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Lindner S, Hoermann C, Teichert J, Ziyadova S, Michels-Zetsche JD, Neetz B, Herth FJF, Duerschmied D, Britsch S. Correlation of diaphragm thickening fraction and oesophageal pressure swing in non-invasive ventilation of healthy subjects. BMC Pulm Med 2024; 24:289. [PMID: 38902702 PMCID: PMC11191247 DOI: 10.1186/s12890-024-03096-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION The diaphragm thickening fraction (DTF) may be a valuable tool for estimating respiratory effort in non-invasive ventilation. The primary aim of this physiological study is the investigation of the correlation of DTF with oesophageal pressure swings (ΔPoes). A secondary aim is to assess the discriminatory capacity of the index tests for different exercise loads. METHODS Healthy volunteers underwent spontaneous breathing and non-invasive ventilation with a sequence of different respirator settings. The first sequence was carried out at rest. The same sequence was repeated twice, with additional ergometry of 25 and 50 Watts, respectively. DTF and ΔPoes were measured during each ventilation configuration. RESULTS 23 individuals agreed to participate. DTF was moderately correlated with ΔPoes (repeated measures correlation ρ = 0.410, p < 0.001). Both ΔPoes and DTF increased consistently with exercise loading in every ventilation configuration, however ΔPoes showed greater discriminatory capacity. CONCLUSION DTF was moderately correlated with ΔPoes and could discriminate reasonably between exercise loads in a small cohort of non-invasively ventilated healthy subjects. While it may not accurately reflect the absolute respiratory effort, DTF might help titrating individual non-invasive respiratory support. Further investigations are needed to test this hypothesis. TRIAL REGISTRATION This study was not prospectively registered.
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Affiliation(s)
- Simon Lindner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany.
| | - Clara Hoermann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Jan Teichert
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Sevil Ziyadova
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Julia D Michels-Zetsche
- Department of Pneumology and Critical Care, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Neetz
- Department of Pneumology and Critical Care, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Felix J F Herth
- Department of Pneumology and Critical Care, Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Thoraxklinik Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Simone Britsch
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
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Diao S, Li S, Dong R, Jiang W, Wang C, Chen Y, Wang J, He S, Wang Y, Du B, Weng L. The diaphragmatic electrical activity during spontaneous breathing trial in patients with mechanical ventilation: physiological description and potential clinical utility. BMC Pulm Med 2024; 24:263. [PMID: 38816810 PMCID: PMC11140881 DOI: 10.1186/s12890-024-03077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUNDS Increased respiratory drive has been demonstrated to correlate with weaning failure, which could be quantified by electrical activity of the diaphragm (EAdi). We described the physiological process of EAdi-based parameters during the spontaneous breathing trial (SBT) and evaluated the change of EAdi-based parameters as potential predictors of weaning failure. METHODS We conducted a prospective study in 35 mechanically ventilated patients who underwent a 2-hour SBT. EAdi and ventilatory parameters were continuously measured during the SBT. Diaphragm ultrasound was performed before the SBT and at the 30 min of the SBT. Three EAdi-based parameters were calculated: neuro-ventilatory efficiency, neuro-excursion efficiency and neuro-discharge per min. RESULTS Of the thirty 35 patients studied, 25 patients were defined as SBT success, including 22 patients weaning successfully and 3 patients reintubated. Before the SBT, neuro-excursion efficiency differed significantly between two groups and had the highest predictive value for SBT failure (AUROC 0.875, p < 0.01). Early increases in EAdi were observed in SBT, which are more prominent in SBT failure group. One minute, changes in EAdi and neuro-discharge per min also predicted weaning outcome (AUROCs 0.944 and 0.918, respectively). CONCLUSIONS EAdi-based parameters, especially neuro-excursion efficiency and changes in neuro-discharge per min, may detect impending weaning failure earlier than conventional indices. EAdi monitoring provides physiological insights and a more tailored approach to facilitate successful weaning. Further research should validate these findings and explore the utility of combined EAdi and diaphragm ultrasound assessment in weaning ICU patients from mechanical ventilation. TRIAL REGISTRATION Registered at ClinicalTrials.gov on 20 September 2022 (Identifier: NCT05632822).
