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Amirkhosravi F, Allenson KC, Moore LW, Kolman JM, Foster M, Hsu E, Sasangohar F, Dhala A. Multimodal prehabilitation and postoperative outcomes in upper abdominal surgery: systematic review and meta-analysis. Sci Rep 2024; 14:16012. [PMID: 38992072 PMCID: PMC11239889 DOI: 10.1038/s41598-024-66633-6] [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: 06/21/2023] [Accepted: 07/03/2024] [Indexed: 07/13/2024] Open
Abstract
The impact of multimodal prehabilitation on postoperative complications in upper abdominal surgeries is understudied. This review analyzes randomized trials on multimodal prehabilitation with patient and hospital outcomes. MEDLINE, Embase, CINAHL, and Cochrane CENTRAL were searched for trials on prehabilitation before elective (non-emergency) abdominal surgery. Two reviewers independently screened studies, extracted data, and assessed study quality. Primary outcomes of interest were postoperative pulmonary complications (PPCs) and all-cause complications; secondary outcomes included hospital and intensive care length of stay. A meta-analysis with random-effect models was performed, and heterogeneity was evaluated with I-square and Cochran's Q test. Dichotomous variables were reported in log-odds ratio and continuous variables were presented as mean difference. Ten studies (total 1503 patients) were included. Odds of developing complications after prehabilitation were significantly lower compared to various control groups (- 0.38 [- 0.75- - 0.004], P = 0.048). Five studies described PPCs, and participants with prehabilitation had decreased odds of PPC (- 0.96 [- 1.38- - 0.54], P < 0.001). Prehabilitation did not significantly reduce length of stay, unless exercise was implemented; with exercise, hospital stay decreased significantly (- 0.91 [- 1.67- - 0.14], P = 0.02). Multimodal prehabilitation may decrease complications in upper abdominal surgery, but not necessarily length of stay; research should address heterogeneity in the literature.
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Affiliation(s)
| | | | - Linda W Moore
- Department of Surgery, Houston Methodist, Houston, TX, USA
| | - Jacob M Kolman
- Office of Faculty and Research Development, Department of Academic Affairs, Houston Methodist, Houston, TX, USA
| | - Margaret Foster
- School of Medicine, Department of Medical Education, Texas A&M University, College Station, TX, USA
| | - Enshuo Hsu
- Center for Health Data Science and Analytics, Houston Methodist, Houston, TX, USA
| | - Farzan Sasangohar
- Wm Michael Barnes '64 Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, USA
- Center for Critical Care, Houston Methodist, Houston, TX, USA
| | - Atiya Dhala
- Department of Surgery, Houston Methodist, Houston, TX, USA.
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de Abranches Oliveira Santos Filho ID, Rodrigues MA, Ferreira LM, Nahas FX. Is There a Direct Effect Between the Plication of the Myoaponeurotic Layer and the Force of Inspiratory and Expiratory Muscles After Abdominoplasty? Ann Plast Surg 2024; 93:14-21. [PMID: 38885160 DOI: 10.1097/sap.0000000000003940] [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: 06/20/2024]
Abstract
OBJECTIVE Abdominoplasty may generate an increase in the intra-abdominal pressure (IAP) and consequently an alteration in the pulmonary ventilation. The purpose of this study was to evaluate the potential alterations in the maximal static inspiratory pressure (MIP) and maximal static expiratory pressure (MEP) after abdominoplasty. METHODS Thirty-three female patients, aged between 18 and 60, with type III/B Nahas abdominal deformity that underwent abdominoplasty with plication of the anterior rectus and external oblique aponeurosis were selected. The MIP and MEP were measured using a mouthpiece. This is a simple way to indirectly gauge inspiratory and expiratory muscle strength. Measurements were performed before surgery and on the 2nd, 7th, 15th, and 180th postoperative day. In addition, IAP was measured before abdominoplasty and after the placement of compression garment. The MIP and MEP were compared using analysis of variance, followed by the Bonferroni multiple comparison test pairing the different points in time. Paired Student's t test was used for comparing IAP measurements. Pearson's correlation test was used to compare MIP and MEP variations with IAP variation. Results were considered statistically significant when P ≤ 0.05. RESULTS A decrease was observed in MEP on the 2nd day, with a return close to normal values on the 15th day. In opposition MIP had a surprisingly increase on the 15th postoperative day (129 cmH2O), normalizing 180 days after the operation. A leap in IAP values was revealed at the end of the surgical procedure. It was not possible to establish a positive correlation between the increase of IAP and the alterations of MIP and MEP. CONCLUSIONS There is a decrease in maximum expiratory pressure on the very early postoperative day (2nd postoperative day) and an increase in maximum inspiratory pressure on the 15th postoperative day in patients who underwent abdominoplasty. There was no correlation between the IAP and maximum respiratory pressure variations, both inspiratory and expiratory.
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Yao XY, Li HM, Sun BW, Zhang YY, Feng JG, Jia J, Liu L. Ultrasound assessment of diaphragmatic dysfunction in non-critically ill patients: relevant indicators and update. Front Med (Lausanne) 2024; 11:1389040. [PMID: 38957305 PMCID: PMC11217340 DOI: 10.3389/fmed.2024.1389040] [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: 02/20/2024] [Accepted: 06/03/2024] [Indexed: 07/04/2024] Open
Abstract
Diaphragm dysfunction (DD) can be classified as mild, resulting in diaphragmatic weakness, or severe, resulting in diaphragmatic paralysis. Various factors such as prolonged mechanical ventilation, surgical trauma, and inflammation can cause diaphragmatic injury, leading to negative outcomes for patients, including extended bed rest and increased risk of pulmonary complications. Therefore, it is crucial to protect and monitor diaphragmatic function. Impaired diaphragmatic function directly impacts ventilation, as the diaphragm is the primary muscle involved in inhalation. Even unilateral DD can cause ventilation abnormalities, which in turn lead to impaired gas exchange, this makes weaning from mechanical ventilation challenging and contributes to a higher incidence of ventilator-induced diaphragm dysfunction and prolonged ICU stays. However, there is insufficient research on DD in non-ICU patients, and DD can occur in all phases of the perioperative period. Furthermore, the current literature lacks standardized ultrasound indicators and diagnostic criteria for assessing diaphragmatic dysfunction. As a result, the full potential of diaphragmatic ultrasound parameters in quickly and accurately assessing diaphragmatic function and guiding diagnostic and therapeutic decisions has not been realized.
