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Pu H, Doig GS, Lv Y, Wu X, Yang F, Zhang S, Liang Z, Zhou Y, Kang Y. Modifiable risk factors for ventilator associated diaphragmatic dysfunction: a multicenter observational study. BMC Pulm Med 2023; 23:343. [PMID: 37700263 PMCID: PMC10498609 DOI: 10.1186/s12890-023-02633-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Diaphragmatic dysfunction is known to be associated with difficulties weaning from invasive mechanical ventilation and is related to worse patient outcomes yet our understanding of how to prevent diaphragmatic dysfunction remains incomplete. We examined potentially modifiable risk factors for diaphragmatic dysfunction and attempted to estimate benefits attributable to altering these modifiable risk factors. METHODS This prospective multicenter observational study was undertaken in the general ICUs of two tertiary care teaching hospitals. Critically ill adults expected to receive invasive mechanical ventilation for at least 48 h were enrolled. Diaphragm function was assessed by ultrasound each study day, with dysfunction defined as thickening fraction less than 20%. RESULTS From January to December 2019, 856 patients were screened and 126 patients were enrolled. Overall, 40.5% (51/126) of patients experienced diaphragmatic dysfunction during invasive mechanical ventilation. Patients with diaphragmatic dysfunction were more likely to develop ventilator associated pneumonia (risk difference [RD] + 12.9%, 95% Confidence Interval [CI] 1.4 to 24.4%, P = 0.028), were more likely to experience extubation failure (RD + 8.5%, 95% CI 0.4 to 16.6%, P = 0.039) and required a longer duration of invasive mechanical ventilation (RD + 1.3 days, 95% CI 0.1 to 2.5 days, P = 0.035). They also required a longer hospital stay (RD + 1.2 days, 95% CI 0.04 to 2.4 days, P = 0.041) and were more likely to die before hospital discharge (RD + 18.1%, 95% CI 3.7 to 32.5%, P = 0.014). Multivariable analysis considered the impact of age, sex, pre-existing nutritional status, caloric intake, amino acid intake, acute disease severity, modes of mechanical ventilation, measures of respiratory status, sedation, pain control and baseline diaphragm thickness. Only SOFA score (P = 0.008) and early amino acid intake (P = 0.001) remained significant independent risk factors for the onset of diaphragmatic dysfunction. Causal path modeling suggested early amino acid intake may significantly reduce diaphragmatic dysfunction (RRR 29%, 95% CI 10% to 48%, P = 0.003) and may also reduce mortality (RRR 49%, 95% CI 25% to 73%, P < 0.0001). CONCLUSIONS Amino acid intake during the first 24 h of ICU stay may represent an important, modifiable risk factor for diaphragmatic dysfunction and may have a direct causal effect on mortality. We recommend additional research on this topic.
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Affiliation(s)
- Hong Pu
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Gordon S Doig
- Northern Clinical School Intensive Care Research Unit, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Yu Lv
- Healthcare-Associated Infection Control Center, Sichuan Academy of Medical Sciences, School of Medicine, Sichuan People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Xiaoxiao Wu
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences, School of Medicine, Sichuan People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Fu Yang
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Shurong Zhang
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan Zhou
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan Kang
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
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Zambelli V, Murphy EJ, Delvecchio P, Rizzi L, Fumagalli R, Rezoagli E, Bellani G. Treatment with levosimendan in an experimental model of early ventilator-induced diaphragmatic dysfunction. Drug Target Insights 2023; 17:39-44. [PMID: 37070031 PMCID: PMC10105369 DOI: 10.33393/dti.2023.2574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/29/2023] [Indexed: 04/19/2023] Open
Abstract
Introduction Mechanical ventilation (MV) is a life-saving approach in critically ill patients. However, it may affect the diaphragmatic structure and function, beyond the lungs. Levosimendan is a calcium sensitizer widely used in clinics to improve cardiac contractility in acute heart failure patients. In vitro studies have demonstrated that levosimendan increased force-generating capacity of the diaphragm in chronic obstructive pulmonary disease patients. Thus the aim of this study was to evaluate the effects of levosimendan administration in an animal model of ventilator-induced diaphragmatic dysfunction (VIDD) on muscle contraction and diaphragm muscle cell viability. Methods Sprague-Dawley rats underwent prolonged MV (5 hours). VIDD+Levo group received a starting bolus of levosimendan immediately after intratracheal intubation and then an intravenous infusion of levosimendan throughout the study. Diaphragms were collected for ex vivo contractility measurement (with electric stimulation), histological analysis and Western blot analysis. Healthy rats were used as the control. Results Levosimendan treatment maintained an adequate mean arterial pressure during the entire experimental protocol, preserved levels of autophagy-related proteins (LC3BI and LC3BII) and the muscular cell diameter demonstrated by histological analysis. Levosimendan did not affect the diaphragmatic contraction or the levels of proteins involved in the protein degradation (atrogin). Conclusions Our data suggest that levosimendan preserves muscular cell structure (cross-sectional area) and muscle autophagy after 5 hours of MV in a rat model of VIDD. However, levosimendan did not improve diaphragm contractile efficiency.
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Affiliation(s)
- Vanessa Zambelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
| | - Emma J Murphy
- LIFE - Health and Bioscience Research Institute, Midwest Campus, Technological University of the Shannon, Limerick - Ireland
| | - Paolo Delvecchio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
| | - Laura Rizzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan - Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza - Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza - Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza - Italy
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Ultrasound Versus Computed Tomography for Diaphragmatic Thickness and Skeletal Muscle Index during Mechanical Ventilation. Diagnostics (Basel) 2022; 12:diagnostics12112890. [PMID: 36428947 PMCID: PMC9689333 DOI: 10.3390/diagnostics12112890] [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: 10/11/2022] [Revised: 11/08/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Diaphragmatic alterations occurring during mechanical ventilation (MV) can be monitored using ultrasound (US). The performance of computed tomography (CT) to evaluate diaphragmatic thickness is limited. Further, the association between muscle mass and outcome is increasingly recognized. However, no data are available on its correlation with diaphragmatic thickness. We aimed to determine correlation and agreement of diaphragmatic thickness between CT and US; and its association with muscle mass and MV parameters. Methods: Prospective observational study. US measurements of the diaphragmatic thickness were collected in patients undergoing MV within 12 h before or after performing a CT scan of the thorax and/or upper abdomen. Data on skeletal muscle index (SMI), baseline, and ventilatory data were recorded and correlated with US and CT measures of diaphragmatic thickness. Agreement was explored between US and CT data. Results: Twenty-nine patients were enrolled and the diaphragm measured by CT resulted overall thicker than US-based measurement of the right hemidiaphragm. The US thickness showed the strongest correlation with the left posterior pillar at CT (r = 0.49, p = 0.008). The duration of the controlled MV was negatively correlated with US thickness (r = -0.45, p = 0.017), the thickness of the right anterior pillar (r = -0.41, p = 0.029), and splenic dome by CT (r = -0.43, p = 0.023). SMI was positively correlated with US diaphragmatic thickness (r = 0.50, p = 0.007) and inversely correlated with the duration of MV before enrollment (r = -0.426, p = 0.027). Conclusions: CT scan of the left posterior pillar can estimate diaphragmatic thickness and is moderately correlated with US measurements. Both techniques show that diaphragm thickness decreases with MV duration. The diaphragmatic thickness by US showed a good correlation with SMI.
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Murray B, Sikora A, Mock JR, Devlin T, Keats K, Powell R, Bice T. Reverse Triggering: An Introduction to Diagnosis, Management, and Pharmacologic Implications. Front Pharmacol 2022; 13:879011. [PMID: 35814233 PMCID: PMC9256988 DOI: 10.3389/fphar.2022.879011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Reverse triggering is an underdiagnosed form of patient-ventilator asynchrony in which a passive ventilator-delivered breath triggers a neural response resulting in involuntary patient effort and diaphragmatic contraction. Reverse triggering may significantly impact patient outcomes, and the unique physiology underscores critical potential implications for drug-device-patient interactions. The purpose of this review is to summarize what is known of reverse triggering and its pharmacotherapeutic consequences, with a particular focus on describing reported cases, physiology, historical context, epidemiology, and management. The PubMed database was searched for publications that reported patients presenting with reverse triggering. The current body of evidence suggests that deep sedation may predispose patients to episodes of reverse triggering; as such, providers may consider decreasing sedation or modifying ventilator settings in patients exhibiting ventilator asynchrony as an initial measure. Increased clinician awareness and research focus are necessary to understand appropriate management of reverse triggering and its association with patient outcomes.
