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de Lima JCC, Resqueti VR, Marcelino AA, da Fonsêca JDM, Paz AL, Dias FAL, Otto-Yañez M, Fregonezi GAF. Reliability of maximal respiratory nasal pressure tests in healthy young adults. PLoS One 2023; 18:e0287188. [PMID: 38019835 PMCID: PMC10686475 DOI: 10.1371/journal.pone.0287188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Sniff nasal inspiratory (SNIP) and expiratory pressure (SNEP) may complement the assessment of respiratory muscle strength. Thus, specifying their reliability is relevant to improving the clinical consistency of both tests. OBJECTIVE To assess the reliability of SNIP and SNEP in healthy young adults. METHODS This cross-sectional study included self-reported healthy aged 18 to 29 years. SNIP was performed using a plug to occlude one nostril, while SNEP was conducted using a facemask. Participants performed 20 SNIP and SNEP maneuvers with 30-second intervals in between. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimum detectable change (MDC) assessed the reliability of SNIP and SNEP. Analyses were conducted between the highest peak pressure and the first reproducible maneuver in men and women. RESULTS The total sample comprised 32 participants: 16 men and 16 women. The ICC, SEM, and MDC for SNIP maneuvers were 0.994 (95%CI 0.988 to 0.997), 1.820 cmH2O, and 5.043 cmH2O, respectively. For SNEP, these parameters were 0.950 (95%CI 0.897 to 0.976), 6.03 cmH2O, and 16.716 cmH2O. The SNIP and SNEP in men showed ICC of 0.992 (95%CI 0.977 to 0.997) and 0.877 (95%CI 0.648 to 0.957), SEM of 2.07 and 7.66 cmH2O, and MDC of 5.74 and 21.23 cmH2O. In women, SNIP and SNEP presented ICC of 0.992 (95%CI 0.977 to 0.997) and 0.957 (95%CI 0.878 to 0.985), SEM of 1.15 and 6.11 cmH2O, and MDC of 3.19 and 16.95 cmH2O. Also, 60% of the highest SNIPs occurred among the 11th and 20th maneuvers in men and women. In men, 55% of the highest SNEPs occurred among the 11th and 20th maneuvers; this value was 50% in women. CONCLUSION SNIP and SNEP showed excellent reliability. The reliability of SNIP and SNEP in men was good and excellent, respectively, whereas both tests had excellent reliability in women. Also, women reached the highest peak pressure faster than men in both tests.
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Affiliation(s)
- Jackson C. C de Lima
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Departamento de Fisioterapia Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
- Laboratório de Inovação Tecnológica em Reabilitação, Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
| | - Vanessa R. Resqueti
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Departamento de Fisioterapia Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
- Laboratório de Inovação Tecnológica em Reabilitação, Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
| | - Ana Aline Marcelino
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Departamento de Fisioterapia Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
- Laboratório de Inovação Tecnológica em Reabilitação, Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
| | - Jéssica Danielle M. da Fonsêca
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Departamento de Fisioterapia Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
- Laboratório de Inovação Tecnológica em Reabilitação, Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
| | - Ana Lista Paz
- Facultad de Fisioterapia, Universidade da Coruña, A Coruña, España
| | | | | | - Guilherme A. F. Fregonezi
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Departamento de Fisioterapia Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
- Laboratório de Inovação Tecnológica em Reabilitação, Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brasil
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Koco E, Soilemezi E, Sotiriou P, Savvidou S, Tsagourias M, Pnevmatikos I, Matamis D. Ultrasonographic assessment of diaphragmatic contraction and relaxation properties: correlations of diaphragmatic displacement with oesophageal and transdiaphragmatic pressure. BMJ Open Respir Res 2021; 8:8/1/e001006. [PMID: 34556491 PMCID: PMC8461713 DOI: 10.1136/bmjresp-2021-001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/30/2021] [Indexed: 11/06/2022] Open
Abstract
Transdiaphragmatic (Pdi) and oesophageal pressures (Pes) are useful in understanding the pathophysiology of the respiratory system. They provide insight into respiratory drive, intrinsic positive end-expiratory pressure, diaphragmatic fatigue and weaning failure.