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Affiliation(s)
- Shitong Diao
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunyao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingyi Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuhua He
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yifan Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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Chiumello D, Fioccola A. Recent advances in cardiorespiratory monitoring in acute respiratory distress syndrome patients. J Intensive Care 2024; 12:17. [PMID: 38706001 PMCID: PMC11070081 DOI: 10.1186/s40560-024-00727-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Recent advances on cardiorespiratory monitoring applied in ARDS patients undergoing invasive mechanical ventilation and noninvasive ventilatory support are available in the literature and may have potential prognostic implication in ARDS treatment. MAIN BODY The measurement of oxygen saturation by pulse oximetry is a valid, low-cost, noninvasive alternative for assessing arterial oxygenation. Caution must be taken in patients with darker skin pigmentation, who may experience a greater incidence of occult hypoxemia. Dead space surrogates, which are easy to calculate, have important prognostic implications. The mechanical power, which can be automatically computed by intensive care ventilators, is an important parameter correlated with ventilator-induced lung injury and outcome. In patients undergoing noninvasive ventilatory support, the use of esophageal pressure can measure inspiratory effort, avoiding possible delays in endotracheal intubation. Fluid responsiveness can also be evaluated using dynamic indices in patients ventilated at low tidal volumes (< 8 mL/kg). In patients ventilated at high levels of positive end expiratory pressure (PEEP), the PEEP test represents a valid alternative to passive leg raising. There is growing evidence on alternative parameters for evaluating fluid responsiveness, such as central venous oxygen saturation variations, inferior vena cava diameter variations and capillary refill time. CONCLUSION Careful cardiorespiratory monitoring in patients affected by ARDS is crucial to improve prognosis and to tailor treatment via mechanical ventilatory support.
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Affiliation(s)
- Davide Chiumello
- Department of Health Sciences, University of Milan, Milan, Italy.
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Via Di Rudinì 9, Milan, Italy.
- Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - Antonio Fioccola
- Department of Health Sciences, University of Milan, Milan, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
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Vetrugno L, Deana C, Spadaro S, Cammarota G, Grieco DL, Tullio A, Bove T, Di Loreto C, Maggiore SM, Orsaria M, Study Group D. Diaphragmatic morphological post-mortem findings in critically ill COVID-19 patients: an observational study. Monaldi Arch Chest Dis 2024. [PMID: 38656318 DOI: 10.4081/monaldi.2024.2829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Our study investigates the post-mortem findings of the diaphragm's muscular structural changes in mechanically ventilated COVID-19 patients. Diaphragm samples of the right side from 42 COVID-19 critically ill patients were analyzed and correlated with the type and length of mechanical ventilation (MV), ventilatory parameters, prone positioning, and use of sedative drugs. The mean number of fibers was 550±626. The cross-sectional area was 4120±3280 μm2, while the muscular fraction was 0.607±0.126. The overall population was clustered into two distinct populations (clusters 1 and 2). Cluster 1 showed a lower percentage of slow myosin fiber and higher fast fiber content than cluster 2, 68% versus 82%, p<0.00001, and 29.8% versus 18.8%, p=0.00045 respectively. The median duration of MV was 180 (41-346) hours. In cluster 1, a relationship between assisted ventilation and fast myosin fiber percentage (R2=-0.355, p=0.014) was found. In cluster 2, fast fiber content increased with increasing the length of the controlled MV (R2=0.446, p=0.006). A high grade of fibrosis was reported. Cluster 1 was characterized by fibers' atrophy and cluster 2 by hypertrophy, supposing different effects of ventilation on the diaphragm but without excluding a possible direct viral effect on diaphragmatic fibers.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti Pescara, Chieti; Department of Anesthesiology, Critical Care Medicine and Emergency, Annunziata Hospital, Chieti.
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara; Intensive Care Unit, Azienda Ospedaliera Universitaria Sant'Anna, Ferrara.
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara; Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara.
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome.
| | - Annarita Tullio
- Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine; Department of Medicine, University of Udine.
| | - Carla Di Loreto
- Department of Medicine, University of Udine; Institute of Anatomic Pathology, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, Annunziata Hospital, Chieti; Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti Pescara, Chieti.
| | - Maria Orsaria
- Institute of Anatomic Pathology, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
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Le Stang V, Latronico N, Dres M, Bertoni M. Critical illness-associated limb and diaphragmatic weakness. Curr Opin Crit Care 2024; 30:121-130. [PMID: 38441088 PMCID: PMC10919276 DOI: 10.1097/mcc.0000000000001135] [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] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). RECENT FINDINGS In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. SUMMARY This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.
