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Mu H, Zhang Q. The Application of Diaphragm Ultrasound in Chronic Obstructive Pulmonary Disease: A Narrative Review. COPD 2024; 21:2331202. [PMID: 38634575 DOI: 10.1080/15412555.2024.2331202] [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: 12/18/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a prevalent condition that poses a significant burden on individuals and society due to its high morbidity and mortality rates. The diaphragm is the main respiratory muscle, its function has a direct impact on the quality of life and prognosis of COPD patients. This article aims to review the structural measurement and functional evaluation methods through the use of diaphragmatic ultrasound and relevant research on its application in clinical practice for COPD patients. Thus, it serves to provide valuable insights for clinical monitoring of diaphragm function in COPD patients, facilitating early clinical intervention and aiding in the recovery of diaphragm function.
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Affiliation(s)
- Heng Mu
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
- State Key Laboratory of Ultrasound in Medicine and Engineering of Chongqing Medical University, Chongqing, PR China
| | - Qunxia Zhang
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
- State Key Laboratory of Ultrasound in Medicine and Engineering of Chongqing Medical University, Chongqing, PR China
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Qu LL, Zhao WP, Li JP, Zhang W. Predictive value of diaphragm ultrasound for mechanical ventilation outcome in patients with acute exacerbation of chronic obstructive pulmonary disease. World J Clin Cases 2024; 12:5893-5900. [DOI: 10.12998/wjcc.v12.i26.5893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/07/2024] [Accepted: 07/01/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is often combined with respiratory failure, which increases the patient's morbidity and mortality. Diaphragm ultrasound (DUS) has developed rapidly in the field of critical care in recent years. Studies with DUS monitoring diaphragm-related rapid shallow breathing index have demonstrated important results in guiding intensive care unit patients out of the ventilator. Early prediction of the indications for withdrawal of non-invasive ventilator and early evaluation of patients to avoid or reduce disease progression are very important.
AIM To explore the predictive value of DUS indexes for non-invasive ventilation outcome in patients with AECOPD.
METHODS Ninety-four patients with AECOPD who received mechanical ventilation in our hospital from January 2022 to December 2023 were retrospectively analyzed, and they were divided into a successful ventilation group (68 cases) and a failed ventilation group (26 cases) according to the outcome of ventilation. The clinical data of patients with successful and failed noninvasive ventilation were compared, and the independent predictors of noninvasive ventilation outcomes in AECOPD patients were identified by multivariate logistic regression analysis.
RESULTS There were no significant differences in gender, age, body mass index, complications, systolic pressure, heart rate, mean arterial pressure, respiratory rate, oxygen saturation, partial pressure of oxygen, oxygenation index, or time of inspiration between patients with successful and failed mechanical ventilation (P > 0.05). The patients with successful noninvasive ventilation had shorter hospital stays and lower partial pressure of carbon dioxide (PaCO2) than those with failed treatment, while potential of hydrogen (pH), diaphragm thickening fraction (DTF), diaphragm activity, and diaphragm movement time were significantly higher than those with failed treatment (P < 0.05). pH [odds ratio (OR) = 0.005, P < 0.05], PaCO2 (OR = 0.430, P < 0.05), and DTF (OR = 0.570, P < 0.05) were identified to be independent factors influencing the outcome of mechanical ventilation in AECOPD patients.
CONCLUSION The DUS index DTF can better predict the outcome of non-invasive ventilation in AECOPD patients.
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Affiliation(s)
- Lei-Lei Qu
- The First Department of Respiratory and Critical Care Medical Center, The First People's Hospital of Baiyin City, Baiyin 730900, Gansu Province, China
| | - Wen-Ping Zhao
- Department of Nursing, The First People's Hospital of Baiyin City, Baiyin 730900, Gansu Province, China
| | - Ji-Ping Li
- The First Department of Respiratory and Critical Care Medical Center, The First People's Hospital of Baiyin City, Baiyin 730900, Gansu Province, China
| | - Wei Zhang
- The First Department of Respiratory and Critical Care Medical Center, The First People's Hospital of Baiyin City, Baiyin 730900, Gansu Province, China
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Itagaki T, Akimoto Y, Takashima T, Oto J. Ultrasonographic Assessment of the Diaphragm. Diagnostics (Basel) 2024; 14:1481. [PMID: 39061618 PMCID: PMC11276413 DOI: 10.3390/diagnostics14141481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Mechanical ventilation injures not only the lungs but also the diaphragm, resulting in dysfunction associated with poor outcomes. Diaphragm ultrasonography is a noninvasive, cost-effective, and reproducible diagnostic method used to monitor the condition and function of the diaphragm. With advances in ultrasound technology and the expansion of its clinical applications, diaphragm ultrasonography has become increasingly important as a tool to visualize and quantify diaphragmatic morphology and function across multiple medical specialties, including pulmonology, critical care, and rehabilitation medicine. This comprehensive review aims to provide an in-depth analysis of the role and limitations of ultrasonography in assessing the diaphragm, especially among critically ill patients. Furthermore, we discuss a recently published expert consensus and provide a perspective for the future.
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Affiliation(s)
- Taiga Itagaki
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
| | - Yusuke Akimoto
- Emergency Department, Tokushima Prefectural Miyoshi Hospital, 815-2 Ikedacho Shima, Miyoshi 778-0005, Japan;
| | - Takuya Takashima
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate Hospital of Biomedical Sciences, 3-18-15 Kuramoto, Tokushima 770-8503, Japan; (T.T.); (J.O.)
| | - Jun Oto
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate Hospital of Biomedical Sciences, 3-18-15 Kuramoto, Tokushima 770-8503, Japan; (T.T.); (J.O.)
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Hu J, Guo R, Li H, Wen H, Wang Y. Perioperative Diaphragm Dysfunction. J Clin Med 2024; 13:519. [PMID: 38256653 PMCID: PMC10816119 DOI: 10.3390/jcm13020519] [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: 11/06/2023] [Revised: 01/07/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
Diaphragm Dysfunction (DD) is a respiratory disorder with multiple causes. Although both unilateral and bilateral DD could ultimately lead to respiratory failure, the former is more common. Increasing research has recently delved into perioperative diaphragm protection. It has been established that DD promotes atelectasis development by affecting lung and chest wall mechanics. Diaphragm function must be specifically assessed for clinicians to optimally select an anesthetic approach, prepare for adequate monitoring, and implement the perioperative plan. Recent technological advancements, including dynamic MRI, ultrasound, and esophageal manometry, have critically aided disease diagnosis and management. In this context, it is noteworthy that therapeutic approaches for DD vary depending on its etiology and include various interventions, either noninvasive or invasive, aimed at promoting diaphragm recruitment. This review aims to unravel alternative anesthetic and operative strategies that minimize postoperative dysfunction by elucidating the identification of patients at a higher risk of DD and procedures that could cause postoperative DD, facilitating the recognition and avoidance of anesthetic and surgical interventions likely to impair diaphragmatic function.
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Affiliation(s)
- Jinge Hu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China;
| | - Ruijuan Guo
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
| | - Huili Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
| | - Hong Wen
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China;
| | - Yun Wang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China; (J.H.); (R.G.); (H.L.)
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Toledo TG, Bacci MR. Value of Diaphragm Ultrasonography for Extubation: A Single-Blinded Randomized Clinical Trial. Crit Care Res Pract 2023; 2023:8403971. [PMID: 37766780 PMCID: PMC10522420 DOI: 10.1155/2023/8403971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Daily evaluation of mechanically ventilated (MV) patients is essential for successful extubation. Proper withdrawal prevents complications and reduces the cost of hospitalization in the intensive care unit (ICU). Diaphragm ultrasonography (DUS) has emerged as a potential instrument for determining whether a patient is ready to be extubated. This study compared the efficacy rate of extubation using a standard withdrawal protocol and DUS in patients with MV. Methods A randomized, parallel, single-blind, controlled study was conducted on ICU patients undergoing MV. Patients were randomly assigned to either the control (conventional weaning protocol) group or intervention (DUS-guided weaning) group in a 1 : 1 ratio. The primary outcome measure was the rate of reintubation and hospital mortality. Results Forty patients were randomized to the trial. The mean age of the sample was 70 years, representing an older population. The extubation success rate was 90% in both groups. There was no reintubation in the first 48 hours and only two reintubations in both groups between the second and seventh days. The hospital mortality risk in patients with acute kidney injury was positively correlated with age and the need for hemodialysis. Discussion. This study demonstrates the usefulness of DUS measurement protocols for withdrawing MV. The rate of reintubation was low for both cessation methods. As a parameter, the diaphragm thickness fraction comprehensively evaluates the diaphragm function. The results demonstrate that DUS has the potential to serve as a noninvasive tool for guiding extubation decisions. In conclusion, using DUS in patients with respiratory failure revealed no difference in reintubation rates or mortality compared with the conventional method. Future research should concentrate on larger, multicentered, randomized trials employing a multimodal strategy that combines diaphragmatic parameters with traditional clinical withdrawal indices.
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Affiliation(s)
| | - M. R. Bacci
- Centro Universitario FMABC, Santo Andre, Brazil
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Parada-Gereda HM, Tibaduiza AL, Rico-Mendoza A, Molano-Franco D, Nieto VH, Arias-Ortiz WA, Perez-Terán P, Masclans JR. Effectiveness of diaphragmatic ultrasound as a predictor of successful weaning from mechanical ventilation: a systematic review and meta-analysis. Crit Care 2023; 27:174. [PMID: 37147688 PMCID: PMC10161591 DOI: 10.1186/s13054-023-04430-9] [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: 12/23/2022] [Accepted: 04/04/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Several measurements have been used to predict the success of weaning from mechanical ventilation; however, their efficacy varies in different studies. In recent years, diaphragmatic ultrasound has been used for this purpose. We conducted a systematic review and meta-analysis to evaluate the effectiveness of diaphragmatic ultrasound in predicting the success of weaning from mechanical ventilation. METHODS Two investigators independently searched PUBMED, TRIP, EMBASE, COCHRANE, SCIENCE DIRECT, and LILACS for articles published between January 2016 and July 2022. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool; additionally, the certainty of the evidence is evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. Sensitivity and specificity analysis was performed for diaphragmatic excursion and diaphragmatic thickening fraction; positive and negative likelihood ratios and diagnostic odds ratios (DOR) with their confidence intervals (95% CI) were calculated by random effects analysis, summary receiver operating characteristic curve was estimated. Sources of heterogeneity were explored by subgroup analysis and bivariate meta-regression. RESULTS Twenty-six studies were included, of which 19 were included in the meta-analysis (1204 patients). For diaphragmatic excursion, sensitivity was 0.80 (95% CI 0.77-0.83), specificity 0.80 (95% CI 0.75-0.84), area under the summary receiver operating characteristic curve 0.87 and DOR 17.1 (95% CI 10.2-28.6). For the thickening fraction, sensitivity was 0.85 (95% CI 0.82-0.87), specificity 0.75 (95% CI 0.69-0.80), area under the summary receiver operating characteristic curve 0.87 and DOR 17.2 (95% CI 9.16-32.3). There was heterogeneity among the included studies. When performing a subgroup analysis and excluding studies with atypical cutoff values, sensitivity and specificity increased for diaphragmatic thickening fraction; sensitivity increased and specificity decreased for diaphragmatic excursion; when comparing studies using pressure support (PS) versus T-tube, there was no significant difference in sensitivity and specificity; bivariate meta-regression analysis shows that patient position at the time of testing was a factor of heterogeneity in the included studies. CONCLUSIONS Measurement of diaphragmatic excursion and diaphragmatic thickening fraction predict the probability of successful weaning from mechanical ventilation with satisfactory diagnostic accuracy; however, significant heterogeneity was evident in the different included studies. Studies of high methodological quality in specific subgroups of patients in intensive care units are needed to evaluate the role of diaphragmatic ultrasound as a predictor of weaning from mechanical ventilation.