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Affiliation(s)
- Entela Koco
- Department of Intensive Care Medicine, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
| | - Eleni Soilemezi
- Department of Intensive Care Medicine, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
| | - Panagiota Sotiriou
- Department of Intensive Care Medicine, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
| | - Savvoula Savvidou
- Department of Intensive Care Medicine, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
| | - Matthew Tsagourias
- Department of Intensive Care Medicine, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
| | - Ioannis Pnevmatikos
- Department of Intensive Care Medicine, Democritus University of Thrace, Komotini, Greece
| | - Dimitrios Matamis
- Department of Intensive Care Medicine, General Hospital of Thessaloniki Papageorgiou, Thessaloniki, Greece
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Tuinman PR, Jonkman AH, Dres M, Shi ZH, Goligher EC, Goffi A, de Korte C, Demoule A, Heunks L. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients-a narrative review. Intensive Care Med 2020; 46:594-605. [PMID: 31938825 PMCID: PMC7103016 DOI: 10.1007/s00134-019-05892-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
Respiratory muscle ultrasound is used to evaluate the anatomy and function of the respiratory muscle pump. It is a safe, repeatable, accurate, and non-invasive bedside technique that can be successfully applied in different settings, including general intensive care and the emergency department. Mastery of this technique allows the intensivist to rapidly diagnose and assess respiratory muscle dysfunction in critically ill patients and in patients with unexplained dyspnea. Furthermore, it can be used to assess patient-ventilator interaction and weaning failure in critically ill patients. This paper provides an overview of the basic and advanced principles underlying respiratory muscle ultrasound with an emphasis on the diaphragm. We review different ultrasound techniques useful for monitoring of the respiratory muscle pump and possible therapeutic consequences. Ideally, respiratory muscle ultrasound is used in conjunction with other components of critical care ultrasound to obtain a comprehensive evaluation of the critically ill patient. We propose the ABCDE-ultrasound approach, a systematic ultrasound evaluation of the heart, lungs and respiratory muscle pump, in patients with weaning failure.
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Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Martin Dres
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Capital Medical University, Beijing Tiantan Hospital, Beijing, 100050, China
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Critical Care Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Critical Care Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Chris de Korte
- Department of Radiology, Radboud UMC, Nijmegen, The Netherlands
| | - Alexandre Demoule
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
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4
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Yu TJ, Liu YC, Chu CM, Hu HC, Kao KC. Effects of theophylline therapy on respiratory muscle strength in patients with prolonged mechanical ventilation: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e13982. [PMID: 30633180 PMCID: PMC6336648 DOI: 10.1097/md.0000000000013982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanical ventilation may cause diaphragm weakness an effect termed ventilator-induced diaphragm dysfunction (VIDD). The prevalence of VIDD among patients receiving mechanical ventilation is very high, with the degree of diaphragmatic atrophy being associated with the length of mechanical ventilation. Theophylline is known to increase diaphragmatic contractility and reduce fatigue, so in this study, we evaluated the effect of theophylline in patients with prolonged mechanical ventilation.Patients who depended on mechanical ventilation were included in the study. We compared the maximum inspiratory pressure (PImax) values, rapid shallow breathing index (RSBI) values, and successful weaning rates of theophylline-treated and non-theophylline-treated patients.Eighty-four patients received theophylline and 76 patients did not. These 2 groups' clinical characteristics, including their PImax and RSBI at initial admission, were similar. The results showed that the theophylline-treated group had significantly better PImax and RSBI, with a higher last PImax (30.1 ± 9.7 cmH2O vs 26.9 ± 9.1 cmH2O; P = .034) and lower last RSBI (107.0 ± 68.4 vs 131.4 ± 77.7; P = .036). The improvements to each respective patient's PImax and RSBI were also significantly higher in the theophylline-treated group (PImax: 20.1 ± 5.7% vs 3.2 ± 1.1%, P = .005; RSBI: 11.2 ± 3.0% vs 2.7 ± 1.6%, P = .015). The weaning success rate of the theophylline-treated group was also higher, but not significantly so.Theophylline might improve respiratory muscle strength in patients with prolonged mechanical ventilation and it needs further prospective studies to confirm.