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Affiliation(s)
- Valentine Le Stang
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- ‘Alessandra BONO’ Interdepartmental University Research Center on LOng Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Michele Bertoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
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Boscolo A, Sella N, Pettenuzzo T, Pistollato E, Calabrese F, Gregori D, Cammarota G, Dres M, Rea F, Navalesi P. Diaphragm Dysfunction Predicts Weaning Outcome after Bilateral Lung Transplant. Anesthesiology 2024; 140:126-136. [PMID: 37552079 DOI: 10.1097/aln.0000000000004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuroventilatory efficiency (the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. The authors hypothesized that (1) diaphragm dysfunction, as defined by a diaphragm thickening fraction less than 29%, is more likely to occur in difficult weaning; (2) diaphragm thickening fraction and neuroventilatory efficiency predict weaning outcome; and (3) duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction. METHODS Adult bilateral-lung transplant patients admitted to the intensive care unit were screened at the time of the first spontaneous breathing trial (pressure-support of 5 cm H2O and 0 positive end-expiratory pressure). At the fifth minute, diaphragm thickening fraction and neuroventilatory efficiency were measured during three respiratory cycles. Weaning was classified as simple, difficult, or prolonged (successful extubation at the first spontaneous breathing trial, within three or after three spontaneous breathing trials, respectively). RESULTS Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%), all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both diaphragm thickening fraction (24 [20 to 29] vs. 39 [35 to 45]%) and neuroventilatory efficiency (34 [26 to 45] vs. 55 [43 to 62] ml/µV) were lower in difficult weaning (both P < 0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 (95% CI, 0.73 to 0.99) for diaphragm thickening fraction and 0.85 (95% CI, 0.71 to 0.95) for neuroventilatory efficiency. The duration of ventilation demonstrated a linear inverse correlation with both diaphragm thickening fraction and neuroventilatory efficiency. CONCLUSIONS Diaphragm dysfunction is common after bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for diaphragm thickening fraction and neuroventilatory efficiency were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine, and Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | | | - Fiorella Calabrese
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | | | - Martin Dres
- Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Center, Keenan Research Center for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada
| | - Federico Rea
- Thoracic Surgery and Lung Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy; Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
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Laghi F. Clarifying the Role of Diaphragm Ultrasound Imaging in the Discontinuation of Mechanical Ventilation. Anesthesiology 2024; 140:4-7. [PMID: 38085158 DOI: 10.1097/aln.0000000000004810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois; Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
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Vega ML, Schifino G, Pisani L, Catalanotti V, Prediletto I, Nava S. Diaphragm thickening fraction and inspiratory effort in patients with SARS-COV II pneumonia receiving different non-invasive respiratory supports. Pulmonology 2023; 29:424-427. [PMID: 36906464 PMCID: PMC9922577 DOI: 10.1016/j.pulmoe.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/10/2023] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Affiliation(s)
- M L Vega
- Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Respiratory and Critical Care Unit- Bologna, Italy
| | - G Schifino
- Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Respiratory and Critical Care Unit- Bologna, Italy
| | - L Pisani
- Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Respiratory and Critical Care Unit- Bologna, Italy
| | - V Catalanotti
- IRCCS Azienda Ospedaliero Universitaria di Bologna, Respiratory and Critical Care Unit- Bologna, Italy
| | - I Prediletto
- Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Respiratory and Critical Care Unit- Bologna, Italy
| | - S Nava
- Alma Mater Studiorum, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero Universitaria di Bologna, Respiratory and Critical Care Unit- Bologna, Italy.
