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Affiliation(s)
- Şükrü Güngör
- Department of Pediatric Gastroenterology, School of Medicine, Kahramanmaras Sütcü İmam University, Kahramanmaras, Turkey
| | - Adil Doğan
- Department of Radiology, School of Medicine, Kahramanmaras Sütcü İmam University, 46010, Kahramanmaras, Turkey.
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15
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Klawitter F, Walter U, Axer H, Patejdl R, Ehler J. Neuromuscular Ultrasound in Intensive Care Unit-Acquired Weakness: Current State and Future Directions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050844. [PMID: 37241077 DOI: 10.3390/medicina59050844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023]
Abstract
Intensive care unit-acquired weakness (ICUAW) is one of the most common causes of muscle atrophy and functional disability in critically ill intensive care patients. Clinical examination, manual muscle strength testing and monitoring are frequently hampered by sedation, delirium and cognitive impairment. Many different attempts have been made to evaluate alternative compliance-independent methods, such as muscle biopsies, nerve conduction studies, electromyography and serum biomarkers. However, they are invasive, time-consuming and often require special expertise to perform, making them vastly impractical for daily intensive care medicine. Ultrasound is a broadly accepted, non-invasive, bedside-accessible diagnostic tool and well established in various clinical applications. Hereby, neuromuscular ultrasound (NMUS), in particular, has been proven to be of significant diagnostic value in many different neuromuscular diseases. In ICUAW, NMUS has been shown to detect and monitor alterations of muscles and nerves, and might help to predict patient outcome. This narrative review is focused on the recent scientific literature investigating NMUS in ICUAW and highlights the current state and future opportunities of this promising diagnostic tool.
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Affiliation(s)
- Felix Klawitter
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Center, Gehlsheimer Straße 20, 18147 Rostock, Germany
| | - Hubertus Axer
- Department of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Robert Patejdl
- Department of Medicine, Health and Medical University Erfurt, 99089 Erfurt, Germany
| | - Johannes Ehler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
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16
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Formenti P, Miori S, Galimberti A, Umbrello M. The Effects of Positive End Expiratory Pressure and Lung Volume on Diaphragm Thickness and Thickening. Diagnostics (Basel) 2023; 13:diagnostics13061157. [PMID: 36980465 PMCID: PMC10047794 DOI: 10.3390/diagnostics13061157] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Introduction: Diaphragm dysfunction is common in patients undergoing mechanical ventilation. The application of positive end-expiratory pressure (PEEP) and the varying end-expiratory lung volume cause changes in diaphragm geometry. We aimed to assess the impact of the level of PEEP and lung inflation on diaphragm thickness, thickening fraction and displacement. Methods: An observational study in a mixed medical and surgical ICU was conducted. The patients underwent a PEEP-titration trial with the application of three random levels of PEEP: 0 cmH2O (PEEP0), 8 cmH2O (PEEP8) and 15 cmH2O (PEEP15). At each step, the indices of respiratory effort were assessed, together with arterial blood and diaphragm ultrasound; end-expiratory lung volume was measured. Results: 14 patients were enrolled. The tidal volume, diaphragm displacement and thickening fraction were significantly lower with higher levels of PEEP, while both the expiratory and inspiratory thickness increased with higher PEEP levels. The inspiratory effort, as evaluated by the esophageal pressure swing, was unchanged. Both the diaphragm thickening fraction and displacement were significantly correlated with inspiratory effort in the whole dataset. For both measurements, the correlation was stronger at lower levels of PEEP. The difference in the diaphragm thickening fraction during tidal breathing between PEEP 15 and PEEP 0 was negatively related to the change in the functional residual capacity and the change in alveolar dead space. Conclusions: Different levels of PEEP significantly modified the diaphragmatic thickness and thickening fraction, showing a PEEP-induced decrease in the diaphragm contractile efficiency. When using ultrasound to assess diaphragm size and function, the potential effect of lung inflation should be taken into account.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione I, ASST Santi Paolo e Carlo-Polo Universitario, Ospedale San Paolo, 20142 Milan, Italy
| | - Sara Miori
- SC Anestesia e Rianimazione I, Ospedale Santa Chiara, APSS, 30014 Trento, Italy
| | - Andrea Galimberti
- SC Anestesia Rianimazione e Terapia Intensiva ASST Nord Milano Ospedale Bassini, 20092 Cinisello Balsamo, Italy
| | - Michele Umbrello
- SC Anestesia e Rianimazione II, ASST Santi Paolo e Carlo-Polo Universitario, Ospedale San Carlo Borromeo, 20148 Milan, Italy
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17
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Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
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Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
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18
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Ureyen Ozdemir E, Buyuk GN, Acar D, Elmas B, Yilmaz G, Özcan NN, Keskin HL, Moraloglu Tekin Ö. The relationship between diaphragm thickness and the severity of the disease in pregnant patients with Covid-19. Taiwan J Obstet Gynecol 2023; 62:275-279. [PMID: 36965895 PMCID: PMC9729641 DOI: 10.1016/j.tjog.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We aimed to investigate whether there is a relationship between diaphragm thickness and disease severity in Covid-19 pregnant subgroups. MATERIAL AND METHODS In this prospective study 100 pregnant patients were enrolled. Thickness of the diaphragm muscle at end-expiration was measured using B-Mode US. Hemoglobin,WBC, NLR, procalcitonin and LDH levels were measured. RESULTS There was a statistically significant difference between the groups in terms of diaphragm thickness, and the diaphragm thickness was thinner in the severe disease group (p < 0.001). There was no statistically significant difference between the groups with mild to moderate disease severity (p = 0.708). CONCLUSION Covid-19 patients who developed serious infection has thinner diaphragms than those who did not. Low diaphragm muscle thickness at the outset of Covid-19 disease, may predispose to poor clinical outcomes. Diaphragmatic ultrasound may be a promising tool to evaluate the risk of Covid-19 disease severity.
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Affiliation(s)
- Eda Ureyen Ozdemir
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Gul Nihal Buyuk
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Dilek Acar
- Department of Radiology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Burak Elmas
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Gamze Yilmaz
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Namik Nebi Özcan
- Department of Anesthesia and Reanimation, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Hüseyin Levent Keskin
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Özlem Moraloglu Tekin
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey.
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19
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Ribeiro F, Alves PKN, Bechara LRG, Ferreira JCB, Labeit S, Moriscot AS. Small-Molecule Inhibition of MuRF1 Prevents Early Disuse-Induced Diaphragmatic Dysfunction and Atrophy. Int J Mol Sci 2023; 24:ijms24043637. [PMID: 36835047 PMCID: PMC9965746 DOI: 10.3390/ijms24043637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
In clinical conditions such as diaphragm paralysis or mechanical ventilation, disuse-induced diaphragmatic dysfunction (DIDD) is a condition that poses a threat to life. MuRF1 is a key E3-ligase involved in regulating skeletal muscle mass, function, and metabolism, which contributes to the onset of DIDD. We investigated if the small-molecule mediated inhibition of MuRF1 activity (MyoMed-205) protects against early DIDD after 12 h of unilateral diaphragm denervation. Wistar rats were used in this study to determine the compound's acute toxicity and optimal dosage. For potential DIDD treatment efficacy, diaphragm contractile function and fiber cross-sectional area (CSA) were evaluated. Western blotting investigated potential mechanisms underlying MyoMed-205's effects in early DIDD. Our results indicate 50 mg/kg bw MyoMed-205 as a suitable dosage to prevent early diaphragmatic contractile dysfunction and atrophy following 12 h of denervation without detectable signs of acute toxicity. Mechanistically, treatment did not affect disuse-induced oxidative stress (4-HNE) increase, whereas phosphorylation of (ser632) HDAC4 was normalized. MyoMed-205 also mitigated FoxO1 activation, inhibited MuRF2, and increased phospho (ser473) Akt protein levels. These findings may suggest that MuRF1 activity significantly contributes to early DIDD pathophysiology. Novel strategies targeting MuRF1 (e.g., MyoMed-205) have potential therapeutic applications for treating early DIDD.