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Affiliation(s)
- Henry M Parada-Gereda
- Intensive Care Unit Clínica Reina Sofia, Clínica Colsanitas, Grupo de Investigación en Nutrición Clínica y Rehabilitación, Fundación Universitaria Sanitas, Keralty Bogotá- Colombia, Universidad del Rosario Bogotá- Colombia, Faculty of Medicine. Research group Medicina Comunitaria y Salud Colectiva Universidad El Bosque, Bogotá, Colombia.
| | - Adriana L Tibaduiza
- Physician Subinvestigator Oficina de Investigaciones Hospital San Ignacio, Bogotá, Colombia
| | - Alejandro Rico-Mendoza
- Epidemiology Master's Degree Coordinator. Universidad El Bosque. Faculty of Medicine. Research group Medicina Comunitaria y Salud Colectiva. Bogotá Colombia, Universidad El Bosque, Bogotá, Colombia
| | - Daniel Molano-Franco
- Intensive Care Cobos Medical Center - Universidad El Bosque, group Recerca-GRIBOS, Bogota, Colombia
| | - Victor H Nieto
- Intensive Care Cobos Medical Center - Universidad El Bosque, group Recerca-GRIBOS, Bogota, Colombia
- Head of Intensive Care Unit Centro de Tratamento e Investigación sobre Cáncer CTIC, group Recerca- GRIBOS, Bogotá, Colombia
| | - Wanderley A Arias-Ortiz
- Master in Epidemiology, Specialist in Applied Statistics, Universidad El Bosque. Faculty of Medicine. Research group Medicina Comunitaria y Salud Colectiva, Bogotá, Colombia
| | - Purificación Perez-Terán
- Critical Care Department Hospital del Mar-Parc de Salut MAR. GREPAC-Group Recerca Departamento de Medicina y Ciencias de la Vida Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Joan R Masclans
- Critical Care Department Hospital del Mar-Parc de Salut MAR. GREPAC-Group Recerca Departamento de Medicina y Ciencias de la Vida Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Director de Docencia PSMAR, Intensive Care Unit Hospital del Mar. Professor of Medicine Universitat Pompeu Fabra (UPF) IMIM (GREPAC - Group Recerca Patologia Critica) Departamento de Medicina Y Ciencias de la Vida (MELIS), Universidad Pompeu Fabra (UPF), Barcelona, Spain
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Safai Zadeh E, Görg C, Prosch H, Horn R, Jenssen C, Dietrich CF. The Role of Thoracic Ultrasound for Diagnosis of Diseases of the Chest Wall, the Mediastinum, and the Diaphragm-Narrative Review and Pictorial Essay. Diagnostics (Basel) 2023; 13:767. [PMID: 36832255 PMCID: PMC9956010 DOI: 10.3390/diagnostics13040767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/29/2023] [Accepted: 02/08/2023] [Indexed: 02/22/2023] Open
Abstract
The diagnostic capabilities of ultrasound extend far beyond the evaluation of the pleural space and lungs. Sonographic evaluation of the chest wall is a classic extension of the clinical examination of visible, palpable, or dolent findings. Unclear mass lesions of the chest wall can be differentiated accurately and with low risk by additional techniques such as color Doppler imaging, contrast-enhanced ultrasound, and, in particular, ultrasound-guided biopsy. For imaging of mediastinal pathologies, ultrasound has only a complementary function but is valuable for guidance of percutaneous biopsies of malignant masses. In emergency medicine, ultrasound can verify and support correct positioning of endotracheal tubes. Diaphragmatic ultrasound benefits from the real-time nature of sonographic imaging and is becoming increasingly important for the assessment of diaphragmatic function in long-term ventilated patients. The clinical role of thoracic ultrasound is reviewed in a combination of narrative review and pictorial essay.
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Affiliation(s)
- Ehsan Safai Zadeh
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | - Christian Görg
- Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, Interdisciplinary Center of Ultrasound Diagnostics, University Hospital Giessen and Marburg, Philipps University Marburg, Baldingerstraße, 35033 Marburg, Germany
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria
| | - Rudolf Horn
- Center da Sandà Val Müstair, 7536 Sta. Maria, Switzerland
| | - Christian Jenssen
- Medical Department, Krankenhaus Maerkisch-Oderland, 15344 Strausberg, Germany
- Brandenburg Institute of Clinical Ultrasound, Medical University Brandenburg, 16816 Neuruppin, Germany
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Bern, Beau Site, Salem und Permanence, 3018 Bern, Switzerland
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Truong D, Abo S, Whish-Wilson GA, D'Souza AN, Beach LJ, Mathur S, Mayer KP, Ntoumenopoulos G, Baldwin C, El-Ansary D, Paris MT, Mourtzakis M, Morris PE, Pastva AM, Granger CL, Parry SM, Sarwal A. Methodological and Clinimetric Evaluation of Inspiratory Respiratory Muscle Ultrasound in the Critical Care Setting: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:e24-e36. [PMID: 36661463 PMCID: PMC11210606 DOI: 10.1097/ccm.0000000000005739] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Significant variations exist in the use of respiratory muscle ultrasound in intensive care with no society-level consensus on the optimal methodology. This systematic review aims to evaluate, synthesize, and compare the clinimetric properties of different image acquisition and analysis methodologies. DATA SOURCES Systematic search of five databases up to November 24, 2021. STUDY SELECTION Studies were included if they enrolled at least 50 adult ICU patients, reported respiratory muscle (diaphragm or intercostal) ultrasound measuring either echotexture, muscle thickness, thickening fraction, or excursion, and evaluated at least one clinimetric property. Two independent reviewers assessed titles, abstracts, and full text against eligibility. DATA EXTRACTION Study demographics, ultrasound methodologies, and clinimetric data. DATA SYNTHESIS Sixty studies, including 5,025 patients, were included with 39 studies contributing to meta-analyses. Most commonly measured was diaphragm thickness (DT) or diaphragm thickening fraction (DTF) using a linear transducer in B-mode, or diaphragm excursion (DE) using a curvilinear transducer in M-mode. There are significant variations in imaging methodology and acquisition across all studies. Inter- and intrarater measurement reliabilities were generally excellent, with the highest reliability reported for DT (ICC, 0.98; 95% CI, 0.94-0.99). Pooled data demonstrated acceptable to excellent accuracy for DT, DTF, and DE to predicting weaning outcome after 48 to 72 hours postextubation (DTF AUC, 0.79; 95% CI, 0.73-0.85). DT imaging was responsive to change over time. Only three eligible studies were available for intercostal muscles. Intercostal thickening fraction was shown to have excellent accuracy of predicting weaning outcome after 48-hour postextubation (AUC, 0.84; 95% CI, 0.78-0.91). CONCLUSIONS Diaphragm muscle ultrasound is reliable, valid, and responsive in ICU patients, but significant variation exists in the imaging acquisition and analysis methodologies. Future work should focus on developing standardized protocols for ultrasound imaging and consider further research into the role of intercostal muscle imaging.
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Affiliation(s)
- Dominic Truong
- Department of Physiotherapy, The University of Melbourne, Parkville, VIC, Australia
| | - Shaza Abo
- Department of Physiotherapy, The University of Melbourne, Parkville, VIC, Australia
| | | | - Aruska N D'Souza
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Lisa J Beach
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Sunita Mathur
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY
| | | | - Claire Baldwin
- Caring Futures Institute and College of Nursing and Health Sciences, Flinders University, Bedford Park, SA, Australia
| | - Doa El-Ansary
- Department of Surgery, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- School of Health Sciences, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Michael T Paris
- School of Kinesiology, University of Western Ontario, London, ON, Canada
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Marina Mourtzakis
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Peter E Morris
- Division of Pulmonary, Allergy, and Critical Care Medicine, Heersink School of Medicine, University of Alabama, Birmingham, AL
| | | | - Catherine L Granger
- Department of Physiotherapy, The University of Melbourne, Parkville, VIC, Australia
- Department of Physiotherapy, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Parkville, VIC, Australia
| | - Aarti Sarwal
- Atrium Wake Forest School of Medicine, Winston Salem, NC
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Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure. Diagnostics (Basel) 2023; 13:diagnostics13030411. [PMID: 36766515 PMCID: PMC9914801 DOI: 10.3390/diagnostics13030411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying etiologies. In these cases, many factors related to systemic inflammation, prolonged use of steroids, and lung mechanical abnormalities (such as hyperinflation or increased elastic recoil due to pulmonary oedema or fibrosis) may act as synergic mechanisms leading to diaphragm dysfunction. The assessment of diaphragm function with ultrasound has been increasingly investigated in the emergency department and during hospital stay as a valuable tool for providing additional anatomical and functional information in many acute respiratory diseases. The diaphragmatic ultrasound is a noninvasive and repeatable bedside tool, has no contraindications, and allows the physician to rapidly assess the presence of diaphragmatic dysfunction; this evaluation may help in estimating the need for mechanical ventilation (and the risk of weaning failure), as well as the risk of longer hospital stay and higher mortality rate. This study presents an overview of the recent evidence regarding the evaluation of diaphragmatic function with bedside ultrasound and its clinical applications, including a discussion of real-life clinical cases.
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Laguado-Nieto MA, Roberto-Avilán SL, Naranjo-Junoy F, Meléndez-Flórez HJ, Lozada-Martinez ID, Domínguez-Alvarado GA, Campos-Castillo VA, Ríos-Orozco SU, Narváez-Rojas AR. Diaphragmatic Dynamics and Thickness Parameters Assessed by Ultrasonography Predict Extubation Success in Critically Ill Patients. CLINICAL MEDICINE INSIGHTS: CIRCULATORY, RESPIRATORY AND PULMONARY MEDICINE 2023; 17:11795484231165940. [PMID: 37008792 PMCID: PMC10052899 DOI: 10.1177/11795484231165940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION A frequent cause of weaning and extubation failure in critically ill mechanically ventilated patients is diaphragm muscle dysfunction. Ultrasound (US) evaluation of the diaphragm yields important data regarding its thickness (diaphragm thickening fraction [TFdi]) and its movement or excursion (diaphragmatic dynamics) that reveal the presence of diaphragmatic dysfunction. METHODS Cross-sectional study, which included patients older than 18 years with invasive mechanical ventilation with an expected duration of more than 48 h, in a tertiary referral center in Colombia. The excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi were evaluated by US. Prevalence and use of medications were evaluated, and the association with failure in ventilatory weaning and extubation was analyzed. RESULTS Sixty-one patients were included. The median age and APACHE IV score were 62.42 years and 78.23, respectively. The prevalence of diaphragmatic dysfunction (assessed by excursion and TFdi) was 40.98%. The sensibility, specificity, positive predictive value, and negative predictive value for TFdi < 20% was 86%, 24%, 75%, and 40%, respectively, with an area under the receiver operating characteristic (ROC) curve of 0.6. The ultrasonographic analysis of excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi (>20%) allow in its set and with normal values, predict success or failure for the extubation with an area under the ROC curve of 0.87. CONCLUSION Diaphragmatic dynamics and thickness parameters together assessed by ultrasonography could predict the success of extubation in critically ill patients in Colombia, based on the finding of diaphragmatic dysfunction.
