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Ghiani A, Walcher S, Lutfi A, Paderewska J, Jaeger SU, Kneidinger N, Stecher SS, Trudzinski FC, Neurohr C. Mechanical power density, spontaneous breathing indexes, and prolonged weaning failure: a prospective cohort study. Sci Rep 2024; 14:16297. [PMID: 39009821 PMCID: PMC11251183 DOI: 10.1038/s41598-024-67237-w] [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: 12/21/2023] [Accepted: 07/09/2024] [Indexed: 07/17/2024] Open
Abstract
A prospective observational study comparing mechanical power density (MP normalized to dynamic compliance) with traditional spontaneous breathing indexes (e.g., predicted body weight normalized tidal volume [VT/PBW], rapid shallow breathing index [RSBI], or the integrative weaning index [IWI]) for predicting prolonged weaning failure in 140 tracheotomized patients. We assessed the diagnostic accuracy of these indexes at the start and end of the weaning procedure using ROC curve analysis, expressed as the area under the receiver operating characteristic curve (AUROC). Weaning failure occurred in 41 out of 140 patients (29%), demonstrating significantly higher MP density (6156 cmH2O2/min [4402-7910] vs. 3004 cmH2O2/min [2153-3917], P < 0.01), lower spontaneous VT/PBW (5.8 mL*kg-1 [4.8-6.8] vs. 6.6 mL*kg-1 [5.7-7.9], P < 0.01) higher RSBI (68 min-1*L-1 [44-91] vs. 55 min-1*L-1 [41-76], P < 0.01) and lower IWI (41 L2/cmH2O*%*min*10-3 [25-72] vs. 71 L2/cmH2O*%*min*10-3 [50-106], P < 0.01) and at the end of weaning. MP density was more accurate at predicting weaning failures (AUROC 0.91 [95%CI 0.84-0.95]) than VT/PBW (0.67 [0.58-0.74]), RSBI (0.62 [0.53-0.70]), or IWI (0.73 [0.65-0.80]), and may help clinicians in identifying patients at high risk for long-term ventilator dependency.
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Affiliation(s)
- Alessandro Ghiani
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| | - Swenja Walcher
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Azal Lutfi
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Joanna Paderewska
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Simon Ulrich Jaeger
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, LMU University Hospital, LMU Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Franziska Christina Trudzinski
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, Translational Lung Research Center Heidelberg (TLRC-H), German Center for Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
| | - Claus Neurohr
- Department of Pulmonology and Respiratory Medicine, Lung Center Stuttgart - Schillerhoehe Lung Clinic, affiliated to the Robert-Bosch-Hospital GmbH, Auerbachstrasse 110, 70376, Stuttgart, Germany
- Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Munich, Germany
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Ultrasound Evaluation of Diaphragm Force Reserve in Patients with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 17:1222-1230. [PMID: 32614240 DOI: 10.1513/annalsats.202002-129oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Diaphragm function is a key determinant of dyspnea in chronic obstructive pulmonary disease (COPD); however, it is rarely assessed in clinical practice. Lung hyperinflation can also impair diaphragm function. Ultrasound can assess the activity, function, and force reserve of the diaphragm.Objectives: To compare diaphragm activity, function, and force reserve among patients with COPD and healthy control subjects.Methods: Patients with stable COPD (n = 80) and healthy control subjects (n = 20) were enrolled (97% of them were men). Ultrasound was used to measure the thickening fraction of the diaphragm during tidal breathing and maximum volitional effort. Outcome measures were as follows: 1) the difference in diaphragm force reserve, activity, and function between patients with COPD and control subjects; 2) the correlation between lung volumes and diaphragm force reserve, activity, and function; and 3) the relationship between diaphragm force reserve and the rate of moderate to severe exacerbation of COPD.Results: The tidal thickening fraction of the diaphragm during resting breathing (TFdi-tidal) was higher in patients with COPD than in control subjects (P = 0.002); it was approximately twice as high in patients with severe COPD than in control subjects. Patients with COPD had poorer diaphragm function than control subjects as assessed by the maximal thickening fraction of the diaphragm during Muller maneuver (P < 0.01). Diaphragm force reserve ratio assessed by 1-(tidal thickening fraction of the diagphragm during resting breathing/maximal thickening fraction of the diaphragm) was lower in patients with COPD than in control subjects, and it fell with increasing Global Initiative for Chronic Obstructive Lung Disease stages (P < 0.001); it correlated with inspiratory capacity (r = 0.46) and the body mass index, airflow obstruction, dyspnea, exercise capacity (BODE) index, a multidimensional scoring system (r = -0.49). Patients who developed exacerbation during the following 2 years had less force reserve than patients without exacerbation (P = 0.024).Conclusions: Male patients with COPD have increased diaphragm workload, impaired diaphragm function, and reduced force reserve compared with healthy subjects. Ultrasound assessment of the diaphragm in COPD provides important functional information.Clinical trial registered with the Thai Clinical Trials Registry (TCTR20160411001). Registered 31 April 5, 2016.