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Affiliation(s)
- Fernando Ribeiro
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Paula K. N. Alves
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Luiz R. G. Bechara
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Julio C. B. Ferreira
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Siegfried Labeit
- DZHK Partner Site Mannheim-Heidelberg, Medical Faculty Mannheim, University of Heidelberg, 68169 Mannheim, Germany
- Myomedix GmbH, 69151 Neckargemünd, Germany
| | - Anselmo S. Moriscot
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
- Correspondence: ; Tel.: +55-11-3091-0946
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20
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Gutierrez-Arias R, Nydahl P, Pieper D, González-Seguel F, Jalil Y, Oliveros MJ, Torres-Castro R, Seron P. Effectiveness of physical rehabilitation interventions in critically ill patients-A protocol for an overview of systematic reviews. PLoS One 2023; 18:e0284417. [PMID: 37053257 PMCID: PMC10101388 DOI: 10.1371/journal.pone.0284417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/26/2023] [Indexed: 04/14/2023] Open
Abstract
INTRODUCTION Adult and pediatric patients admitted to intensive care units (ICUs) requiring invasive ventilatory support, sedation, and muscle blockade may present neuromusculoskeletal deterioration. Different physical rehabilitation interventions have been studied to evaluate their effectiveness in improving critically ill patients' outcomes. Given that many published systematic reviews (SRs) aims to determine the effectiveness of different types of physical rehabilitation interventions, it is necessary to group them systematically and assess the methodological quality of SRs to help clinicians make better evidence-based decisions. This overview of SRs (OoSRs) aims to map the existing evidence and to determine the effectiveness of physical rehabilitation interventions to improve neuromusculoskeletal function and other clinical outcomes in adult and pediatric critically ill patients. METHODS An OoSRs of randomized and non-randomized clinical trials involving critically ill adult and pediatric patients receiving physical rehabilitation intervention will be conducted. A sensitive search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos, and other search resources will be conducted. Two independent reviewers will conduct study selection, data extraction, and methodological quality assessment. Discrepancies will be resolved by consensus or a third reviewer. The degree of overlap of studies will be calculated using the corrected covered area. The methodological quality of the SRs will be measured using the AMSTAR-2 tool. The GRADE framework will report the certainty of evidence by selecting the "best" SR for each physical rehabilitation intervention and outcome. DISCUSSION The findings of this overview are expected to determine the effectiveness and safety of physical rehabilitation interventions to improve neuromusculoskeletal function in adult and pediatric critically ill patients based on a wide selection of the best available evidence and to determine the knowledge gaps in this topic by mapping and assessing the methodological quality of published SRs. REGISTRATION NUMBER CRD42023389672.
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Affiliation(s)
- Ruvistay Gutierrez-Arias
- Servicio de Medicina Física y Rehabilitación, Unidad de Kinesiología, Instituto Nacional del Tórax, Santiago, Chile
- Exercise and Rehabilitation Sciences Laboratory, Faculty of Rehabilitation Sciences, School of Physical Therapy, Universidad Andres Bello, Santiago, Chile
| | - Peter Nydahl
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Dawid Pieper
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School (Theodor Fontane), Institute for Health Services and Health Systems Research, Rüdersdorf, Germany
- Center for Health Services Research, Brandenburg Medical School (Theodor Fontane), Rüdersdorf, Germany
| | - Felipe González-Seguel
- Carrera de Kinesiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Yorschua Jalil
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maria-Jose Oliveros
- Departamento de Ciencias de la Rehabilitación, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
- Centro de Excelencia CIGES, Universidad de La Frontera, Temuco, Chile
| | | | - Pamela Seron
- Departamento de Ciencias de la Rehabilitación, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
- Centro de Excelencia CIGES, Universidad de La Frontera, Temuco, Chile
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21
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Louvaris Z, Van Hollebeke M, Poddighe D, Meersseman P, Wauters J, Wilmer A, Gosselink R, Langer D, Hermans G. Do Cerebral Cortex Perfusion, Oxygen Delivery, and Oxygen Saturation Responses Measured by Near-Infrared Spectroscopy Differ Between Patients Who Fail or Succeed in a Spontaneous Breathing Trial? A Prospective Observational Study. Neurocrit Care 2023; 38:105-117. [PMID: 36450970 PMCID: PMC9713166 DOI: 10.1007/s12028-022-01641-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 11/07/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Alterations in perfusion to the brain during the transition from mechanical ventilation (MV) to a spontaneous breathing trial (SBT) remain poorly understood. The aim of the study was to determine whether changes in cerebral cortex perfusion, oxygen delivery (DO2), and oxygen saturation (%StiO2) during the transition from MV to an SBT differ between patients who succeed or fail an SBT. METHODS This was a single-center prospective observational study conducted in a 16-bed medical intensive care unit of the University Hospital Leuven, Belgium. Measurements were performed in 24 patients receiving MV immediately before and at the end of a 30-min SBT. Blood flow index (BFI), DO2, and %StiO2 in the prefrontal cortex, scalene, rectus abdominis, and thenar muscle were simultaneously assessed by near-infrared spectroscopy using the tracer indocyanine green dye. Cardiac output, arterial blood gases, and systemic oxygenation were also recorded. RESULTS During the SBT, prefrontal cortex BFI and DO2 responses did not differ between SBT-failure and SBT-success groups (p > 0.05). However, prefrontal cortex %StiO2 decreased in six of eight patients (75%) in the SBT-failure group (median [interquartile range 25-75%]: MV = 57.2% [49.1-61.7] vs. SBT = 51.0% [41.5-62.5]) compared to 3 of 16 patients (19%) in the SBT-success group (median [interquartile range 25-75%]: MV = 65.0% [58.6-68.5] vs. SBT = 65.1% [59.5-71.1]), resulting in a significant differential %StiO2 response between groups (p = 0.031). Similarly, a significant differential response in thenar muscle %StiO2 (p = 0.018) was observed between groups. A receiver operating characteristic analysis identified a decrease in prefrontal cortex %StiO2 > 1.6% during the SBT as an optimal cutoff, with a sensitivity of 94% and a specificity of 75% to predict SBT failure and an area under the curve of 0.79 (95% CI: 0.55-1.00). Cardiac output, systemic oxygenation, scalene, and rectus abdominis BFI, DO2, and %StiO2 responses did not differ between groups (p > 0.05); however, during the SBT, a significant positive association in prefrontal cortex BFI and partial pressure of arterial carbon dioxide was observed only in the SBT-success group (SBT success: Spearman's ρ = 0.728, p = 0.002 vs. SBT failure: ρ = 0.048, p = 0.934). CONCLUSIONS This study demonstrated a reduced differential response in prefrontal cortex %StiO2 in the SBT-failure group compared with the SBT-success group possibly due to the insufficient increase in prefrontal cortex perfusion in SBT-failure patients. A > 1.6% drop in prefrontal cortex %StiO2 during SBT was sensitive in predicting SBT failure. Further research is needed to validate these findings in a larger population and to evaluate whether cerebral cortex %StiO2 measurements by near-infrared spectroscopy can assist in the decision-making process on liberation from MV.