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Affiliation(s)
| | | | - Francisco Naranjo-Junoy
- Department of Critical Medicine and Intensive Care, FOSCAL International Clinic, Bucaramanga, Colombia
| | | | - Ivan David Lozada-Martinez
- Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia
- Grupo Prometheus y Biomedicina Aplicada a las Ciencias Clínicas, School of Medicine, Universidad de Cartagena, Cartagena, Colombia
- International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
| | | | | | | | - Alexis Rafael Narváez-Rojas
- International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
- Division of Breast Surgical Oncology, DeWitt Daughtry Family Department of Surgery, Jackson Health System / University of Miami Miller School of Medicine, Miami, FL, USA
- Alexis Rafael Narvaez-Rojas, International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua; Breast Surgical Oncology Division, DeWitt Daughtry Family Department of Surgery, Jackson Health System / University of Miami Miller School of Medicine, FL, USA.
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11
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Erfan A, Khalil M, Elmaraghy A, Abd Elkader M. Ultrasonographic assessment of diaphragmatic performance in two chronic obstructive pulmonary disease phenotypes admitted with acute exacerbation and its relation to outcome. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2023. [DOI: 10.4103/ecdt.ecdt_57_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
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12
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Song J, Qian Z, Zhang H, Wang M, Yu Y, Ye C, Hu W, Gong S. Diaphragmatic ultrasonography-based rapid shallow breathing index for predicting weaning outcome during a pressure support ventilation spontaneous breathing trial. BMC Pulm Med 2022; 22:337. [PMID: 36071420 PMCID: PMC9450260 DOI: 10.1186/s12890-022-02133-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background The optimum timing to wean is crucial to avoid negative outcomes for mechanically ventilated patients. The rapid shallow breathing index (RSBI), a widely used weaning index, has limitations in predicting weaning outcomes. By replacing the tidal volume of the RSBI with diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) assessed by ultrasonography, we calculated two weaning indices, the diaphragmatic excursion rapid shallow breathing index (DE-RSBI, respiratory rate [RR]/DE) and the diaphragm thickening fraction rapid shallow breathing index (DTF-RSBI, RR/DTF). The aim of this study was to evaluate the predictive values of DTF-RSBI, DE-RSBI and traditional RSBI in weaning failure. Methods This prospective observational study included patients undergoing mechanical ventilation (MV) for > 48 h and who were readied for weaning. During a pressure support ventilation (PSV) spontaneous breathing trial (SBT), right hemidiaphragmatic excursion and DTF were measured by bedside ultrasonography as well as RSBI. Weaning failure was defined as: (1) failing the SBT and (2) SBT success but inability to maintain spontaneous breathing for more than 48 h without noninvasive or invasive ventilation. A receiver operator characteristic (ROC) curve was used for analyzing the diagnostic accuracy of RSBI, DE-RSBI, and DTF-RSBI. Results Of the 110 patients studied, 37 patients (33.6%) failed weaning. The area under the ROC (AUROC) curves for RSBI, DE-RSBI, and DTF-RSBI for predicting failed weaning were 0.639, 0.813, and 0.859, respectively. The AUROC curves for DE-RSBI and DTF-RSBI were significantly higher than for RSBI (P = 0.004 and P < 0.001, respectively). The best cut-off values for predicting failed weaning were RSBI > 51.2 breaths/min/L, DE-RSBI > 1.38 breaths/min/mm, and DTF-RSBI > 78.1 breaths/min/%. Conclusions In this study, two weaning indices determined by bedside ultrasonography, the DE-RSBI (RR/DE) and DTF-RSBI (RR/DTF), were shown to be more accurate than the traditional RSBI (RR/VT) in predicting weaning outcome during a PSV SBT. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02133-5.
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Affiliation(s)
- Jia Song
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Xihu District, Hangzhou, 310013, Zhejiang, China
| | - Zhixian Qian
- Department of Cardiovascular Medicine, Xinchang People's Hospital, No. 117, Gushan Road, Nanming St, Xinchang, 312500, China
| | - Haixiang Zhang
- Department of Gastroenterology and Hepatology, The First People's Hospital of Xiaoshan District, No. 199, Shixin Road, Xiaoshan District, Hangzhou, 311203, China
| | - Minjia Wang
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Xihu District, Hangzhou, 310013, Zhejiang, China
| | - Yihua Yu
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Xihu District, Hangzhou, 310013, Zhejiang, China
| | - Cong Ye
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Xihu District, Hangzhou, 310013, Zhejiang, China
| | - Weihang Hu
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Xihu District, Hangzhou, 310013, Zhejiang, China
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Xihu District, Hangzhou, 310013, Zhejiang, China.
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ALTINKAYA ÇAVUŞ M, GÖKBULUT BEKTAŞ Ş, SİPAHİOĞLU H, ERTÜRK ZARARSIZ G, TURAN S. Diyafram ultrasonografisinin weaning başarısını tahmin etmedeki gücü. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1037159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amaç: Bu çalışmada amaç; diyafram kalınlığının weaning üzerine etkilerini ultrasonografi (USG) ile değerlendirmektir.
Gereç ve Yöntem: Prospektif olarak yapılan bu çalışmada; hastaların demografik özellikleri, yoğun bakıma yatış ve mekanik ventilasyon endikasyonları, ek hastalıkları, diyafram kalınlığı, Sıralı Organ Yetmezliği Değerlendirmesi (SOFA) skoru ve Basitleştirilmiş Akut Fizyoloji Skoru (SAPS) II, mortalite oranı, periferik oksijen satürasyonu (SpO2), IMV süresi, dakika hacmi, solunum sayısı (RR), ekspiratuar hacimleri, RSBI değerleri kaydedildi.Hastalar invaziv mekanik ventilatör (IMV) basınç desteği (PS) modunda 30 dakika boyunca spontan olarak ventile edildi . Diyafram kalınlığı (DT), B moduna ayarlanmış 7-10 MHz lineer ultrason probu kullanılarak ölçüldü. Sağ hemidiyafram, 8. ve 10. interkostal boşluklar arasındaki midaksiller çizgide diyafram ve göğüs kafesinin birleştiği bölgede görüntülendi. Ölçümler sonrasında hastalar stabil hale geldikten sonra 1 saat boyunca T-tüpe alındı. T-tüpte spontan solunum denemeleri (SBT)'ni başarıyla tamamlayan hastalar ekstübe edildi. Hastalar başarılı ve başarısız weaning olmak üzere 2 gruba ayrıldı.
Bulgular: Toplam 72 hasta çalışmaya dahil edilme kriterlerini sağlayarak değerlendirilmeye alındı. Hastaların 4 tanesi 24 saatten daha kısa süre IMV desteği aldığı için çalışma dışı bırakıldı. Diyafram kalınlık indeksi (DTI) ve diyafram kalınlaşma fraksiyonu (DTF) oranlarında gruplar arasında bir farklılık gözlenmedi. İnspirasyon sonunu diyafram kalınlığı (DTV) ve ekspirasyon sonunu diyafram kalınlığı (DFRV) olarak tanımlanan diyaframın kalınlık ölçümleri başarılı weaning grubunda daha yüksekti. Weaning başarısını tahmin etmek için DTV'nin en iyi eşik değeri 0.72, DFRV değeri 0.669 olarak bulundu.
Sonuç: Weaning başarısı diyafram fonksiyonları, diyafram kalınlık parametreleri ve akciğer kapasiteleri ile yakından ilişkilidir. USG, diyaframı değerlendirmek için kullanılabilecek pratik, hasta başı uygulanabilen, noninvaziv bir yöntemdir. DTV ve DFRV weaning sürecinde başarıyı tahmin edebilecek parametreler arasındadır. DTF ve DTI weaning başarısını öngörmede yetersiz bulundu.
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Affiliation(s)
- Mine ALTINKAYA ÇAVUŞ
- Department of Intensive Care, University of Health Sciences, Kayseri City Hospital, Kayseri, Turkey
| | | | - Hilal SİPAHİOĞLU
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, KAYSERİ SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | | | - Sema TURAN
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
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Jia Y, Zhang Q. Research Progress on Diaphragm Ultrasound in Chronic Obstructive Pulmonary Disease: A Narrative Review. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:587-597. [PMID: 35065813 DOI: 10.1016/j.ultrasmedbio.2021.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 06/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common disease of the respiratory system, and its prevalence and mortality remain high. COPD results in continuous impairment of lung function, which severely affects the patient's work and life. In severe cases, there will be acute respiratory failure, which endangers the lives of patients, and respiratory muscle dysfunction is one of the main reasons for this result. As the diaphragm is the most important inspiratory muscle, its dysfunction has a great impact on the deterioration of respiratory function in COPD patients. With the development of ultrasound, more and more studies have found that diaphragm ultrasound can play an important role in the diagnosis and treatment of COPD patients. The main purpose of this article is to review the research progress on diaphragm ultrasound in COPD and briefly introduce diaphragmatic ultrasound examination methods.
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Affiliation(s)
- Yuhao Jia
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Qunxia Zhang
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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Martins G, Verdeal JCR, Tostes H, da Silva ARO, Tessarollo B, Rocha NN, Rocco PRM, Silva PL. Testosterone Therapy and Diaphragm Performance in a Male Patient with COVID-19: A Case Report. Diagnostics (Basel) 2022; 12:diagnostics12020535. [PMID: 35204624 PMCID: PMC8871258 DOI: 10.3390/diagnostics12020535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Low levels of testosterone may lead to reduced diaphragm excursion and inspiratory time during COVID-19 infection. We report the case of a 38-year-old man with a positive result on a reverse transcriptase-polymerase chain reaction test for SARS-CoV-2, admitted to the intensive care unit with acute respiratory failure. After several days on mechanical ventilation and use of rescue therapies, during the weaning phase, the patient presented dyspnea associated with low diaphragm performance (diaphragm thickness fraction, amplitude, and the excursion-time index during inspiration were 37%, 1.7 cm, and 2.6 cm/s, respectively) by ultrasonography and reduced testosterone levels (total testosterone, bioavailable testosterone and sex hormone binding globulin (SHBG) levels were 9.3 ng/dL, 5.8 ng/dL, and 10.5 nmol/L, respectively). Testosterone was administered three times 2 weeks apart (testosterone undecanoate 1000 mg/4 mL intramuscularly). Diaphragm performance improved significantly (diaphragm thickness fraction, amplitude, and the excursion-time index during inspiration were 70%, 2.4 cm, and 3.0 cm/s, respectively) 45 and 75 days after the first dose of testosterone. No adverse events were observed, although monitoring was required after testosterone administration. Testosterone replacement therapy led to good diaphragm performance in a male patient with COVID-19. This should be interpreted with caution due to the exploratory nature of the study.
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Affiliation(s)
- Gloria Martins
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro 21941-599, Brazil; (G.M.); (N.N.R.); (P.R.M.R.)
- Barra D’Or, Rio de Janeiro 22775-002, Brazil; (J.C.R.V.); (H.T.); (A.R.O.d.S.); (B.T.)
| | | | - Helio Tostes
- Barra D’Or, Rio de Janeiro 22775-002, Brazil; (J.C.R.V.); (H.T.); (A.R.O.d.S.); (B.T.)
| | | | - Bernardo Tessarollo
- Barra D’Or, Rio de Janeiro 22775-002, Brazil; (J.C.R.V.); (H.T.); (A.R.O.d.S.); (B.T.)
| | - Nazareth Novaes Rocha
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro 21941-599, Brazil; (G.M.); (N.N.R.); (P.R.M.R.)