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Affiliation(s)
- Brian Murray
- University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Andrea Sikora
- College of Pharmacy, University of Georgia, Athens, GA, United States
- *Correspondence: Andrea Sikora,
| | - Jason R. Mock
- University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Thomas Devlin
- University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Kelli Keats
- Augusta University Medical Center, Augusta, GA, United States
| | - Rebecca Powell
- College of Pharmacy, University of Georgia, Athens, GA, United States
| | - Thomas Bice
- Novant Health, Winston-Salem, NC, United States
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Kiefer D, Müller-Wirtz LM, Maurer F, Hüppe T, Mathes AM, Volk T, Kreuer S, Fink T. Intravenous propofol, ketamine (ketofol) and rocuronium after sevoflurane induction provides long lasting anesthesia in ventilated rats. Exp Anim 2021; 71:231-239. [PMID: 34880161 PMCID: PMC9130037 DOI: 10.1538/expanim.21-0147] [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] [Indexed: 11/26/2022] Open
Abstract
Rats are commonly used animals for laboratory experiments and many experiments require general anesthesia. However, the lack of published and reproducible intravenous anesthesia protocols
for rats results in unnecessary animal use to establish new anesthesia techniques across institutions. We therefore developed an anesthesia protocol with propofol, ketamine, and rocuronium
for mechanically ventilated rats, and evaluated vital parameters and plasma concentrations. 15 male Sprague-Dawley rats underwent inhalation induction with sevoflurane and tracheal, venous
and arterial cannulation. After established venous access, sevoflurane was substituted by propofol and ketamine (ketofol). Rocuronium was added under mechanical ventilation for 7 h. Drug
dosages were stepwise reduced to prevent accumulation. All animals survived the observation period and showed adequate depth of anesthesia. Mean arterial pressure and heart rate remained
within normal ranges. Median propofol plasma concentrations remained stable: 1, 4, 7 h: 2.0 (interquartile range (IQR): 1.8–2.2), 2.1 (1.8–2.2), 1.8 (1.6–2.1) µg/ml, whereas
median ketamine concentrations slightly differed after 7 h compared to 1 h: 1, 4, 7 h: 3.7 (IQR: 3.5–4.5), 3.8 (3.3–4.1), 3.8 (3.0–4.1) µg/ml. Median rocuronium plasma
concentrations were lower after 4 and 7 h compared to 1 h: 1, 4, 7 h: 3.9 (IQR: 3.5–4.9), 3.2 (2.7–3.3), 3.0 (2.4–3.4) µg/ml. Our anesthesia protocol provides stable and
reliable anesthesia in mechanically ventilated rats for several hours.
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Affiliation(s)
- Daniel Kiefer
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
| | - Lukas M Müller-Wirtz
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
| | - Felix Maurer
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
| | - Tobias Hüppe
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
| | - Alexander M Mathes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Faculty of Medicine
| | - Thomas Volk
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
| | - Sascha Kreuer
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
| | - Tobias Fink
- CBR - Center of Breath Research, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine
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Rationale and design of a mechanistic clinical trial of JAK inhibition to prevent ventilator-induced diaphragm dysfunction. Respir Med 2021; 189:106620. [PMID: 34655959 DOI: 10.1016/j.rmed.2021.106620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Ventilator-induced diaphragm dysfunction (VIDD) is an important phenomenon that has been repeatedly demonstrated in experimental and clinical models of mechanical ventilation. Even a few hours of MV initiates signaling cascades that result in, first, reduced specific force, and later, atrophy of diaphragm muscle fibers. This severe, progressive weakness of the critical ventilatory muscle results in increased duration of MV and thus increased MV-associated complications/deaths. A drug that could prevent VIDD would likely have a major positive impact on intensive care unit outcomes. We identified the JAK/STAT pathway as important in VIDD and then demonstrated that JAK inhibition prevents VIDD in rats. We subsequently developed a clinical model of VIDD demonstrating reduced contractile force of isolated diaphragm fibers harvested after ∼7 vs ∼1 h of MV during a thoracic surgical procedure. MATERIALS AND METHODS The NIH-funded clinical trial that has been initiated is a prospective, placebo controlled trial: subjects undergoing esophagectomy are randomized to receive 6 preoperative doses of the FDA-approved JAK inhibitor Tofacitinib (commonly used for rheumatoid arthritis) vs. placebo. The primary outcome variable will be the difference in the reduction that occurs in force generation of diaphragm single muscle fibers (normalized to their cross-sectional area), in the Tofacitinib vs. placebo subjects, over 6 h of MV. DISCUSSION This trial represents a first-in-human, mechanistic clinical trial of a drug to prevent VIDD. It will provide proof-of-concept in human subjects whether JAK inhibition prevents clinical VIDD, and if successful, will support an ICU-based clinical trial that would determine whether JAK inhibition impacts clinical outcome variables such as duration of MV and mortality.
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Mehta S, Zhou Q, Pinto R, Friedrich JO, Lamontagne F, Ferguson ND, Meade MO, Adhikari NKJ. Utilization and effect of neuromuscular blockade in a randomized trial of high-frequency oscillation. J Crit Care 2021; 66:86-92. [PMID: 34474282 DOI: 10.1016/j.jcrc.2021.08.006] [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: 04/14/2021] [Revised: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE We evaluated characteristics associated with neuromuscular blockade (NMB) use, center-level variation, and whether NMB mediated excess mortality among patients assigned to high-frequency oscillatory ventilation (HFOV) in the OSCILLATE trial. MATERIALS AND METHODS NMB exposure was defined as receipt after randomization; the primary outcome was hospital mortality. Descriptive analyses compared NMB-exposed vs unexposed patients. Multivariable analyses included patients not on baseline NMB. Cox regression evaluated associations of patient- and center-level variables with NMB use. A log-normal frailty model evaluated center effects. Mediation analysis examined the effect of NMB in HFOV-assigned patients. RESULTS 376/548 patients (39 centers) received post-randomization NMB, of whom 165 received baseline NMB. Patients receiving post-randomization NMB (vs. not) had worse lung mechanics and gas exchange, received more sedation and vasopressors (p < 0.05), and had higher hospital mortality (44% vs. 34%, p = 0.03). Mean airway pressure ≥ 24 cmH2O, randomization to HFOV, and intensive care unit size ≥ 31 beds were associated with post-randomization NMB. After adjustment, center had a negligible effect on post-randomization NMB (median hazard ratio 1.01, p = 0.047). NMB use did not mediate excess mortality among HFOV-allocated patients (p = 0.80). CONCLUSIONS In OSCILLATE, receipt of post-randomization NMB was associated with worse outcomes, but NMB use did not mediate HFOV-associated higher mortality.
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Affiliation(s)
- Sangeeta Mehta
- Department of Medicine, Sinai Health, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - Qi Zhou
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jan O Friedrich
- Critical Care and Medicine Departments, St. Michael's Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - François Lamontagne
- Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute, University Health Network and Sinai Health, Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Université de Sherbrooke and Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Canada
| | - Maureen O Meade
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine and Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
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Abstract
PURPOSE OF REVIEW Diaphragm weakness can impact survival and increases comorbidities in ventilated patients. Mechanical ventilation is linked to diaphragm dysfunction through several mechanisms of injury, referred to as myotrauma. By monitoring diaphragm activity and titrating ventilator settings, the critical care clinician can have a direct impact on diaphragm injury. RECENT FINDINGS Both the absence of diaphragm activity and excessive inspiratory effort can result in diaphragm muscle weakness, and recent evidence demonstrates that a moderate level of diaphragm activity during mechanical ventilation improves ICU outcome. This supports the hypothesis that by avoiding ventilator overassistance and underassistance, the clinician can implement a diaphragm-protective ventilation strategy. Furthermore, eccentric diaphragm contractions and end-expiratory shortening could impact diaphragm strength as well. This review describes these potential targets for diaphragm protective ventilation. SUMMARY A ventilator strategy that results in appropriate levels of diaphragm activity has the potential to be diaphragm-protective and improve clinical outcome. Monitoring respiratory effort during mechanical ventilation is becoming increasingly important.
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Affiliation(s)
- Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Adult Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury. Sports Med 2020; 49:1183-1198. [PMID: 31098990 DOI: 10.1007/s40279-019-01122-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Moderate-to-severe traumatic brain injury (TBI) is a chronic health condition with multi-systemic effects. Survivors face significant long-term functional limitations, including physical activity intolerance and disordered sleep. Persistent cardiorespiratory dysfunction is a potentially modifiable yet often overlooked major contributor to the alarmingly high long-term morbidity and mortality rates in these patients. This narrative review was developed through systematic and non-systematic searches for research relating cardiorespiratory function to moderate-to-severe TBI. The literature reveals patients who have survived moderate-to-severe TBI have ~ 25-35% reduction in maximal aerobic capacity 6-18 months post-injury, resting pulmonary capacity parameters that are reduced 25-40% for weeks to years post-injury, increased sedentary behavior, and elevated risk of cardiorespiratory-related morbidity and mortality. Synthesis of data from other patient populations reveals that cardiorespiratory dysfunction is likely a consequence of ventilator-induced diaphragmatic dysfunction (VIDD), which is not currently addressed in TBI management. Thus, cardiopulmonary exercise testing should be routinely performed in this patient population and those with cardiorespiratory deficits should be further evaluated for diaphragmatic dysfunction. Lack of targeted treatment for underlying cardiorespiratory dysfunction, including VIDD, likely contributes to physical activity intolerance and poor functional outcomes in these patients. Interventional studies have demonstrated that short-term exercise training programs are effective in patients with moderate-to-severe TBI, though improvement is variable. Inspiratory muscle training is beneficial in other patient populations with diaphragmatic dysfunction, and may be valuable for patients with TBI who have been mechanically ventilated. Thus, clinicians with expertise in cardiorespiratory fitness assessment and exercise training interventions should be included in patient management for individuals with moderate-to-severe TBI.