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Affiliation(s)
- Xin-Yu Yao
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Hong-Mei Li
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Anesthesiology, Chengdu Fifth People’s Hospital, Chengdu, China
| | - Bo-Wen Sun
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Ying-Ying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Jian-Guo Feng
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Jing Jia
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
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Cursino de Moura JF, Oliveira CB, Coelho Figueira Freire AP, Elkins MR, Pacagnelli FL. Preoperative respiratory muscle training reduces the risk of pulmonary complications and the length of hospital stay after cardiac surgery: a systematic review. J Physiother 2024; 70:16-24. [PMID: 38036402 DOI: 10.1016/j.jphys.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 09/11/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
QUESTIONS What is the effect of preoperative respiratory muscle training (RMT) on the incidence of postoperative pulmonary complications (PPCs) after open cardiac surgery? What is the effect of RMT on the duration of mechanical ventilation, postoperative length of stay and respiratory muscle strength? DESIGN Systematic review of randomised trials with meta-analysis. PARTICIPANTS Adults undergoing elective open cardiac surgery. INTERVENTION The experimental groups received preoperative RMT and the comparison groups received no intervention. OUTCOME MEASURES The primary outcomes were PPCs, length of hospital stay, respiratory muscle strength, oxygenation and duration of mechanical ventilation. The methodological quality of studies was assessed using the PEDro scale and the overall certainty of the evidence was assessed using the GRADE approach. RESULTS Eight trials involving 696 participants were included. Compared with the control group, the respiratory training group had fewer PPCs (RR 0.51, 95% CI 0.38 to 0.70), less pneumonia (RR 0.44, 95% CI 0.25 to 0.78), shorter hospital stay (MD -1.7 days, 95% CI -2.4 to -1.1) and higher maximal inspiratory pressure values at the end of the training protocol (MD 12 cmH2O, 95% CI 8 to 16). The mechanical ventilation time was similar in both groups. The quality of evidence was high for pneumonia, length of hospital stay and maximal inspiratory pressure. CONCLUSION Preoperative RMT reduced the risk of PPCs and pneumonia after cardiac surgery. The training also improved the maximal inspiratory pressure and reduced hospital stay. The effects on PPCs were large enough to warrant use of RMT in this population. REGISTRATION CRD42021227779.
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Affiliation(s)
| | | | | | - Mark Russell Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Sydney Education, Sydney Local Health District, Sydney, Australia
| | - Francis Lopes Pacagnelli
- Physiotherapy Department, University of Western São Paulo (UNOESTE), Presidente Prudente, Brazil.
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Zhao B, Zhang T, Chen Y, Zhang C. Effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer: a systematic review and meta-analysis. Support Care Cancer 2023; 32:15. [PMID: 38060053 DOI: 10.1007/s00520-023-08229-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/02/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE To evaluate the effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer. METHODS We conducted a systematic search of the PubMed, Embase, CINAHL, Web of Science, and Cochrane Library (CENTRAL) databases from database inception to May 5, 2023, for randomized controlled trials (RCTs) and cohort studies that investigated prehabilitation in the context of esophagogastric cancer. A random-effects model was used for meta-analysis. RESULTS We identified 2,994 records and eventually included 12 studies (6 RCTs and 6 cohort studies) with a total of 910 patients. According to random-effects pooled estimates, prehabilitation reduced the incidence of all complications (RR = 0.79, 95% CI: 0.66 to 0.93, P = 0.006), pulmonary complications (RR = 0.61, 95% CI: 0.47 to 0.79, P = 0.0002), and severe complications (RR = 0.63, 95% CI: 0.47 to 0.84, P = 0.002), and shortened the length of stay (MD = -1.92, 95% CI: -3.11 to -0.73, P = 0.002) compared to usual care. However, there were no statistically significant differences in 30-day readmission rates or in-hospital mortality. Subgroup analysis showed that multimodal prehabilitation was effective in reducing the risk of all complications and severe complications, while unimodal prehabilitation was not. CONCLUSIONS Our findings suggested that prehabilitation may be beneficial in reducing postoperative complications and length of stay. We recommend preoperative prehabilitation to improve postoperative outcomes and hasten recovery following esophagogastric cancer surgery, and multimodal prehabilitation seems to be more advantageous in reducing complications. However, further studies are needed to confirm these results.
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Affiliation(s)
- Bingyan Zhao
- Graduate School of Tianjin University of Chinese Medicine, Tianjin, 301617, China
| | - Tongyu Zhang
- Graduate School of Tianjin University of Chinese Medicine, Tianjin, 301617, China
| | - Yu Chen
- Graduate School of Tianjin University of Chinese Medicine, Tianjin, 301617, China
| | - Chunmei Zhang
- School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China.
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Okura K, Suto A, Sato Y, Takahashi Y, Hatakeyama K, Nagaki Y, Wakita A, Kasukawa Y, Miyakoshi N, Minamiya Y. Preoperative inspiratory muscle weakness as a risk factor of postoperative pulmonary complications in patients with esophageal cancer. J Surg Oncol 2023; 128:1259-1267. [PMID: 37671598 DOI: 10.1002/jso.27436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/02/2023] [Accepted: 08/25/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVE We examined whether preoperative inspiratory muscle weakness (IMW) is a risk factor for postoperative pulmonary complications (PPCs) in patients with esophageal cancer who underwent subtotal esophagectomy. METHODS This single-center retrospective cohort study enrolled patients with esophageal cancer who underwent a scheduled subtotal esophagectomy between June 2020 and May 2022. Maximal inspiratory pressure (MIP) was measured as inspiratory muscle strength using a respiratory dynamometer, and we defined IMW as MIP < 80% of the predicted value. Our primary outcome comprised overall PPCs. We investigated the relationship between IMW and PPCs using the Bayesian logistic regression model. RESULTS After exclusion, 72 patients were included in this study. IMW was identified in 26 patients (36%), and PPCs developed in 28 patients (39%). Among patients with IMW, 15 (58%) developed PPCs. Preoperative IMW was associated with PPCs (mean odds ratio [OR]: 3.58; 95% credible interval [95% CrI]: 1.29, 9.73) in the unweighted model. A similar association was observed in the weighted model adjusted for preoperative and intraoperative contributing factors (mean OR: 4.15; 95% CrI: 2.04, 8.45). CONCLUSIONS Preoperative IMW was associated with PPCs in patients with esophageal cancer who underwent subtotal esophagectomy. This association remained after adjusting for preoperative and intraoperative contributing factors.
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Affiliation(s)
- Kazuki Okura
- Division of Rehabilitation, Akita University Hospital, Akita City, Japan
| | - Akiyoshi Suto
- Department of Data Science, Yokohama City University Graduate School of Data Science, Yokohama City, Japan
| | - Yusuke Sato
- Department of Esophageal Surgery, Akita University Hospital, Akita City, Japan
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
| | - Yusuke Takahashi
- Division of Rehabilitation, Akita University Hospital, Akita City, Japan
| | | | - Yushi Nagaki
- Department of Esophageal Surgery, Akita University Hospital, Akita City, Japan
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
| | - Akiyuki Wakita
- Department of Esophageal Surgery, Akita University Hospital, Akita City, Japan
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
| | - Yuji Kasukawa
- Department of Rehabilitation Medicine, Akita University Hospital, Akita City, Japan
| | - Naohisa Miyakoshi
- Department of Rehabilitation Medicine, Akita University Hospital, Akita City, Japan
| | - Yoshihiro Minamiya
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita City, Japan
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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: 7] [Impact Index Per Article: 7.0] [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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Okura K, Takahashi Y, Hatakeyama K, Saito K, Kasukawa Y, Imai K, Minamiya Y. Preoperative inspiratory muscle training in a patient with lung cancer and comorbid chronic obstructive pulmonary disease and respiratory sarcopenia: A case report. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2022; 28:e1987. [PMID: 36533560 DOI: 10.1002/pri.1987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/24/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Sarcopenia and chronic obstructive pulmonary disease (COPD) are risk factors for postoperative pulmonary complications (PPCs). Preoperative inspiratory muscle weakness is also a risk factor for PPCs. Sarcopenia and COPD are often associated with inspiratory muscle weakness. Respiratory sarcopenia has been defined as the coexistence of whole-body sarcopenia and respiratory muscle weakness. We report our experience with preoperative pulmonary rehabilitation, including inspiratory muscle training (IMT), in a patient with lung cancer and comorbid respiratory sarcopenia and COPD. CASE PRESENTATION A 73-year-old man with squamous cell lung cancer (cStage IA2) was hospitalized for pulmonary rehabilitation before lung resection. He had comorbid severe sarcopenia and COPD (GOLD stage III). He also had inspiratory muscle weakness and a thin diaphragm. We conducted IMT on the patient in addition to aerobic exercise and instruction regarding sputum expectoration for 2 weeks before the surgery. Consequently, his pulmonary function, respiratory muscle strength, and exercise capacity improved. Segmentectomy was performed using video-assisted thoracic surgery. No postoperative complications occurred. CONCLUSION IMT in a patient with lung cancer and comorbid respiratory sarcopenia and COPD resulted in improved respiratory muscle strength and pulmonary function. IMT may have reduced the risk of PPCs by strengthening the respiratory muscles and improving pulmonary function.