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Hyatt HW, Ozdemir M, Yoshihara T, Nguyen BL, Deminice R, Powers SK. Calpains play an essential role in mechanical ventilation-induced diaphragmatic weakness and mitochondrial dysfunction. Redox Biol 2020; 38:101802. [PMID: 33279868 PMCID: PMC7724197 DOI: 10.1016/j.redox.2020.101802] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention for many critically ill patients. Unfortunately, an unintended consequence of prolonged MV is the rapid development of diaphragmatic atrophy and contractile dysfunction, known as ventilator-induced diaphragm dysfunction (VIDD). Although the mechanism(s) responsible for VIDD are not fully understood, abundant evidence reveals that oxidative stress leading to the activation of the major proteolytic systems (i.e., autophagy, ubiquitin-proteasome, caspase, and calpain) plays a dominant role. Of the proteolytic systems involved in VIDD, calpain has received limited experimental attention due to the longstanding dogma that calpain plays a minor role in inactivity-induced muscle atrophy. Guided by preliminary experiments, we tested the hypothesis that activation of calpains play an essential role in MV-induced oxidative stress and the development of VIDD. This premise was rigorously tested by transgene overexpression of calpastatin, an endogenous inhibitor of calpains. Animals with/without transfection of the calpastatin gene in diaphragm muscle fibers were exposed to 12 h of MV. Results confirmed that overexpression of calpastatin barred MV-induced activation of calpain in diaphragm fibers. Importantly, deterrence of calpain activation protected the diaphragm against MV-induced oxidative stress, fiber atrophy, and contractile dysfunction. Moreover, prevention of calpain activation in the diaphragm forstalled MV-induced mitochondrial dysfunction and prevented MV-induced activation of caspase-3 along with the transcription of muscle specific E3 ligases. Collectively, these results support the hypothesis that calpain activation plays an essential role in the early development of VIDD. Further, these findings provide the first direct evidence that calpain plays an important function in inactivity-induced mitochondrial dysfunction and oxidative stress in skeletal muscle fibers. Inhibiting calpains during mechanical ventilation protects the diaphragm. Calpains play an important role in muscle atrophy and contractile dysfunction. Calpain inhibition during mechanical ventilation prevents mitochondrial dysfunction. Calpain-cleaved molecules may play important signaling roles. Calpain activation cross-talks with other proteolytic systems.
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Affiliation(s)
- Hayden W Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA.
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Exercise and Sport Sciences, Hacettepe University, Ankara, Turkey
| | - Toshinori Yoshihara
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Exercise Physiology, Juntendo University, Tokyo, Japan
| | - Branden L Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Rafael Deminice
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Physical Education, State University of Londrina, Londrina, Brazil
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
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Spadaro S, Karbing DS, Dalla Corte F, Mauri T, Moro F, Gioia A, Volta CA, Rees SE. An open-loop, physiological model based decision support system can reduce pressure support while acting to preserve respiratory muscle function. J Crit Care 2018; 48:407-413. [PMID: 30317049 DOI: 10.1016/j.jcrc.2018.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess whether a clinical decision support system (CDSS) suggests PS and FIO2 maintaining appropriate breathing effort, and minimizing FIO2. MATERIALS Prospective, cross-over study in PS ventilated ICU patients. Over support (150% baseline) and under support (50% baseline) were applied by changing PS (15 patients) or PEEP (8 patients). CDSS advice was followed. Tension time index of inspiratory muscles (TTies), respiratory and metabolic variables were measured. RESULTS PS over support (median 8.0 to 12.0 cmH2O) reduced respiratory muscle activity (TTies 0.090 ± 0.028 to 0.049 ± 0.030; p < .01), and tended to increase tidal volume (VT: 8.6 ± 3.0 to 10.1 ± 2.9 ml/kg; p = .08). CDSS advice reduced PS (6.0 cmH2O, p = .005), increased TTies (0.076 ± 0.038, p < .01), and tended to reduce VT (8.9 ± 2.4 ml/kg, p = .08). PS under support (12.0 to 4.0 cmH2O) slightly increased respiratory muscle activity, (TTies to 0.120 ± 0.044; p = .007) with no significant CDSS advice. CDSS advice reduced FIO2 by 12-14% (p = .005), resulting in median SpO2 = 96% (p < .02). PEEP changes did not result in changes in physiological variables, or CDSS advice. CONCLUSION The CDSS advised on low values of PS often not prohibiting extubation, while acting to preserve respiratory muscle function and preventing passive lung inflation. CDSS advice minimized FIO2 maintaining SpO2 at safe and beneficial values.