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Affiliation(s)
- Zafeiris Louvaris
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Marine Van Hollebeke
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Diego Poddighe
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology and Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Rik Gosselink
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Langer
- Research Group for Rehabilitation in Internal Disorders, Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Katholieke University Leuven, Campus Gasthuisberg O&N4, Herestraat 49, Box 1510, B-3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, Katholieke University Leuven, Leuven, Belgium
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22
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Severin R, Franz CK, Farr E, Meirelles C, Arena R, Phillips SA, Bond S, Ferraro F, Faghy M. The effects of COVID-19 on respiratory muscle performance: making the case for respiratory muscle testing and training. Eur Respir Rev 2022; 31:31/166/220006. [PMID: 36198415 PMCID: PMC9724806 DOI: 10.1183/16000617.0006-2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/22/2022] [Indexed: 01/28/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection results in multiorgan damage primarily mediated by viral infiltration via angiotensin-converting enzyme-2 receptors on the surface of cells. A primary symptom for many patients is exertional dyspnoea which may persist even beyond recovery from the viral infection. Respiratory muscle (RM) performance was hypothesised as a contributing factor to the severity of coronavirus disease 2019 (COVID-19) symptoms, such as dyspnoea, and outcomes. This was attributed to similarities between patient populations at elevated risk for severe COVID-19 symptoms and those with a greater likelihood of baseline RM weakness and the effects of prolonged mechanical ventilation. More recent evidence suggests that SARS-CoV-2 infection itself may cause damage to the RM, and many patients who have recovered report persistent dyspnoea despite having mild cases, normal lung function or undamaged lung parenchyma. These more recent findings suggest that the role of RM in the persistent dyspnoea due to COVID-19 may be more substantial than originally hypothesised. Therefore, screening for RM weakness and providing interventions to improve RM performance appears to be important for patients with COVID-19. This article will review the impact of SARS-CoV-2 infection on RM performance and provide clinical recommendations for screening RM performance and treatment interventions.
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Affiliation(s)
- Richard Severin
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA,Department of Physical Therapy, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, USA,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA,Corresponding author: Richard Severin ()
| | - Colin K. Franz
- The Shirley Ryan Ability Lab, Chicago, IL, USA,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ellen Farr
- The Shirley Ryan Ability Lab, Chicago, IL, USA,Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cristiane Meirelles
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA
| | - Shane A. Phillips
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA
| | - Sam Bond
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA
| | | | - Mark Faghy
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Chicago, IL, USA,Human Sciences Research Centre, University of Derby, Derby, UK
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23
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Dot I, Pérez-Terán P, Francés A, Díaz Y, Vilà-Vilardell C, Salazar-Degracia A, Chalela R, Barreiro E, Rodriguez-Fuster A, Masclans JR, Marin-Corral J. Association between histological diaphragm atrophy and ultrasound diaphragm expiratory thickness in ventilated patients. J Intensive Care 2022; 10:40. [PMID: 35986366 PMCID: PMC9392308 DOI: 10.1186/s40560-022-00632-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background Diaphragm fiber atrophy has been evidenced after short periods of mechanical ventilation (MV) and related to critical illness-associated diaphragm weakness. Atrophy is described as a decrease in diaphragm fiber cross-sectional area (CSA) in human diaphragm biopsy, but human samples are still difficult to obtain in clinics. In recent years, ultrasound has become a useful tool in intensive care to evaluate diaphragm anatomy. The present study aimed to evaluate the ability of diaphragm expiratory thickness (Tdi) measured by ultrasound to predict diaphragm atrophy, defined by a decrease in diaphragm fiber CSA obtained through diaphragm biopsy (the gold standard technique) in ventilated patients. Methods Diaphragm biopsies and diaphragm ultrasound were performed in ventilated donors and in control subjects. Demographic variables, comorbidities, severity on admission, treatment, laboratory test results and evolution variables were evaluated. Immunohistochemical analysis to determine CSA and ultrasound measurements of Tdi at end-expiration were performed, and median values of the control group were used as thresholds to determine agreement between them in further analysis. Sensitivity, specificity, and positive and negative predictive values of an ultrasound Tdi cutoff for detecting histologic atrophy were calculated. Agreement between two ultrasound observers was also assessed. Results Thirty-five ventilated organ donors and 5 ventilated controls were included, without differences in basic characteristics. CSA and Tdi were lower in donors than in controls. All donors presented lower CSA, but only 74% lower Tdi regarding control group thresholds. The cut-off value for lower diaphragm expiratory thickness (Tdi < 1.7 mm) presented a sensitivity of 73%, a specificity of 67%, a positive predictive value of 96% and a negative predictive value of 17% for determining the presence of diaphragm atrophy (CSA < 2851 μm2). Conclusions Diaphragm atrophy and thickness reduction is associated to MV. While a lower Tdi in diaphragm ultrasound is a good tool for diagnosing atrophy, normal or increased Tdi cannot rule atrophy out showing that both parameters should not be considered as synonymous.
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24
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Parlak S, Beşler MS, Gökhan MB. Association of diaphragm thickness and density measured on chest CT with disease severity in COVID-19 patients. Am J Emerg Med 2022; 61:29-33. [PMID: 36029668 PMCID: PMC9387025 DOI: 10.1016/j.ajem.2022.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/07/2022] [Accepted: 08/14/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction A decrease in muscle mass of the diaphragm could be a significant risk factor for pneumonia. The aim of our study was to evaluate whether diaphragm thickness (DT) and density measured on chest computed tomography (CT) were associated with clinical course and mortality in adult patients with coronavirus disease 2019 (COVID-19) in emergency department admission. Methods We retrospectively analyzed 404 patients with a positive polymerase chain reaction test for COVID-19 and pneumonia findings on chest CT between September 1 and November 1, 2020. Bilateral DT measurements were performed at the level of the celiac artery origin, and the total mean diaphragm thickness (TMDT) was estimated. Hemidiaphragm density was measured at the level of the celiac artery origin. The relationship between demographic characteristics, comorbidities, TMDT, mean hemidiaphragm density (MHD) and clinical outcomes was investigated using the logistic regression analyses. The reliability of the measurement of the two observers was evaluated by intraclass correlation analyses. Results Intraclass correlation analyses demonstrated almost perfect inter-observer agreement for TMDT and substantial agreement for MHD. There was a statistically significant relationship between the presence of a thinner diaphragm and mortality (p < 0.001). Bilateral diaphragm densities were lower in the patients with severe disease and mortality (p < 0.001). The threshold values of TMDT were 3.67 mm and 3.47 mm for the prediction of ICU admission and mortality, respectively. TMDT (odds ratio [OR]: 0.634, 95% confidence interval [CI]: 0.447–0.901), age (OR: 1.053, 95% CI: 1.027–1.081) and MHD (OR: 0.920, 95% CI: 0.883–0.959) were found to be independent predictors for severe disease in the multivariable model. In addition, MHD (OR: 0.883, 95% CI: 0.827–0.942) and age (OR: 1.040, 95% CI: 1.003–1.078) were independent risk factors for mortality. Conclusion Our study demonstrated that a low diaphragm thickness and density measured on chest CT were associated with severe disease in patients with COVID-19 and could be evaluated as poor prognostic markers.