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Affiliation(s)
- Kazuki Okura
- Division of Rehabilitation Akita University Hospital Akita Japan
| | - Yusuke Takahashi
- Division of Rehabilitation Akita University Hospital Akita Japan
| | | | - Kimio Saito
- Division of Rehabilitation Akita University Hospital Akita Japan
| | - Yuji Kasukawa
- Division of Rehabilitation Akita University Hospital Akita Japan
| | - Kazuhiro Imai
- Department of Thoracic Surgery Akita University Graduate School of Medicine Akita Japan
| | - Yoshihiro Minamiya
- Department of Thoracic Surgery Akita University Graduate School of Medicine Akita Japan
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Steinberg I, Bisciaio A, Rosboch GL, Ceraolo E, Guerrera F, Ruffini E, Brazzi L. Impact of intubated vs. non-intubated anesthesia on postoperative diaphragmatic function: Results from a prospective observational study. Front Physiol 2022; 13:953951. [PMID: 36003644 PMCID: PMC9393254 DOI: 10.3389/fphys.2022.953951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/14/2022] [Indexed: 12/02/2022] Open
Abstract
Background: An altered diaphragmatic function was associated with the development of postoperative pulmonary complications following thoracic surgery. Methods: To evaluate the impact of different anesthetic techniques on postoperative diaphragmatic dysfunction, patients undergoing video-assisted thoracoscopic surgery (VATS) lung biopsy for interstitial lung disease were enrolled in a monocentric observational prospective study. Patients received intubated or non-intubated anesthesia according to risk assessment and preferences following multidisciplinary discussion. Ultrasound measured diaphragmatic excursion (DIA) and Thickening Fraction (TF) were recorded together with arterial blood gases and pulmonary function tests (PFT) immediately before and 12 h after surgery. Pain control and postoperative nausea and vomiting (PONV) were also evaluated. Results: From February 2019 to September 2020, 41 consecutive patients were enrolled. Five were lost due to difficulties in collecting postoperative data. Of the remaining 36 patients, 25 underwent surgery with a non-intubated anesthesia approach whereas 11 underwent intubated general anesthesia. The two groups had similar baseline characteristics. On the operated side, DIA and TF showed a lower residual postoperative function in the intubated group compared to the non-intubated group (54 vs. 82% of DIA and 36 vs. 97% of TF; p = 0.001 for both). The same was observed on the non-operated side (58 vs. 82% and 62 vs. 94%; p = 0.005 and p = 0.045, respectively, for DIA and TF). No differences were observed between groups in terms of pain control, PONV, gas exchange and PFT. Conclusion: This study suggests that maintenance of spontaneous breathing during VATS lung biopsy is associated with better diaphragmatic residual function after surgery.
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Affiliation(s)
- Irene Steinberg
- Department of Surgical Sciences, University of Turin, Turin, Italy
- *Correspondence: Irene Steinberg,
| | - Agnese Bisciaio
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Giulio Luca Rosboch
- Department of Anaesthesia, Intensive Care and Emergency—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Edoardo Ceraolo
- Department of Anaesthesia, Intensive Care and Emergency—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Francesco Guerrera
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Thoracic Surgery—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Enrico Ruffini
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Thoracic Surgery—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Intensive Care and Emergency—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
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Preoperative Exercise Training to Prevent Postoperative Pulmonary Complications in Adults Undergoing Major Surgery. A Systematic Review and Meta-analysis with Trial Sequential Analysis. Ann Am Thorac Soc 2021; 18:678-688. [PMID: 33030962 DOI: 10.1513/annalsats.202002-183oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: Poor preoperative physical fitness and respiratory muscle weakness are associated with postoperative pulmonary complications (PPCs) that result in prolonged hospital length of stay and increased mortality.Objectives: To examine the effect of preoperative exercise training on the risk of PPCs across different surgical settings.Methods: We searched MEDLINE, Web of Science, Embase, the Physiotherapy Evidence Database, and the Cochrane Central Register, without language restrictions, for studies from inception to July 2020. We included randomized controlled trials that compared patients receiving exercise training with those receiving usual care or sham training before cardiac, lung, esophageal, or abdominal surgery. PPCs were the main outcome; secondary outcomes were preoperative functional changes and postoperative mortality, cardiovascular complications, and hospital length of stay. The study was registered with PROSPERO (International Prospective Register of Systematic Reviews).Results: From 29 studies, 2,070 patients were pooled for meta-analysis. Compared with the control condition, preoperative exercise training was associated with a lower incidence of PPCs (23 studies, 1,864 patients; relative risk, 0.52; 95% confidence interval [CI], 0.41 to 0.66; grading of evidence, moderate); Trial Sequential Analysis confirmed effectiveness, and there was no evidence of difference of effect across surgeries, type of training (respiratory muscles, endurance or combined), or preoperative duration of training. At the end of the preoperative period, exercise training resulted in increased peak oxygen uptake (weighted mean difference [WMD], +2 ml/kg/min; 99% CI, 0.3 to 3.7) and higher maximal inspiratory pressure (WMD, +12.2 cm H2O; 99% CI, 6.3 to 18.2). Hospital length of stay was shortened (WMD, -2.3 d; 99% CI, -3.82 to -0.75) in the intervention group, whereas no difference was found in postoperative mortality.Conclusions: Preoperative exercise training improves physical fitness and reduces the risk of developing PPCs while minimizing hospital resources use, regardless of the type of intervention and surgery performed.Systematic review registered with https://www.crd.york.ac.uk/prospero/ (CRD 42018096956).