- Department of Physiology, Fluminense Federal University, Niterói 24210-130, Brazil
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro 21941-599, Brazil; (G.M.); (N.N.R.); (P.R.M.R.)
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro 21941-599, Brazil; (G.M.); (N.N.R.); (P.R.M.R.)
- Correspondence:
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16
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Fayssoil A, Mansencal N, Nguyen LS, Orlikowski D, Prigent H, Bergounioux J, Annane D, Lofaso F. Diaphragm Ultrasound in Cardiac Surgery: State of the Art. MEDICINES 2022; 9:medicines9010005. [PMID: 35049938 PMCID: PMC8779362 DOI: 10.3390/medicines9010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/01/2022] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
In cardiac surgery, patients are at risk of phrenic nerve injury, which leads to diaphragm dysfunction and acute respiratory failure. Diaphragm dysfunction (DD) is relatively frequent in cardiac surgery and particularly affects patients after coronary artery bypass graft. The onset of DD affects patients’ prognosis in term of weaning from mechanical ventilation and hospital length of stay. The authors present a narrative review about diaphragm physiology, techniques used to assess diaphragm function, and the clinical application of diaphragm ultrasound in patients undergoing cardiac surgery.
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Affiliation(s)
- Abdallah Fayssoil
- Echo Lab, CHU de Raymond-Poincaré, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- INSERM U1179, END-ICAP, Université de Versailles-Saint Quentin, University of Paris-Saclay, 78180 Montigny-le-Bretonneux, France; (H.P.); (F.L.)
- Raymond Poincaré Hospital, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- Centre de Référence des Cardiomyopathies et des Troubles du Rythme Cardiaque Héréditaires ou Rares, Department of Cardiology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Université de Versailles-Saint Quentin, 92100 Boulogne, France;
- Correspondence:
| | - Nicolas Mansencal
- Centre de Référence des Cardiomyopathies et des Troubles du Rythme Cardiaque Héréditaires ou Rares, Department of Cardiology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Université de Versailles-Saint Quentin, 92100 Boulogne, France;
- INSERM U-1018, CESP, Épidémiologie Clinique, 94807 Villejuif, France
| | - Lee S. Nguyen
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, AP-HP, Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France;
- France Research and Innovation Department, CMC Ambroise Paré, RICAP, 27 bd Victor Hugo, 92200 Neuilly-sur-Seine, France
| | - David Orlikowski
- Service de Réanimation Médicale, CHU Raymond Poincaré, AP-HP, Université de Versailles Saint Quentin en Yvelines, 92380 Garches, France;
- Centre d’Investigation Clinique et Innovation Technologique CIC 14.29, INSERM, 92380 Garches, France
| | - Hélène Prigent
- INSERM U1179, END-ICAP, Université de Versailles-Saint Quentin, University of Paris-Saclay, 78180 Montigny-le-Bretonneux, France; (H.P.); (F.L.)
- Raymond Poincaré Hospital, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest—Site Raymond Poincaré—AP-HP, 92380 Garches, France
| | - Jean Bergounioux
- Pediatric Neurology and ICU, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond-Poincaré, 92380 Garches, France;
| | - Djillali Annane
- Laboratory Infection and Inflammation, Department of Critical Care, Raymond Poincaré Hospital (AP-HP), U1173, Faculty of Health Science Simone Veil, Université de Versailles-Saint Quentin, University Paris Saclay, INSERM, FHU SEPSIS, RHU RECORDS, 78180 Montigny-le-Bretonneux, France;
| | - Frédéric Lofaso
- INSERM U1179, END-ICAP, Université de Versailles-Saint Quentin, University of Paris-Saclay, 78180 Montigny-le-Bretonneux, France; (H.P.); (F.L.)
- Raymond Poincaré Hospital, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest—Site Raymond Poincaré—AP-HP, 92380 Garches, France
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Prediction of Loss of Muscle Mass in Sarcopenia Using Ultrasonic Diaphragm Excursion. CONTRAST MEDIA & MOLECULAR IMAGING 2021; 2021:4754705. [PMID: 34949970 PMCID: PMC8668300 DOI: 10.1155/2021/4754705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/05/2021] [Accepted: 11/15/2021] [Indexed: 01/11/2023]
Abstract
Background The diagnosis of sarcopenia is based on the mass and function of appendicular skeletal muscle. It is not clear whether diaphragm excursion is related to muscle mass loss. We try to fill the gap by measuring ultrasonic diaphragm excursion during quiet breathing (Dq) and forced deep breathing (Df) and test whether they could predict the muscle mass loss in sarcopenia. Methods The subjects are recruited from the elderly patients diagnosed with pulmonary nodules in community physical examination. According to the definition, the subjects were divided into group A (who did not meet the diagnostic criteria for muscle mass loss in sarcopenia) and group B (who met the criteria). Participants were assessed for ultrasonic diaphragm excursion, pulmonary function, and cardiopulmonary exercise testing. Logistic regression was used to assess the correlation between right diaphragm excursion and skeletal muscle mass, and receiver-operating characteristic curve (ROC) was applied to determine the best threshold. Results We recruited 64 elderly participants: 52 in group A (39 males) and 12 in group B (8 males). The Df in group A were higher than in group B (6.02 (5.44–6.60) vs. 4.31 (3.53–5.09) cm, P=0.008). The difference also exists in FVC, FEV1.0, PEF, Pimax, WRmax, and VO2max, but neither in Dq. Logical regression showed that Df was negatively related to muscle mass (B = −0.525, OR = 0.591 (0.378–0.926), P=0.022), even after adjusted age. Based on ROC, a cutoff value of 5.27 cm (AUC = 0.7783, P=0.0028) was selected, and Df ≤ 5.27 cm indicates the increase in odds of existing muscle mass loss. Conclusion Ultrasonic diaphragm excursion in forced deep breath is helpful for predicting muscle mass loss in sarcopenia. The trial is registered with ChiCTR1800019742.
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Mohamed RSE, Mohamed ASE, Fathalah WF, Mohamed MF, Ahmed AA. The role of diaphragmatic ultrasound as a predictor of successful extubation from mechanical ventilation in respiratory intensive care unit. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2021. [PMCID: PMC8593640 DOI: 10.1186/s43168-021-00095-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The diaphragm muscle whose dysfunction may be very common in patients undergoing mechanical ventilation (Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Aprà F. Crit Ultrasound J 6:8, 2014). Aim: To evaluate real-time ultrasound in the evaluation of diaphragmatic thickening, thickening fraction, and/or excursion to predict extubation outcomes. We aimed to compare these parameters with other traditional weaning measures is a fundamental. Results Out of 80 included patients, 20 (25%) have failed extubation. Diaphragmatic thickening (DT), thickening fraction (DTF), and/or excursion (DE) were significantly higher in the successful group compared to those who failed extubation (p < 0.05). Cutoff values of diaphragmatic measures associated with successful extubation (during tidal breathing) were ≥ 17 mm for DE; ≥ 2.1 cm for DT inspiration; ≥ 15.5 mm for DT expiration, functional residual capacity (FRC); and ≥ 32.82% for DTF %, giving 68%, 95%, 62%, and 90% sensitivity, respectively, and 65%, 100%, 100%, and 75% specificity, respectively. Cutoff values of diaphragmatic parameters associated with successful extubation (during deep breathing) were > 28.5 mm DT Insp, total lung capacity (TLC); >22.5mm DT Exp (RV); >37 DTF %; and > 31 mm DE, giving 100%, 73%, 97%, and 75% sensitivity and 65%, 75%, 100%, and 55% specificity, respectively. Rapid shallow breathing index (RSBI) had 47% sensitivity but 90% specificity. Conclusion Ultrasound evaluation of diaphragmatic parameters could be a good predictor of weaning in patients who passed the T-tube.
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Nascimento TS, de Queiroz RS, Ramos ACC, Martinez BP, Da Silva E Silva CM, Gomes-Neto M. Ultrasound Protocols to Assess Skeletal and Diaphragmatic Muscle in People Who Are Critically Ill: A Systematic Review. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3041-3067. [PMID: 34417065 DOI: 10.1016/j.ultrasmedbio.2021.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 06/13/2023]
Abstract
This study aims to review published studies that use protocols and ultrasound measurements to evaluate skeletal and diaphragmatic muscles in patients who are critically ill. We searched for references on databases through September 2020 and included in our systematic review studies that used muscular ultrasound to assess skeletal or diaphragm muscles in patients who are critically ill. Seventy-six studies were included, 32 (1720 patients) using skeletal-muscle ultrasound and 44 (2946 patients) using diaphragmatic-muscle ultrasound, with a total of 4666 patients. The population is predominantly adult men. As for designs, most studies (n = 62) were cohort studies. B-mode B was dominant in the evaluations. Medium-to-high frequency bands were used in the analysis of peripheral muscles and medium-to-low frequency bands for diaphragmatic muscles. Evaluation of the echogenicity, muscle thickness and pennation angle of the muscle was also reported. These variables are important in the composition of the diagnosis of muscle loss. Studies demonstrate great variability in their protocols, and sparse description of the important variables that can directly interfere with the quality and validity of these measures. Therefore, a document is needed that standardizes these parameters for ultrasound assessment in patients who are critically ill.
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Affiliation(s)
- Taís Silva Nascimento
- Physiotherapy Research Group, Federal University of Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil.
| | - Rodrigo Santos de Queiroz
- Department of Health 1, State University of Southwest Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
| | | | - Bruno Prata Martinez
- Physiotherapy Research Group, Federal University of Bahia, Brazil; Physical Therapy Department, Federal University of Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
| | | | - Mansueto Gomes-Neto
- Physical Therapy Department, Federal University of Bahia, Brazil; Program in Medicine and Health of the Faculty of Medicine, Federal University of Bahia, Salvador, Brazil
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Oliveira TS, Santos AT, Andrade CBV, Silva JD, Blanco N, Rocha NDN, Woyames J, Silva PL, Rocco PRM, da-Silva WS, Ortiga-Carvalho TM, Bloise FF. Sepsis Disrupts Mitochondrial Function and Diaphragm Morphology. Front Physiol 2021; 12:704044. [PMID: 34557108 PMCID: PMC8452856 DOI: 10.3389/fphys.2021.704044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background The diaphragm is the primary muscle of inspiration, and its dysfunction is frequent during sepsis. However, the mechanisms associated with sepsis and diaphragm dysfunction are not well understood. In this study, we evaluated the morphophysiological changes of the mitochondrial diaphragm 5 days after sepsis induction. Methods Male C57Bl/6 mice were divided into two groups, namely, cecal ligation and puncture (CLP, n = 26) and sham-operated (n = 19). Mice received antibiotic treatment 8 h after surgery and then every 24 h until 5 days after surgery when mice were euthanized and the diaphragms were collected. Also, diaphragm function was evaluated in vivo by ultrasound 120 h after CLP. The tissue fiber profile was evaluated by the expression of myosin heavy chain and SERCA gene by qPCR and myosin protein by using Western blot. The Myod1 and Myog expressions were evaluated by using qPCR. Diaphragm ultrastructure was assessed by electron microscopy, and mitochondrial physiology was investigated by high-resolution respirometry, Western blot, and qPCR. Results Cecal ligation and puncture mice developed moderated sepsis, with a 74% survivor rate at 120 h. The diaphragm mass did not change in CLP mice compared with control, but we observed sarcomeric disorganization and increased muscle thickness (38%) during inspiration and expiration (21%). Septic diaphragm showed a reduction in fiber myosin type I and IIb mRNA expression by 50% but an increase in MyHC I and IIb protein levels compared with the sham mice. Total and healthy mitochondria were reduced by 30% in septic mice, which may be associated with a 50% decrease in Ppargc1a (encoding PGC1a) and Opa1 (mitochondria fusion marker) expressions in the septic diaphragm. The small and non-functional OPA1 isoform also increased 70% in the septic diaphragm. These data suggest an imbalance in mitochondrial function. In fact, we observed downregulation of all respiratory chain complexes mRNA expression, decreased complex III and IV protein levels, and reduced oxygen consumption associated with ADP phosphorylation (36%) in CLP mice. Additionally, the septic diaphragm increased proton leak and downregulated Sod2 by 70%. Conclusion The current model of sepsis induced diaphragm morphological changes, increased mitochondrial damage, and induced functional impairment. Thus, diaphragm damage during sepsis seems to be associated with mitochondrial dysfunction.