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Affiliation(s)
- Selçuk Parlak
- Department of Radiology, Ankara City Hospital, Ankara, Turkey
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25
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Spiesshoefer J, Friedrich J, Regmi B, Geppert J, Jörn B, Kersten A, Giannoni A, Boentert M, Marx G, Marx N, Daher A, Dreher M. Diaphragm dysfunction as a potential determinant of dyspnea on exertion in patients 1 year after COVID-19-related ARDS. Respir Res 2022; 23:187. [PMID: 35841032 PMCID: PMC9284093 DOI: 10.1186/s12931-022-02100-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022] Open
Abstract
Some COVID-19 patients experience dyspnea without objective impairment of pulmonary or cardiac function. This study determined diaphragm function and its central voluntary activation as a potential correlate with exertional dyspnea after COVID-19 acute respiratory distress syndrome (ARDS) in ten patients and matched controls. One year post discharge, both pulmonary function tests and echocardiography were normal. However, six patients with persisting dyspnea on exertion showed impaired volitional diaphragm function and control based on ultrasound, magnetic stimulation and balloon catheter-based recordings. Diaphragm dysfunction with impaired voluntary activation can be present 1 year after severe COVID-19 ARDS and may relate to exertional dyspnea. This prospective case–control study was registered under the trial registration number NCT04854863 April, 22 2021
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Affiliation(s)
- Jens Spiesshoefer
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany. .,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
| | - Janina Friedrich
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Binaya Regmi
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Jonathan Geppert
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Benedikt Jörn
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Alexander Kersten
- Department of Cardiology, Vascular and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Alberto Giannoni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Matthias Boentert
- Department of Neurology with Institute for Translational Neurology, University Hospital of Muenster, Muenster, Germany.,Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, University Hospital Rheinisch Westfaelische Technische Hochschule Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Vascular and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Ayham Daher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
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26
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Maslove DM, Sibley S, Boyd JG, Goligher EC, Munshi L, Bogoch II, Rochwerg B. Complications of Critical COVID-19: Diagnostic and Therapeutic Considerations for the Mechanically Ventilated Patient. Chest 2022; 161:989-998. [PMID: 34655568 PMCID: PMC8511547 DOI: 10.1016/j.chest.2021.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/04/2021] [Accepted: 10/06/2021] [Indexed: 01/31/2023] Open
Abstract
Patients admitted to the ICU with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated patient with COVID-19 who shows persistent or worsening signs of critical illness, and we offer an approach to treating this complex but common scenario.
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Affiliation(s)
- David M. Maslove
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada,CORRESPONDENCE TO: David M. Maslove, MD
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J. Gordon Boyd
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,University Health Network, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,Sinai Health System, Toronto, ON, Canada
| | - Isaac I. Bogoch
- University Health Network, Toronto, ON, Canada,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada,Juravinski Hospital, Hamilton, ON, Canada
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27
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Espiritu AI, Reyes NGD, Leochico CFD, Sy MCC, Villanueva Iii EQ, Anlacan VMM, Jamora RDG. Body mass index and its association with COVID-19 clinical outcomes: Findings from the Philippine CORONA study. Clin Nutr ESPEN 2022; 49:402-410. [PMID: 35623845 PMCID: PMC8968152 DOI: 10.1016/j.clnesp.2022.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 02/04/2022] [Accepted: 03/11/2022] [Indexed: 12/17/2022]
Abstract
Background and aims To explore the association between body mass index (BMI) and adverse outcomes in a large cohort of patients with coronavirus disease 2019 (COVID-19). Methods This is a secondary analysis of a 37-site, nationwide, multicenter, retrospective cohort study that investigated the clinical and neurological outcomes of adult patients with confirmed COVID-19 admitted from February to December 15, 2020. Results We analyzed 4,463 patients with BMI and outcome data. A total of 790 (17.7%) and 710 (15.9%) had the primary outcome of in-hospital mortality and need for invasive mechanical ventilation (IMV), respectively. There was no significant association between WHO BMI groups and these outcomes. Using Asia-Pacific cutoffs showed a significant association between obesity and in-hospital mortality risk (P = 0.012). Being underweight was an independent predictor of prolonged IMV requirement regardless of BMI criteria used (P < 0.01). Obesity correlated with the need for intensive care unit admission using Asia-Pacific cutoffs (P = 0.029). There was a significant association between any BMI abnormality and odds of severe/critical COVID-19 (P < 0.05). Obese patients with concomitant acute neurological presentation/diagnosis during their COVID-19 admission were shown to have lower odds of neurologic recovery (P < 0.05). Conclusions We found BMI abnormalities to be associated with several adverse clinical and neurologic outcomes, although such associations may be more evident with the use of race-specific BMI criteria.
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Affiliation(s)
- Adrian I Espiritu
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Manila, Philippines; Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, ON M5B 1W8, Canada.
| | - Nikolai Gil D Reyes
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Carl Froilan D Leochico
- Department of Rehabilitation Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Department of Physical Medicine and Rehabilitation, St. Luke's Medical Center, Quezon City and Global City, Philippines.
| | - Marie Charmaine C Sy
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Emilio Q Villanueva Iii
- Department of Pathology, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Philippines.
| | - Veeda Michelle M Anlacan
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines.
| | - Roland Dominic G Jamora
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines; Institute for Neurosciences, St. Luke's Medical Center, Quezon City & Global City, Philippines.
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Van Hollebeke M, Poddighe D, Clerckx B, Muller J, Hermans G, Gosselink R, Langer D, Louvaris Z. High-Intensity Inspiratory Muscle Training Improves Scalene and Sternocleidomastoid Muscle Oxygenation Parameters in Patients With Weaning Difficulties: A Randomized Controlled Trial. Front Physiol 2022; 13:786575. [PMID: 35222072 PMCID: PMC8864155 DOI: 10.3389/fphys.2022.786575] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCritically ill patients who have difficulties weaning from the mechanical ventilator are prone to develop respiratory muscle weakness. Inspiratory muscle training (IMT) can improve respiratory muscle strength. Whether IMT can improve scalene and sternocleidomastoid muscle oxygenation parameters is unknown.AimTo compare changes in muscle oxygenation parameters of scalene and sternocleidomastoid inspiratory muscles during a standardized task between patients with weaning difficulties who received either high-intensity IMT (intervention) or sham low-intensity IMT (control).MethodForty-one patients performed daily IMT sessions (4 sets, 6–10 breaths) until weaning success or for 28 consecutive days. The training load was progressively adjusted in the intervention group (n = 22) to the highest tolerable load, whilst the control group (n = 19) kept training at 10% of their baseline maximal inspiratory pressure (PImax). Breathing characteristics (i.e., work and power of breathing, PoB), respiratory muscle function [i.e., PImax and forced vital capacity (FVC)] were measured during a standardized loaded breathing task against a load of 30% of baseline PImax before and after the IMT period. In addition, during the same loaded breathing task, absolute mean and nadir changes from baseline in local scalene and sternocleidomastoid muscle oxygen saturation index (Δ%StiO2) (an index of oxygen extraction) and nadir Δ%StiO2 normalized for the PoB were measured by near-infrared spectroscopy.ResultsAt post measures, only the intervention group improved mean PoB compared to pre measures (Pre: 0.42 ± 0.33 watts, Post: 0.63 ± 0.51watts, p-value < 0.01). At post measures, both groups significantly improved nadir scalene muscles StiO2% normalized for the mean PoB (ΔStiOnadir%/watt) compared to pre measurements and the improvement was not significant different between groups (p-value = 0.40). However, at post measures, nadir sternocleidomastoid muscle StiO2% normalized for the mean PoB (ΔStiOnadir%/watt) was significantly greater improved in the intervention group (mean difference: +18.4, 95%CI: −1.4; 38.1) compared to the control group (mean difference: +3.7, 95%CI: −18.7; 26.0, between group p-value < 0.01). Both groups significantly improved PImax (Intervention: +15 ± 13 cmH2O p-value < 0.01, Control: +13 ± 15 cmH2O p-value < 0.01). FVC only significantly improved in the intervention group (+0.33 ± 0.31 L p < 0.01) report also change in control group.ConclusionThis exploratory study suggests that high-intensity IMT induces greater improvements in scalene and sternocleidomastoid muscle oxygenation parameters attributed for oxygen delivery, utilization and oxygen saturation index compared to low-intensity IMT in patients with weaning difficulties.