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Mistri S, Dhochak N, Jana M, Jat KR, Sankar J, Kabra SK, Lodha R. Diaphragmatic atrophy and dysfunction in critically ill mechanically ventilated children. Pediatr Pulmonol 2020; 55:3457-3464. [PMID: 32940958 DOI: 10.1002/ppul.25076] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/13/2020] [Accepted: 09/10/2020] [Indexed: 11/06/2022]
Abstract
RATIONALE The extent of diaphragmatic atrophy and dysfunction in critically ill children from developing countries is not established. OBJECTIVES To estimate changes in ultrasound measurements of diaphragmatic thickness over the first week of mechanical ventilation. To assess magnitude and risk factors of diaphragmatic atrophy. METHODS In an observational cohort study, children aged 1-18 years, requiring mechanical ventilation were included. Ultrasound measurements of diaphragmatic thickness at end-expiration (DTe) and end-inspiration (DTi), and diaphragmatic thickening fraction (DTF) were performed daily during the first week of admission, and pre- and post-extubation. Diaphragmatic atrophy (%) and atrophy rate (rate of decline in DTe, % per day) were calculated. MEASUREMENTS AND MAIN RESULTS Of 55 children (74.6% boys) enrolled, 20 (36.4%) died. Of 35 children with planned extubation, 5 (14.3%) required reintubation. Baseline median (interquartile range [IQR]) DTe, DTi, and DTF were 1.27 mm (1, 1.6), 1.76 mm (1.35, 2.10), and 33.75% (26.90, 44.60), respectively. There was a significant reduction in DTe over the first week of mechanical ventilation (p < .001), median (IQR) diaphragmatic atrophy and atrophy rate of 9.91% (5.26, 17.35) and 2.01% (1.08, 3.04) per day, respectively. Diaphragmatic atrophy rate was lower in pressure targeted ventilation (n = 44; 1.79% [1.03, 2.87]) than volume targeted ventilation (n = 11; 3.10% [1.31, 5.49]), p = .038. There was no difference in diaphragmatic parameters (atrophy rate, and peri-extubation DTe and DTF) in extubation success versus failure. CONCLUSIONS The diaphragm undergoes progressive atrophy during the first week of mechanical ventilation in critically ill children. Future studies should evaluate ventilation strategies to reduce the diaphragmatic atrophy.
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Affiliation(s)
- Sabyasachi Mistri
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Nitin Dhochak
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Kana R Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sushil K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Fiorelli S, Leopizzi G, Menna C, Teodonio L, Ibrahim M, Rendina EA, Ricci A, De Blasi RA, Rocco M, Massullo D. Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2020; 34:2421-2429. [DOI: 10.1053/j.jvca.2020.01.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/11/2020] [Accepted: 01/14/2020] [Indexed: 11/11/2022]
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13
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Lachmann G, Mörgeli R, Kuenz S, Piper SK, Spies C, Kurpanik M, Weber-Carstens S, Wollersheim T. Perioperatively Acquired Weakness. Anesth Analg 2020; 130:341-351. [PMID: 30855340 DOI: 10.1213/ane.0000000000004068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Skeletal muscle failure in critical illness (intensive care unit-acquired weakness) is a well-known complication developing early during intensive care unit stay. However, muscle weakness during the perioperative setting has not yet been investigated. METHODS We performed a subgroup investigation of a prospective observational trial to investigate perioperative muscle weakness. Eighty-nine patients aged 65 years or older were assessed for handgrip strength preoperatively, on the first postoperative day, at intensive care unit discharge, at hospital discharge, and at 3-month follow-up. Functional status was evaluated perioperatively via Barthel index, instrumental activities of daily living, Timed Up and Go test, and functional independence measure. After exclusion of patients with intensive care unit-acquired weakness or intensive care unit stay of ≥72 hours, 59 patients were included into our analyses. Of these, 14 patients had additional pulmonary function tests preoperatively and on postoperative day 1. Blood glucose was measured intraoperatively every 20 minutes. RESULTS Handgrip strength significantly decreased after surgery on postoperative day 1 by 16.4% (P < .001). Postoperative pulmonary function significantly decreased by 13.1% for vital capacity (P = .022) and 12.6% for forced expiratory volume in 1 second (P = .001) on postoperative day 1. Handgrip strength remained significantly reduced at hospital discharge (P = .016) and at the 3-month follow-up (P = .012). Perioperative glucose levels showed no statistically significant impact on muscle weakness. Instrumental activities of daily living (P < .001) and functional independence measure (P < .001) were decreased at hospital discharge, while instrumental activities of daily living remained decreased at the 3-month follow-up (P = .026) compared to preoperative assessments. CONCLUSIONS Perioperatively acquired weakness occurred, indicated by a postoperatively decreased handgrip strength, decreased respiratory muscle function, and impaired functional status, which partly remained up to 3 months.
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Affiliation(s)
- Gunnar Lachmann
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Rudolf Mörgeli
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophia Kuenz
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie K Piper
- Berlin Institute of Health (BIH), Berlin, Germany.,Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maryam Kurpanik
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Steffen Weber-Carstens
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Tobias Wollersheim
- From the Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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14
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Ataya A, Silverman EP, Bagchi A, Sarwal A, Criner GJ, McDonagh DL. Temporary Transvenous Diaphragmatic Neurostimulation in Prolonged Mechanically Ventilated Patients: A Feasibility Trial (RESCUE 1). Crit Care Explor 2020; 2:e0106. [PMID: 32426748 PMCID: PMC7188416 DOI: 10.1097/cce.0000000000000106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Prolonged mechanical ventilation promotes diaphragmatic atrophy and weaning difficulty. The study uses a novel device containing a transvenous phrenic nerve stimulating catheter (Lungpacer IntraVenous Electrode Catheter) to stimulate the diaphragm in ventilated patients. We set out to determine the feasibility of temporary transvenous diaphragmatic neurostimulation using this device. DESIGN Multicenter, prospective open-label single group feasibility study. SETTING ICUs of tertiary care hospitals. PATIENTS Adults on mechanical ventilation for greater than or equal to 7 days that had failed two weaning trials. INTERVENTIONS Stimulation catheter insertion and transvenous diaphragmatic neurostimulation therapy up to tid, along with standard of care. MEASUREMENTS AND MAIN RESULTS Primary outcomes were successful insertion and removal of the catheter and safe application of transvenous diaphragmatic neurostimulation. Change in maximal inspiratory pressure and rapid shallow breathing index were also evaluated. Eleven patients met all entry criteria with a mean mechanical ventilation duration of 19.7 days; nine underwent successful catheter insertion. All nine had successful mapping of one or both phrenic nerves, demonstrated diaphragmatic contractions during therapy, and underwent successful catheter removal. Seven of nine met successful weaning criteria. Mean maximal inspiratory pressure increased by 105% in those successfully weaned (mean change 19.7 ± 17.9 cm H2O; p = 0.03), while mean rapid shallow breathing index improved by 44% (mean change -63.5 ± 64.4; p = 0.04). CONCLUSIONS The transvenous diaphragmatic neurostimulation system is a feasible and safe therapy to stimulate the phrenic nerves and induce diaphragmatic contractions. Randomized clinical trials are underway to compare it to standard-of-care therapy for mechanical ventilation weaning.
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Affiliation(s)
- Ali Ataya
- Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Erin P Silverman
- Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Aranya Bagchi
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Abstract
BACKGROUND Postoperative diaphragmatic dysfunction after thoracic surgery is underestimated due to the lack of reproducible bedside diagnostic methods. We used point of care ultrasound to assess diaphragmatic function bedside in patients undergoing video-assisted thoracoscopic or thoracotomic lung resection. Our main hypothesis was that the thoracoscopic approach may be associated with lower incidence of postoperative diaphragm dysfunction as compared to thoracotomy. Furthermore, we assessed the association between postoperative diaphragmatic dysfunction and postoperative pulmonary complications. METHODS This was a prospective observational cohort study. Two cohorts of patients were evaluated: those undergoing video-assisted thoracoscopic surgery versus those undergoing thoracotomy. Diaphragmatic dysfunction was defined as a diaphragmatic excursion less than 10 mm. The ultrasound evaluations were carried out before (preoperative) and after (i.e., 2 h and 24 h postoperatively) surgery. The occurrence of postoperative pulmonary complications was assessed up to 7 days after surgery. RESULTS Among the 75 patients enrolled, the incidence of postoperative diaphragmatic dysfunction at 24 h was higher in the thoracotomy group as compared to video-assisted thoracoscopic surgery group (29 of 35, 83% vs. 22 of 40, 55%, respectively; odds ratio = 3.95 [95% CI, 1.5 to 10.3]; P = 0.005). Patients with diaphragmatic dysfunction on the first day after surgery had higher percentage of postoperative pulmonary complications (odds ratio = 5.5 [95% CI, 1.9 to 16.3]; P = 0.001). Radiologically assessed atelectasis was 46% (16 of 35) in the thoracotomy group versus 13% (5 of 40) in the video-assisted thoracoscopic surgery group (P = 0.040). Univariate logistic regression analysis indicated postoperative diaphragmatic dysfunction as a risk factor for postoperative pulmonary complications (odds ratio = 5.5 [95% CI, 1.9 to 16.3]; P = 0.002). CONCLUSIONS Point of care ultrasound can be used to evaluate postoperative diaphragmatic function. On the first postoperative day, diaphragmatic dysfunction was less common after video-assisted than after the thoracotomic surgery and is associated with postoperative pulmonary complications.