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Abstract
PURPOSE OF REVIEW Diaphragm dysfunction is common in mechanically ventilated patients and predisposes them to prolonged ventilator dependence and poor clinical outcomes. Mechanical ventilation is a major cause of diaphragm dysfunction in these patients, raising the possibility that diaphragm dysfunction might be prevented if mechanical ventilation can be optimized to avoid diaphragm injury - a concept referred to as diaphragm-protective ventilation. This review surveys the evidence supporting the concept of diaphragm-protective ventilation and introduces potential routes and challenges to pursuing this strategy. RECENT FINDINGS Mechanical ventilation can cause diaphragm injury (myotrauma) by a variety of mechanisms. An understanding of these various mechanisms raises the possibility of a new approach to ventilatory management, a diaphragm-protective ventilation strategy. Deranged inspiratory effort is the main mediator of diaphragmatic myotrauma; titrating ventilation to maintain an optimal level of inspiratory effort may help to limit diaphragm dysfunction and accelerate liberation of mechanical ventilation. SUMMARY Mechanical ventilation can cause diaphragm injury and weakness. A novel diaphragm-protective ventilation strategy, avoiding the harmful effects of both excessive and insufficient inspiratory effort, has the potential to substantially improve outcomes for patients.
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Molina Peña ME, Sánchez CM, Rodríguez-Triviño CY. Physiopathological mechanisms of diaphragmatic dysfunction associated with mechanical ventilation. ACTA ACUST UNITED AC 2020; 67:195-203. [PMID: 31982168 DOI: 10.1016/j.redar.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
Ventilator-induced diaphragm dysfunction (VIDD) is the loss of diaphragmatic muscle strength'related to of mechanical ventilation, noticed during the first day or 48hours after initiating controlled mechanical ventilation. This alteration has been related to disruption on the insulin growth factor/phosphoinositol 3-kinase/kinase B protein pathway (IGF/PI3K/AKT), in addition to an overexpression of FOXO, expression of NF-kB signaling, increase function of muscular ubiquitin ligase and activation of caspasa-3. VIDD has a negative impact on quality of life, duration of mechanical ventilation, and hospitalization stance and cost. More studies are necessary to understated the process and impact of VIDD. This is a narrative review of non-systematic literature, aiming to explain the molecular pathways involved in VIDD.
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Affiliation(s)
- M E Molina Peña
- Semillero de Fisiología Pr ctica aplicada, Grupo Navarra Medicina, Departamento de Ciencias Fisiológicas, Facultad de Ciencias de la Salud, Fundación Universitaria Navarra-UNINAVARRA, Neiva, Huila, Colombia.
| | - C M Sánchez
- Semillero de Fisiología Pr ctica aplicada, Grupo Navarra Medicina, Departamento de Ciencias Fisiológicas, Facultad de Ciencias de la Salud, Fundación Universitaria Navarra-UNINAVARRA, Neiva, Huila, Colombia
| | - C Y Rodríguez-Triviño
- Grupo Navarra Medicina, Departamento de Ciencias Fisiológicas, Facultad de Ciencias de la Salud, Fundación Universitaria Navarra-UNINAVARRA, Neiva, Huila, Colombia; Grupo Cuidar, Facultad de Ciencias de la Salud, Universidad Surcolombiana, Neiva, Huila, Colombia
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Dexmedetomidine Impairs Diaphragm Function and Increases Oxidative Stress but Does Not Aggravate Diaphragmatic Atrophy in Mechanically Ventilated Rats. Anesthesiology 2019; 128:784-795. [PMID: 29346133 DOI: 10.1097/aln.0000000000002081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anesthetics in ventilated patients are critical as any cofactor hampering diaphragmatic function may have a negative impact on the weaning progress and therefore on patients' mortality. Dexmedetomidine may display antioxidant and antiproteolytic properties, but it also reduced glucose uptake by the muscle, which may impair diaphragm force production. This study tested the hypothesis that dexmedetomidine could inhibit ventilator-induced diaphragmatic dysfunction. METHODS Twenty-four rats were separated into three groups (n = 8/group). Two groups were mechanically ventilated during either dexmedetomidine or pentobarbital exposure for 24 h, referred to as interventional groups. A third group of directly euthanized rats served as control. Force generation, fiber dimensions, proteolysis markers, protein oxidation and lipid peroxidation, calcium homeostasis markers, and glucose transporter-4 (Glut-4) translocation were measured in the diaphragm. RESULTS Diaphragm force, corrected for cross-sectional area, was significantly decreased in both interventional groups compared to controls and was significantly lower with dexmedetomidine compared to pentobarbital (e.g., 100 Hz: -18%, P < 0.0001). In contrast to pentobarbital, dexmedetomidine did not lead to diaphragmatic atrophy, but it induced more protein oxidation (200% vs. 73% in pentobarbital, P = 0.0015), induced less upregulation of muscle atrophy F-box (149% vs. 374% in pentobarbital, P < 0.001) and impaired Glut-4 translocation (-73%, P < 0.0005). It activated autophagy, the calcium-dependent proteases, and caused lipid peroxidation similarly to pentobarbital. CONCLUSIONS Twenty-four hours of mechanical ventilation during dexmedetomidine sedation led to a worsening of ventilation-induced diaphragm dysfunction, possibly through impaired Glut-4 translocation. Although dexmedetomidine prevented diaphragmatic fiber atrophy, it did not inhibit oxidative stress and activation of the proteolytic pathways.
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Reilly JP, Calfee CS, Christie JD. Acute Respiratory Distress Syndrome Phenotypes. Semin Respir Crit Care Med 2019; 40:19-30. [PMID: 31060085 DOI: 10.1055/s-0039-1684049] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The acute respiratory distress syndrome (ARDS) phenotype was first described over 50 years ago and since that time significant progress has been made in understanding the biologic processes underlying the syndrome. Despite this improved understanding, no pharmacologic therapies aimed at the underlying biology have been proven effective in ARDS. Increasingly, ARDS has been recognized as a heterogeneous syndrome characterized by subphenotypes with distinct clinical, radiographic, and biologic differences, distinct outcomes, and potentially distinct responses to therapy. The Berlin Definition of ARDS specifies three severity classifications: mild, moderate, and severe based on the PaO2 to FiO2 ratio. Two randomized controlled trials have demonstrated a potential benefit to prone positioning and neuromuscular blockade in moderate to severe phenotypes of ARDS only. Precipitating risk factor, direct versus indirect lung injury, and timing of ARDS onset can determine other clinical phenotypes of ARDS after admission. Radiographic phenotypes of ARDS have been described based on a diffuse versus focal pattern of infiltrates on chest imaging. Finally and most promisingly, biologic subphenotypes or endotypes have increasingly been identified using plasma biomarkers, genetics, and unbiased approaches such as latent class analysis. The potential of precision medicine lies in identifying novel therapeutics aimed at ARDS biology and the subpopulation within ARDS most likely to respond. In this review, we discuss the challenges and approaches to subphenotype ARDS into clinical, radiologic, severity, and biologic phenotypes with an eye toward the future of precision medicine in critical care.
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Affiliation(s)
- John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carolyn S Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lu Z, Ge H, Xu L, Guo F, Zhang G, Wu Y. Alterations in diaphragmatic function assessed by ultrasonography in mechanically ventilated patients with sepsis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:206-211. [PMID: 30671990 DOI: 10.1002/jcu.22690] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/01/2018] [Accepted: 12/25/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE To assess alteration of diaphragmatic function by ultrasonography in a population of mechanically ventilated patients with or without sepsis. METHODS We performed a prospective, 6-month, single-center, observational cohort study. Mechanically ventilated septic and nonseptic patients were studied within 24 hours following intubation and before the moment of ventilator liberation. Diaphragm thickness and contractile activity (quantified by diaphragmatic thickening fraction, DTF) were measured by ultrasonography at the zone of apposition. Intraobserver and interobserver reproducibility were measured. RESULTS Fifty-two critically ill patients were included, 28 with sepsis and 24 without sepsis. Upon initiation of ventilation, DTF was lower in septic than that in nonseptic patients (P = 0.03). No difference was observed between septic and nonseptic patients for diaphragm thickness. Mean 188 ± 111 hours after the first measurement, both diaphragm thickness and DTF decreased significantly compared with first measurements in septic and nonseptic patients, all P < 0.001. Diaphragm thickness decreased by 9.1 ± 10.7% in nonseptic and by 16.0 ± 13.5% in septic patients, P = 0.049. DTF decreased by 15.2 ± 21.3% in nonseptic and by 30.7 ± 22.0% in septic patients, P = 0.013. CONCLUSIONS Mechanically ventilated patients with sepsis were associated with an earlier and more severe diaphragm dysfunction compared with patients without sepsis.
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Affiliation(s)
- Zhihua Lu
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lilong Xu
- Department of Diagnostic Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Feng Guo
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ge Zhang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yinshan Wu
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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15
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van der Pijl RJ, Granzier HL, Ottenheijm CAC. Diaphragm contractile weakness due to reduced mechanical loading: role of titin. Am J Physiol Cell Physiol 2019; 317:C167-C176. [PMID: 31042425 DOI: 10.1152/ajpcell.00509.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The diaphragm, the main muscle of inspiration, is constantly subjected to mechanical loading. Only during controlled mechanical ventilation, as occurs during thoracic surgery and in the intensive care unit, is mechanical loading of the diaphragm arrested. Animal studies indicate that the diaphragm is highly sensitive to unloading, causing rapid muscle fiber atrophy and contractile weakness; unloading-induced diaphragm atrophy and contractile weakness have been suggested to contribute to the difficulties in weaning patients from ventilator support. The molecular triggers that initiate the rapid unloading atrophy of the diaphragm are not well understood, although proteolytic pathways and oxidative signaling have been shown to be involved. Mechanical stress is known to play an important role in the maintenance of muscle mass. Within the muscle's sarcomere, titin is considered to play an important role in the stress-response machinery. Titin is a giant protein that acts as a mechanosensor regulating muscle protein expression in a sarcomere strain-dependent fashion. Thus titin is an attractive candidate for sensing the sudden mechanical arrest of the diaphragm when patients are mechanically ventilated, leading to changes in muscle protein expression. Here, we provide a novel perspective on how titin and its biomechanical sensing and signaling might be involved in the development of mechanical unloading-induced diaphragm weakness.