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Affiliation(s)
- Teng-Jen Yu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Memorial Hospital, Keelung
| | - Yu-Chih Liu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Memorial Hospital, Keelung
| | - Chien-Min Chu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Memorial Hospital, Keelung
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang-Gung Memorial Hospital
- Department of Respiratory Therapy, Chang-Gung University, Taoyuan, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang-Gung Memorial Hospital
- Department of Respiratory Therapy, Chang-Gung University, Taoyuan, Taiwan
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5
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Sarmento A, Aliverti A, Marques L, Pennati F, Dourado-Júnior ME, Fregonezi G, Resqueti V. Multiparametric Analysis of Sniff Nasal Inspiratory Pressure Test in Middle Stage Amyotrophic Lateral Sclerosis. Front Neurol 2018; 9:306. [PMID: 29770120 PMCID: PMC5940741 DOI: 10.3389/fneur.2018.00306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/18/2018] [Indexed: 11/24/2022] Open
Abstract
The relaxation rates and contractile properties of inspiratory muscles are altered with inspiratory muscle weakness and fatigue. This fact plays an important role in neuromuscular disorders patients and had never been extensively studied in amyotrophic lateral sclerosis (ALS). In this cross-sectional study, these parameters were investigated non-invasively through nasal inspiratory sniff pressure test (SNIP) in 39 middle stage spinal onset ALS subjects and compared with 39 healthy controls. ALS patients were also divided into three subgroups according to a decline in their percentage of predicted forced vital capacity (FVC%pred) as well as a decline in the ALS functional rating scale score and its respiratory subscore (R-subscore) in order to determine the best parameter linked to early respiratory muscle weakness. When compared with healthy subjects, middle stage ALS subjects exhibited a significantly lower (p < 0.0001) maximum relaxation rate and maximum rate of pressure development (MRPD), as well as a significantly higher (p < 0.0001) tau (τ), contraction time, and half-relaxation time. The results from receiver operating characteristic curves showed that MRPD (AUC 0.735, p < 0.001) and FVC%pred (AUC 0.749, p = 0.009) were the best discriminator parameters between ALS patients with ≤30 and >30 points in the ALS functional rating scale. In addition, 1/2RT (AUC 0.720, p = 0.01), FVC%pred (AUC 0.700, p = 0.03), τ (AUC 0.824, p < 0.0001), and MRPD (AUC 0.721, p = 0.01) were the parameters more sensitive in detecting a fall of three points in the R-subscore. On the other hand, MRPD (AUC 0.781, p < 0.001), τ (AUC 0.794, p = 0.0001), and percentage of predicted of SNIP (AUC 0.769, p = 0.002) were the parameters able to detect a fall in 30% of the FVC%pred in middle stage ALS patients. The contractile properties and relaxation rates of the diaphragm are altered in middle stage spinal onset ALS when compared with healthy subjects. These parameters are able to discriminate between those middle stage ALS subjects with early decline in inspiratory muscle function and those who not.
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Affiliation(s)
- Antonio Sarmento
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Layana Marques
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Mario Emílio Dourado-Júnior
- Ambulatório de Neurologia, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Medicina Integrada, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Guilherme Fregonezi
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Vanessa Resqueti
- PneumoCardioVascular Laboratory, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH), Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
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6
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Dassios T, Kaltsogianni O, Dixon P, Greenough A. Effect of maturity and infection on the rate of relaxation of the respiratory muscles in ventilated, newborn infants. Acta Paediatr 2018; 107:587-592. [PMID: 29243318 DOI: 10.1111/apa.14188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/08/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022]
Abstract
AIM To assess the respiratory muscle time constant of relaxation (τ), an index of respiratory muscle function in ventilated newborns. METHODS Sixty-two infants (42 born prematurely) with a median gestational age of 29 [interquartile range (IQR) 26-37] weeks were prospectively studied. Measurement of τ was taken during spontaneous breathing on endotracheal continuous positive airway pressure prior to extubation, and τ was calculated from the reciprocal of the slope of the airway pressure decline versus time. Infants were classified as having had systemic or respiratory infection (positive microbiology) if they had any positive bacterial blood or respiratory culture prior to measurement. RESULTS Measurement of τ was taken at a median post-natal age of 6 (IQR 3-29) days. The median τ was higher in premature infants [17.4 (IQR 7.7-28.3) sec/cmH2 O] compared to term infants [6.8 (IQR 4.4-8.7) sec/cmH2 O, p < 0.001]. The median τ was higher in infants who had had positive microbiology [17.6 (IQR 9.9-29.1) sec/cmH2 O] compared to infants with negative microbiology [8.0 (IQR 6.3-17.9) sec/cmH2 O, p = 0.034]. τ was related to gestational age (r = -0.265, p = 0.003) and weight at measurement (r = -0.269, p = 0.002). CONCLUSION Respiratory muscle function in ventilated newborns is negatively affected by prematurity and previous systemic or respiratory infection.