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Affiliation(s)
- Savino Spadaro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Francesca Dalla Corte
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Moro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Antonio Gioia
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
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Ortega ICM, Valdivieso AMH, Lopez JFA, Villanueva MÁM, Lopez LHA. Assessment of weaning indexes based on diaphragm activity in mechanically ventilated subjects after cardiovascular surgery. A pilot study. Rev Bras Ter Intensiva 2017; 29:213-221. [PMID: 28977261 PMCID: PMC5496756 DOI: 10.5935/0103-507x.20170030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/20/2017] [Indexed: 11/21/2022] Open
Abstract
Objective The aim of this pilot study was to evaluate the feasibility of surface
electromyographic signal derived indexes for the prediction of weaning
outcomes among mechanically ventilated subjects after cardiac surgery. Methods A sample of 10 postsurgical adult subjects who received cardiovascular
surgery that did not meet the criteria for early extubation were included.
Surface electromyographic signals from diaphragm and ventilatory variables
were recorded during the weaning process, with the moment determined by the
medical staff according to their expertise. Several indexes of respiratory
muscle expenditure from surface electromyography using linear and non-linear
processing techniques were evaluated. Two groups were compared: successfully
and unsuccessfully weaned patients. Results The obtained indexes allow estimation of the diaphragm activity of each
subject, showing a correlation between high expenditure and weaning test
failure. Conclusion Surface electromyography is becoming a promising procedure for assessing the
state of mechanically ventilated patients, even in complex situations such
as those that involve a patient after cardiovascular surgery.
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Affiliation(s)
- Isabel Cristina Muñoz Ortega
- Grupo de Pesquisa em Bioinstrumentação e Engenharia Clínica, Departamento de Bioengenharia, Faculdade de Engenharia, Universidad de Antioquia - Medellín, Colômbia
| | - Alher Mauricio Hernández Valdivieso
- Grupo de Pesquisa em Bioinstrumentação e Engenharia Clínica, Departamento de Bioengenharia, Faculdade de Engenharia, Universidad de Antioquia - Medellín, Colômbia
| | - Joan Francesc Alonso Lopez
- Departamento de Controle Automático e Centro de Pesquisa em Engenharia Biomédica, Universitat Politécnica de Catalunya - Barcelona, Espanha
| | - Miguel Ángel Mañanas Villanueva
- Departamento de Controle Automático e Centro de Pesquisa em Engenharia Biomédica, Universitat Politécnica de Catalunya - Barcelona, Espanha
| | - Luis Horacio Atehortúa Lopez
- Programa de Medicina Intensiva e Crítica, Faculdade de Medicina, Universidad de Antioquia - Medellín, Colômbia.,Unidade de Terapia Intensiva Cardiovascular, Hospital San Vicente Fundación - Medellín, Colômbia
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Abstract
This review documents important progress made in 2013 in the field of critical care respirology, in particular with regard to acute respiratory failure and acute respiratory distress syndrome. Twenty-five original articles published in the respirology and critical care sections of Critical Care are discussed in the following categories: pre-clinical studies, protective lung ventilation – how low can we go, non-invasive ventilation for respiratory failure, diagnosis and prognosis in acute respiratory distress syndrome and respiratory failure, and promising interventions for acute respiratory distress syndrome.