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Affiliation(s)
- Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona
| | - Coen A C Ottenheijm
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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16
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Liang F, Emeriaud G, Rassier DE, Shang D, Gusev E, Hussain SNA, Sage M, Crulli B, Fortin-Pellerin E, Praud JP, Petrof BJ. Mechanical ventilation causes diaphragm dysfunction in newborn lambs. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:123. [PMID: 30992039 PMCID: PMC6469194 DOI: 10.1186/s13054-019-2409-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/25/2019] [Indexed: 01/11/2023]
Abstract
Background Diaphragm weakness occurs rapidly in adult animals treated with mechanical ventilation (MV), but the effects of MV on the neonatal diaphragm have not been determined. Furthermore, it is unknown whether co-existent lung disease exacerbates ventilator-induced diaphragmatic dysfunction (VIDD). We investigated the impact of MV (mean duration = 7.65 h), either with or without co-existent respiratory failure caused by surfactant deficiency, on the development of VIDD in newborn lambs. Methods Newborn lambs (1–4 days) were assigned to control (CTL, non-ventilated), mechanically ventilated (MV), and MV + experimentally induced surfactant deficiency (MV+SD) groups. Immunoblotting and quantitative PCR assessed inflammatory signaling, the ubiquitin-proteasome system, autophagy, and oxidative stress. Immunostaining for myosin heavy chain (MyHC) isoforms and quantitative morphometry evaluated diaphragm atrophy. Contractile function of the diaphragm was determined in isolated myofibrils ex vivo. Results Equal decreases (25–30%) in myofibrillar force generation were found in MV and MV+SD diaphragms compared to CTL. In comparison to CTL, both MV and MV+SD diaphragms also demonstrated increased STAT3 transcription factor phosphorylation. Ubiquitin-proteasome system (Atrogin1 and MuRF1) transcripts and autophagy indices (Gabarapl1 transcripts and the ratio of LC3B-II/LC3B-I protein) were greater in MV+SD relative to MV alone, but fiber type atrophy was not observed in any group. Protein carbonylation and 4-hydroxynonenal levels (indices of oxidative stress) also did not differ among groups. Conclusions In newborn lambs undergoing controlled MV, there is a rapid onset of diaphragm dysfunction consistent with VIDD. Superimposed lung injury caused by surfactant deficiency did not influence the severity of early diaphragm weakness. Electronic supplementary material The online version of this article (10.1186/s13054-019-2409-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Feng Liang
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Dilson E Rassier
- Department of Kinesiology, McGill University, Montreal, QC, Canada
| | - Dong Shang
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Ekaterina Gusev
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Sabah N A Hussain
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Michael Sage
- Neonatal Respiratory Research Unit, Department of Pediatrics, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Benjamin Crulli
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, QC, Canada
| | - Etienne Fortin-Pellerin
- Neonatal Respiratory Research Unit, Department of Pediatrics, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Department of Pediatrics, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Basil J Petrof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada.
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17
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Abstract
Respiratory failure affects a significant percentage of critically ill children, necessitating both invasive and non-invasive respiratory support. As the outcomes of these patients have improved, children with higher acuity and more complex respiratory pathophysiology require mechanical ventilation. Despite growing understanding of lung-protective strategies and ventilation induced lung injury, certain patients still require harmful ventilatory settings with conventional mechanical ventilation (CMV). High frequency ventilation, neurally adjusted ventilatory assist, and airway pressure release ventilation offer feasible alternatives to CMV. In addition to minimizing the risk of ventilatory induced lung injury when used appropriately, they provide a unique environment to facilitate operations on certain neonates and older children. Finally, non-invasive ventilation is now commonly employed in children with surgical conditions.
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Affiliation(s)
- Ana Ruzic
- Department of Surgery, UK Healthcare Kentucky Children's Hospital, 800 Rose St, Lexington KY 40536, USA.
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18
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Zambelli V, Sigurtà A, Rizzi L, Zucca L, Delvecchio P, Bresciani E, Torsello A, Bellani G. Angiotensin-(1-7) exerts a protective action in a rat model of ventilator-induced diaphragmatic dysfunction. Intensive Care Med Exp 2019; 7:8. [PMID: 30659381 PMCID: PMC6338614 DOI: 10.1186/s40635-018-0218-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 12/25/2018] [Indexed: 12/11/2022] Open
Abstract
Background Ventilator-induced diaphragmatic dysfunction (VIDD) is a common event during mechanical ventilation (MV) leading to rapid muscular atrophy and contractile dysfunction. Recent data show that renin-angiotensin system is involved in diaphragmatic skeletal muscle atrophy after MV. In particular, angiotensin-II can induce marked diaphragm muscle wasting, whereas angiotensin-(1–7) (Ang-(1–7)) could counteract this activity. This study was designed to evaluate the effects of the treatment with Ang-(1–7) in a rat model of VIDD with neuromuscular blocking agent infusion. Moreover, we studied whether the administration of A-779, an antagonist of Ang-(1–7) receptor (Mas), alone or in combination with PD123319, an antagonist of AT2 receptor, could antagonize the effects of Ang-(1–7). Methods Sprague-Dawley rats underwent prolonged MV (8 h), while receiving an iv infusion of sterile saline 0.9% (vehicle) or Ang-(1–7) or Ang-(1–7) + A-779 or Ang-(1–7) + A-779 + PD123319. Diaphragms were collected for ex vivo contractility measurement (with electric stimulation), histological analysis, quantitative real-time PCR, and Western blot analysis. Results MV resulted in a significant reduction of diaphragmatic contractility in all groups of treatment. Ang-(1–7)-treated rats showed higher muscular fibers cross-sectional area and lower atrogin-1 and myogenin mRNA levels, compared to vehicle treatment. Treatment with the antagonists of Mas and Ang-II receptor 2 (AT2R) caused a significant reduction of muscular contractility and an increase of atrogin-1 and MuRF-1 mRNA levels, not affecting the cross-sectional fiber area and myogenin mRNA levels. Conclusions Systemic Ang-(1–7) administration during MV exerts a protective role on the muscular fibers of the diaphragm preserving muscular fibers anatomy, and reducing atrophy. The involvement of Mas and AT2R in the mechanism of action of Ang-(1–7) still remains controversial.
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Affiliation(s)
- Vanessa Zambelli
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Anna Sigurtà
- Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Rizzi
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Letizia Zucca
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Paolo Delvecchio
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Elena Bresciani
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Antonio Torsello
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Department of Medicine, University of Milano-Bicocca, Monza, Italy.
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19
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Yang T, Li Z, Jiang L, Wang Y, Xi X. Risk factors for intensive care unit-acquired weakness: A systematic review and meta-analysis. Acta Neurol Scand 2018; 138:104-114. [PMID: 29845614 DOI: 10.1111/ane.12964] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2018] [Indexed: 12/22/2022]
Abstract
Intensive care unit-acquired weakness (ICUAW) occurs frequently in the context of critical illness without alternative plausible cause and specific treatment options, and it is important to identify and summarize the independent risk factors for ICUAW. PubMed, Embase, Central, China Biological Medicine, China National Knowledge Infrastructure, VIP and Wanfang databases were searched from database inception until 10 July 2017. Prospective cohort studies on adult ICU patients who were diagnosed with ICUAW using either clinical or electrophysiological criteria were selected. Meta-analysis was performed using Stata version 12.0. The results were analysed using odds ratios (OR) and 95% confidence intervals (CI). Data were pooled using a random-effects model, and heterogeneity was assessed using the I2 statistic. Qualitative analysis and systematic review were used for risk factors that were deemed inappropriate to combine. Fourteen prospective cohort studies were included in this review. The meta-analysis showed that Acute Physiology and Chronic Health Evaluation II score (OR, 1.05; 95%CI, 1.01-1.10), neuromuscular blocking agents (OR, 2.03; 95%CI, 1.22-3.40) and aminoglycosides (OR, 2.27; 95%CI, 1.07-4.81) were found to be significantly associated with ICUAW. Other risk factors, including female, multiple organ failure, systemic inflammatory response syndrome, sepsis, electrolyte disturbances, hyperglycaemia, hyperosmolarity, high lactate level, duration of mechanical ventilation, parenteral nutrition and use of norepinephrine, were statistically significant on multivariable analysis in each single studies. This review provides a number of independent risk factors for ICUAW, which should be guided for early prediction and prevention of the disorder.