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Affiliation(s)
- Theodore Dassios
- Neonatal Intensive Care Centre; King's College Hospital NHS Foundation Trust; London UK
| | - Ourania Kaltsogianni
- Neonatal Intensive Care Centre; King's College Hospital NHS Foundation Trust; London UK
| | | | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology; MRC & Asthma UK Centre in Allergic Mechanisms of Asthma; King's College London; London UK
- NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust and King's College London; London UK
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7
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Loizou CP, Matamis D, Minas G, Kyprianou T, Loizou CD, Soilemezi E, Kotco E, Pattichis CS. A New Method for Diaphragmatic Maximum Relaxation Rate Ultrasonographic Measurement in the Assessment of Patients With Diaphragmatic Dysfunction. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2018; 6:2700710. [PMID: 30405977 PMCID: PMC6204329 DOI: 10.1109/jtehm.2018.2868671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/05/2018] [Accepted: 08/29/2018] [Indexed: 11/30/2022]
Abstract
Measurements of ultrasound diaphragmatic motion, amplitude, force, and velocity of contraction may provide important and essential information about diaphragmatic fatigue, weakness, or paralysis. In this paper, we propose and evaluate a semi-automated analysis system for measuring the diaphragmatic motion and estimating the maximum relaxation rate (MRR_SAUS) from ultrasound M-mode images of the diaphragmatic muscle. The system was evaluated on 27 M-mode ultrasound images of the diaphragmatic muscle [20 with no resistance (NRES) and 7 with resistance (RES)]. We computed semi-automated ultrasound MRR measurements on all NRES/RES images, using the proposed system (MRR_SAUS = 3.94 ± 0.91/4.98 ± 1.98 [1/s]), and compared them with the manual measurements made by a clinical expert (MRR_MUS = 2.36 ± 1.19/5.8 ± 2.1 [1/s],) and those made by a reference manual method (MRR_MB = 3.93 ± 0.89/3.73 ± 0.52 [1/sec], performed manually with the Biopac system. MRR_SAUS and MRR_MB measurements were not statistically significantly different for NRES and RES subjects but were significantly different with the MRR-MUS measurements made by the clinical expert. It is anticipated that the proposed system might be used in the future in the clinical practice in the assessment and follow up of patients with diaphragmatic weakness or paralysis. It may thus potentially help to understand post-operative pulmonary dysfunction or weaning failure from mechanical ventilation. Further validation and additional experimentation in a larger sample of images and different patient groups is required for further validating the proposed system.
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Kim WY, Park SH, Kim WY, Huh JW, Hong SB, Koh Y, Lim CM. Effect of theophylline on ventilator-induced diaphragmatic dysfunction. J Crit Care 2016; 33:145-50. [PMID: 26948253 DOI: 10.1016/j.jcrc.2016.01.007] [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: 07/18/2015] [Revised: 11/13/2015] [Accepted: 01/06/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the effect of theophylline in patients with ventilator-induced diaphragmatic dysfunction (VIDD). MATERIALS AND METHODS Patients who required mechanical ventilation at least 72 hours, met the criteria for a spontaneous breathing trial, and had evidence of VIDD by ultrasonography were included in the study. RESULTS Of the 40 patients, 21 received theophylline and 19 did not. Clinical characteristics were similar in the 2 groups. Assessment of VIDD showed no between-group differences in baseline diaphragmatic excursion (DE) of both hemidiaphragms. Changes in DE from baseline to 72 hours (ΔDE) were significantly higher in the theophylline group than in the nontheophylline group in the right (3.5 ± 4.5 mm vs 0.4 ± 2.1 mm; P = .004) and left (3.2 ± 5.1 mm vs 0.1 ± 4.0 mm; P = .03) hemidiaphragms and in the total DE of both diaphragms (6.9 ± 9.1 mm vs 0.5 ± 5.7 mm; P = .02). In the theophylline group, theophylline was effective for the diaphragms with VIDD, whereas it was not effective for the diaphragms without VIDD. ΔDE in the right (rs = -0.49, P = .006) hemidiaphragm and total Δ DE in both diaphragms (rs = -0.46, P = .01) correlated negatively with weaning time. CONCLUSIONS Theophylline significantly improved diaphragmatic movements in patients with VIDD. Our results warrant a larger study to determine whether theophylline use has benefits during weaning from mechanical ventilation.
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Affiliation(s)
- Won-Young Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.