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16
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Dres M, Jung B, Molinari N, Manna F, Dubé BP, Chanques G, Similowski T, Jaber S, Demoule A. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:370. [PMID: 31752937 PMCID: PMC6873450 DOI: 10.1186/s13054-019-2650-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 10/16/2019] [Indexed: 01/16/2023]
Abstract
Background Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. Methods Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. Results One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). Conclusion Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.
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Affiliation(s)
- Martin Dres
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Boris Jung
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Medical Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Federico Manna
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Bruno-Pierre Dubé
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Gerald Chanques
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Thomas Similowski
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Samir Jaber
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Alexandre Demoule
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France. .,Service de Pneumologie, Médecine Intensive et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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17
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Dres M, Jung B, Molinari N, Manna F, Dubé BP, Chanques G, Similowski T, Jaber S, Demoule A. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. CRITICAL CARE (LONDON, ENGLAND) 2019. [PMID: 31752937 DOI: 10.1186/s13054-019-2650-z].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. METHODS Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. RESULTS One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). CONCLUSION Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.
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Affiliation(s)
- Martin Dres
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Boris Jung
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Medical Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Federico Manna
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Bruno-Pierre Dubé
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Gerald Chanques
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Thomas Similowski
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Samir Jaber
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Alexandre Demoule
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France. .,Service de Pneumologie, Médecine Intensive et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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18
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Dres M, Jung B, Molinari N, Manna F, Dubé BP, Chanques G, Similowski T, Jaber S, Demoule A. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. CRITICAL CARE (LONDON, ENGLAND) 2019. [PMID: 31752937 DOI: 10.1186/s13054-019-2650-z]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. METHODS Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH2O and ICU-AW was defined as Medical Research Council Score < 48. RESULTS One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). CONCLUSION Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.
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Affiliation(s)
- Martin Dres
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Boris Jung
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Medical Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France
| | - Nicolas Molinari
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Federico Manna
- Department of Statistics, CHU Montpellier, IMAG, CNRS, Univ Montpellier, Montpellier, France
| | - Bruno-Pierre Dubé
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Gerald Chanques
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Thomas Similowski
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France
| | - Samir Jaber
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Alexandre Demoule
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), F-75013, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Intensive Care Unit and Respiratory Division (Département "R3S"), F-75013, Paris, France. .,Service de Pneumologie, Médecine Intensive et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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19
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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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20
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Moury PH, Cuisinier A, Durand M, Bosson JL, Chavanon O, Payen JF, Jaber S, Albaladejo P. Diaphragm thickening in cardiac surgery: a perioperative prospective ultrasound study. Ann Intensive Care 2019; 9:50. [PMID: 31016412 PMCID: PMC6478777 DOI: 10.1186/s13613-019-0521-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background Diaphragm paresis is common after cardiac surgery and may delay the weaning from the ventilator. Our objective was to evaluate diaphragm thickening during weaning and secondly the muscle thickness as a marker of myotrauma. Methods Patients undergoing elective cardiac surgery were prospectively included. Ultrasonic index of right hemidiaphragm thickening fraction (TF) was measured as a surrogate criterion of work of breathing. A TF < 20% was defined as a low diaphragm thickening. Measurements of TF were performed during three periods to study diaphragm thickening evolution defined by the difference between two consecutive time line point: preoperative (D − 1), during a spontaneous breathing trial (SBT) in the intensive care unit and postoperative (D + 1). We studied three patterns of diaphragm thickness at end expiration evolution from D − 1 to D + 1: > 10% decrease, stability and > 10% increase. Demographical data, length of surgery, type of surgery, ICU length of stay (LOS) and extubation failure were collected. Results Of the 100 consecutively included patients, 75 patients had a low diaphragm thickening during SBT. Compared to TF values at D − 1 (36% ± 18), TF was reduced during SBT (17% ± 14) and D + 1 (12% ± 11) (P < 0.0001). Thickness and TF did not change according to the type of surgery or cooling method. TF at SBT was correlated to the length of surgery (both r = − 0.4; P < 0.0001). Diaphragm thickness as continuous variable did not change over time. Twenty-eight patients (42%) had a > 10% decrease thickness, 19 patients (29%) stability and 19 patients (28%) in > 10% increase, and this thickness evolution pattern was associated with: a longer LOS 3 days [2–5] versus 2 days [2–4] and 2 days [2], respectively (ANOVA P = 0.046), and diaphragm thickening evolution (ANOVA P = 0.02). Two patients experience extubation failure. Conclusion These findings indicate that diaphragm thickening is frequently decreased after elective cardiac surgery without impact on respiratory outcome, whereas an altered thickness pattern was associated with a longer length of stay in the ICU. Contractile activity influenced thickness evolution. Trial registry number ClinicalTrial.gov ID NCT02208479 Electronic supplementary material The online version of this article (10.1186/s13613-019-0521-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pierre-Henri Moury
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France.
| | - Adrien Cuisinier
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Michel Durand
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Jean-Luc Bosson
- Department of Biostatistics, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France
| | - Olivier Chavanon
- Department of Cardiac Surgery, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France
| | - Jean-François Payen
- Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Pierre Albaladejo
- Department of Anesthesia and Intensive Care, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France
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Fujimoto S, Nakayama T. Effect of combination of pre- and postoperative pulmonary rehabilitation on onset of postoperative pneumonia: a retrospective cohort study based on data from the diagnosis procedure combination database in Japan. Int J Clin Oncol 2018; 24:211-221. [PMID: 30145745 DOI: 10.1007/s10147-018-1343-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/21/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND To examine the effect of rehabilitation on postoperative pulmonary complication when it is conducted in combination of both before and after lung cancer surgery, as compared with either before or after surgery and no rehabilitation. METHODS A retrospective cohort study was conducted to examine the effect of rehabilitation before and after lung cancer surgery on the causes of postoperative pneumonia. Data were collected from the diagnosis procedure combination (DPC) database. Patients admitted who received operative treatment for a new primary (ICD codes: C34) were selected. The inclusion criteria were patients who had pneumonectomy, malignant tumor surgery for the lung (thoracotomy), or thoracoscopic surgery (endoscopic; treatment code: K511-00, K513-00~03, and K514-00, 02). The exclusion criteria were patients who had a lung transplantation (treatment code: K514-03~06), suspected diagnosis, and a pneumonia within 3 months before being diagnosed as having lung cancer. Main outcome was onset of postoperative pneumonia. RESULTS Among 76,739 lung cancer patients, 15,146 who underwent lung cancer surgery were included in the analysis. In the combination of pre- and postoperative group, as compared with the preoperative [odds ratio (OR), 95% confidence interval (CI) 2.8, 1.8-4.4], postoperative (1.9, 1.6-2.3), and no rehabilitation group (2.5, 2.1-2.8), the onset of pneumonia was less frequent. CONCLUSIONS Combination of preoperative and postoperative rehabilitations significantly prevents postoperative pneumonia as compared with having preoperative, postoperative, or no rehabilitation.