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Affiliation(s)
- Marine Van Hollebeke
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Marine Van Hollebeke,
| | - Diego Poddighe
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Beatrix Clerckx
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Muller
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Daniel Langer
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Zafeiris Louvaris
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Validation of a Web-based Platform for Online Training in Point-of-Care Diaphragm Ultrasound. ATS Sch 2022; 3:13-19. [PMID: 35633997 PMCID: PMC9131881 DOI: 10.34197/ats-scholar.2021-0057br] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
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Itagaki T. Diaphragm-protective mechanical ventilation in acute respiratory failure. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:165-172. [DOI: 10.2152/jmi.69.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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Formenti P, Coppola S, Umbrello M, Froio S, Caccioppola A, De Giorgis V, Galanti V, Lusardi AC, Ferrari E, Noè D, Carnier S, Folli F, Chiumello D. Time course of the Bioelectrical Impedance Vector Analysis and muscular ultrasound in critically ill patients. J Crit Care 2021; 68:89-95. [PMID: 34952476 DOI: 10.1016/j.jcrc.2021.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Several different tools have been developed to integrate the clinical and biochemical nutritional evaluations in critical care patients. Aims of this study were to evaluate the changes in the Bioelectrical Impedance Vector Analysis (BIVA) and ultrasonographic features of the diaphragm (DTee) and rectus femoris (RFCSA) during the first week of ICU stay. MATERIALS AND METHODS Ninety-six adult mechanically ventilated patients enrolled within 24 h after the admission to the ICU (T1). RFCSA and diaphragm end-expiratory thickness were measured, as well as BIVA parameters. Anthropometric data and biochemical parameters were collected. The measurements were repeated on the 3rd (T3) and 7th (T7) days of ICU stay. RESULTS During the study period, the phase angle significantly decreased by 21%, reactance by 27%, and resistance by 11%. Both RFCSA and DTee significantly decreased, while neither were correlated to any BIVA parameter. DTee was considerably higher in survivors vs. non-survivors. CONCLUSIONS Body composition is significantly modified after one week of ICU stay. BIVA may be useful in the definition of hydration state, while it does not seem to track muscle mass. Different temporal trends of specific BIVA and muscle ultrasound parameters were found in patients with high or low severity of illness.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Michele Umbrello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Sara Froio
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
| | - Alessio Caccioppola
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Valentina De Giorgis
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Valentina Galanti
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Andrea Clarissa Lusardi
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Erica Ferrari
- Dipartimento di fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Donatella Noè
- SSD Servizio Dietetico e Nutrizione Clinica- ASST Santi Paolo e Carlo, Ospedali San Paolo e San Carlo Borromeo, Milan, Italy
| | - Simone Carnier
- Endocrinology and Metabolism, Department of Health Science, University of Milan - ASST Santi Paolo e Carlo, Ospedali San Paolo e San Carlo Borromeo, Milan, Italy
| | - Franco Folli
- Endocrinology and Metabolism, Department of Health Science, University of Milan - ASST Santi Paolo e Carlo, Ospedali San Paolo e San Carlo Borromeo, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy; Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy; Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
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Arai Y, Nakanishi N, Ono Y, Inoue S, Kotani J, Harada M, Oto J. Ultrasound assessment of muscle mass has potential to identify patients with low muscularity at intensive care unit admission: A retrospective study. Clin Nutr ESPEN 2021; 45:177-183. [PMID: 34620314 DOI: 10.1016/j.clnesp.2021.08.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Muscle mass is an important biomarker of survival from a critical illness; however, there is no widely accepted method for routine assessment of low muscularity at intensive care unit (ICU) admission. We hypothesize that ultrasound-based partial muscle mass assessments can reflect the trunk muscle mass. Therefore, we aimed to investigate whether ultrasound muscle mass measurements could reflect trunk muscle mass and identify patients with low muscularity. METHODS We performed a retrospective analysis of prospectively obtained ultrasound data at ICU admission. We included patients who underwent computed tomography (CT) imaging at the third lumbar vertebra (L3) within 2 days before and 2 days after ICU admission. Primary outcomes included the correlation between the femoral muscle mass measurements using ultrasound and the cross-sectional area (CSA) at L3 obtained by CT. Low muscularity was defined as a skeletal muscle index of 36.0 cm2/m2 for males and 29.0 cm2/m2 for females. Secondary outcomes included the correlation with the ultrasound measurements of the biceps brachii muscle mass and diaphragm thickness. RESULTS Among 133 patients, 89 underwent CT imaging, which included the L3. The patient mean age was 72 ± 13 years, and 60 patients (67%) were male. The correlation between the femoral muscle ultrasound and CT was ρ = 0.57 (p < 0.01, n = 89) and ρ = 0.48 (p < 0.01, n = 89) for quadriceps muscle layer thickness and rectus femoris muscle CSA, and these had the discriminative power to assess low muscularity, with the areas under the curve of 0.84 and 0.76, respectively. The ultrasound measurements of the biceps brachii muscle mass and diaphragm thickness were correlated with CT imaging [ρ = 0.57-0.60 (p < 0.01, n = 52) and ρ = 0.35 (p < 0.01, n = 79)]. CONCLUSIONS Ultrasound measurements of muscle mass were correlated with CT measurements, and the measurements of femoral muscle mass were useful to assess low muscularity at ICU admission. TRIAL REGISTRATION UMIN000044032 (retrospectively registered on April 25, 2021).