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Medrinal C, Machefert M, Lamia B, Bonnevie T, Gravier FE, Hilfiker R, Prieur G, Combret Y. Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study. Crit Care 2023; 27:338. [PMID: 37649092 PMCID: PMC10469422 DOI: 10.1186/s13054-023-04597-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Few specific methods are available to reduce the risk of diaphragmatic dysfunction for patients under mechanical ventilation. The number of studies involving transcutaneous electrical stimulation of the diaphragm (TEDS) is increasing but none report results for diaphragmatic measurements, and they lack power. We hypothesised that the use of TEDS would decrease diaphragmatic dysfunction and improve respiratory muscle strength in patients in ICU. METHODS We conducted a controlled trial to assess the impact of daily active electrical stimulation versus sham stimulation on the prevention of diaphragm dysfunction during the weaning process from mechanical ventilation. The evaluation was based on ultrasound measurements of diaphragm thickening fraction during spontaneous breathing trials. We also measured maximal inspiratory muscle pressure (MIP), peak cough flow (PEF) and extubation failure. RESULTS Sixty-six patients were included and randomised using a 1:1 ratio. The mean number of days of mechanical ventilation was 10 ± 6.8. Diaphragm thickening fraction was > 30% at the SBT for 67% of participants in the TEDS group and 54% of the Sham group (OR1.55, 95% CI 0.47-5.1; p = 0.47). MIP and PEF were similar in the TEDS and Sham groups (respectively 35.5 ± 11.9 vs 29.7 ± 11.7 cmH20; p = 0.469 and 83.2 ± 39.5 vs. 75.3 ± 34.08 L/min; p = 0.83). Rate of extubation failure was not different between groups. CONCLUSION TEDS did not prevent diaphragm dysfunction or improve inspiratory muscle strength in mechanically ventilated patients. TRIAL REGISTRATION Prospectively registered on the 20th November 2019 on ClinicalTrials.gov Identifier NCT04171024.
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Affiliation(s)
- Clément Medrinal
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France.
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France.
| | - Margaux Machefert
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Physiotherapy Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Bouchra Lamia
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology, Respiratory Department, Rouen University Hospital, Rouen, France
| | - Tristan Bonnevie
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Adir Association, 76230, Bois Guillaume, France
| | - Francis-Edouard Gravier
- Normandie Univ, UNIROUEN, EA3830-GRHV, 76 000, Rouen, France
- Institute for Research and Innovation in Biomedicine (IRIB), 76 000, Rouen, France
- Adir Association, 76230, Bois Guillaume, France
| | - Roger Hilfiker
- Research and Independent Studies in Private Physiotherapy (RISE), 3902, Brig, Switzerland
| | - Guillaume Prieur
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
| | - Yann Combret
- Université Paris-Saclay, UVSQ, Erphan, 78000, Versailles, France
- Intensive Care Unit Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
- Pulmonology Department, Le Havre Hospital, Avenue Pierre Mendes France, 76290, Montivilliers, France
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10
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Jonkman AH, Telias I, Spinelli E, Akoumianaki E, Piquilloud L. The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects. Eur Respir Rev 2023; 32:220186. [PMID: 37197768 PMCID: PMC10189643 DOI: 10.1183/16000617.0186-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/22/2023] [Indexed: 05/19/2023] Open
Abstract
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure (P oes) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, P oes monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using P oes measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of P oes-guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital-Unity Health Toronto, Toronto, ON, Canada
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evangelia Akoumianaki
- Adult Intensive Care Unit, University Hospital of Heraklion, Heraklion, Greece
- Medical School, University of Crete, Heraklion, Greece
| | - Lise Piquilloud
- Adult Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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11
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Bureau C, Van Hollebeke M, Dres M. Managing respiratory muscle weakness during weaning from invasive ventilation. Eur Respir Rev 2023; 32:32/168/220205. [PMID: 37019456 PMCID: PMC10074167 DOI: 10.1183/16000617.0205-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 04/07/2023] Open
Abstract
Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH2O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
| | - Marine Van Hollebeke
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Martin Dres
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
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12
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Littleton SW, Laghi F. Pearls and pitfalls of respiratory testing in a patient with amyotrophic lateral sclerosis and COPD. Breathe (Sheff) 2023; 19:230043. [PMID: 37645021 PMCID: PMC10461734 DOI: 10.1183/20734735.0043-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/06/2023] [Indexed: 08/31/2023] Open
Abstract
Interpretation of pulmonary function testing in patients with amyotrophic lateral sclerosis must account for coexisting lung diseases, when making patient care decisions. https://bit.ly/3Co2yR0.