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Affiliation(s)
- Shuhei Fujimoto
- Department of Health Informatics, Graduate School of Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan.
| | - Takeo Nakayama
- Department of Health Informatics, Graduate School of Public Health, Kyoto University, Yoshidakonoe-cho, Sakyo-ku, Kyoto, Kyoto, 606-8501, Japan
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Diaphragm Weakness in the Critically Ill: Basic Mechanisms Reveal Therapeutic Opportunities. Chest 2018; 154:1395-1403. [PMID: 30144420 DOI: 10.1016/j.chest.2018.08.1028] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022] Open
Abstract
The diaphragm is the primary muscle of inspiration. Its capacity to respond to the load imposed by pulmonary disease is a major determining factor both in the onset of ventilatory failure and in the ability to successfully separate patients from ventilator support. It has recently been established that a very large proportion of critically ill patients exhibit major weakness of the diaphragm, which is associated with poor clinical outcomes. The two greatest risk factors for the development of diaphragm weakness in critical illness are the use of mechanical ventilation and the presence of sepsis. Loss of force production by the diaphragm under these conditions is caused by a combination of defective contractility and reduced diaphragm muscle mass. Importantly, many of the same molecular mechanisms are implicated in the diaphragm dysfunction associated with both mechanical ventilation and sepsis. This review outlines the primary cellular mechanisms identified thus far at the nexus of diaphragm dysfunction associated with mechanical ventilation and/or sepsis, and explores the potential for treatment or prevention of diaphragm weakness in critically ill patients through therapeutic manipulation of these final common pathway targets.
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Dres M, Demoule A. Diaphragm dysfunction during weaning from mechanical ventilation: an underestimated phenomenon with clinical implications. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:73. [PMID: 29558983 PMCID: PMC5861656 DOI: 10.1186/s13054-018-1992-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Martin Dres
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ″R3S″), Paris, France.
| | - Alexandre Demoule
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ″R3S″), Paris, France
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Tams CG, Ataya A, Euliano NR, Stephan P, Martin AD, Alnuaimat H, Gabrielli A. Decision support system facilitates rapid decreases in pressure support and appropriate inspiratory muscle workloads in adults with respiratory failure. J Crit Care 2017; 42:213-217. [DOI: 10.1016/j.jcrc.2017.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/30/2017] [Accepted: 07/26/2017] [Indexed: 10/19/2022]
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Karenovics W, Licker M, Ellenberger C, Christodoulou M, Diaper J, Bhatia C, Robert J, Bridevaux PO, Triponez F. Short-term preoperative exercise therapy does not improve long-term outcome after lung cancer surgery: a randomized controlled study†. Eur J Cardiothorac Surg 2017; 52:47-54. [DOI: 10.1093/ejcts/ezx030] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 12/18/2016] [Indexed: 11/13/2022] Open
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Zhu X, van Hees HWH, Heunks L, Wang F, Shao L, Huang J, Shi L, Ma S. The role of calpains in ventilator-induced diaphragm atrophy. Intensive Care Med Exp 2017; 5:14. [PMID: 28290154 PMCID: PMC5348482 DOI: 10.1186/s40635-017-0127-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 02/24/2017] [Indexed: 11/24/2022] Open
Abstract
Background Controlled mechanical ventilation (CMV) is associated with diaphragm dysfunction. Dysfunction results from muscle atrophy and injury of diaphragm muscle fibers. Enhanced proteolysis and reduced protein synthesis play an important role in the development of atrophy. The current study is to evaluate the effects of the calpains inhibitor calpeptin on the development of diaphragm atrophy and activation of key enzymes of the ubiquitin-proteasome pathway in rats under CMV. Methods Three groups of rats were studied: control animals (CON, n = 8), rats subjected to 24 h of MV (CMV, n = 8), and rats subjected to 24 h of MV after administration of the calpain inhibitor calpeptin (CMVC, n = 8). The diaphragm was analyzed for calpain activity, myosin heavy chain (MHC) content, and cross-sectional area (CSA) of diaphragmatic muscle fibers as a marker for muscle atrophy. In addition, key enzymes of the ubiquitin-proteasome pathway (MAFbx and MuRF1) were also studied. Results CMV resulted in loss of both MHCfast and MHCslow. Furthermore, the CSA of diaphragmatic muscle fibers was significantly decreased after 24 h of CMV. However, calpain inhibitor calpeptin prevented loss of MHC and CSA after CMV. In addition, calpeptin prevented the increase in protein expression of calpain1 and calpain2 and reduced calpain activity as indicated by reduced generation of the calpain cleavage product αII-spectrin in the diaphragm. CMV-induced upregulation of both MAFbx and MuRF1 protein levels was attenuated by treatment with calpeptin. Conclusions The calpain inhibitor calpeptin prevents MV-induced muscle atrophy. In addition, calpeptin attenuated the expression of key proteolytic enzymes known to be involved in ventilator-induced diaphragm atrophy, including MAFbx and MuRF1.
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Affiliation(s)
- Xiaoping Zhu
- Department of Pulmonary Diseases, Shanghai East Hospital, Tongji University, Shanghai, 200120, China
| | - Hieronymus W H van Hees
- Department of Pulmonary Diseases, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands
| | - Leo Heunks
- Intensive Care Medicine, Radboud University Medical Centre, Postbox 9101, Nijmegen, 6500 HB, the Netherlands
| | - Feifei Wang
- NingXia Medical University, Yinchuan, 750004, China
| | - Lei Shao
- Department of Pulmonary Diseases, Shanghai East Hospital, Tongji University, Shanghai, 200120, China
| | - Jiaru Huang
- NingXia Medical University, Yinchuan, 750004, China
| | - Lei Shi
- NingXia Medical University, Yinchuan, 750004, China
| | - Shaolin Ma
- Department of Intensive Care Unit, Shanghai East Hospital, Tongji University, Shanghai, 200120, China.
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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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Krüger M, Kötter S. Titin, a Central Mediator for Hypertrophic Signaling, Exercise-Induced Mechanosignaling and Skeletal Muscle Remodeling. Front Physiol 2016; 7:76. [PMID: 26973541 PMCID: PMC4771757 DOI: 10.3389/fphys.2016.00076] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/15/2016] [Indexed: 01/09/2023] Open
Abstract
Titin is a giant scaffold protein with multiple functions in striated muscle physiology. Due to the elastic I-band domains and the filament-like integration in the half-sarcomere titin is an important factor for sarcomere assembly and serves as an adaptable molecular spring that determines myofilament distensibility. Protein-interactions e.g., with muscle ankyrin repeat proteins or muscle LIM-protein link titin to hypertrophic signaling and via p62 and Muscle Ring Finger proteins to mechanisms that control protein quality control. This review summarizes our current knowledge on titin as a central node for exercise-induced mechanosignaling and remodeling and further highlights the pathophysiological implications.