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Affiliation(s)
- Yuta Arai
- Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan; Department of Radiology, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan
| | - Nobuto Nakanishi
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan; Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan.
| | - Yuko Ono
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan
| | - Joji Kotani
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, 7-5-2 Kusunoki, Chuo-ward, Kobe, 650-0017, Japan
| | - Masafumi Harada
- Department of Radiology, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan
| | - Jun Oto
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima, 770-8503, Japan
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Umbrello M, Guglielmetti L, Formenti P, Antonucci E, Cereghini S, Filardo C, Montanari G, Muttini S. Qualitative and quantitative muscle ultrasound changes in patients with COVID-19-related ARDS. Nutrition 2021; 91-92:111449. [PMID: 34583135 PMCID: PMC8364677 DOI: 10.1016/j.nut.2021.111449] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/31/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Severe forms of the novel coronavirus-19 (COVID-19) are associated with systemic inflammation and hypercatabolism. The aims of this study were to compare the time course of the size and quality of both rectus femoris and diaphragm muscles between critically ill, COVID-19 survivors and non-survivors and to explore the correlation between the change in muscles size and quality with the amount of nutritional support delivered and the cumulative fluid balance. METHODS This was a prospective observational study in the general intensive care unit (ICU) of a tertiary care hospital for COVID-19. The right rectus femoris cross-sectional area and the right diaphragm thickness, as well as their echo densities were assessed within 24 h from ICU admission and on day 7. We recorded anthropometric and biochemical data, respiratory mechanics and gas exchange, daily fluid balance, and the number of calories and proteins administered. RESULTS Twenty-eight patients were analyzed (65 ± 10 y of age; 80% men, body mass index 30 ± 7.8 kg/m2). Rectus femoris and diaphragm sizes were significantly reduced at day 7 (median = -26.1 [interquartile ratio [IQR], = -37.8 to -15.2] and -29.2% [-37.8% to -19.6%], respectively) and this reduction was significantly higher in non-survivors. Both rectus femoris and diaphragm echo density were significantly increased at day 7, with a significantly higher increase in non-survivors. The change in both rectus femoris and diaphragm size at day 7 was related to the cumulative protein deficit (R = 0.664, P < 0.001 and R = 0.640, P < 0.001, respectively), whereas the change in rectus femoris and diaphragm echo density was related to the cumulative fluid balance (R = 0.734, P < 0.001 and R = 0.646, P < 0.001, respectively). CONCLUSIONS Early changes in muscle size and quality seem related to the outcome of critically ill COVID-19 patients, and to be influenced by nutritional and fluid management strategies.
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Affiliation(s)
- Michele Umbrello
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy.
| | - Luigi Guglielmetti
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Paolo Formenti
- U.O. Anestesia e Rianimazione I, Ospedale San Paolo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Edoardo Antonucci
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Sergio Cereghini
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Clelia Filardo
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Giulia Montanari
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
| | - Stefano Muttini
- U.O. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo - Polo Universitario, Milano, Italy
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De Marchi T, Frâncio F, Ferlito JV, Weigert R, de Oliveira C, Merlo AP, Pandini DL, Pasqual-Júnior BA, Giovanella D, Tomazoni SS, Leal-Junior EC. Effects of Photobiomodulation Therapy Combined with Static Magnetic Field in Severe COVID-19 Patients Requiring Intubation: A Pragmatic Randomized Placebo-Controlled Trial. J Inflamm Res 2021; 14:3569-3585. [PMID: 34335043 PMCID: PMC8318710 DOI: 10.2147/jir.s318758] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/10/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose We aimed to investigate the effects of photobiomodulation therapy combined with static magnetic field (PBMT-sMF) on the length of intensive care unit (ICU) stay and mortality rate of severe COVID-19 patients requiring invasive mechanical ventilation and assess its role in preserving respiratory muscles and modulating inflammatory processes. Patients and Methods We conducted a prospectively registered, triple-blinded, randomized, placebo-controlled trial of PBMT-sMF in severe COVID-19 ICU patients requiring invasive mechanical ventilation. Patients were randomly assigned to receive either PBMT-sMF or a placebo daily throughout their ICU stay. The primary outcome was length of ICU stay, defined by either discharge or death. The secondary outcomes were survival rate, diaphragm muscle function, and the changes in blood parameters, ventilatory parameters, and arterial blood gases. Results Thirty patients were included and equally randomized into the two groups. There were no significant differences in the length of ICU stay (mean difference, MD = −6.80; 95% CI = −18.71 to 5.11) between the groups. Among the secondary outcomes, significant differences were observed in diaphragm thickness, fraction of inspired oxygen, partial pressure of oxygen/fraction of inspired oxygen ratio, C-reactive protein levels, lymphocyte count, and hemoglobin (p < 0.05). Conclusion Among severe COVID-19 patients requiring invasive mechanical ventilation, the length of ICU stay was not significantly different between the PBMT-sMF and placebo groups. In contrast, PBMT-sMF was significantly associated with reduced diaphragm atrophy, improved ventilatory parameters and lymphocyte count, and decreased C-reactive protein levels and hemoglobin count. Trial Registration Number (Clinical Trials.gov) NCT04386694.
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Affiliation(s)
- Thiago De Marchi
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil.,Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Fabiano Frâncio
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil.,Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Renata Weigert
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Ana Paula Merlo
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | | | | | - Shaiane Silva Tomazoni
- Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
| | - Ernesto Cesar Leal-Junior
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil.,Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
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De Marchi T, Frâncio F, Ferlito JV, Weigert R, de Oliveira C, Merlo AP, Pandini DL, Pasqual-Júnior BA, Giovanella D, Tomazoni SS, Leal-Junior EC. Effects of Photobiomodulation Therapy Combined with Static Magnetic Field in Severe COVID-19 Patients Requiring Intubation: A Pragmatic Randomized Placebo-Controlled Trial. J Inflamm Res 2021; 14:3569-3585. [PMID: 34335043 DOI: 10.1101/2020.12.02.20237974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/10/2021] [Indexed: 05/28/2023] Open
Abstract
PURPOSE We aimed to investigate the effects of photobiomodulation therapy combined with static magnetic field (PBMT-sMF) on the length of intensive care unit (ICU) stay and mortality rate of severe COVID-19 patients requiring invasive mechanical ventilation and assess its role in preserving respiratory muscles and modulating inflammatory processes. PATIENTS AND METHODS We conducted a prospectively registered, triple-blinded, randomized, placebo-controlled trial of PBMT-sMF in severe COVID-19 ICU patients requiring invasive mechanical ventilation. Patients were randomly assigned to receive either PBMT-sMF or a placebo daily throughout their ICU stay. The primary outcome was length of ICU stay, defined by either discharge or death. The secondary outcomes were survival rate, diaphragm muscle function, and the changes in blood parameters, ventilatory parameters, and arterial blood gases. RESULTS Thirty patients were included and equally randomized into the two groups. There were no significant differences in the length of ICU stay (mean difference, MD = -6.80; 95% CI = -18.71 to 5.11) between the groups. Among the secondary outcomes, significant differences were observed in diaphragm thickness, fraction of inspired oxygen, partial pressure of oxygen/fraction of inspired oxygen ratio, C-reactive protein levels, lymphocyte count, and hemoglobin (p < 0.05). CONCLUSION Among severe COVID-19 patients requiring invasive mechanical ventilation, the length of ICU stay was not significantly different between the PBMT-sMF and placebo groups. In contrast, PBMT-sMF was significantly associated with reduced diaphragm atrophy, improved ventilatory parameters and lymphocyte count, and decreased C-reactive protein levels and hemoglobin count. TRIAL REGISTRATION NUMBER CLINICAL TRIALSGOV NCT04386694.