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Affiliation(s)
- Thamires Siqueira Oliveira
- Laboratory of Translational Endocrinology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Anderson Teixeira Santos
- Laboratory of Metabolic Adaptations, Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cherley Borba Vieira Andrade
- Laboratory of Translational Endocrinology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Johnatas Dutra Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Natália Blanco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nazareth de Novaes Rocha
- Physiology and Pharmacology Department, Biomedical Institute, Fluminense Federal University, Niteroi, Brazil
| | - Juliana Woyames
- Laboratory of Molecular Endocrinology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Wagner Seixas da-Silva
- Laboratory of Metabolic Adaptations, Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tânia Maria Ortiga-Carvalho
- Laboratory of Translational Endocrinology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Flavia Fonseca Bloise
- Laboratory of Translational Endocrinology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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21
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Weber MD, Lim JKB, Glau C, Conlon T, James R, Lee JH. A narrative review of diaphragmatic ultrasound in pediatric critical care. Pediatr Pulmonol 2021; 56:2471-2483. [PMID: 34081825 DOI: 10.1002/ppul.25518] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 01/20/2023]
Abstract
The use of point of care ultrasound (POCUS) at the bedside has increased dramatically within emergency medicine and in critical care. Applications of POCUS have spread to include diaphragmatic assessments in both adults and children. Diaphragm POCUS can be used to assess for diaphragm dysfunction (DD) and atrophy or to guide ventilator titration and weaning. Quantitative, semi-quantitative and qualitative measurements of diaphragm thickness, diaphragm excursion, and diaphragm thickening fraction provide objective data related to DD and atrophy. The potential for quick, noninvasive, and repeatable bedside diaphragm assessments has led to a growing amount of literature on diaphragm POCUS. To date, there are no reviews of the current state of diaphragm POCUS in pediatric critical care. The aims of this narrative review are to summarize the current literature regarding techniques, reference values, applications, and future innovations of diaphragm POCUS in critically ill children. A summary of current practice and future directions will be discussed.
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Affiliation(s)
- Mark D Weber
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joel K B Lim
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Christie Glau
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas Conlon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard James
- University of Pennsylvania Biomedical Library, Philadelphia, Pennsylvania, USA
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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22
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Fossat G, Daillet B, Desmalles E, Boulain T. Does diaphragm ultrasound improve the rapid shallow breathing index accuracy for predicting the success of weaning from mechanical ventilation? Aust Crit Care 2021; 35:233-240. [PMID: 34340902 DOI: 10.1016/j.aucc.2021.05.008] [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: 01/02/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND This prospective study investigated whether taking into account diaphragmatic excursion (DE) measured by ultrasonography would improve the performance of the rapid shallow breathing index (RSBI) to predict extubation success or failure. OBJECTIVES The aim of the study was to compare the new composite index named the rapid shallow diaphragmatic index (RSDI), and the RSBI measured during a spontaneous breathing trial regarding their ability to predict the need for re-intubation at 72 h. METHODS One hundred mechanically ventilated patients underwent daily 30-min spontaneous breathing trials (SBTs) under pressure support ventilation of 6 cm H2O and end-expiratory pressure of 0 cm H2O until the SBT was considered successful and followed by extubation. The performances of RSBI (respiratory rate/tidal volume) and of the ratio RSBI/DE measured at 5 and 25 min of the successful SBT were compared in terms of area under the receiver operating characteristics curve (AUC), for predicting extubation success at 72 h. As secondary analysis, extubation and weaning success at 7 d were also considered. As exploratory analyses, predictive indices incorporating both clinical characteristics, the DE, and ultrasound diaphragm thickening fraction (DTF) were investigated. RESULTS RSBI and RSBI/DE showed AUCs with 95% confidence intervals consistently extending below 0.50, either at the 5th (0.55 [0.36-0.74] and 0.55 [0.34-0.75], respectively) or at the 25th minute of SBT (0.49 [0.27-0.71] and 0.50 [0.29-0.68], respectively) for predicting weaning success at 72 h or at 7 d (5th min: 0.53 [0.37-0.70] and 0.54 [0.37-0.70], respectively; 25th min: 0.54 [0.37-0.71] and 0.55 [0.39-0.71], respectively). An exploratory index incorporating the accessory respiratory muscle activity, DE, DTF, and respiratory rate at 5th min of SBT showed AUCs for predicting extubation success at 7 d in the 78 patients with DTF measurement (0.77 [0.64-0.90]) that were significantly higher than that of the RSBI (P = 0.017) and RSBI/DE (P < 0.001) in the same respective populations. CONCLUSIONS The RSBI and the ratio RSBI/DE failed to predict weaning success when measured during an SBT performed under minimal pressure support. Predictive indices incorporating ultrasound DE and DTF may merit further investigation.
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Affiliation(s)
- Guillaume Fossat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
| | - Blanche Daillet
- Ecole Universitaire de Kinésithérapie Centre Val de Loire, Orléans, France.
| | - Emmanuelle Desmalles
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
| | - Thierry Boulain
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
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23
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Guarracino F, Vetrugno L, Forfori F, Corradi F, Orso D, Bertini P, Ortalda A, Federici N, Copetti R, Bove T. Lung, Heart, Vascular, and Diaphragm Ultrasound Examination of COVID-19 Patients: A Comprehensive Approach. J Cardiothorac Vasc Anesth 2021; 35:1866-1874. [PMID: 32624431 PMCID: PMC7289113 DOI: 10.1053/j.jvca.2020.06.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
Lung ultrasound (LU) has a multitude of features and capacities that make it a useful medical tool to assist physicians contending with the pandemic spread of novel coronavirus disease-2019 (COVID-19) caused by coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thus, an LU approach to patients with suspected COVID-19 is being implemented worldwide. In noncritical COVID-19 patients, 2 new LU signs have been described and proposed, the "waterfall" and the "light beam" signs. Both signs have been hypothesized to increase the diagnostic accuracy of LU for COVID-19 interstitial pneumonia. In critically ill patients, a distinct pattern of LU changes seems to follow the disease's progression, and this information can be used to guide decisions about when a patient needs to be ventilated, as occurs in other disease states similar to COVID-19. Furthermore, a new algorithm has been published, which enables the automatic detection of B-lines as well as quantification of the percentage of the pleural line associated with lung disease. In COVID-19 patients, a direct involvement of cardiac function has been demonstrated, and ventilator-induced diaphragm dysfunction might be present due to the prolonged mechanical ventilation often involved, as reported for similar diseases. For this reason, cardiac and diaphragm ultrasound evaluation are highly important. Last but not least, due to the thrombotic tendency of COVID-19 patients, particular attention also should be paid to vascular ultrasound. This review is primarily devoted to the study of LU in COVID-19 patients. The authors explain the significance of its "light and shadows," bearing in mind the context in which LU is being used-the emergency department and the intensive care setting. The use of cardiac, vascular, and diaphragm ultrasound is also discussed, as a comprehensive approach to patient care.
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Affiliation(s)
- Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Luigi Vetrugno
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy.
| | - Francesco Forfori
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Corradi
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy; Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Daniele Orso
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy
| | - Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Federici
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy
| | - Roberto Copetti
- Emergency Department, Azienda Sanitaria Universitaria Friuli Centrale, Latisana General Hospital, Latisana, Italy
| | - Tiziana Bove
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy; Department of Anesthesia and Intensive care, University-Hospital of Udine, Italy, Udine, Italy
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24
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Gong J, Zhang B, Huang X, Li B, Huang J. Product of driving pressure and respiratory rate for predicting weaning outcomes. J Int Med Res 2021; 49:3000605211010045. [PMID: 33969736 PMCID: PMC8113923 DOI: 10.1177/03000605211010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective Clinicians cannot precisely determine the time for withdrawal of ventilation.
We aimed to evaluate the performance of driving pressure (DP)×respiratory
rate (RR) to predict the outcome of weaning. Methods Plateau pressure (Pplat) and total positive end-expiratory pressure (PEEPtot)
were measured during mechanical ventilation with brief deep sedation and on
volume-controlled mechanical ventilation with a tidal volume of 6 mL/kg and
a PEEP of 0 cmH2O. Pplat and PEEPtot were measured by patients
holding their breath for 2 s after inhalation and exhalation, respectively.
DP was determined as Pplat minus PEEPtot. The rapid shallow breathing index
was measured from the ventilator. The highest RR was recorded within 3
minutes during a spontaneous breathing trial. Patients who tolerated a
spontaneous breathing trial for 1 hour were extubated. Results Among the 105 patients studied, 44 failed weaning. During ventilation
withdrawal, DP×RR was 136.7±35.2 cmH2O breaths/minute in the
success group and 230.2±52.2 cmH2O breaths/minute in the failure
group. A DP×RR index >170.8 cmH2O breaths/minute had a
sensitivity of 93.2% and specificity of 88.5% to predict failure of
weaning. Conclusions Measurement of DP×RR during withdrawal of ventilation may help predict the
weaning outcome. A high DP×RR increases the likelihood of weaning
failure. Statement: This manuscript was previously posted as a preprint
on Research Square with the following link: https://www.researchsquare.com/article/rs-15065/v3 and DOI:
10.21203/rs.2.24506/v3
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Affiliation(s)
- Ju Gong
- Department of Emergency Medicine, The First affiliated Hospital of Soochow University, Suzhou, China
| | - Bibo Zhang
- Department of Emergency Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Changshu, China
| | - Xiaowen Huang
- Department of Acupuncture and Tuina, Changshu Hospital of Traditional Chinese Medicine, Changshu, China
| | - Bin Li
- Department of Critical Care Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Changshu, China
| | - Jian Huang
- Department of Emergency Medicine, The First affiliated Hospital of Soochow University, Suzhou, China
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25
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Laghi FA, Saad M, Shaikh H. Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction. BMC Pulm Med 2021; 21:85. [PMID: 33722215 PMCID: PMC7958108 DOI: 10.1186/s12890-021-01441-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/19/2021] [Indexed: 12/25/2022] Open
Abstract
Diaphragm muscle dysfunction is increasingly recognized as an important element of several diseases including neuromuscular disease, chronic obstructive pulmonary disease and diaphragm dysfunction in critically ill patients. Functional evaluation of the diaphragm is challenging. Use of volitional maneuvers to test the diaphragm can be limited by patient effort. Non-volitional tests such as those using neuromuscular stimulation are technically complex, since the muscle itself is relatively inaccessible. As such, there is a growing interest in using imaging techniques to characterize diaphragm muscle dysfunction. Selecting the appropriate imaging technique for a given clinical scenario is a critical step in the evaluation of patients suspected of having diaphragm dysfunction. In this review, we aim to present a detailed analysis of evidence for the use of ultrasound and non-ultrasound imaging techniques in the assessment of diaphragm dysfunction. We highlight the utility of the qualitative information gathered by ultrasound imaging as a means to assess integrity, excursion, thickness, and thickening of the diaphragm. In contrast, quantitative ultrasound analysis of the diaphragm is marred by inherent limitations of this technique, and we provide a detailed examination of these limitations. We evaluate non-ultrasound imaging modalities that apply static techniques (chest radiograph, computerized tomography and magnetic resonance imaging), used to assess muscle position, shape and dimension. We also evaluate non-ultrasound imaging modalities that apply dynamic imaging (fluoroscopy and dynamic magnetic resonance imaging) to assess diaphragm motion. Finally, we critically review the application of each of these techniques in the clinical setting when diaphragm dysfunction is suspected.