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Affiliation(s)
- Martina Krüger
- Institute of Cardiovascular Physiology, Heinrich Heine University Düsseldorf Düsseldorf, Germany
| | - Sebastian Kötter
- Institute of Cardiovascular Physiology, Heinrich Heine University Düsseldorf Düsseldorf, Germany
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Hooijman PE, Beishuizen A, Witt CC, de Waard MC, Girbes ARJ, Spoelstra-de Man AME, Niessen HWM, Manders E, van Hees HWH, van den Brom CE, Silderhuis V, Lawlor MW, Labeit S, Stienen GJM, Hartemink KJ, Paul MA, Heunks LMA, Ottenheijm CAC. Diaphragm muscle fiber weakness and ubiquitin-proteasome activation in critically ill patients. Am J Respir Crit Care Med 2015; 191:1126-38. [PMID: 25760684 DOI: 10.1164/rccm.201412-2214oc] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
RATIONALE The clinical significance of diaphragm weakness in critically ill patients is evident: it prolongs ventilator dependency, and increases morbidity and duration of hospital stay. To date, the nature of diaphragm weakness and its underlying pathophysiologic mechanisms are poorly understood. OBJECTIVES We hypothesized that diaphragm muscle fibers of mechanically ventilated critically ill patients display atrophy and contractile weakness, and that the ubiquitin-proteasome pathway is activated in the diaphragm. METHODS We obtained diaphragm muscle biopsies from 22 critically ill patients who received mechanical ventilation before surgery and compared these with biopsies obtained from patients during thoracic surgery for resection of a suspected early lung malignancy (control subjects). In a proof-of-concept study in a muscle-specific ring finger protein-1 (MuRF-1) knockout mouse model, we evaluated the role of the ubiquitin-proteasome pathway in the development of contractile weakness during mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Both slow- and fast-twitch diaphragm muscle fibers of critically ill patients had approximately 25% smaller cross-sectional area, and had contractile force reduced by half or more. Markers of the ubiquitin-proteasome pathway were significantly up-regulated in the diaphragm of critically ill patients. Finally, MuRF-1 knockout mice were protected against the development of diaphragm contractile weakness during mechanical ventilation. CONCLUSIONS These findings show that diaphragm muscle fibers of critically ill patients display atrophy and severe contractile weakness, and in the diaphragm of critically ill patients the ubiquitin-proteasome pathway is activated. This study provides rationale for the development of treatment strategies that target the contractility of diaphragm fibers to facilitate weaning.
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Byrne PIBJ, Collins S, Mah CC, Smith B, Conlon T, Martin SD, Corti M, Cleaver B, Islam S, Lawson LA. Phase I/II trial of diaphragm delivery of recombinant adeno-associated virus acid alpha-glucosidase (rAAaV1-CMV-GAA) gene vector in patients with Pompe disease. HUM GENE THER CL DEV 2015; 25:134-63. [PMID: 25238277 DOI: 10.1089/humc.2014.2514] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Ahn B, Beaver T, Martin T, Hess P, Brumback BA, Ahmed S, Smith BK, Leeuwenburgh C, Martin AD, Ferreira LF. Phrenic nerve stimulation increases human diaphragm fiber force after cardiothoracic surgery. Am J Respir Crit Care Med 2015; 190:837-9. [PMID: 25271750 DOI: 10.1164/rccm.201405-0993le] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Bumsoo Ahn
- 1 University of Florida Gainesville, Florida
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Abstract
PURPOSE OF REVIEW Advances in medical care have led to an increasing elderly population. Elderly individuals should be able to participate in society as long as possible. However, with an increasing age their adaptive capacity gradually decreases, specially before and after major life events (like hospitalization and surgery) making them vulnerable to reduced functioning and societal participation. Therapeutic exercise before and after surgery might augment the postoperative outcomes by improving functional status and reducing the complication and mortality rate. RECENT FINDINGS There is high quality evidence that preoperative exercise in patients scheduled for cardiovascular surgery is well tolerated and effective. Moreover, there is circumstantial evidence suggesting preoperative exercise for thoracic, abdominal and major joint replacement surgery is effective, provided that this is offered to the high-risk patients. Postoperative exercise should be initiated as soon as possible after surgery according to fast-track or enhanced recovery after surgery principles. SUMMARY The perioperative exercise training protocol known under the name 'Better in, Better out' could be implemented in clinical care for the vulnerable group of patients scheduled for major elective surgery who are at risk for prolonged hospitalization, complications and/or death. Future research should aim to include this at-risk group, evaluate perioperative high-intensity exercise interventions and conduct adequately powered trials.
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Hooijman PE, Paul MA, Stienen GJM, Beishuizen A, Van Hees HWH, Singhal S, Bashir M, Budak MT, Morgen J, Barsotti RJ, Levine S, Ottenheijm CAC. Unaffected contractility of diaphragm muscle fibers in humans on mechanical ventilation. Am J Physiol Lung Cell Mol Physiol 2014; 307:L460-70. [PMID: 25038190 DOI: 10.1152/ajplung.00076.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Several studies have indicated that diaphragm dysfunction develops in patients on mechanical ventilation (MV). Here, we tested the hypothesis that the contractility of sarcomeres, i.e., the smallest contractile unit in muscle, is affected in humans on MV. To this end, we compared diaphragm muscle fibers of nine brain-dead organ donors (cases) that had been on MV for 26 ± 5 h with diaphragm muscle fibers from nine patients (controls) undergoing surgery for lung cancer that had been on MV for less than 2 h. In each diaphragm specimen we determined 1) muscle fiber cross-sectional area in cryosections by immunohistochemical methods and 2) the contractile performance of permeabilized single muscle fibers by means of maximum specific force, kinetics of cross-bridge cycling by rate of tension redevelopment, myosin heavy chain content and concentration, and calcium sensitivity of force of slow-twitch and fast-twitch muscle fibers. In case subjects, we noted no statistically significant decrease in outcomes compared with controls in slow-twitch or fast-twitch muscle fibers. These observations indicate that 26 h of MV of humans is not invariably associated with changes in the contractile performance of sarcomeres in the diaphragm.