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Benício K, Dias FAL, Gualdi LP, Aliverti A, Resqueti VR, Fregonezi GAF. Effects of diaphragmatic control on the assessment of sniff nasal inspiratory pressure and maximum relaxation rate. Braz J Phys Ther 2015; 20:96-103. [PMID: 26578254 PMCID: PMC4835170 DOI: 10.1590/bjpt-rbf.2014.0101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/17/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To assess the influence of diaphragmatic activation control (diaphC) on Sniff
Nasal-Inspiratory Pressure (SNIP) and Maximum Relaxation Rate of inspiratory
muscles (MRR) in healthy subjects. METHOD: Twenty subjects (9 male; age: 23 (SD=2.9) years; BMI: 23.8 (SD=3)
kg/m2; FEV1/FVC: 0.9 (SD=0.1)] performed 5 sniff maneuvers
in two different moments: with or without instruction on diaphC. Before the first
maneuver, a brief explanation was given to the subjects on how to perform the
sniff test. For sniff test with diaphC, subjects were instructed to perform
intense diaphragm activation. The best SNIP and MRR values were used for analysis.
MRR was calculated as the ratio of first derivative of pressure over time
(dP/dtmax) and were normalized by dividing it by peak pressure
(SNIP) from the same maneuver. RESULTS: SNIP values were significantly different in maneuvers with and without diaphC
[without diaphC: -100 (SD=27.1) cmH2O/ with diaphC: -72.8 (SD=22.3)
cmH2O; p<0.0001], normalized MRR values were not statistically
different [without diaphC: -9.7 (SD=2.6); with diaphC: -8.9 (SD=1.5); p=0.19].
Without diaphC, 40% of the sample did not reach the appropriate sniff criteria
found in the literature. CONCLUSION: Diaphragmatic control performed during SNIP test influences obtained inspiratory
pressure, being lower when diaphC is performed. However, there was no influence on
normalized MRR.
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Affiliation(s)
- Kadja Benício
- Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Fernando A L Dias
- Departamento de Fisiologia, Universidade Federal do Paraná, Curitiba, PR, Brazil
| | - Lucien P Gualdi
- Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico Di Milano, Milano, Italy
| | - Vanessa R Resqueti
- Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Guilherme A F Fregonezi
- Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
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10
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Muttini S, Villani PG, Trimarco R, Bellani G, Grasselli G, Patroniti N. Relation between peak and integral of the diaphragm electromyographic activity at different levels of support during weaning from mechanical ventilation: A physiologic study. J Crit Care 2015; 30:7-12. [DOI: 10.1016/j.jcrc.2014.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 08/06/2014] [Accepted: 08/23/2014] [Indexed: 11/16/2022]
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Laghi F, D’Alfonso N, Tobin MJ. A paper on the pace of recovery from diaphragmatic fatigue and its unexpected dividends. Intensive Care Med 2014; 40:1220-6. [DOI: 10.1007/s00134-014-3340-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/12/2014] [Indexed: 11/30/2022]
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Tobin MJ, Laghi F, Jubran A. Ventilatory failure, ventilator support, and ventilator weaning. Compr Physiol 2013; 2:2871-921. [PMID: 23720268 DOI: 10.1002/cphy.c110030] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The development of acute ventilatory failure represents an inability of the respiratory control system to maintain a level of respiratory motor output to cope with the metabolic demands of the body. The level of respiratory motor output is also the main determinant of the degree of respiratory distress experienced by such patients. As ventilatory failure progresses and patient distress increases, mechanical ventilation is instituted to help the respiratory muscles cope with the heightened workload. While a patient is connected to a ventilator, a physician's ability to align the rhythm of the machine with the rhythm of the patient's respiratory centers becomes the primary determinant of the level of rest accorded to the respiratory muscles. Problems of alignment are manifested as failure to trigger, double triggering, an inflationary gas-flow that fails to match inspiratory demands, and an inflation phase that persists after a patient's respiratory centers have switched to expiration. With recovery from disorders that precipitated the initial bout of acute ventilatory failure, attempts are made to discontinue the ventilator (weaning). About 20% of weaning attempts fail, ultimately, because the respiratory controller is unable to sustain ventilation and this failure is signaled by development of rapid shallow breathing. Substantial advances in the medical management of acute ventilatory failure that requires ventilator assistance are most likely to result from research yielding novel insights into the operation of the respiratory control system.
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Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, Illinois, USA.