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Affiliation(s)
- Franco A Laghi
- Department of Internal Medicine, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA
| | - Marina Saad
- Department of Biomedical and Clinical Sciences (DIBIC), Division of Pulmonary Diseases, University of Milan, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, V. G.B. Grassi, 74, 20157, Milan, Italy
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N), 5th Avenue and Roosevelt Road, Hines, IL, 60141, USA. .,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL, 60153, USA.
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Diaphragmatic Ultrasonography, a Novel Approach in Critical Care: A Proposal for a New Weaning Index. Ultrasound Q 2020; 36:54-58. [PMID: 31008860 DOI: 10.1097/ruq.0000000000000442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The evaluation of the diaphragm in critically ill patients is simple and noninvasive and has shown good repeatability. The aim of the study was to generate a predictive index for successful weaning (ULDIMex) from invasive mechanical ventilation (IMV) based on an ultrasonographic diaphragmatic assessment before performing a spontaneous breathing test. We recruited patients who required IMV and who were candidates for weaning from ventilation. The measurement of diaphragmatic excursion and time during inspiration and expiration was obtained with a 3- to 5-MHz probe in the M mode. Using the formula (a + b)c/2, the value for the ULDIMex was obtained to evaluate its impact on predicting the successful weaning of IMV, where a is the time during the inspiratory phase, b is the time during expiration, and c is the diaphragmatic excursion during the inspiratory phase, which corresponds to the highest point of the curve from the baseline. We recruited 114 patients, of whom 86 (76%) were successfully weaned from IMV. The patients who were successfully weaned from the IMV had a cutoff value greater than 4.06 cm/s for the ULDIMex index, with a sensitivity of 92.8% (95% confidence interval, 76.5-99.1), specificity of 63.9% (95% confidence interval, 52.9-74.0), positive predictive value of 45.6%, and negative predictive value of 96.5%. The ULDIMex index demonstrated a good level of discrimination for successful weaning prediction. Considering the excellent negative likelihood ratio of the ULDIMex index of greater than 4.06, this index may be considered before performing an spontaneous breathing test to identify critically ill adult patients who will extubate successfully.
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27
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Diaphragm Ultrasound in Weaning From Mechanical Ventilation. Chest 2020; 159:1166-1172. [PMID: 33309837 DOI: 10.1016/j.chest.2020.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/30/2020] [Accepted: 12/06/2020] [Indexed: 11/20/2022] Open
Abstract
A 65-year-old man was admitted to the ICU for septic shock due to pneumonia. He remained on mechanical ventilation for 96 hours. His shock resolved, and he no longer required IV vasopressor therapy. His vital signs included a BP of 105/70 mm Hg, heart rate 85 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 95%. His ventilator settings were volume control/assist control with a positive end-expiratory pressure of 5 and an Fio2 set to 40%. On these setting his blood gas showed an Pao2 of 75 mm Hg. He was following simple commands and had minimal tracheobronchial secretions. He was placed on a spontaneous breathing trial with a spontaneous mode of ventilation and pressure support of 7/5. He remained hemodynamically stable and showed no distress through the procedure, so he was extubated to 6 L oxygen by nasal cannula. Eighteen hours later, the patient was found to have increased work of breathing, with use of accessory respiratory muscles. A blood gas showed an elevated level of CO2, so the patient was reintubated. After intubation, the patient again appeared comfortable on minimal ventilator settings. Chest radiography before reintubation showed no new parenchymal process, but an elevated left diaphragm. After a thorough workup, it was determined that diaphragmatic weakness was the most likely reason for respiratory failure. The team questioned whether there was a way to have detected this before extubation.
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Abstract
PURPOSE OF REVIEW To review the clinical problem of diaphragm function in critically ill patients and describes recent advances in bedside monitoring of diaphragm function. RECENT FINDINGS Diaphragm weakness, a consequence of diaphragm dysfunction and atrophy, is common in the ICU and associated with serious clinical consequences. The use of ultrasound to assess diaphragm structure (thickness, thickening) and mobility (caudal displacement) appears to be feasible and reproducible, but no large-scale 'real-life' study is available. Diaphragm ultrasound can also be used to evaluate diaphragm muscle stiffness by means of shear-wave elastography and strain by means of speckle tracking, both of which are correlated with diaphragm function in healthy. Electrical activity of the diaphragm is correlated with diaphragm function during brief airway occlusion, but the repeatability of these measurements exhibits high within-subject variability. SUMMARY Mechanical ventilation is involved in the pathogenesis of diaphragm dysfunction, which is associated with severe adverse events. Although ultrasound and diaphragm electrical activity could facilitate monitoring of diaphragm function to deliver diaphragm-protective ventilation, no guidelines concerning the use of these modalities have yet been published. The weaning process, assessment of patient-ventilator synchrony and evaluation of diaphragm function may be the most clinically relevant indications for these techniques.
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Soilemezi E, Savvidou S, Sotiriou P, Smyrniotis D, Tsagourias M, Matamis D. Tissue Doppler Imaging of the Diaphragm in Healthy Subjects and Critically Ill Patients. Am J Respir Crit Care Med 2020; 202:1005-1012. [PMID: 32614246 PMCID: PMC7528801 DOI: 10.1164/rccm.201912-2341oc] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Rationale: Tissue Doppler imaging (TDI) is an echocardiographic method that measures the velocity of moving tissue. Objectives: We applied this technique to the diaphragm to assess the velocity of diaphragmatic muscle motion during contraction and relaxation. Methods: In 20 healthy volunteers, diaphragmatic TDI was performed to assess the pattern of diaphragmatic motion velocity, measure its normal values, and determine the intra- and interobserver variability of measurements. In 116 consecutive ICU patients, diaphragmatic excursion, thickening, and TDI parameters of peak contraction velocity, peak relaxation velocity, velocity–time integral, and TDI-derived maximal relaxation rate were assessed during weaning. In a subgroup of 18 patients, transdiaphragmatic pressure (Pdi)-derived parameters (peak Pdi, pressure–time product, and diaphragmatic maximal relaxation rate) were recorded simultaneously with TDI. Measurements and Main Results: In terms of reproducibility, the intercorrelation coefficients were >0.89 for all TDI parameters (P < 0.001). Healthy volunteers and weaning success patients exhibited lower values for all TDI parameters compared with weaning failure patients, except for velocity–time integral, as follows: peak contraction velocity, 1.35 ± 0.34 versus 1.50 ± 0.59 versus 2.66 ± 2.14 cm/s (P < 0.001); peak relaxation velocity, 1.19 ± 0.39 versus 1.53 ± 0.73 versus 3.36 ± 2.40 cm/s (P < 0.001); and TDI-maximal relaxation rate, 3.64 ± 2.02 versus 10.25 ± 5.88 versus 29.47 ± 23.95 cm/s2 (P < 0.001), respectively. Peak contraction velocity was strongly correlated with peak transdiaphragmatic pressure and pressure–time product, whereas Pdi-maximal relaxation rate was significantly correlated with TDI-maximal relaxation rate. Conclusions: Diaphragmatic tissue Doppler allows real-time assessment of the diaphragmatic tissue motion velocity. Diaphragmatic TDI-derived parameters differentiate patients who fail a weaning trial from those who succeed and correlate well with Pdi-derived parameters.
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Affiliation(s)
- Eleni Soilemezi
- ICU, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Savvoula Savvidou
- ICU, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Sotiriou
- ICU, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | | | - Matthew Tsagourias
- ICU, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Matamis
- ICU, "Papageorgiou" General Hospital of Thessaloniki, Thessaloniki, Greece
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Disfunción diafragmática evaluada por ecografía como predictora del fracaso de la extubación: Revisión sistemática y metanálisis. OPEN RESPIRATORY ARCHIVES 2020. [DOI: 10.1016/j.opresp.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Boussuges A, Rives S, Finance J, Brégeon F. Assessment of diaphragmatic function by ultrasonography: Current approach and perspectives. World J Clin Cases 2020; 8:2408-2424. [PMID: 32607319 PMCID: PMC7322428 DOI: 10.12998/wjcc.v8.i12.2408] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/19/2020] [Accepted: 06/02/2020] [Indexed: 02/05/2023] Open
Abstract
This article reports the various methods used to assess diaphragmatic function by ultrasonography. The excursions of the two hemidiaphragms can be measured using two-dimensional or M-mode ultrasonography, during respiratory maneuvers such as quiet breathing, voluntary sniffing and deep inspiration. On the zone of apposition to the rib cage for both hemidiaphragms, it is possible to measure the thickness on expiration and during deep breathing to assess the percentage of thickening during inspiration. These two approaches make it possible to assess the quality of the diaphragmatic function and the diagnosis of diaphragmatic paralysis or dysfunction. These methods are particularly useful in circumstances where there is a high risk of phrenic nerve injury or in diseases affecting the contractility or the motion of the diaphragm such as neuro-muscular diseases. Recent methods such as speckle tracking imaging and ultrasound shear wave elastography should provide more detailed information for better assessment of diaphragmatic function.