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Affiliation(s)
| | | | - Ger J M Stienen
- Departments of Physiology, Faculty of Science, Department of Physics and Astronomy, Vrije Universiteit, Amsterdam, The Netherlands
| | - Albertus Beishuizen
- Intensive Care, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Hieronymus W H Van Hees
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Muhammad Bashir
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Murat T Budak
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Jacqueline Morgen
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Robert J Barsotti
- Department of Physiology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Sanford Levine
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Gift of Life Donor Program, Philadelphia, Pennsylvania; and
| | - Coen A C Ottenheijm
- Departments of Physiology, Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
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Hooijman PE, Beishuizen A, de Waard MC, de Man FS, Vermeijden JW, Steenvoorde P, Bouwman RA, Lommen W, van Hees HWH, Heunks LMA, Dickhoff C, van der Peet DL, Girbes ARJ, Jasper JR, Malik FI, Stienen GJM, Hartemink KJ, Paul MA, Ottenheijm CAC. Diaphragm fiber strength is reduced in critically ill patients and restored by a troponin activator. Am J Respir Crit Care Med 2014; 189:863-5. [PMID: 24684359 DOI: 10.1164/rccm.201312-2260le] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Laghi F, Shaikh H. Preventing ventilator-induced diaphragmatic dysfunction with phrenic nerve stimulation. Crit Care Med 2014; 42:492-4. [PMID: 24434468 DOI: 10.1097/ccm.0000000000000003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL; and, Division of Pulmonary and Critical Care, Department of Medicine, Loyola University, Maywood, IL Pulmonary and Critical Care Section, Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL
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Effect of intermittent phrenic nerve stimulation during cardiothoracic surgery on mitochondrial respiration in the human diaphragm. Crit Care Med 2014; 42:e152-6. [PMID: 24126442 DOI: 10.1097/ccm.0b013e3182a63fdf] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Recent studies have shown that brief periods of mechanical ventilation in animals and humans can lead to ventilator-induced diaphragmatic dysfunction, which includes muscle atrophy, reduced force development, and impaired mitochondrial function. Studies in animal models have shown that short periods of increased diaphragm activity during mechanical ventilation support can attenuate ventilator-induced diaphragmatic dysfunction but corresponding human data are lacking. The purpose of this study was to examine the effect of intermittent diaphragm contractions during cardiothoracic surgery, including controlled mechanical ventilation, on mitochondrial respiration in the human diaphragm. DESIGN Within subjects repeated measures study. SETTING Operating room in an academic health center. PATIENTS Five subjects undergoing elective cardiothoracic surgery. INTERVENTIONS In patients (age 65.6 ± 6.3 yr) undergoing cardiothoracic surgery, one phrenic nerve was stimulated hourly (30 pulses/min, 1.5 msec duration, 17.0 ± 4.4 mA) during the surgery. Subjects received 3.4 ± 0.6 stimulation bouts during surgery. Thirty minutes following the last stimulation bout, samples of diaphragm muscle were obtained from the anterolateral costal regions of the stimulated and inactive hemidiaphragms. MEASUREMENTS AND MAIN RESULTS Mitochondrial respiration was measured in permeabilized muscle fibers with high-resolution respirometry. State III mitochondrial respiration rates (pmol O2/s/mg wet weight) were 15.05 ± 3.92 and 11.42 ± 2.66 for the stimulated and unstimulated samples, respectively (p < 0.05). State IV mitochondrial respiration rates were 3.59 ± 1.25 and 2.11 ± 0.97 in the stimulated samples and controls samples, respectively (p < 0.05). CONCLUSION These are the first data examining the effect of intermittent contractions on mitochondrial respiration rates in the human diaphragm following surgery/mechanical ventilation. Our results indicate that very brief periods (duty cycle ~1.7%) of activity can improve mitochondrial function in the human diaphragm following surgery/mechanical ventilation.
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Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective. Respir Physiol Neurobiol 2013; 189:377-83. [PMID: 23692928 DOI: 10.1016/j.resp.2013.05.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 11/24/2022]
Abstract
Most patients are easily liberated from mechanical ventilation (MV) following resolution of respiratory failure and a successful trial of spontaneous breathing, but about 25% of patients experience difficult weaning. MV use leads to cellular changes and weakness, which has been linked to weaning difficulties and has been labeled ventilator induced diaphragm dysfunction (VIDD). Aggravating factors in human studies with prolonged weaning include malnutrition, chronic electrolyte abnormalities, hyperglycemia, excessive resistive and elastic loads, corticosteroids, muscle relaxant exposure, sepsis and compromised cardiac function. Numerous animal studies have investigated the effects of MV on diaphragm function. Virtually all these studies have concluded that MV use rapidly leads to VIDD and have identified cellular and molecular mechanisms of VIDD. Molecular and functional studies on the effects of MV on the human diaphragm have largely confirmed the animal results and identified potential treatment strategies. Only recently potential VIDD treatments have been tested in humans, including pharmacologic interventions and diaphragm "training". A limited number of human studies have found that specific diaphragm training can increase respiratory muscle strength in FTW patients and facilitate weaning, but larger, multicenter trials are needed.
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Mans CM, Reeve JC, Gasparini CA, Elkins MR. Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing open cardiothoracic or upper abdominal surgery: protocol for a systematic review. Syst Rev 2012; 1:63. [PMID: 23249730 PMCID: PMC3541345 DOI: 10.1186/2046-4053-1-63] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/26/2012] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In patients undergoing open cardiothoracic and upper abdominal surgery, postoperative pulmonary complications remain an important cause of postoperative morbidity and mortality, impacting upon hospital length of stay and health care resources. Adequate preoperative respiratory muscle strength may help protect against the development of postoperative pulmonary complications and therefore preoperative inspiratory muscle training has been suggested to be of potential value in improving postoperative outcomes. METHODS/DESIGN A systematic search of electronic databases will be undertaken to identify randomized trials of preoperative inspiratory muscle training in patients undergoing elective open cardiothoracic and upper abdominal surgery. From these trials, we will extract available data for a list of predefined outcomes, including postoperative pulmonary complications, hospital length of stay and respiratory muscle strength. We will meta-analyze comparable results where possible, and report a summary of the available pool of evidence. DISCUSSION This review will provide the most comprehensive answer available to the question of whether preoperative inspiratory muscle training is clinically useful in improving postoperative outcomes in patients undergoing cardiothoracic and upper abdominal surgery. It will help inform clinicians working in the surgical arena of the likely effectiveness of instituting preoperative inspiratory muscle training programs to improve postoperative outcomes.
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Affiliation(s)
- Christina M Mans
- Physiotherapy Department, Waikato Hospital, Waikato District Health Board, Hamilton, New Zealand
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Lollo P, Silva L, Batista T, Morato P, Moura C, Cruz A, Faria J, Carneiro E, Amaya-Farfan J. Effects of whey protein and casein plus leucine on diaphragm the mTOR pathway of sedentary, trained rats. Food Res Int 2012. [DOI: 10.1016/j.foodres.2012.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Manders E, de Man FS, Handoko ML, Westerhof N, van Hees HWH, Stienen GJM, Vonk-Noordegraaf A, Ottenheijm CAC. Diaphragm weakness in pulmonary arterial hypertension: role of sarcomeric dysfunction. Am J Physiol Lung Cell Mol Physiol 2012; 303:L1070-8. [PMID: 22962018 DOI: 10.1152/ajplung.00135.2012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We previously demonstrated that diaphragm muscle weakness is present in experimental pulmonary arterial hypertension (PH). However, the nature of this diaphragm weakness is still unknown. Therefore, the aim of this study was to investigate whether changes at the sarcomeric level contribute to diaphragm weakness in PH. For this purpose, in control rats and rats with monocrotaline-induced PH, contractile performance and myosin heavy chain content of demembranated single diaphragm fibers were determined. We observed a reduced maximal tension of 20% (P < 0.05), whereas tension cost was preserved in type 2X and 2B diaphragm fibers in PH compared with control. The reduced maximal tension was associated with a reduction of force generated per half-sarcomeric myosin heavy chain content. Additionally, reduced Ca(2+) sensitivity of force generation was found in type 2X fibers compared with control, which could exacerbate diaphragm muscle weakness at submaximal activation. No changes in maximal tension and Ca(2+) sensitivity of force generation were observed in fibers from the nonrespiratory extensor digitorum longus muscle. Together, these findings indicate that diaphragm weakness in PH is at least partly caused by sarcomeric dysfunction, which appears to be specific for the diaphragm.
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Affiliation(s)
- Emmy Manders
- Department of Pulmonology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
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