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Bortezomib partially protects the rat diaphragm from ventilator-induced diaphragm dysfunction. Crit Care Med 2012; 40:2449-55. [PMID: 22809912 DOI: 10.1097/ccm.0b013e3182553a88] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Controlled mechanical ventilation leads to diaphragmatic contractile dysfunction and atrophy. Since proteolysis is enhanced in the diaphragm during controlled mechanical ventilation, we examined whether the administration of a proteasome inhibitor, bortezomib, would have a protective effect against ventilator-induced diaphragm dysfunction. DESIGN Randomized, controlled experiment. SETTINGS Basic science animal laboratory. INTERVENTIONS Anesthetized rats were submitted for 24 hrs to controlled mechanical ventilation while receiving 0.05 mg/kg bortezomib or saline. Control rats were acutely anesthetized. MEASUREMENTS AND MAIN RESULTS After 24 hrs, diaphragm force production was significantly lower in mechanically ventilated animals receiving an injection of saline compared to control animals (-36%, p<.001). Importantly, administration of bortezomib improved the diaphragmatic force compared to mechanically ventilated animals receiving an injection of saline (+15%, p<.01), but force did not return to control levels. Compared to control animals, diaphragm cross-sectional area of the type IIx/b fibers was significantly decreased by 28% in mechanically ventilated animals receiving an injection of saline (p<.01) and by 16% in mechanically ventilated animals receiving an injection of bortezomib (p<.05). Diaphragmatic calpain activity was significantly increased in mechanically ventilated animals receiving an injection of saline (+52%, p<.05) and in mechanically ventilated animals receiving an injection of bortezomib (+36%, p<.05). Caspase-3 activity was increased after controlled mechanical ventilation with saline by 55% (p<.05), while it remained similar to control animals in mechanically ventilated animals receiving an injection of bortezomib. Diaphragm 20S proteasome activity was slightly increased in both ventilated groups, and the amount of ubiquitinated proteins was significantly and similarly enhanced in mechanically ventilated animals receiving an injection of saline and mechanically ventilated animals receiving an injection of bortezomib. CONCLUSIONS These data show that the administration of bortezomib partially protects the diaphragm from controlled mechanical ventilation-induced diaphragm contractile dysfunction without preventing atrophy. The fact that calpain activity was still increased after bortezomib treatment may explain the persistence of atrophy. Part of bortezomib effects might have been due to its ability to inhibit caspase-3 in this model.
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Liu L, Liu H, Yang Y, Huang Y, Liu S, Beck J, Slutsky AS, Sinderby C, Qiu H. Neuroventilatory efficiency and extubation readiness in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R143. [PMID: 22849707 PMCID: PMC3580730 DOI: 10.1186/cc11451] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 07/31/2012] [Indexed: 12/28/2022]
Abstract
Introduction Based on the hypothesis that failure of weaning from mechanical ventilation is caused by respiratory demand exceeding the capacity of the respiratory muscles, we evaluated whether extubation failure could be characterized by increased respiratory drive and impaired efficiency to generate inspiratory pressure and ventilation. Methods Airway pressure, flow, volume, breathing frequency, and diaphragm electrical activity were measured in a heterogeneous group of patients deemed ready for a spontaneous breathing trial. Efficiency to convert neuromuscular activity into inspiratory pressure was calculated as the ratio of negative airway pressure and diaphragm electrical activity during an inspiratory occlusion. Efficiency to convert neuromuscular activity into volume was calculated as the ratio of the tidal volume to diaphragm electrical activity. All variables were obtained during a 30-minute spontaneous breathing trial on continuous positive airway pressure (CPAP) of 5 cm H2O and compared between patients for whom extubation succeeded with those for whom either the spontaneous breathing trial failed or for those who passed, but then the extubation failed. Results Of 52 patients enrolled in the study, 35 (67.3%) were successfully extubated, and 17 (32.7%) were not. Patients for whom it failed had higher diaphragm electrical activity (48%; P < 0.001) and a lower efficiency to convert neuromuscular activity into inspiratory pressure and tidal volume (40% (P < 0.001) and 53% (P < 0.001)), respectively. Neuroventilatory efficiency demonstrated the greatest predictability for weaning success. Conclusions This study shows that a mixed group of critically ill patients for whom weaning fails have increased neural respiratory drive and impaired ability to convert neuromuscular activity into tidal ventilation, in part because of diaphragm weakness. Trial Registration Clinicaltrials.gov identifier NCT01065428. ©2012 Liu et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Su KC, Tsai CC, Chou KT, Lu CC, Liu YY, Chen CS, Wu YC, Lee YC, Perng DW. Spontaneous breathing trial needs to be prolonged in critically ill and older patients requiring mechanical ventilation. J Crit Care 2011; 27:324.e1-7. [PMID: 21798702 DOI: 10.1016/j.jcrc.2011.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/31/2011] [Accepted: 06/09/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate a modified weaning procedure to predict extubation outcome in critically older and ventilated patients. METHODS We retrospectively analyzed extubation outcome in older (≥ 70 years) and ventilated patients. In period I (2007), patients passing a 2-hour spontaneous breathing trial (SBT) were extubated. In period II (2008), patients underwent an 8-hour SBT on day 1 and a 2-hour SBT, followed by extubation on day 2. Weaning parameters were recorded at baseline (T(0)) (periods I and II), 2 and 8 (T(8)) hours after SBT (period II). RESULTS The demographic data of patients in each period (n = 64 and 67, respectively) were similar. Patients in period II demonstrated a higher rate of SBT failure but a significantly lower rate of extubation failure and reintubation mortality. In period II, successfully extubated patients demonstrated a significantly lower value of rapid shallow breathing index (RSBI) at T(8). The ratio of RSBI at T(8) over T(0) (T(8)/T(0) ≤ 1.4) demonstrated good diagnostic value (sensitivity 89.5%, specificity 80.0%, accuracy 88.4%) in predicting successful extubation. CONCLUSIONS For critically older and ventilated patients, a prolonged SBT in conjunction with evolution of the RSBI ratio over baseline during SBT may serve as a useful procedure to predict extubation outcome.