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Affiliation(s)
- Stephen W. Littleton
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Administration Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL, USA
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Administration Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL, USA
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13
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Lassola S, Miori S, Sanna A, Umbrello M, De Rosa S, Bellani G. Lack of Association between Diaphragm Thickening Fraction and Transdiaphragmatic Pressure Swing in COVID-19 Pneumonia during Helmet Continuous Positive Airway Pressure: Research Letter. Anesthesiology 2023:138190. [PMID: 37158978 DOI: 10.1097/aln.0000000000004575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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14
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Formenti P, Miori S, Galimberti A, Umbrello M. The Effects of Positive End Expiratory Pressure and Lung Volume on Diaphragm Thickness and Thickening. Diagnostics (Basel) 2023; 13:diagnostics13061157. [PMID: 36980465 PMCID: PMC10047794 DOI: 10.3390/diagnostics13061157] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Introduction: Diaphragm dysfunction is common in patients undergoing mechanical ventilation. The application of positive end-expiratory pressure (PEEP) and the varying end-expiratory lung volume cause changes in diaphragm geometry. We aimed to assess the impact of the level of PEEP and lung inflation on diaphragm thickness, thickening fraction and displacement. Methods: An observational study in a mixed medical and surgical ICU was conducted. The patients underwent a PEEP-titration trial with the application of three random levels of PEEP: 0 cmH2O (PEEP0), 8 cmH2O (PEEP8) and 15 cmH2O (PEEP15). At each step, the indices of respiratory effort were assessed, together with arterial blood and diaphragm ultrasound; end-expiratory lung volume was measured. Results: 14 patients were enrolled. The tidal volume, diaphragm displacement and thickening fraction were significantly lower with higher levels of PEEP, while both the expiratory and inspiratory thickness increased with higher PEEP levels. The inspiratory effort, as evaluated by the esophageal pressure swing, was unchanged. Both the diaphragm thickening fraction and displacement were significantly correlated with inspiratory effort in the whole dataset. For both measurements, the correlation was stronger at lower levels of PEEP. The difference in the diaphragm thickening fraction during tidal breathing between PEEP 15 and PEEP 0 was negatively related to the change in the functional residual capacity and the change in alveolar dead space. Conclusions: Different levels of PEEP significantly modified the diaphragmatic thickness and thickening fraction, showing a PEEP-induced decrease in the diaphragm contractile efficiency. When using ultrasound to assess diaphragm size and function, the potential effect of lung inflation should be taken into account.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia e Rianimazione I, ASST Santi Paolo e Carlo-Polo Universitario, Ospedale San Paolo, 20142 Milan, Italy
| | - Sara Miori
- SC Anestesia e Rianimazione I, Ospedale Santa Chiara, APSS, 30014 Trento, Italy
| | - Andrea Galimberti
- SC Anestesia Rianimazione e Terapia Intensiva ASST Nord Milano Ospedale Bassini, 20092 Cinisello Balsamo, Italy
| | - Michele Umbrello
- SC Anestesia e Rianimazione II, ASST Santi Paolo e Carlo-Polo Universitario, Ospedale San Carlo Borromeo, 20148 Milan, Italy
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15
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Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
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Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
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16
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Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure. Diagnostics (Basel) 2023; 13:diagnostics13030411. [PMID: 36766515 PMCID: PMC9914801 DOI: 10.3390/diagnostics13030411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying etiologies. In these cases, many factors related to systemic inflammation, prolonged use of steroids, and lung mechanical abnormalities (such as hyperinflation or increased elastic recoil due to pulmonary oedema or fibrosis) may act as synergic mechanisms leading to diaphragm dysfunction. The assessment of diaphragm function with ultrasound has been increasingly investigated in the emergency department and during hospital stay as a valuable tool for providing additional anatomical and functional information in many acute respiratory diseases. The diaphragmatic ultrasound is a noninvasive and repeatable bedside tool, has no contraindications, and allows the physician to rapidly assess the presence of diaphragmatic dysfunction; this evaluation may help in estimating the need for mechanical ventilation (and the risk of weaning failure), as well as the risk of longer hospital stay and higher mortality rate. This study presents an overview of the recent evidence regarding the evaluation of diaphragmatic function with bedside ultrasound and its clinical applications, including a discussion of real-life clinical cases.