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Affiliation(s)
- Tao Yang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Zhiqiang Li
- Department of Critical Care Medicine, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Li Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Yinhua Wang
- Department of Critical Care Medicine, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, China
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20
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Salah H, Li M, Cacciani N, Gastaldello S, Ogilvie H, Akkad H, Namuduri AV, Morbidoni V, Artemenko KA, Balogh G, Martinez-Redondo V, Jannig P, Hedström Y, Dworkin B, Bergquist J, Ruas J, Vigh L, Salviati L, Larsson L. The chaperone co-inducer BGP-15 alleviates ventilation-induced diaphragm dysfunction. Sci Transl Med 2017; 8:350ra103. [PMID: 27488897 DOI: 10.1126/scitranslmed.aaf7099] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/29/2016] [Indexed: 12/28/2022]
Abstract
Ventilation-induced diaphragm dysfunction (VIDD) is a marked decline in diaphragm function in response to mechanical ventilation, which has negative consequences for individual patients' quality of life and for the health care system, but specific treatment strategies are still lacking. We used an experimental intensive care unit (ICU) model, allowing time-resolved studies of diaphragm structure and function in response to long-term mechanical ventilation and the effects of a pharmacological intervention (the chaperone co-inducer BGP-15). The marked loss of diaphragm muscle fiber function in response to mechanical ventilation was caused by posttranslational modifications (PTMs) of myosin. In a rat model, 10 days of BGP-15 treatment greatly improved diaphragm muscle fiber function (by about 100%), although it did not reverse diaphragm atrophy. The treatment also provided protection from myosin PTMs associated with HSP72 induction and PARP-1 inhibition, resulting in improvement of mitochondrial function and content. Thus, BGP-15 may offer an intervention strategy for reducing VIDD in mechanically ventilated ICU patients.
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Affiliation(s)
- Heba Salah
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden. Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala 75124, Sweden
| | - Meishan Li
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Nicola Cacciani
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Stefano Gastaldello
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Hannah Ogilvie
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Hazem Akkad
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Arvind Venkat Namuduri
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Valeria Morbidoni
- Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova 35128, Italy
| | - Konstantin A Artemenko
- Analytical Chemistry, Department of Chemistry-Biomedical Centre and Science for Life Laboratory (SciLifeLab), Uppsala University, Uppsala 75124, Sweden
| | - Gabor Balogh
- Institute of Biochemistry, Biological Research Centre, Hungarian Academy of Sciences, Szeged H-6726, Hungary
| | | | - Paulo Jannig
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Yvette Hedström
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Barry Dworkin
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden. Department of Neuroscience, Pennsylvania State University, Hershey, PA 17033, USA
| | - Jonas Bergquist
- Analytical Chemistry, Department of Chemistry-Biomedical Centre and Science for Life Laboratory (SciLifeLab), Uppsala University, Uppsala 75124, Sweden. Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT 84112, USA. Precision Medicine, Binzhou Medical University, Yantai City, Shandong 264003, China
| | - Jorge Ruas
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden
| | - Laszlo Vigh
- Institute of Biochemistry, Biological Research Centre, Hungarian Academy of Sciences, Szeged H-6726, Hungary
| | - Leonardo Salviati
- Clinical Genetics Unit, Department of Women's and Children's Health, University of Padova, Padova 35128, Italy
| | - Lars Larsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm SE-177 77, Sweden. Department of Biobehavioral Health, Pennsylvania State University, University Park, PA 16802, USA. Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm SE-177 77, Sweden.
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21
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Critical illness-associated diaphragm weakness. Intensive Care Med 2017; 43:1441-1452. [DOI: 10.1007/s00134-017-4928-4] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 08/31/2017] [Indexed: 11/26/2022]
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22
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Schepens T, Cammu G, Maes S, Desmedt B, Vos W, Deseure K. [Functional respiratory imaging after neostigmine- or sugammadex-enhanced recovery from neuromuscular blockade in the anesthetised rat: a randomised controlled pilot study]. Rev Bras Anestesiol 2017; 67:443-449. [PMID: 28526472 DOI: 10.1016/j.bjan.2017.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/23/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Reductions in diaphragm activity are associated with the postoperative development of atelectasis. Neostigmine reversal is also associated with increased atelectasis. We assessed the effects of neostigmine, sugammadex, and spontaneous reversal on regional lung ventilation and airway flow. METHODS Six Sprague-Dawley rats were paralysed with rocuronium and mechanically ventilated until recovery of the train-of-four ratio to 0.5. We administered neostigmine (0.06mg.kg-1), sugammadex (15mg.kg-1), or saline (n=2 per group). Computed tomography scans were obtained during the breathing cycle. Three-dimensional models of lung lobes were generated using functional respiratory imaging technology, and lobar volumes were calculated during the breathing cycle. The diaphragmatic surface was segmented for the end-expiratory and end-inspiratory scans. The total change in volume was reported by the lung volume change from the end-expiratory scan to the end-inspiratory scan. Chest wall movement was defined as the lung volume change minus the volume change that resulted from diaphragm excursion. RESULTS The two rats that received neostigmine exhibited a smaller relative contribution of diaphragm movement to the total change in lung volume compared with the two rats that received sugammadex or saline (chest wall contribution (%): 26.69 and 25.55 for neostigmine; -2.77 and 15.98 for sugammadex; 18.82 and 10.30 for saline). CONCLUSION This pilot study in rats demonstrated an increased relative contribution of chest wall expansion after neostigmine compared with sugammadex or saline. This smaller relative contribution of diaphragm movement may be explained by a neostigmine-induced decrease in phrenic nerve activity or by remaining occupied acetylcholine receptors after neostigmine.
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Affiliation(s)
- Tom Schepens
- Antwerp University Hospital, Department of Anesthesiology, Edegem, Bélgica
| | - Guy Cammu
- Onze-Lieve-Vrouw Ziekenhuis, Anesthesiology and Critical Care Medicine, Aalst, Bélgica.
| | - Sabine Maes
- Antwerp University Hospital, Department of Anesthesiology, Edegem, Bélgica
| | | | | | - Kristof Deseure
- University of Antwerp, Deparment of Algology, Wilrijk, Bélgica
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23
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Respiratory muscle contractile inactivity induced by mechanical ventilation in piglets leads to leaky ryanodine receptors and diaphragm weakness. J Muscle Res Cell Motil 2017; 38:17-24. [PMID: 28260211 DOI: 10.1007/s10974-017-9464-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
Respiratory muscle contractile inactivity during mechanical ventilation (MV) induces diaphragm muscle weakness, a condition referred to as ventilator-induced diaphragmatic dysfunction (VIDD). Although VIDD pathophysiological mechanisms are still not fully understood, it has been recently suggested that remodeling of the sarcoplasmic reticulum (SR) calcium release channel/ryanodine receptors (RyR1) in the diaphragm is a proximal mechanism of VIDD. Here, we used piglets, a large animal model of VIDD that is more relevant to human pathophysiology, to determine whether RyR1 alterations are observed in the presence of diaphragm weakness. In piglets, diaphragm weakness induced by 72 h of respiratory muscle unloading was associated with SR RyR1 remodeling and abnormal resting SR Ca2+ leak in the diaphragm. Specifically, following controlled mechanical ventilation, diaphragm contractile function was reduced. Moreover, RyR1 macromolecular complexes were more oxidized, S-nitrosylated and phosphorylated at Ser-2844 and depleted of the stabilizing subunit calstabin1 compared with controls on adaptive support ventilation that maintains diaphragmatic contractile activity. Our study strongly supports the hypothesis that RyR1 is a potential therapeutic target in VIDD and the interest of using small molecule drugs to prevent RyR1-mediated SR Ca2+ leak induced by respiratory muscle unloading in patients who require controlled mechanical ventilation.
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Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis. J Pediatr 2017; 182:190-196.e4. [PMID: 28063686 DOI: 10.1016/j.jpeds.2016.12.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 10/18/2016] [Accepted: 12/08/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease. STUDY DESIGN We conducted a prospective observational study of neonates ≤30 days of age who underwent cardiac surgery at 7 centers within the US in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified with the use of multivariable logistic regression analysis and reported as OR with 95% CIs. Multivariable logistic regression analysis was conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length of stay in the upper 25% or operative mortality. RESULTS We enrolled 283 neonates, of whom 35 (12%) failed their first extubation at a median time of 7.5 hours (range 1-70 hours). In a multivariable model, use of uncuffed endotracheal tubes (OR 4.6; 95% CI 1.8-11.6) and open sternotomy of 4 days or more (OR 4.8; 95% CI 1.3-17.1) were associated independently with extubation failure. Accordingly, extubation failure was determined to be an independent risk factor for worse clinical outcome (OR 5.1; 95% CI 2-13). CONCLUSIONS In this multicenter cohort of neonates who underwent surgery for congenital heart disease, extubation failure occurred in 12% of cases and was associated independently with worse clinical outcome. Use of uncuffed endotracheal tubes and prolonged open sternotomy were identified as independent and potentially modifiable risk factors for the occurrence of this precarious complication.
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25
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Diaphragm Dysfunction: Diagnostic Approaches and Management Strategies. J Clin Med 2016; 5:jcm5120113. [PMID: 27929389 PMCID: PMC5184786 DOI: 10.3390/jcm5120113] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 12/12/2022] Open
Abstract
The diaphragm is the main inspiratory muscle, and its dysfunction can lead to significant adverse clinical consequences. The aim of this review is to provide clinicians with an overview of the main causes of uni- and bi-lateral diaphragm dysfunction, explore the clinical and physiological consequences of the disease on lung function, exercise physiology and sleep and review the available diagnostic tools used in the evaluation of diaphragm function. A particular emphasis is placed on the clinical significance of diaphragm weakness in the intensive care unit setting and the use of ultrasound to evaluate diaphragmatic action.