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Affiliation(s)
- Thiago De Marchi
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
| | - Fabiano Frâncio
- University Center of Bento Gonçalves (UNICNEC), Bento Gonçalves, Rio Grande do Sul, Brazil
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Renata Weigert
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | - Ana Paula Merlo
- Hospital Tacchini, Bento Gonçalves, Rio Grande do Sul, Brazil
| | | | | | | | - Shaiane Silva Tomazoni
- Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
| | - Ernesto Cesar Leal-Junior
- Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT), Post-graduate Program in Rehabilitation Sciences, Nove de Julho University, São Paulo, Brazil
- Physiotherapy Research Group, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- ELJ Consultancy, Scientific Consultants, São Paulo, Brazil
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Association of baseline diaphragm, rectus femoris and vastus intermedius muscle thickness with weaning from mechanical ventilation. Respir Med 2021; 185:106503. [PMID: 34166958 DOI: 10.1016/j.rmed.2021.106503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND To determine whether baseline diaphragm (Tdi), rectus femoris (RF) and vastus intermedius (VI) muscle thickness (TRF and TRF + VI) are associated with weaning success. MATERIAL AND METHODS Right Tdi, TRF and TRF + VI were measured by ultrasonography within 36 h of intubation and diaphragmatic excursion (DE) was evaluated at the first spontaneous breathing trial in adult critically-ill patients. Reintubation or death within 7 days after extubation was defined as weaning failure. Weaning failure and success groups were compared in terms of ultrasonographic measurements and clinical features. RESULTS Thirty-eight patients were assessed for weaning, 15 (39.4%) being in the weaning failure group. The median body mass index (BMI) was lower while the median clinical frailty scale (CFS), vasopressor use, duration of mechanical ventilation, intensive care and hospital mortality rate were higher in the weaning failure group, and the median TRF + VI (14.0 [12.3-26.2] vs 23.6 [21.3-27.1] mm, p = 0.03) and median DE (19.4 [14.6-24.0] vs 25.9 [19.3-38.5] mm, p = 0.045) were lower. The median Tdi was similar in two groups (1.9 [1.5-2.3] vs 2.0 [1.7-2.4] mm, p = 0.26). In ROC analysis, area under the curve for TRF + VI was 0.71 (95% CI: 0.51-0.90; p = 0.035), with 21 mm cut-off having sensitivity of 82% and specificity of 57%. Binary logistic regression analysis revealed TRF + VI < 21 mm as the only predictor of weaning failure with an odds ratio of 10.5 (95% CI: 1.1-97.8, p = 0.038) after adjusting for age, sex, BMI and CFS. CONCLUSIONS TRF + VI lower than 21 mm, measured by ultrasonography within 36 h of intubation, was associated with weaning failure among critically-ill patients.
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Diaphragm function in acute respiratory failure and the potential role of phrenic nerve stimulation. Curr Opin Crit Care 2021; 27:282-289. [PMID: 33899818 DOI: 10.1097/mcc.0000000000000828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review was to describe the risk factors for developing diaphragm dysfunction, discuss the monitoring techniques for diaphragm activity and function, and introduce potential strategies to incorporate diaphragm protection into conventional lung-protective mechanical ventilation strategies. RECENT FINDINGS It is increasingly apparent that an approach that addresses diaphragm-protective ventilations goals is needed to optimize ventilator management and improve patient outcomes. Ventilator-induced diaphragm dysfunction (VIDD) is common and is associated with increased ICU length of stay, prolonged weaning and increased mortality. Over-assistance, under-assistance and patient-ventilator dyssynchrony may have important downstream clinical consequences related to VIDD. Numerous monitoring techniques are available to assess diaphragm function, including respiratory system pressures, oesophageal manometry, diaphragm ultrasound and electromyography. Novel techniques including phrenic nerve stimulation may facilitate the achievement of lung and diaphragm-protective goals for mechanical ventilation. SUMMARY Diaphragm protection is an important consideration in optimizing ventilator management in patients with acute respiratory failure. The delicate balance between lung and diaphragm-protective goals is challenging. Phrenic nerve stimulation may be uniquely situated to achieve and balance these two commonly conflicting goals.
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Abstract
PURPOSE OF REVIEW Ventilator weaning forms an integral part in critical care medicine and strategies to shorten duration are rapidly evolving alongside our knowledge of the relevant physiological processes. The purpose of the current review is to discuss new physiological and clinical insights in ventilator weaning that help us to fasten liberation from mechanical ventilation. RECENT FINDINGS Several new concepts have been introduced in the field of ventilator weaning in the past 2 years. Approaches to shorten the time until ventilator liberation include frequent spontaneous breathing trials, early noninvasive mechanical ventilation to shorten invasive ventilation time, novel ventilatory modes, such as neurally adjusted ventilatory assist and drugs to enhance the contractile efficiency of respiratory muscles. Equally important, ultrasound has been shown to be a versatile tool to monitor physiological changes of the cardiorespiratory system during weaning and steer targeted interventions to improve extubation outcome. SUMMARY A thorough understanding of the physiological adaptations during withdrawal of positive pressure ventilation is extremely important for clinicians in the ICU. We summarize and discuss novel insights in this field.
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Corradi F, Isirdi A, Malacarne P, Santori G, Barbieri G, Romei C, Bove T, Vetrugno L, Falcone M, Bertini P, Guarracino F, Landoni G, Forfori F. Low diaphragm muscle mass predicts adverse outcome in patients hospitalized for COVID-19 pneumonia: an exploratory pilot study. Minerva Anestesiol 2021; 87:432-438. [PMID: 33594871 DOI: 10.23736/s0375-9393.21.15129-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether measurement of diaphragm thickness (DT) by ultrasonography may be a clinically useful noninvasive method for identifying patients at risk of adverse outcomes defined as need of invasive mechanical ventilation or death. METHODS We prospectively enrolled 77 patients with laboratory-confirmed COVID-19 infection admitted to our intermediate care unit in Pisa between March 5 and March 30, 2020, with follow-up until hospital discharge or death. Logistic regression was used identify variables potentially associated with adverse outcomes and those P<0.10 were entered into a multivariate logistic regression model. Cumulative probability for lack of adverse outcomes in patients with or without low baseline diaphragm muscle mass was calculated with the Kaplan-Meier product-limit estimator. RESULTS The main findings of this study are that: 1) patients who developed adverse outcomes had thinner diaphragm than those who did not (2.0 vs. 2.2 mm, P=0.001); and 2) DT and lymphocyte count were independent significant predictors of adverse outcomes, with end-expiratory DT being the strongest (ß=-708; OR=0.492; P=0.018). CONCLUSIONS Diaphragmatic ultrasound may be a valid tool to evaluate the risk of respiratory failure. Evaluating the need of mechanical ventilation treatment should be based not only on PaO<inf>2</inf>/FiO<inf>2</inf>, but on a more comprehensive assessment including DT because if the lungs become less compliant a thinner diaphragm, albeit free of intrinsic abnormality, may become exhausted, thus contributing to severe respiratory failure.