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17
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Duyndam A, Smit J, Houmes RJ, Heunks L, Molinger J, IJland M, van Rosmalen J, van Dijk M, Tibboel D, Ista E. No association between thickening fraction of the diaphragm and extubation success in ventilated children. Front Pediatr 2023; 11:1147309. [PMID: 37033174 PMCID: PMC10081691 DOI: 10.3389/fped.2023.1147309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction In mechanically ventilated adults, thickening fraction of diaphragm (dTF) measured by ultrasound is used to predict extubation success. Whether dTF can also predict extubation success in children is unclear. Aim To investigate the association between dTF and extubation success in children. Second, to assess diaphragm thickness during ventilation and the correlation between dTF, diaphragm thickness (Tdi), age and body surface. Method Prospective observational cohort study in children aged 0-18 years old with expected invasive ventilation for >48 h. Ultrasound was performed on day 1 after intubation (baseline), day 4, day 7, day 10, at pre-extubation, and within 24 h after extubation. Primary outcome was the association between dTF pre-extubation and extubation success. Secondary outcome measures were Tdi end-inspiratory and Tdi end-expiratory and atrophy defined as <10% decrease of Tdi end-expiratory versus baseline at pre-extubation. Correlations were calculated with Spearman correlation coefficients. Inter-rater reliability was calculated with intraclass correlation (ICC). Results Fifty-three patients, with median age 3.0 months (IQR 0.1-66.0) and median duration of invasive ventilation of 114.0 h (IQR 55.5-193.5), were enrolled. Median dTF before extubation with Pressure Support 10 above 5 cmH2O was 15.2% (IQR 9.7-19.3). Extubation failure occurred in six children, three of whom were re-intubated and three then received non-invasive ventilation. There was no significant association between dTF and extubation success; OR 0.33 (95% CI; 0.06-1.86). Diaphragmatic atrophy was observed in 17/53 cases, in three of extubation failure occurred. Children in the extubation failure group were younger: 2.0 months (IQR 0.81-183.0) vs. 3.0 months (IQR 0.10-48.0); p = 0.045. At baseline, pre-extubation and post-extubation there was no significant correlation between age and BSA on the one hand and dTF, Tdi- insp and Tdi-exp on the other hand. The ICC representing the level of inter-rater reliability between the two examiners performing the ultrasounds was 0.994 (95% CI 0.970-0.999). The ICC of the inter-rater reliability between the raters in 36 paired assessments was 0.983 (95% CI 0.974-0.990). Conclusion There was no significant association between thickening fraction of the diaphragm and extubation success in ventilated children.
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Affiliation(s)
- Anita Duyndam
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Correspondence: Anita Duyndam
| | - Joke Smit
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert Jan Houmes
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Leo Heunks
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jeroen Molinger
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Division of Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Marloes IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Monique van Dijk
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dick Tibboel
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Erwin Ista
- Pediatric Intensive Care, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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18
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Hua-Rong Z, Liang C, Rong L, Yi-Fan T, Dou-Zi S, Yue C, Zu-Lin L. Ultrasonographic evaluation of diaphragm function in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e32560. [PMID: 36595865 PMCID: PMC9794219 DOI: 10.1097/md.0000000000032560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Some studies have reported using ultrasonic evaluations to assess diaphragm function in patients with chronic obstructive pulmonary disease (COPD). However, they have limitations and thus cannot provide strong evidence to support ultrasound evaluations for diaphragm function and dysfunction severity assessments in this patient population. Additionally, quantitative studies on the relationship between ultrasound evaluations and diaphragm function do not exist. Therefore, we performed a systematic review and meta-analysis to explore the usefulness of ultrasonography for evaluating diaphragm function in patients with COPD. METHODS The Cochrane Library, PubMed, Embase, Web of Science, Chinese Biomedical Literature Database, Wanfang Data, China National Knowledge Network, and Chinese Scientific Journal Database (i.e., VIP) databases were searched for literature about ultrasonic evaluations of diaphragm function in patients with COPD for systematic review. We extracted patient demographic, diaphragm mobility, diaphragm thickness, diaphragm thickening score, and other related parameter data using RevMan 5.3 software for the meta-analysis. RESULTS We included 13 articles in the systematic review, 8 of which (494 participants) were included in the meta-analysis. The degree of diaphragm offset in patients with COPD was significantly lower than that in healthy controls (weighted mean difference [WMD] = -1.34; 95% confidence interval [CI]: -2.15, 0.53; P < .05). The diaphragm deviation was lower in the severe COPD group than in the mild-to-moderate COPD group (WMD = 0.50; 95% CI: -0.01, 1.01; P = .06), but the difference was not significant. CONCLUSION Ultrasonography effectively evaluates diaphragm function in patients with COPD. The diaphragm offset can be used as an auxiliary diagnostic index for COPD, which is also related to disease severity.