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Affiliation(s)
- Alain Boussuges
- Institut de Recherche Biomédicale des Armées, ERRSO, Toulon 83800, France
- Center for Cardiovascular and Nutrition Research (C2VN), Aix Marseille Université, INSERM (1260), INRAE (1263), Toulon 83800, France
| | - Sarah Rives
- Institut de Recherche Biomédicale des Armées, ERRSO, Toulon 83800, France
| | - Julie Finance
- Service d’Explorations Fonctionnelles Respiratoires, CHU Nord, Assistance Publique des Hôpitaux de Marseille et Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille 13015, France
| | - Fabienne Brégeon
- Service d’Explorations Fonctionnelles Respiratoires, CHU Nord, Assistance Publique des Hôpitaux de Marseille et Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille 13015, France
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32
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Adhikari S, Situ-LaCasse E, Acuña J, Irving S, Weaver C, Samsel K, Biffar DE, Motlagh M, Sakles J. Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program. Indian J Crit Care Med 2020; 24:179-183. [PMID: 32435096 PMCID: PMC7225761 DOI: 10.5005/jp-journals-10071-23370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives To determine the feasibility of integrating pre-intubation ultrasound into airway course and assess emergency medicine (EM) residents’ confidence and comfort level in using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session. Materials and methods This is a retrospective study. Pre-intubation ultrasound training was delivered with the following ultrasound components (didactics and hands-on sessions using human models) to EM residents: (1) sonoanatomy and scanning technique to identify cricothyroid membrane and (2) pre-intubation echocardiography for recognition of acute right ventricular failure and pre-intubation hemodynamic stabilization. Results A total of 56 EM residents participated in this study. Only 21% [95% confidence interval (CI), 10–31%] reported using ultrasound for pre-intubation hemodynamic stabilization. After the training session, 89% (95% CI, 81–97%) reported that ultrasound-based teaching increased their knowledge of pre-intubation hemodynamic stabilization compared with traditional teaching methods. On a scale of 1 (low) through 10 (high), the average comfort level for integrating ultrasound findings into medical decision making for pre-intubation hemodynamic stabilization was 6.8 (95% CI, 6.3–7.3). Seventy-nine percent (95% CI, 68–89%) reported that focused training in airway ultrasound is adequate to identify cricothyroid membrane. On a scale of 1 (low) through 10 (high), the average confidence level for identifying cricothyroid membrane using ultrasound was 6.6 (95% CI, 6.1–7.1). Conclusion At our institution, we successfully integrated pre-intubation ultrasound into an airway course. Emergency medicine residents had a moderate level of comfort and confidence level using ultrasound for pre-intubation hemodynamic stabilization and identifying cricothyroid membrane after the training session. How to cite this article Adhikari S, Situ-LaCasse E, Acuña J, Irving S, Weaver C, Samsel K, et al. Integration of Pre-intubation Ultrasound into Airway Management Course: A Novel Training Program. Indian J Crit Care Med 2020;24(3):179–183.
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Affiliation(s)
- Srikar Adhikari
- Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, USA
| | - Elaine Situ-LaCasse
- Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, USA
| | - Josie Acuña
- Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, USA
| | - Steven Irving
- Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, USA
| | - Christina Weaver
- AT Still University School of Osteopathic Medicine, Mesa, Arizona, USA
| | - Kara Samsel
- Department of Emergency Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - David E Biffar
- Arizona Simulation Technology and Education Center, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mahsaw Motlagh
- University of Arizona College of Medicine, Tucson, Arizona, USA
| | - John Sakles
- Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, USA
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Vetrugno L, Guadagnin GM, Brussa A, Orso D, Garofalo E, Bruni A, Longhini F, Bove T. Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 1. Ultrasound J 2020; 12:9. [PMID: 32166566 PMCID: PMC7067937 DOI: 10.1186/s13089-020-00161-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/06/2020] [Indexed: 12/11/2022] Open
Abstract
Although mechanical ventilation may be a patient’s vital ally during acute illness, it can quickly transform into an enemy during chronic conditions. The weaning process is the fundamental phase that enables the resumption of physiological respiratory function; however, it is also associated with a number of life-threatening complications, and a large percentage of critically ill patients never achieve airway device removal or require the resumption of mechanical ventilation just a few days post-weaning. Indeed, the weaning process is, at present, more of an art than a science. As such, there is urgent need for novel contributions from the scientific literature to abate the growing rates of morbidity and mortality associated with weaning failure. The physician attempting to wean a patient must integrate clinical parameters and common-sense criteria. Numerous studies have striven to identify single predictive factors of weaning failure and sought to standardize the weaning process, but the results are characterized by remarkable heterogeneity. Despite the lack of benchmarks, it is clear that the analysis of respiratory function must include a detailed overview of the five situations described below rather than a single aspect. The purpose of this two-part review is to provide a comprehensive description of these situations to clarify the “arena” physicians are entering when weaning critically ill patients from mechanical ventilation.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy.
| | - Giovanni Maria Guadagnin
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy.
| | - Alessandro Brussa
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Daniele Orso
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
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Tuinman PR, Jonkman AH, Dres M, Shi ZH, Goligher EC, Goffi A, de Korte C, Demoule A, Heunks L. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients-a narrative review. Intensive Care Med 2020; 46:594-605. [PMID: 31938825 PMCID: PMC7103016 DOI: 10.1007/s00134-019-05892-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
Respiratory muscle ultrasound is used to evaluate the anatomy and function of the respiratory muscle pump. It is a safe, repeatable, accurate, and non-invasive bedside technique that can be successfully applied in different settings, including general intensive care and the emergency department. Mastery of this technique allows the intensivist to rapidly diagnose and assess respiratory muscle dysfunction in critically ill patients and in patients with unexplained dyspnea. Furthermore, it can be used to assess patient-ventilator interaction and weaning failure in critically ill patients. This paper provides an overview of the basic and advanced principles underlying respiratory muscle ultrasound with an emphasis on the diaphragm. We review different ultrasound techniques useful for monitoring of the respiratory muscle pump and possible therapeutic consequences. Ideally, respiratory muscle ultrasound is used in conjunction with other components of critical care ultrasound to obtain a comprehensive evaluation of the critically ill patient. We propose the ABCDE-ultrasound approach, a systematic ultrasound evaluation of the heart, lungs and respiratory muscle pump, in patients with weaning failure.
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Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Martin Dres
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Capital Medical University, Beijing Tiantan Hospital, Beijing, 100050, China
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Critical Care Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Critical Care Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Chris de Korte
- Department of Radiology, Radboud UMC, Nijmegen, The Netherlands
| | - Alexandre Demoule
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
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Varón-Vega F, Hernández Á, López M, Cáceres E, Giraldo-Cadavid LF, Uribe-Hernandez AM, Crevoisier S. [Usefulness of diaphragmatic ultrasound in predicting extubation success]. Med Intensiva 2019; 45:226-233. [PMID: 31870509 DOI: 10.1016/j.medin.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/16/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of diaphragmatic ultrasound in predicting extubation success. DESIGN A diagnostic accuracy study was carried out. SCOPE Intensive Care Unit of an Academic hospital in the city of Bogotá (Colombia). PATIENTS OR PARTICIPANTS A consecutive sample of patients >18 years of age subjected to invasive mechanical ventilation for >48h. INTERVENTIONS Diaphragmatic ultrasound evaluation at the end of spontaneous ventilation testing. MAIN VARIABLES OF INTEREST Diaphragmatic excursion (DE, cm), inspiration time (TPIAdia, s), diaphragm contraction speed (DE/TPIAdia, cm/s) and total time (Ttot, s) were evaluated, together with thickening fraction (TFdi, %). RESULTS A total of 84 patients were included, 79.8% (n=67) with successful extubation and 20.2% (n=17) with failed extubation. The variable with the best discriminatory capacity in predicting extubation success was diaphragm contraction speed, with AUC-ROC 0.70 (p=0.008). CONCLUSIONS Diaphragm contraction speed exhibited acceptable discriminatory capacity. Ultrasound could be part of a multifactorial approach in the extubation process.
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Affiliation(s)
- F Varón-Vega
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia; Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Departamento de Anestesiología y Cuidados Intensivos, Universidad de Navarra, Pamplona, España
| | - Á Hernández
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - M López
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - E Cáceres
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - L F Giraldo-Cadavid
- Departamento de Investigación, Fundación Neumológica Colombiana, Bogotá, Colombia; Departamento de Epidemiología y de Medicina Interna, Universidad de La Sabana, Chía, Colombia
| | - A M Uribe-Hernandez
- Unidad de Cuidado Intensivo Médico, Fundación Neumológica Colombiana, Bogotá, Colombia; Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia; Departamento de Investigación, Fundación Neumológica Colombiana, Bogotá, Colombia.
| | - S Crevoisier
- Medicina Crítica y Cuidado Intensivo, Universidad de La Sabana, Chía, Colombia
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Prada G, Vieillard-Baron A, Martin AK, Hernandez A, Mookadam F, Ramakrishna H, Diaz-Gomez JL. Tracheal, Lung, and Diaphragmatic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth 2019; 35:310-322. [PMID: 31883769 DOI: 10.1053/j.jvca.2019.11.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 11/11/2022]
Abstract
Today, proficiency in cardiopulmonary ultrasound is considered essential for anesthesiologists and critical care physicians. Conventional 2-dimensional images, however, do not permit optimal characterization of specific conditions (eg, diaphragmatic paralysis, major atelectasis, and pneumothorax) that may have relevant clinical implications in critical care and perioperative settings. By contrast, M-mode (motion-based) ultrasonographic imaging modality offers the highest temporal resolution in ultrasonography; this modality, therefore, can provide important information in ultrasound-driven approaches performed by anesthesiologists and intensivists for diagnosis, monitoring, and procedural guidance. Despite its practicability, M-mode has been progressively abandoned in echocardiography and is often underused in lung and diaphragmatic ultrasound. This review describes contemporary applications of M-mode ultrasonography in the practice of critical care and perioperative medicine. Information presented for each clinical application includes image acquisition and interpretation, evidence-based clinical implications in critically ill and surgical patients, and main limitations. The article focuses on tracheal, lung, and diaphragmatic ultrasound. It reviews tracheal ultrasound for procedural guidance during endotracheal intubation, confirmation of correct tube placement, and detection of esophageal intubation; lung ultrasound for the confirmation of endotracheal and endobronchial (selective) intubation and for the diagnosis of pneumothorax, alveolar-interstitial syndrome (cardiogenic v noncardiogenic pulmonary edema), pulmonary consolidation (pneumonia v major atelectasis) and pleural effusion; and diaphragmatic ultrasound for the diagnosis of diaphragmatic dysfunction and prediction of extubation success.
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Affiliation(s)
- Gabriel Prada
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, Boulogne Billancourt, France; Faculty of Medicine Paris Ile de France Ouest, University of Versailles Saint-Quentin en Yvelines, Saint Quentin En Yvelines, France; INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Phoenix, AZ.
| | - Jose L Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Pérez-Terán P, Marin-Corral J, Dot I, Sans S, Muñoz-Bermúdez R, Bosch R, Vila C, Masclans JR. Aeration changes induced by high flow nasal cannula are more homogeneous than those generated by non-invasive ventilation in healthy subjects. J Crit Care 2019; 53:186-192. [PMID: 31254850 DOI: 10.1016/j.jcrc.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/29/2019] [Accepted: 06/12/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Non-invasive mechanical ventilation (NIV) is a standard respiratory support technique used in intensive care units. High-Flow Nasal Cannula (HFNC) has emerged as an alternative, but further evidence is needed. The lung aeration and diaphragm changes achieved with these two strategies in healthy subjects have not been compared to date. METHODS Twenty healthy subjects were recruited. Ten were ventilated with NIV and ten underwent HFNC. Lung impedance and diaphragmatic ultrasound measurements were performed before and after 30 min of respiratory support. The Mar-index was defined as the ratio of the diaphragm excursion-time index to the respiratory rate. RESULTS Both groups showed significant decreases in respiratory rate (NIV: 14.4 (4.1) vs 10.4 (1.6), p = 0.009; HFNC: 13.6 (4.3) vs 7.9 (1.5) bpm, p = 0.002) and significant increases in the end-expiratory lung impedance (EELI) (NIV: 66,348(10,761) vs. 73,697 (6858), p = 0.005; HFNC: 66,252 (9793) vs 69,869 (9135), p = 0.012). NIV subjects showed a significant increase in non-dependent silent spaces (4.13 (2.25) vs 5.81 (1.49)%, p = 0.037) while the increase was more homogeneous with HFNC. The variation in EELI tended to be higher in NIV than in HFNC (8137.08 (6152.04) vs 3616.94 (3623.03), p = 0.077). The Mar-index was higher in HFNC group (13.15 vs 5.27 cm-sec2/bpm, p = 0.02). CONCLUSIONS NIV and HFNC increased EELI in healthy subjects, suggesting an increase in the functional residual capacity. The EELI increase may be higher in NIV, but HFNC produced a more homogeneous change in lung ventilation. HFNC group has a higher MAR-index that could reflect a different ventilatory system adaptation.