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Affiliation(s)
- Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy - .,E.O. Ospedali Galliera, Genoa, Italy -
| | - Alessandro Isirdi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.,E.O. Ospedali Galliera, Genoa, Italy
| | | | - Gregorio Santori
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Greta Barbieri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Udine, Italy
| | - Marco Falcone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | | | - Giovanni Landoni
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.,E.O. Ospedali Galliera, Genoa, Italy
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DE Robertis E, Cammarota G. Diaphragmatic ultrasound in COVID-19 patients: you will know it only if you try it! Minerva Anestesiol 2021; 87:394-396. [PMID: 33591155 DOI: 10.23736/s0375-9393.21.15573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Edoardo DE Robertis
- Section of Anaesthesia, Analgesia, and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy -
| | - Gianmaria Cammarota
- Section of Anaesthesia, Analgesia, and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Coiffard B, Riegler S, Sklar MC, Dres M, Vorona S, Reid WD, Brochard LJ, Ferguson ND, Goligher EC. Diaphragm echodensity in mechanically ventilated patients: a description of technique and outcomes. Crit Care 2021; 25:64. [PMID: 33593412 PMCID: PMC7884870 DOI: 10.1186/s13054-021-03494-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background Acute increases in muscle sonographic echodensity reflect muscle injury. Diaphragm echodensity has not been measured in mechanically ventilated patients. We undertook to develop a technique to characterize changes in diaphragm echodensity during mechanical ventilation and to assess whether these changes are correlated with prolonged mechanical ventilation. Methods Diaphragm ultrasound images were prospectively collected in mechanically ventilated patients and in 10 young healthy subjects. Echodensity was quantified based on the right-skewed distribution of grayscale values (50th percentile, ED50; 85th percentile, ED85). Intra- and inter-analyzer measurement reproducibility was determined. Outcomes recorded included duration of ventilation and ICU complications (including reintubation, tracheostomy, prolonged ventilation, or death). Results Echodensity measurements were obtained serially in 34 patients comprising a total of 104 images. Baseline (admission) diaphragm ED85 was increased in mechanically ventilated patients compared to younger healthy subjects (median 56, interquartile range (IQR) 42–84, vs. 39, IQR 36–52, p = 0.04). Patients with an initial increase in median echodensity over time (≥ + 10 in ED50 from baseline) had fewer ventilator-free days to day 60 (n = 13, median 46, IQR 0–52) compared to patients without this increase (n = 21, median 53 days, IQR 49–56, unadjusted p = 0.03). Both decreases and increases in diaphragm thickness during mechanical ventilation were associated with increases in ED50 over time (adjusted p = 0.03, conditional R2 = 0.80) and the association between increase in ED50 and outcomes persisted after adjusting for changes in diaphragm thickness. Conclusions Many patients exhibit increased diaphragm echodensity at the outset of mechanical ventilation. Increases in diaphragm echodensity during the early course of mechanical ventilation are associated with prolonged mechanical ventilation. Both decreases and increases in diaphragm thickness during mechanical ventilation are associated with increased echodensity.
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Affiliation(s)
- Benjamin Coiffard
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - Stephen Riegler
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - Michael C Sklar
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Martin Dres
- AP-HP, Service de Pneumologie, Médecine Intensive-Réanimation (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Stefannie Vorona
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - W Darlene Reid
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Laurent J Brochard
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Niall D Ferguson
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Ewan C Goligher
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada. .,Toronto General Hospital Research Institute, Toronto, Canada.
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Dianti J, Angriman F, Ferreyro BL, Sklar MC, Brochard L, Ferguson ND, Goligher EC. Association of Mortality with Neuromuscular Blockade Differs according to Baseline Diaphragm Thickness. Am J Respir Crit Care Med 2021; 202:1717-1720. [PMID: 32717150 DOI: 10.1164/rccm.202004-1157le] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jose Dianti
- University of Toronto Toronto, Ontario, Canada.,University Health Network Toronto, Ontario, Canada
| | - Federico Angriman
- University of Toronto Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre Toronto, Ontario, Canada
| | - Bruno L Ferreyro
- University of Toronto Toronto, Ontario, Canada.,Sinai Health System and University Health Network Toronto, Ontario, Canada
| | | | - Laurent Brochard
- University of Toronto Toronto, Ontario, Canada.,St. Michael's Hospital Toronto, Ontario, Canada and
| | - Niall D Ferguson
- University of Toronto Toronto, Ontario, Canada.,University Health Network Toronto, Ontario, Canada.,Toronto General Hospital Research Institute Toronto, Ontario, Canada
| | - Ewan C Goligher
- University of Toronto Toronto, Ontario, Canada.,University Health Network Toronto, Ontario, Canada.,Toronto General Hospital Research Institute Toronto, Ontario, Canada
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Point-of-Care Ultrasound: Applications in Low- and Middle-Income Countries. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:69-75. [PMID: 33424456 PMCID: PMC7785781 DOI: 10.1007/s40140-020-00429-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/31/2023]
Abstract
Purpose of Review This review highlights the applications of point-of-care ultrasound in low- and middle-income countries and shows the diversity of ultrasound in the diagnosis and management of patients. Recent Findings There is a paucity of data on point-of-care ultrasound in anesthesiology in low- and middle-income countries. However, research has shown that point-of-care ultrasound can effectively help manage infectious diseases, as well as abdominal and pulmonary pathologies. Summary Point-of-care ultrasound is a low-cost imaging modality that can be used for the diagnosis and management of diseases that affect low- and middle-income countries. There is limited data on the use of ultrasound in anesthesiology, which provides clinicians and researchers opportunity to study its use during the perioperative period.
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Goligher EC, Dres M, Patel BK, Sahetya SK, Beitler JR, Telias I, Yoshida T, Vaporidi K, Grieco DL, Schepens T, Grasselli G, Spadaro S, Dianti J, Amato M, Bellani G, Demoule A, Fan E, Ferguson ND, Georgopoulos D, Guérin C, Khemani RG, Laghi F, Mercat A, Mojoli F, Ottenheijm CAC, Jaber S, Heunks L, Mancebo J, Mauri T, Pesenti A, Brochard L. Lung- and Diaphragm-Protective Ventilation. Am J Respir Crit Care Med 2020; 202:950-961. [PMID: 32516052 DOI: 10.1164/rccm.202003-0655cp] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Martin Dres
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, ICU, St. Anne's Archbishop Hospital, University of Ferrara, Ferrara, Italy
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Intensive Care Unit, Department of Medicine, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Amato
- Laboratório de Pneumologia, Laboratório de Investicação Médica 9, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alexandre Demoule
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hopital Edouard Herriot Lyon, Faculté de Médecine Lyon-Est, Université de Lyon, Institut National de la Santé et de la Recherche Médicale 955 Créteil, Lyon, France
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Stritch School of Medicine, Loyola University, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier d'Angers, Angers, France
| | - Francesco Mojoli
- Department of Anesthesia and Intensive Care, Scientific Hospitalization and Care Institute, San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | | | - Samir Jaber
- Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, Montpellier University Hospital Center, University of Montpellier, Joint Research Unit 9214, National Institute of Health and Medical Research U1046, National Scientific Research Center, Montpellier, France; and
| | - Leo Heunks
- Department of Intensive Care, Vrije University Location, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jordi Mancebo
- Servei de Medicina Intensiva Hospital de Sant Pau, Barcelona, Spain
| | - Tommaso Mauri
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Antonio Pesenti
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Abstract
The 2019-2020 coronavirus pandemic elucidated how a single highly infectious virus can overburden health care systems of even highly economically developed nations. A leading contributor to these concerning outcomes is a lack of available intensive care unit (ICU) beds and mechanical ventilation support. Poorer health is associated with a higher risk for severe respiratory complications from the coronavirus. We hypothesize that impaired respiratory muscle performance is an underappreciated factor contributing to poor outcomes unfolding during the coronavirus pandemic. Although impaired respiratory muscle performance is considered to be rare, it is more frequently encountered in patients with poorer health, in particular obesity. However, measures of respiratory muscle performance are not routinely performed in clinical practice, including those with symptoms such as dyspnea. The purpose of this article is to discuss the potential role of respiratory muscle performance from the perspective of the coronavirus pandemic. We also provide a theoretical patient management model to screen for impaired respiratory muscle performance and intervention, if identified, with the goal of unburdening health care systems during future pandemic crises.
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