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Breuer T, Hatam N, Grabiger B, Marx G, Behnke BJ, Weis J, Kopp R, Gayan-Ramirez G, Zoremba N, Bruells CS. Kinetics of ventilation-induced changes in diaphragmatic metabolism by bilateral phrenic pacing in a piglet model. Sci Rep 2016; 6:35725. [PMID: 27759115 PMCID: PMC5069624 DOI: 10.1038/srep35725] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/30/2016] [Indexed: 12/14/2022] Open
Abstract
Perioperative necessity of deep sedation is inevitably associated with diaphragmatic inactivation. This study investigated 1) the feasibility of a new phrenic nerve stimulation method allowing early diaphragmatic activation even in deep sedation and, 2) metabolic changes within the diaphragm during mechanical ventilation compared to artificial activity. 12 piglets were separated into 2 groups. One group was mechanically ventilated for 12 hrs (CMV) and in the second group both phrenic nerves were stimulated via pacer wires inserted near the phrenic nerves to mimic spontaneous breathing (STIM). Lactate, pyruvate and glucose levels were measured continuously using microdialysis. Oxygen delivery and blood gases were measured during both conditions. Diaphragmatic stimulation generated sufficient tidal volumes in all STIM animals. Diaphragm lactate release increased in CMV transiently whereas in STIM lactate dropped during this same time point (2.6 vs. 0.9 mmol L-1 after 5:20 hrs; p < 0.001). CMV increased diaphragmatic pyruvate (40 vs. 146 μmol L-1 after 5:20 hrs between CMV and STIM; p < 0.0001), but not the lactate/pyruvate ratio. Diaphragmatic stimulation via regular electrodes is feasible to generate sufficient ventilation, even in deep sedation. Mechanical ventilation alters the metabolic state of the diaphragm, which might be one pathophysiologic origin of ventilator-induced diaphragmatic dysfunction. Occurrence of hypoxia was unlikely.
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Affiliation(s)
- Thomas Breuer
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany.,Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Nima Hatam
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Benjamin Grabiger
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Bradley J Behnke
- Department of Kinesiology, Johnson Cancer Research Institute, Kansas State University, Manhattan, Kansas, USA
| | - Joachim Weis
- Institute of Neuropathology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Ruedger Kopp
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Norbert Zoremba
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany.,Department of Anaesthesiology, Sankt Elisabeth Hospital, Gütersloh, Germany
| | - Christian S Bruells
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Aachen, Germany
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Wilcox SR. Corticosteroids and neuromuscular blockers in development of critical illness neuromuscular abnormalities: A historical review. J Crit Care 2016; 37:149-155. [PMID: 27736708 DOI: 10.1016/j.jcrc.2016.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 08/31/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
Abstract
Weakness is common in critically ill patients, associated with prolonged mechanical ventilation and increased mortality. Corticosteroids and neuromuscular blockade (NMB) administration have been implicated as etiologies of acquired weakness in the intensive care unit. Medical literature since the 1970s is replete with case reports and small case series of patients with weakness after receiving high-dose corticosteroids, prolonged NMB, or both. Several risk factors for weakness appear in the early literature, including large doses of steroids, the dose and duration of NMB, hyperglycemia, and the duration of mechanical ventilation. With improved quality of data, however, the association between weakness and steroids or NMB wanes. This may reflect changes in clinical practice, such as a reduction in steroid dosing, use of cisatracurium besylate instead of aminosteroid NMBs, improved glycemic control, or trends in minimizing mechanical ventilatory support. Thus, based on the most recent and high-quality literature, neither corticosteroids in commonly used doses nor NMB is associated with increased duration of mechanical ventilation, the greatest morbidity of weakness. Minimizing ventilator support as soon as the patient's condition allows may be associated with a reduction in weakness-related morbidity.
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Affiliation(s)
- Susan R Wilcox
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine and Division of Emergency Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC.
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Dot I, Pérez-Teran P, Samper MA, Masclans JR. Diaphragm Dysfunction in Mechanically Ventilated Patients. Arch Bronconeumol 2016; 53:150-156. [PMID: 27553431 DOI: 10.1016/j.arbres.2016.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 06/04/2016] [Accepted: 07/17/2016] [Indexed: 12/14/2022]
Abstract
Muscle involvement is found in most critical patients admitted to the intensive care unit (ICU). Diaphragmatic muscle alteration, initially included in this category, has been differentiated in recent years, and a specific type of muscular dysfunction has been shown to occur in patients undergoing mechanical ventilation. We found this muscle dysfunction to appear in this subgroup of patients shortly after the start of mechanical ventilation, observing it to be mainly associated with certain control modes, and also with sepsis and/or multi-organ failure. Although the specific etiology of process is unknown, the muscle presents oxidative stress and mitochondrial changes. These cause changes in protein turnover, resulting in atrophy and impaired contractility, and leading to impaired functionality. The term 'ventilator-induced diaphragm dysfunction' was first coined by Vassilakopoulos et al. in 2004, and this phenomenon, along with injury cause by over-distention of the lung and barotrauma, represents a challenge in the daily life of ventilated patients. Diaphragmatic dysfunction affects prognosis by delaying extubation, prolonging hospital stay, and impairing the quality of life of these patients in the years following hospital discharge. Ultrasound, a non-invasive technique that is readily available in most ICUs, could be used to diagnose this condition promptly, thus preventing delays in starting rehabilitation and positively influencing prognosis in these patients.
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Affiliation(s)
- Irene Dot
- Servicio de Medicina Intensiva, Hospital del Mar-Parc de Salut Mar de Barcelona, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)-GREPAC, Barcelona, España
| | - Purificación Pérez-Teran
- Servicio de Medicina Intensiva, Hospital del Mar-Parc de Salut Mar de Barcelona, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)-GREPAC, Barcelona, España
| | - Manuel-Andrés Samper
- Servicio de Medicina Intensiva, Hospital del Mar-Parc de Salut Mar de Barcelona, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)-GREPAC, Barcelona, España
| | - Joan-Ramon Masclans
- Servicio de Medicina Intensiva, Hospital del Mar-Parc de Salut Mar de Barcelona, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)-GREPAC, Barcelona, España; Universitat Pompeu Fabra, Barcelona, España; CIBERES, España.
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Abstract
Abstract
Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.
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Schepens T, Verbrugghe W, Dams K, Corthouts B, Parizel PM, Jorens PG. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:422. [PMID: 26639081 PMCID: PMC4671211 DOI: 10.1186/s13054-015-1141-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/18/2015] [Indexed: 12/22/2022]
Abstract
Introduction Mechanical ventilation and the effect of respiratory muscle unloading on the diaphragm cause ventilator-induced diaphragmatic dysfunction (VIDD). Atrophy of the diaphragmatic muscle is a major part of VIDD, and has a rapid onset in most animal models. We wanted to assess the clinical evolution and risk factors for VIDD in an adult intensive care unit (ICU) by measuring diaphragm thickness using ultrasound. Method We performed a single-centre observational cohort study, including 54 mechanically ventilated patients. The right hemidiaphragm was measured daily at the zone of apposition on the midaxillary line. Results Mean baseline thickness was 1.9 mm (SD ± 0.4 mm), and mean nadir was 1.3 mm (SD ± 0.4 mm), corresponding with a mean change in thickness of 32 % (95 % CI 27–37 %). Length of mechanical ventilation (MV) was associated with the degree of atrophy, whereas other known risk factors for muscle atrophy in an ICU were not. The largest decrease in thickness occurred during the first 72 hours of MV. Conclusions Diaphragm atrophy occurs quickly in mechanically ventilated patients and can accurately be monitored using ultrasound. Length of MV, as opposed to other variables, is associated with the degree of atrophy. Clinical trial registration Clinicaltrials.gov NCT02299986. Registered 10/11/2014 Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1141-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tom Schepens
- Department of Anesthesiology and Critical Care Medicine, Antwerp University Hospital, University of Antwerp, Edegem, Belgium.
| | - Walter Verbrugghe
- Department of Critical Care Medicine, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Karolien Dams
- Department of Critical Care Medicine, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Bob Corthouts
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Paul M Parizel
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
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Lee SH, Kim MJ, Jeong ES, Jo EJ, Eom JS, Mok JH, Kim MH, Kim KU, Park HK, Lee MK, Lee K. Outcomes and prognostic factors in patients with prolonged acute mechanical ventilation: A single-center study in Korea. J Crit Care 2015; 30:1016-20. [PMID: 26100582 DOI: 10.1016/j.jcrc.2015.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/01/2015] [Accepted: 05/27/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of the study is to evaluate outcomes and objective parameters related to poor prognosis in patients who were defined as prolonged acute mechanical ventilation (PAMV; ventilator care ≥96 hours) in the medical intensive care unit of a university-affiliated tertiary care hospital in Korea. MATERIAL AND METHODS We analyzed retrospectively clinical data gathered from the medical records on day 4 of MV between 2008 and 2013. In total, 311 were categorized as PAMV. RESULTS Their median age was 67 years (range, 18-93 years), and 71.7% were male. The 28-day mortality rate after intensive care unit admission was 34.7%. Four variables on day 4 of mechanical ventilation (need for neuromuscular blockers [hazard ratio {HR}, 2.432; 95% confidence interval, 1.337-4.422], need for vasopressors [HR, 2.312; 95% confidence interval, 1.258-4.248], need for hemodialyses [HR, 1.913; 95% confidence interval, 1.018-3.595], and body mass index ≤21 kg/m(2) [HR, 1.827; 95% confidence interval, 1.015-3.288]) were independent factors associated with mortality based on a Cox proportional hazards model. As the number of these prognostic factors increased, the survival rate decreased. CONCLUSIONS Four clinical factors (body mass index ≤21, requirement for neuromuscular blockers, vasopressors, and hemodialysis) on day 4 of mechanical ventilation were associated with 28-day mortality in PAMV patients.