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Affiliation(s)
- Kang-Cheng Su
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei City, 112 Taiwan
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16
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Abstract
OBJECTIVE To review current knowledge about the impact of prolonged mechanical ventilation on diaphragmatic function and biology. MEASUREMENTS Systematic literature review. CONCLUSIONS Prolonged mechanical ventilation can promote diaphragmatic atrophy and contractile dysfunction. As few as 18 hrs of mechanical ventilation results in diaphragmatic atrophy in both laboratory animals and humans. Prolonged mechanical ventilation is also associated with diaphragmatic contractile dysfunction. Studies using animal models revealed that mechanical ventilation-induced diaphragmatic atrophy is due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, and the ubiquitin-proteasome system as key proteases that contribute to mechanical ventilation-induced diaphragmatic proteolysis. The scientific challenge for the future is to delineate the mechanical ventilation-induced signaling pathways that activate these proteases and depress protein synthesis in the diaphragm. Future investigations that define the signaling mechanisms responsible for mechanical ventilation-induced diaphragmatic weakness will provide the knowledge required for the development of new medicines that can maintain diaphragmatic mass and function during prolonged mechanical ventilation.
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Tobin MJ, Laghi F, Brochard L. Role of the respiratory muscles in acute respiratory failure of COPD: lessons from weaning failure. J Appl Physiol (1985) 2009; 107:962-70. [PMID: 19407256 DOI: 10.1152/japplphysiol.00165.2009] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
It is problematic to withhold therapy in a patient with chronic obstructive pulmonary disease (COPD) who presents with acute respiratory failure so that detailed physiological measurements can be obtained. Accordingly, most information on respiratory muscle activity in patients experiencing acute respiratory failure has been acquired by studying patients who fail a trial of weaning after a period of mechanical ventilation. Such patients experience marked increases in inspiratory muscle load consequent to increases in resistance, elastance, and intrinsic positive end-expiratory pressure. Inspiratory muscle strength is reduced secondary to hyperinflation and possibly direct muscle damage and the release of inflammatory mediators. Most patients recruit both their sternomastoid and expiratory muscles, even though airflow limitation prevents the expiratory muscles from lowering lung volume. Even when acute hypercapnia is present, patients do not exhibit respiratory center depression; indeed, voluntary activation of the diaphragm, in absolute terms, is greater in hypercapnic patients than in normocapnic patients. Instead, the major mechanism of acute hypercapnia is the development of rapid shallow breathing. Despite the marked increase in mechanical load and decreased force-generating capacity of the inspiratory muscles, patients do not develop long-lasting muscle fatigue, at least over the period of a failed weaning trial. Although the disease originates within the lung parenchyma, much of the distress faced by patients with COPD, especially during acute respiratory failure, is caused by the burdens imposed on the respiratory muscles.
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Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. VA Hospital, Hines, Illinois 60141, USA.