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Affiliation(s)
- Zeng Hua-Rong
- The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei, China
| | - Chen Liang
- Yichang Maternal and Child Health Hospital, Yichang, Hubei, China
| | - Liu Rong
- The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei, China
- * Correspondence: Liu Rong, The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei 443000, China (e-mail: )
| | - Tu Yi-Fan
- The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei, China
| | - Shi Dou-Zi
- The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei, China
| | - Chen Yue
- The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei, China
| | - Liu Zu-Lin
- The First College of Clinical Medical Science, China Three Gorges University & Ultrasound Department of Yichang Central People’s Hospital, Yichang, Hubei, China
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19
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Bickenbach J, Fritsch S. [Weaning from invasive ventilation : Challenges in the clinical routine]. DIE ANAESTHESIOLOGIE 2022; 71:910-920. [PMID: 36418440 DOI: 10.1007/s00101-022-01219-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.
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Affiliation(s)
- Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| | - Sebastian Fritsch
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
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20
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Haaksma ME, van Tienhoven AJ, Smit JM, Heldeweg MLA, Lissenberg-Witte BI, Wennen M, Jonkman A, Girbes ARJ, Heunks L, Tuinman PR. Anatomical Variation in Diaphragm Thickness Assessed with Ultrasound in Healthy Volunteers. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1833-1839. [PMID: 35691733 DOI: 10.1016/j.ultrasmedbio.2022.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/21/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
Ultrasonography of the diaphragm in the zone of apposition has become increasingly popular to evaluate muscle thickness and thickening fraction. However, measurements in this anatomical location are frequently hindered by factors that constrain physical accessibility or that alter diaphragm position. Therefore, other anatomical positions at the chest wall for transducer placement are used, but the variability in diaphragm thickness across the dome has not been systematically studied. The aim of this study was to evaluate anatomical variation of diaphragm thickness in 46 healthy volunteers on three ventrodorsal lines and two craniocaudal positions on these three lines. The intraclass correlation coefficient (ICC) for diaphragm thickness in the craniocaudal direction on the mid-axillary line was significantly higher than those on the posterior axillary and midclavicular lines, suggesting it had the lowest variability (ICCmidaxillary = .89, 95% confidence interval [CI]: 0.83-0.93, ICCposterior axillary = 0.74, 95% CI: 0.62-0.85, ICCmidclavicular = 0.62, 95% CI: 0.43-0.47, p < 0.05). Average diaphragm thickness was comparable on the posterior axillary and midaxillary lines and substantially larger on the midclavicular line (1.24 mm [1.06-1.47], 1.27 mm [1.10-1.42] and 2.32 [1.97-2.70], p < 0.01). We conclude that the normal diaphragm has a large variability in thickness, especially in the ventrodorsal direction. Variability in craniocaudal position is the lowest at the midaxillary line, which therefore appears to be the preferred site for diaphragm thickness measurement.
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Affiliation(s)
- Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Arne J van Tienhoven
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Myrte Wennen
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands; Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
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21
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Vetrugno L, Orso D, Corradi F, Zani G, Spadaro S, Meroi F, D’Andrea N, Bove T, Cammarota G, De Robertis E, Ferrari S, Guarnieri M, Ajuti M, Fusari M, Grieco DL, Deana C, Boero E, Franchi F, Scolletta S, Maggiore SM, Forfori F. Diaphragm ultrasound evaluation during weaning from mechanical ventilation in COVID-19 patients: a pragmatic, cross-section, multicenter study. Respir Res 2022; 23:210. [PMID: 35989352 PMCID: PMC9392990 DOI: 10.1186/s12931-022-02138-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Diaphragmatic dysfunction is a major factor responsible for weaning failure in patients that underwent prolonged invasive mechanical ventilation for acute severe respiratory failure from COVID-19. This study hypothesizes that ultrasound measured diaphragmatic thickening fraction (DTF) could provide corroborating information for weaning COVID-19 patients from mechanical ventilation.
Methods
This was an observational, pragmatic, cross-section, multicenter study in 6 Italian intensive care units. DTF was assessed in COVID-19 patients undergoing weaning from mechanical ventilation from 1st March 2020 to 30th June 2021. Primary aim was to evaluate whether DTF is a predictive factor for weaning failure.