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Effect of intermittent phrenic nerve stimulation during cardiothoracic surgery on mitochondrial respiration in the human diaphragm. Crit Care Med 2014; 42:e152-6. [PMID: 24126442 DOI: 10.1097/ccm.0b013e3182a63fdf] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Recent studies have shown that brief periods of mechanical ventilation in animals and humans can lead to ventilator-induced diaphragmatic dysfunction, which includes muscle atrophy, reduced force development, and impaired mitochondrial function. Studies in animal models have shown that short periods of increased diaphragm activity during mechanical ventilation support can attenuate ventilator-induced diaphragmatic dysfunction but corresponding human data are lacking. The purpose of this study was to examine the effect of intermittent diaphragm contractions during cardiothoracic surgery, including controlled mechanical ventilation, on mitochondrial respiration in the human diaphragm. DESIGN Within subjects repeated measures study. SETTING Operating room in an academic health center. PATIENTS Five subjects undergoing elective cardiothoracic surgery. INTERVENTIONS In patients (age 65.6 ± 6.3 yr) undergoing cardiothoracic surgery, one phrenic nerve was stimulated hourly (30 pulses/min, 1.5 msec duration, 17.0 ± 4.4 mA) during the surgery. Subjects received 3.4 ± 0.6 stimulation bouts during surgery. Thirty minutes following the last stimulation bout, samples of diaphragm muscle were obtained from the anterolateral costal regions of the stimulated and inactive hemidiaphragms. MEASUREMENTS AND MAIN RESULTS Mitochondrial respiration was measured in permeabilized muscle fibers with high-resolution respirometry. State III mitochondrial respiration rates (pmol O2/s/mg wet weight) were 15.05 ± 3.92 and 11.42 ± 2.66 for the stimulated and unstimulated samples, respectively (p < 0.05). State IV mitochondrial respiration rates were 3.59 ± 1.25 and 2.11 ± 0.97 in the stimulated samples and controls samples, respectively (p < 0.05). CONCLUSION These are the first data examining the effect of intermittent contractions on mitochondrial respiration rates in the human diaphragm following surgery/mechanical ventilation. Our results indicate that very brief periods (duty cycle ~1.7%) of activity can improve mitochondrial function in the human diaphragm following surgery/mechanical ventilation.
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Papuzinski C, Durante M, Tobar C, Martinez F, Labarca E. Predicting the need of tracheostomy amongst patients admitted to an intensive care unit: a multivariate model. Am J Otolaryngol 2013; 34:517-22. [PMID: 23809275 DOI: 10.1016/j.amjoto.2013.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 05/15/2013] [Accepted: 05/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients requiring prolonged invasive mechanical ventilation are prone to complications, such as infections, tracheal stenosis and death. It has been proposed that early tracheostomy could have a role in preventing these outcomes, but the proper identification of patients at risk can be difficult. PURPOSE The aim of this study was to develop a multivariate model that allows the early detection of patients that will require prolonged ventilatory support. PATIENTS AND METHODS A retrospective cohort study was undertaken in the intensive care unit of the Hospital Naval Almirante Nef, Chile, between June 2011 and June 2012. The charts of all intubated patients were reviewed in search for early predictors of prolonged intubation (>7 days). Multivariate logistic regression analysis was used to detect statistically significant associations and to assess potential confounders. RESULTS A total of 349 patients were admitted to the intensive care unit during the study period and 142 (40.7%) required invasive mechanical ventilation. Most of them were male (60.5%), with a mean age of 65.8 ± 16.7 years. Thirty-five patients (24%) required to be ventilated for 7 days or more, and 16 (46%) were tracheostomized for this reason. The regression model showed that older age (p=0.026), a Pa/Fi ratio of less than 200 (p=0.046), and the presence of chronic pulmonary disease (p=0.035) or hypernatremia (p=0.012) on intubation day were significantly associated with the requirement of prolonged intubation. DISCUSSION Invasive mechanical ventilation is a common reason for admittance to the ICU. The abovementioned predictors can be of assistance when selecting patients that could benefit from early tracheostomies, and are in agreement with earlier reports. Although the model's discriminating capacity was good, it is necessary to formally validate it before recommending its widespread use.
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Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective. Respir Physiol Neurobiol 2013; 189:377-83. [PMID: 23692928 DOI: 10.1016/j.resp.2013.05.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 11/24/2022]
Abstract
Most patients are easily liberated from mechanical ventilation (MV) following resolution of respiratory failure and a successful trial of spontaneous breathing, but about 25% of patients experience difficult weaning. MV use leads to cellular changes and weakness, which has been linked to weaning difficulties and has been labeled ventilator induced diaphragm dysfunction (VIDD). Aggravating factors in human studies with prolonged weaning include malnutrition, chronic electrolyte abnormalities, hyperglycemia, excessive resistive and elastic loads, corticosteroids, muscle relaxant exposure, sepsis and compromised cardiac function. Numerous animal studies have investigated the effects of MV on diaphragm function. Virtually all these studies have concluded that MV use rapidly leads to VIDD and have identified cellular and molecular mechanisms of VIDD. Molecular and functional studies on the effects of MV on the human diaphragm have largely confirmed the animal results and identified potential treatment strategies. Only recently potential VIDD treatments have been tested in humans, including pharmacologic interventions and diaphragm "training". A limited number of human studies have found that specific diaphragm training can increase respiratory muscle strength in FTW patients and facilitate weaning, but larger, multicenter trials are needed.
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