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Affiliation(s)
- Sang Hee Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Min Ji Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Eun Suk Jeong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Eun-Jung Jo
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jung Seop Eom
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jeong Ha Mok
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Mi Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Ki Uk Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea.
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Jung B, Gleeton D, Daurat A, Conseil M, Mahul M, Rao G, Matecki S, Lacampagne A, Jaber S. Conséquences de la ventilation mécanique sur le diaphragme. Rev Mal Respir 2015; 32:370-80. [DOI: 10.1016/j.rmr.2014.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 08/25/2014] [Indexed: 01/23/2023]
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Serpa Neto A, Filho RR, Rocha LL, Schultz MJ. Recent advances in mechanical ventilation in patients without acute respiratory distress syndrome. F1000PRIME REPORTS 2014; 6:115. [PMID: 25580269 PMCID: PMC4251417 DOI: 10.12703/p6-115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
While being an essential part of general anesthesia for surgery and at times even a life-saving intervention in critically ill patients, mechanical ventilation has a strong potential to cause harm. Certain ventilation strategies could prevent, at least to some extent, the injury caused by this intervention. One essential element of so-called ‘lung-protective’ ventilation is the use of lower tidal volumes. It is uncertain whether higher levels of positive end-expiratory pressures have lung-protective properties as well. There are indications that too high oxygen fractions of inspired air, or too high blood oxygen targets, are harmful. Circumstantial evidence further suggests that spontaneous modes of ventilation are to be preferred over controlled ventilation to prevent harm to respiratory muscle. Finally, the use of restrictive sedation strategies in critically ill patients indirectly prevents ventilation-induced injury, as daily spontaneous awakening and breathing trials and bolus instead of continuous sedation are associated with shorter duration of ventilation and shorten the exposure to the injurious effects of ventilation.
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Affiliation(s)
- Ary Serpa Neto
- Hospital Israelita Albert Einstein, Department of Critical Care MedicineAv. Albert Einstein 627, 05652-900 São Paulo, SPBrazil
- Academic Medical Center at the University of Amsterdam, Department of Intensive CareMeibergdreef 9, 1105 AZ, AmsterdamThe Netherlands
| | - Roberto R. Filho
- Hospital Israelita Albert Einstein, Department of Critical Care MedicineAv. Albert Einstein 627, 05652-900 São Paulo, SPBrazil
| | - Leonardo L. Rocha
- Hospital Israelita Albert Einstein, Department of Critical Care MedicineAv. Albert Einstein 627, 05652-900 São Paulo, SPBrazil
| | - Marcus J. Schultz
- Academic Medical Center at the University of Amsterdam, Department of Intensive CareMeibergdreef 9, 1105 AZ, AmsterdamThe Netherlands
- Academic Medical Center at the University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A)Meibergdreef 9; 1105 AZ, AmsterdamThe Netherlands
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Sedation using propofol induces similar diaphragm dysfunction and atrophy during spontaneous breathing and mechanical ventilation in rats. Anesthesiology 2014; 120:665-72. [PMID: 24401770 DOI: 10.1097/aln.0000000000000125] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mechanical ventilation is crucial for patients with respiratory failure. The mechanical takeover of diaphragm function leads to diaphragm dysfunction and atrophy (ventilator-induced diaphragmatic dysfunction), with an increase in oxidative stress as a major contributor. In most patients, a sedative regimen has to be initiated to allow tube tolerance and ventilator synchrony. Clinical data imply a correlation between cumulative propofol dosage and diaphragm dysfunction, whereas laboratory investigations have revealed that propofol has some antioxidant properties. The authors hypothesized that propofol reduces markers of oxidative stress, atrophy, and contractile dysfunction in the diaphragm. METHODS Male Wistar rats (n = 8 per group) were subjected to either 24 h of mechanical ventilation or were undergone breathing spontaneously for 24 h under propofol sedation to test for drug effects. Another acutely sacrificed group served as controls. After sacrifice, diaphragm tissue was removed, and contractile properties, cross-sectional areas, oxidative stress, and proteolysis were examined. The gastrocnemius served as internal control. RESULTS Propofol did not protect against diaphragm atrophy, oxidative stress, and protease activation. The decrease in tetanic force compared with controls was similar in the spontaneous breathing group (31%) and in the ventilated group (34%), and both groups showed the same amount of muscle atrophy. The gastrocnemius muscle fibers did not show atrophy. CONCLUSIONS Propofol does not protect against ventilator-induced diaphragmatic dysfunction or oxidative injury. Notably, spontaneous breathing under propofol sedation resulted in the same amount of diaphragm atrophy and dysfunction although diaphragm activation per se protects against ventilator-induced diaphragmatic dysfunction. This makes a drug effect of propofol likely.
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La ventilation spontanée est-elle préférable au cours du syndrome de détresse respiratoire aiguë ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0831-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Powers SK, Wiggs MP, Sollanek KJ, Smuder AJ. Ventilator-induced diaphragm dysfunction: cause and effect. Am J Physiol Regul Integr Comp Physiol 2013; 305:R464-77. [DOI: 10.1152/ajpregu.00231.2013] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Mechanical ventilation (MV) is used clinically to maintain gas exchange in patients that require assistance in maintaining adequate alveolar ventilation. Common indications for MV include respiratory failure, heart failure, drug overdose, and surgery. Although MV can be a life-saving intervention for patients suffering from respiratory failure, prolonged MV can promote diaphragmatic atrophy and contractile dysfunction, which is referred to as ventilator-induced diaphragm dysfunction (VIDD). This is significant because VIDD is thought to contribute to problems in weaning patients from the ventilator. Extended time on the ventilator increases health care costs and greatly increases patient morbidity and mortality. Research reveals that only 18–24 h of MV is sufficient to develop VIDD in both laboratory animals and humans. Studies using animal models reveal that MV-induced diaphragmatic atrophy occurs due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, autophagy, and the ubiquitin-proteasome system as key proteases that participate in MV-induced diaphragmatic proteolysis. The challenge for the future is to define the MV-induced signaling pathways that promote the loss of diaphragm protein and depress diaphragm contractility. Indeed, forthcoming studies that delineate the signaling mechanisms responsible for VIDD will provide the knowledge necessary for the development of a pharmacological approach that can prevent VIDD and reduce the incidence of weaning problems.
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Affiliation(s)
- Scott K. Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Michael P. Wiggs
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Kurt J. Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Ashley J. Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
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Silversides JA, Ferguson ND. Clinical review: Acute respiratory distress syndrome - clinical ventilator management and adjunct therapy. Crit Care 2013; 17:225. [PMID: 23672857 PMCID: PMC3672489 DOI: 10.1186/cc11867] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a potentially devastating form of acute inflammatory lung injury with a high short-term mortality rate and significant long-term consequences among survivors. Supportive care, principally with mechanical ventilation, remains the cornerstone of therapy - although the goals of this support have changed in recent years - from maintaining normal physiological parameters to avoiding ventilator-induced lung injury while providing adequate gas exchange. In this article we discuss the current evidence base for ventilatory support and adjunctive therapies in patients with ARDS. Key components of such a strategy include avoiding lung overdistension by limiting tidal volumes and airway pressures, and the use of positive end-expiratory pressure with or without lung recruitment manoeuvres in patients with severe ARDS. Adjunctive therapies discussed include pharmacologic techniques (for example, vasodilators, diuretics, neuromuscular blockade) and nonpharmacologic techniques (for example, prone position, alternative modes of ventilation).
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Affiliation(s)
- Jonathan A Silversides
- Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
- Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, University of Toronto, Mount Sinai Hospital, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
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Abstract
Abstract
Postoperative pulmonary complications are responsible for significant increases in hospital cost as well as patient morbidity and mortality; respiratory muscle dysfunction represents a contributing factor. Upper airway dilator muscles functionally resist the upper airway collapsing forces created by the respiratory pump muscles. Standard perioperative medications (anesthetics, sedatives, opioids, and neuromuscular blocking agents), interventions (patient positioning, mechanical ventilation, and surgical trauma), and diseases (lung hyperinflation, obesity, and obstructive sleep apnea) have differential effects on the respiratory muscle subgroups. These effects on the upper airway dilators and respiratory pump muscles impair their coordination and function and can result in respiratory failure. Perioperative management strategies can help decrease the incidence of postoperative respiratory muscle dysfunction. Such strategies include minimally invasive procedures rather than open surgery, early and optimal mobilizing of respiratory muscles while on mechanical ventilation, judicious use of respiratory depressant anesthetics and neuromuscular blocking agents, and noninvasive ventilation when possible.