Results
Fifty-seven patients were enrolled, 25 patients failed spontaneous breathing trial (44%). Median length of invasive ventilation was 14 days (IQR 7–22). Median DTF within 24 h since the start of weaning was 28% (IQR 22–39%), RASS score (− 2 vs − 2; p = 0.031); Kelly-Matthay score (2 vs 1; p = 0.002); inspiratory oxygen fraction (0.45 vs 0.40; p = 0.033). PaO2/FiO2 ratio was lower (176 vs 241; p = 0.032) and length of intensive care stay was longer (27 vs 16.5 days; p = 0.025) in patients who failed weaning. The generalized linear regression model did not select any variables that could predict weaning failure. DTF was correlated with pH (RR 1.56 × 1027; p = 0.002); Kelly-Matthay score (RR 353; p < 0.001); RASS (RR 2.11; p = 0.003); PaO2/FiO2 ratio (RR 1.03; p = 0.05); SAPS2 (RR 0.71; p = 0.005); hospital and ICU length of stay (RR 1.22 and 0.79, respectively; p < 0.001 and p = 0.004).
Conclusions
DTF in COVID-19 patients was not predictive of weaning failure from mechanical ventilation, and larger studies are needed to evaluate it in clinical practice further.
Registered: ClinicalTrial.gov (NCT05019313, 24 August 2021).
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22
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Steinberg I, Chiodaroli E, Gattarello S, Cappio Borlino S, Chiumello D. Diaphragmatic ultrasound and esophageal pressure in COVID-19 pneumonia during helmet CPAP. Intensive Care Med 2022; 48:1095-1096. [PMID: 35726028 PMCID: PMC9209321 DOI: 10.1007/s00134-022-06785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Irene Steinberg
- Department of Anesthesiology, Medical University of Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
| | - Elena Chiodaroli
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Simone Gattarello
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simone Cappio Borlino
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Milan, Italy
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23
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van Doorn JLM, Wijntjes J, Saris CGJ, Ottenheijm CAC, van Alfen N, Doorduin J. Association of diaphragm thickness and echogenicity with age, sex, and body mass index in healthy subjects. Muscle Nerve 2022; 66:197-202. [PMID: 35583147 PMCID: PMC9543748 DOI: 10.1002/mus.27639] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 12/02/2022]
Abstract
Introduction/Aims Diaphragm ultrasound is increasingly used in the diagnosis of diaphragm dysfunction and to guide respiratory management in patients with neuromuscular disorders and those who are critically ill. However, the association between diaphragm ultrasound variables and demographic factors like age, sex, and body mass index (BMI) are understudied. Such relationships are important for correct interpretation of normative values and comparison with selected patients groups. The aim of this study was to determine the associations between diaphragm ultrasound variables and subject characteristics. Methods B‐mode ultrasound was used to image the diaphragm at the zone of apposition in 83 healthy subjects. Diaphragm thickness at resting end‐expiration (Tend‐exp), diaphragm thickness at maximal end‐inspiration (Tmax‐insp), diaphragm thickening ratio (Tmax‐insp/Tend‐exp), and diaphragm echogenicity were measured. Multivariate linear regression was used to explore the associations between diaphragm ultrasound variables and subject characteristics. Results Tend‐exp, Tmax‐insp, and thickening ratio do not change with age whereas diaphragm echogenicity increases with age. The thickening ratio had a weak negative association with BMI, while Tend‐exp was positively associated with BMI. Men had a larger Tend‐exp and Tmax‐insp than women (Tend‐exp 1.6 ± 0.5 and 1.4 ± 0.3 mm; p = .011, Tmax‐insp 3.8 ± 1.0 and 3.2 ± 0.9 mm; p = .004), but similar thickening ratios. Discussion Diaphragm thickness, thickening, and echogenicity measured with ultrasound are associated with factors such as age, BMI, and sex. Therefore, subject characteristics should be considered when interpreting diaphragm ultrasound measurements. In the absence of normative values, matched control groups are a prerequisite for research and in clinical practice.
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Affiliation(s)
- Jeroen L M van Doorn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Juerd Wijntjes
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christiaan G J Saris
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Coen A C Ottenheijm
- Department of Physiology, Amsterdam University Medical Center, VUmc, The Netherlands
| | - Nens van Alfen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonne Doorduin
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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24
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Vetrugno L, Corvino A, Maggiore SM. Ultrasound of the diaphragm: Competency ≠ patients outcome. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:263-264. [PMID: 35148002 DOI: 10.1002/jcu.23131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Antonio Corvino
- Department Motor Science and Wellness, University of Naples "Parthenope", Naples, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
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