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Affiliation(s)
- Purificación Pérez-Terán
- Critical Care Department, Hospital del Mar. GREPAC - IMIM, Barcelona, Spain; UAB/UPF School of Medicine, Barcelona, Spain.
| | - Judith Marin-Corral
- Critical Care Department, Hospital del Mar. GREPAC - IMIM, Barcelona, Spain; UAB/UPF School of Medicine, Barcelona, Spain
| | - Irene Dot
- Critical Care Department, Hospital del Mar. GREPAC - IMIM, Barcelona, Spain
| | - Sergio Sans
- UAB/UPF School of Medicine, Barcelona, Spain
| | | | - Raquel Bosch
- Critical Care Department, Hospital del Mar. GREPAC - IMIM, Barcelona, Spain
| | - Clara Vila
- Critical Care Department, Hospital del Mar. GREPAC - IMIM, Barcelona, Spain
| | - Joan Ramon Masclans
- Critical Care Department, Hospital del Mar. GREPAC - IMIM, Barcelona, Spain; UAB/UPF School of Medicine, Barcelona, Spain; HISpaFlow (Grupo Español Multidiscipinar de Terapia de Soporte con Alto Flujo en Adultos), Spain
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Moury PH, Cuisinier A, Durand M, Bosson JL, Chavanon O, Payen JF, Jaber S, Albaladejo P. Diaphragm thickening in cardiac surgery: a perioperative prospective ultrasound study. Ann Intensive Care 2019; 9:50. [PMID: 31016412 PMCID: PMC6478777 DOI: 10.1186/s13613-019-0521-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background Diaphragm paresis is common after cardiac surgery and may delay the weaning from the ventilator. Our objective was to evaluate diaphragm thickening during weaning and secondly the muscle thickness as a marker of myotrauma. Methods Patients undergoing elective cardiac surgery were prospectively included. Ultrasonic index of right hemidiaphragm thickening fraction (TF) was measured as a surrogate criterion of work of breathing. A TF < 20% was defined as a low diaphragm thickening. Measurements of TF were performed during three periods to study diaphragm thickening evolution defined by the difference between two consecutive time line point: preoperative (D − 1), during a spontaneous breathing trial (SBT) in the intensive care unit and postoperative (D + 1). We studied three patterns of diaphragm thickness at end expiration evolution from D − 1 to D + 1: > 10% decrease, stability and > 10% increase. Demographical data, length of surgery, type of surgery, ICU length of stay (LOS) and extubation failure were collected. Results Of the 100 consecutively included patients, 75 patients had a low diaphragm thickening during SBT. Compared to TF values at D − 1 (36% ± 18), TF was reduced during SBT (17% ± 14) and D + 1 (12% ± 11) (P < 0.0001). Thickness and TF did not change according to the type of surgery or cooling method. TF at SBT was correlated to the length of surgery (both r = − 0.4; P < 0.0001). Diaphragm thickness as continuous variable did not change over time. Twenty-eight patients (42%) had a > 10% decrease thickness, 19 patients (29%) stability and 19 patients (28%) in > 10% increase, and this thickness evolution pattern was associated with: a longer LOS 3 days [2–5] versus 2 days [2–4] and 2 days [2], respectively (ANOVA P = 0.046), and diaphragm thickening evolution (ANOVA P = 0.02). Two patients experience extubation failure. Conclusion These findings indicate that diaphragm thickening is frequently decreased after elective cardiac surgery without impact on respiratory outcome, whereas an altered thickness pattern was associated with a longer length of stay in the ICU. Contractile activity influenced thickness evolution. Trial registry number ClinicalTrial.gov ID NCT02208479 Electronic supplementary material The online version of this article (10.1186/s13613-019-0521-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pierre-Henri Moury
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France.
| | - Adrien Cuisinier
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Michel Durand
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Jean-Luc Bosson
- Department of Biostatistics, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France
| | - Olivier Chavanon
- Department of Cardiac Surgery, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France
| | - Jean-François Payen
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Pierre Albaladejo
- Department of Anesthesia and Intensive Care, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
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Bachasson D, Dres M, Niérat MC, Gennisson JL, Hogrel JY, Doorduin J, Similowski T. Diaphragm shear modulus reflects transdiaphragmatic pressure during isovolumetric inspiratory efforts and ventilation against inspiratory loading. J Appl Physiol (1985) 2019; 126:699-707. [DOI: 10.1152/japplphysiol.01060.2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The reference method for the assessment of diaphragm function relies on the measurement of transdiaphragmatic pressure (Pdi). Local muscle stiffness measured using ultrafast shear wave elastography (SWE) provides reliable estimates of muscle force in locomotor muscles. This study aimed at investigating whether SWE could be used as a surrogate of Pdi to evaluate diaphragm function. Fifteen healthy volunteers underwent a randomized stepwise inspiratory loading protocol of 0–60% of maximal isovolumetric inspiratory pressure during closed-airways maneuvers and 0–50% during ventilation against an external inspiratory threshold load. During all tasks, Pdi was measured and SWE was used to assess shear modulus of the right hemidiaphragm (SMdi) at the zone of apposition. Pearson correlation coefficients ( r) and repeated-measures correlation coefficients ( R) were computed to determine within-individual and overall relationships between Pdi and SMdi, respectively. During closed-airways maneuvers, mean Pdi correlated to mean SMdi in all participants [ r ranged from 0.77 to 0.96, all P < 0.01; R = 0.82, 95% confidence intervals (0.76, 0.86), P < 0.01]. During ventilation against inspiratory threshold loading, Pdi swing correlated to maximal SMdi in all participants [ r ranged from 0.40 to 0.90, all P < 0.01; R = 0.70, 95% confidence intervals (0.66, 0.73), P < 0.001]. Changes in diaphragm stiffness as assessed by SWE reflect changes in transdiaphragmatic pressure. SWE provides a new opportunity for direct and noninvasive assessment of diaphragm function. NEW & NOTEWORTHY Accurate and specific estimation of diaphragm effort is critical for evaluating and monitoring diaphragm dysfunction. The measurement of transdiaphragmatic pressure requires the use of invasive gastric and esophageal probes. In the present work, we demonstrate that changes in diaphragm stiffness assessed with ultrasound shear wave elastography reflect changes in transdiaphragmatic pressure, therefore offering a new noninvasive method for gauging diaphragm effort.
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Affiliation(s)
- Damien Bachasson
- Neuromuscular Physiology Laboratory, Neuromuscular Investigation Center, Institute of Myology, Paris, France
| | - Martin Dres
- Service de Pneumologie, Médecine Intensive et Réanimation (Département “R3S”), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Marie-Cécile Niérat
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Jean-Luc Gennisson
- Imagerie par Résonance Magnétique Médicale et Multi-Modalités, Centre National de la Recherche Scientifique UMR8081, Université Paris-Saclay, Orsay, France
| | - Jean-Yves Hogrel
- Neuromuscular Physiology Laboratory, Neuromuscular Investigation Center, Institute of Myology, Paris, France
| | - Jonne Doorduin
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas Similowski
- Service de Pneumologie, Médecine Intensive et Réanimation (Département “R3S”), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
- UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Paris, France
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Turton P, ALAidarous S, Welters I. A narrative review of diaphragm ultrasound to predict weaning from mechanical ventilation: where are we and where are we heading? Ultrasound J 2019; 11:2. [PMID: 31359260 PMCID: PMC6638615 DOI: 10.1186/s13089-019-0117-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/08/2019] [Indexed: 12/19/2022] Open
Abstract
Background The use of ultrasound to visualize the diaphragm is well established. Over the last 15 years, certain indices of diaphragm function, namely diaphragm thickness, thickening fraction and excursion have been established for mechanically ventilated patients to track changes in diaphragm size and function over time, to assess and diagnose diaphragmatic dysfunction, and to evaluate if these indices can predict successful liberation from mechanical ventilation. In the last 2 years, three meta-analyses and a systematic review have assessed the usability of diaphragmatic ultrasound to predict successful weaning. Since then, further data have been published on the topic. Conclusions The aim of this narrative review is to briefly describe the common methods of diaphragmatic function assessment using ultrasound techniques, before summarizing the major points raised by the recent reviews. A narrative summary of the most recent data will be presented, before concluding with a brief discussion of future research directions in this field.
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Affiliation(s)
- Peter Turton
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK. .,Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Sondus ALAidarous
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Critical Care Unit, Royal Liverpool University Hospital, Liverpool, UK.,Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
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Ventilator Weaning: How Far from the Final Quantum Leap? Lung 2018; 196:501. [PMID: 30094795 DOI: 10.1007/s00408-018-0148-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
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Tenza-Lozano E, Llamas-Alvarez A, Jaimez-Navarro E, Fernández-Sánchez J. Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation. Crit Ultrasound J 2018; 10:12. [PMID: 29911284 PMCID: PMC6004341 DOI: 10.1186/s13089-018-0094-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lung and diaphragm ultrasound methods have recently been introduced to predict the outcome of weaning from mechanical ventilation (MV). The aim of this study is to assess the reliability and accuracy of these techniques for predicting successful weaning in critically ill adults. METHODS We conducted two studies: a cross-sectional interobserver agreement study between two sonographers and a prospective cohort study to assess the accuracy of lung and diaphragm ultrasound for predicting weaning and extubation outcome. For the interobserver agreement study, we included 50 general critical care patients who were consecutively admitted to the ICU. For the predictive accuracy study, we included consecutively 69 patients on MV who were ready for weaning. We assessed interobserver agreement of ultrasound measurements, using the weighted kappa coefficient for LUSm score (modified lung ultrasound score) and the intraclass correlation coefficient (ICC) and Bland-Altman method for TI (diaphragm thickening index). We assessed the predictive value of LUSm and TI in weaning outcome by plotting the corresponding ROC curves. RESULTS We found adequate interobserver agreement for both LUSm (weighted kappa 0.95) and TI (ICC 0.78, difference according to Bland-Altman analysis ± 12.5%). LUSm showed good-moderate discriminative power for successful weaning and extubation (area under the ROC curve (AUC) for successful weaning 0.80, and sensitivity and specificity at optimal cut-off point 0.76 and 0.73, respectively; AUC for successful extubation 0.78, and optimal sensitivity and specificity 0.76 and 0.47, respectively. TI was more sensitive but less specific for predicting successful weaning (AUC 0.71, optimal sensitivity and specificity 0.93 and 0.48) and successful extubation (AUC 0.76, optimal sensitivity and specificity 0.93 and 0.58). The area under the ROC curve for predicting weaning success was 0.83 for both ultrasound measurements together. CONCLUSIONS Interobserver agreement was excellent for LUSm and moderate-good for TI. A low TI value or high LUSm value indicates high risk of weaning failure.
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Affiliation(s)
- Eva Tenza-Lozano
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain.
| | - Ana Llamas-Alvarez
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain
| | - Enrique Jaimez-Navarro
- Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain
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