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Doorduin J, van Hees HWH, van der Hoeven JG, Heunks LMA. Monitoring of the respiratory muscles in the critically ill. Am J Respir Crit Care Med 2012; 187:20-7. [PMID: 23103733 DOI: 10.1164/rccm.201206-1117cp] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Evidence has accumulated that respiratory muscle dysfunction develops in critically ill patients and contributes to prolonged weaning from mechanical ventilation. Accordingly, it seems highly appropriate to monitor the respiratory muscles in these patients. Today, we are only at the beginning of routinely monitoring respiratory muscle function. Indeed, most clinicians do not evaluate respiratory muscle function in critically ill patients at all. In our opinion, however, practical issues and the absence of sound scientific data for clinical benefit should not discourage clinicians from having a closer look at respiratory muscle function in critically ill patients. This perspective discusses the latest developments in the field of respiratory muscle monitoring and possible implications of monitoring respiratory muscle function in critically ill patients.
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Affiliation(s)
- Jonne Doorduin
- Department of Critical Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands
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Price D, Kenyon NJ, Stollenwerk N. A fresh look at paralytics in the critically ill: real promise and real concern. Ann Intensive Care 2012; 2:43. [PMID: 23062076 PMCID: PMC3519794 DOI: 10.1186/2110-5820-2-43] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 09/17/2012] [Indexed: 01/20/2023] Open
Abstract
Neuromuscular blocking agents (NMBAs), or “paralytics,” often are deployed in the sickest patients in the intensive care unit (ICU) when usual care fails. Despite the publication of guidelines on the use of NMBAs in the ICU in 2002, clinicians have needed more direction to determine which patients would benefit from NMBAs and which patients would be harmed. Recently, new evidence has shown that paralytics hold more promise when used in carefully selected lung injury patients for brief periods of time. When used in early acute respiratory distress syndrome (ARDS), NMBAs assist to establish a lung protective strategy, which leads to improved oxygenation, decreased pulmonary and systemic inflammation, and potentially improved mortality. It also is increasingly recognized that NMBAs can cause harm, particularly critical illness polyneuromyopathy (CIPM), when used for prolonged periods or in septic shock. In this review, we address several practical considerations for clinicians who use NMBAs in their practice. Ultimately, we conclude that NMBAs should be considered a lung protective adjuvant in early ARDS and that clinicians should consider using an alternative NMBA to the aminosteroids in septic shock with less severe lung injury pending further studies.
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Affiliation(s)
- David Price
- Division of Pulmonary, Critical Care and Sleep Medicine, Univ, of California, Davis, 4150V, Street, Suite 3400, Sacramento, CA 95817, USA.
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Kalkan Y, Bostan H, Tumkaya L, Tomak Y, Bostan M, Yilmaz A, Turut H, Temiz A, Yalçin A, Turan A. The effect of rocuronium, sugammadex, and their combination on cardiac muscle and diaphragmatic skeletal muscle cells. J Anesth 2012; 26:870-7. [DOI: 10.1007/s00540-012-1440-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/13/2012] [Indexed: 12/17/2022]
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Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2011: I. Nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals. Intensive Care Med 2012; 38:192-209. [PMID: 22215044 PMCID: PMC3291847 DOI: 10.1007/s00134-011-2447-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome. Can J Anaesth 2011; 59:105-8. [DOI: 10.1007/s12630-011-9615-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 10/18/2011] [Indexed: 10/16/2022] Open
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van Hees HWH, Schellekens WJM, Linkels M, Leenders F, Zoll J, Donders R, Dekhuijzen PNR, van der Hoeven JG, Heunks LMA. Plasma from septic shock patients induces loss of muscle protein. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R233. [PMID: 21958504 PMCID: PMC3334781 DOI: 10.1186/cc10475] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 08/19/2011] [Accepted: 09/29/2011] [Indexed: 11/13/2022]
Abstract
Introduction ICU-acquired muscle weakness commonly occurs in patients with septic shock and is associated with poor outcome. Although atrophy is known to be involved, it is unclear whether ligands in plasma from these patients are responsible for initiating degradation of muscle proteins. The aim of the present study was to investigate if plasma from septic shock patients induces skeletal muscle atrophy and to examine the time course of plasma-induced muscle atrophy during ICU stay. Methods Plasma was derived from septic shock patients within 24 hours after hospital admission (n = 21) and healthy controls (n = 12). From nine patients with septic shock plasma was additionally derived at two, five and seven days after ICU admission. These plasma samples were added to skeletal myotubes, cultured from murine myoblasts. After incubation for 24 hours, myotubes were harvested and analyzed on myosin content, mRNA expression of E3-ligase and Nuclear Factor Kappa B (NFκB) activity. Plasma samples were analyzed on cytokine concentrations. Results Myosin content was approximately 25% lower in myotubes exposed to plasma from septic shock patients than in myotubes exposed to plasma from controls (P < 0.01). Furthermore, patient plasma increased expression of E3-ligases Muscle RING Finger protein-1 (MuRF-1) and Muscle Atrophy F-box protein (MAFbx) (P < 0.01), enhanced NFκB activity (P < 0.05) and elevated levels of ubiquitinated myosin in myotubes. Myosin loss was significantly associated with elevated plasma levels of interleukin (IL)-6 in septic shock patients (P < 0.001). Addition of antiIL-6 to septic shock plasma diminished the loss of myosin in exposed myotubes by approximately 25% (P < 0.05). Patient plasma obtained later during ICU stay did not significantly reduce myosin content compared to controls. Conclusions Plasma from patients with septic shock induces loss of myosin and activates key regulators of proteolysis in skeletal myotubes. IL-6 is an important player in sepsis-induced muscle atrophy in this model. The potential to induce atrophy is strongest in plasma obtained during the early phase of human sepsis.
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Affiliation(s)
- Hieronymus W H van Hees
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
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High dose methylprednisolone counteracts the negative effects of rocuronium on diaphragm function. Intensive Care Med 2011; 37:1865-72. [DOI: 10.1007/s00134-011-2337-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 07/27/2011] [Indexed: 10/17/2022]
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Ochala J, Renaud G, Llano Diez M, Banduseela VC, Aare S, Ahlbeck K, Radell PJ, Eriksson LI, Larsson L. Diaphragm muscle weakness in an experimental porcine intensive care unit model. PLoS One 2011; 6:e20558. [PMID: 21698290 PMCID: PMC3115952 DOI: 10.1371/journal.pone.0020558] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 05/05/2011] [Indexed: 01/10/2023] Open
Abstract
In critically ill patients, mechanisms underlying diaphragm muscle remodeling and resultant dysfunction contributing to weaning failure remain unclear. Ventilator-induced modifications as well as sepsis and administration of pharmacological agents such as corticosteroids and neuromuscular blocking agents may be involved. Thus, the objective of the present study was to examine how sepsis, systemic corticosteroid treatment (CS) and neuromuscular blocking agent administration (NMBA) aggravate ventilator-related diaphragm cell and molecular dysfunction in the intensive care unit. Piglets were exposed to different combinations of mechanical ventilation and sedation, endotoxin-induced sepsis, CS and NMBA for five days and compared with sham-operated control animals. On day 5, diaphragm muscle fibre structure (myosin heavy chain isoform proportion, cross-sectional area and contractile protein content) did not differ from controls in any of the mechanically ventilated animals. However, a decrease in single fibre maximal force normalized to cross-sectional area (specific force) was observed in all experimental piglets. Therefore, exposure to mechanical ventilation and sedation for five days has a key negative impact on diaphragm contractile function despite a preservation of muscle structure. Post-translational modifications of contractile proteins are forwarded as one probable underlying mechanism. Unexpectedly, sepsis, CS or NMBA have no significant additive effects, suggesting that mechanical ventilation and sedation are the triggering factors leading to diaphragm weakness in the intensive care unit.
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Affiliation(s)
- Julien Ochala
- Department of Neuroscience, Uppsala University, Uppsala, Sweden.
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Tang H, Lee M, Budak MT, Pietras N, Hittinger S, Vu M, Khuong A, Hoang CD, Hussain SNA, Levine S, Shrager JB. Intrinsic apoptosis in mechanically ventilated human diaphragm: linkage to a novel Fos/FoxO1/Stat3-Bim axis. FASEB J 2011; 25:2921-36. [PMID: 21597002 DOI: 10.1096/fj.11-183798] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Mechanical ventilation (MV) is a life-saving measure in many critically ill patients. However, prolonged MV results in diaphragm dysfunction that contributes to the frequent difficulty in weaning patients from the ventilator. The molecular mechanisms underlying ventilator-induced diaphragm dysfunction (VIDD) remain poorly understood. We report here that MV induces myonuclear DNA fragmentation (3-fold increase; P<0.01) and selective activation of caspase 9 (P<0.05) and Bcl2-interacting mediator of cell death (Bim; 2- to 7-fold increase; P<0.05) in human diaphragm. MV also statistically significantly down-regulates mitochondrial gene expression and induces oxidative stress. In cultured muscle cells, we show that oxidative stress activates each of the catabolic pathways thought to underlie VIDD: apoptotic (P<0.05), proteasomal (P<0.05), and autophagic (P<0.01). Further, silencing Bim expression blocks (P<0.05) oxidative stress-induced apoptosis. Overlapping the gene expression profiles of MV human diaphragm and H₂O₂-treated muscle cells, we identify Fos, FoxO1, and Stat3 as regulators of Bim expression as well as of expression of the catabolic markers atrogin and LC3. We thus identify a novel Fos/FoxO1/Stat3-Bim intrinsic apoptotic pathway and establish the centrality of oxidative stress in the development of VIDD. This information may help in the design of specific drugs to prevent this condition.
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Affiliation(s)
- Huibin Tang
- Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
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