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Solsona JF, Díaz Y, Vázquez A, Pilar Gracia M, Zapatero A, Marrugat J. A pilot study of a new test to predict extubation failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R56. [PMID: 19366440 PMCID: PMC2689503 DOI: 10.1186/cc7783] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 02/19/2009] [Accepted: 04/14/2009] [Indexed: 11/16/2022]
Abstract
Introduction To determine whether subjecting patients to 100 ml of additional dead space after a 120-minute weaning trial could predict readiness for extubation. Methods This was a prospective, non-randomised pilot study in an intensive care unit at a university hospital with 14 beds. It included all non-tracheostomised patients with improvement of the underlying cause of acute respiratory failure, and those with no need for vasoactive or sedative drugs were eligible. Patients fulfilling the Consensus Conference on Weaning extubation criteria after 120 minutes spontaneous breathing (n = 152) were included. To the endotracheal tube, 100 cc dead space was added for 30 minutes. Patients tolerating the test were extubated; those not tolerating it received six hours of supplementary ventilation before extubation. The measurements taken and main results were: arterial pressure, heart rate, respiratory rate, oxygen saturation, end-tidal carbon dioxide and signs of respiratory insufficiency were recorded every five minutes; and arterial blood gases were measured at the beginning and end of the test. Extubation failure was defined as the need for mechanical and non-invasive ventilation within 48 hours of extubation. Results Twenty-two patients (14.5%) experienced extubation failure. Only intercostal retraction was independently associated with extubation failure. The sensitivity (40.9%) and specificity (97.7%) yield a probability of extubation failure of 75.1% for patients not tolerating the test versus 9.3% for those tolerating it. Conclusions Observing intercostal retraction after adding dead space may help detect susceptibility to extubation failure. The ideal amount of dead space remains to be determined. Trial registration Current Controlled Trials ISRCTN76206152.
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Affiliation(s)
- José F Solsona
- ICU Hospital de Mar, Paseo Maritimo 25-29 Barcelona 08003, Spain.
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Hypoventilation and Respiratory Muscle Dysfunction. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50043-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Testelmans D, Maes K, Wouters P, Gosselin N, Deruisseau K, Powers S, Sciot R, Decramer M, Gayan-Ramirez G. Rocuronium exacerbates mechanical ventilation-induced diaphragm dysfunction in rats. Crit Care Med 2006; 34:3018-23. [PMID: 17012910 DOI: 10.1097/01.ccm.0000245783.28478.ad] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Nondepolarizing neuromuscular blocking agents are commonly used in the intensive care setting, but they have occasionally been associated with development of myopathy. In addition, diaphragmatic atrophy and a reduction in diaphragmatic force were reported after short-term controlled mechanical ventilation in animal models. We hypothesized that infusion of rocuronium, an aminosteroidal neuromuscular blocking agent, during 24 hrs of controlled mechanical ventilation would further alter diaphragm function and would enhance activation of the ubiquitin- proteasome pathway. DESIGN Randomized, controlled experiment. SETTING Basic animal science laboratory. SUBJECTS Male Wistar rats, 14 wks old. INTERVENTIONS Rats were divided into four groups: a control group, a group of anesthetized rats breathing spontaneously for 24 hrs, and two groups submitted to mechanical ventilation for 24 hrs, receiving a continuous infusion of either 0.9% NaCl or rocuronium. MEASUREMENTS AND MAIN RESULTS In vitro diaphragm force was decreased more significantly after 24 hrs of mechanical ventilation combined with rocuronium infusion than after mechanical ventilation alone (e.g., tetanic force, -27%; p < .001 vs. mechanical ventilation). Similarly, the decrease in diaphragm type IIx/b fiber dimensions was more pronounced after mechanical ventilation with rocuronium treatment than with saline treatment (-38% and -29%, respectively; p < .001 vs. control). Diaphragm hydroperoxide levels increased similarly in both mechanically ventilated groups. Diaphragm muscle RING-finger protein-1 (MURF-1) messenger RNA expression, an E3 ligase of the ubiquitin-proteasome pathway, increased after mechanical ventilation (+212%, p < .001 vs. control) and increased further with combination of rocuronium (+320%, p < .001 vs. control). Significant correlations were found between expression of MURF-1 messenger RNA, diaphragm force, and type IIx/b fiber dimensions. CONCLUSIONS Infusion of rocuronium during controlled mechanical ventilation leads to further deterioration of diaphragm function, additional atrophy of type IIx/b fibers, and an increase in MURF-1 messenger RNA in the diaphragm, which suggests an activation of the ubiquitin-proteasome pathway. These findings could be important with regard to weaning failure in patients receiving this drug for prolonged periods in the intensive care unit setting.
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Affiliation(s)
- Dries Testelmans
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, Leuven, Belgium
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Tanios MA, Nevins ML, Hendra KP, Cardinal P, Allan JE, Naumova EN, Epstein SK. A randomized, controlled trial of the role of weaning predictors in clinical decision making. Crit Care Med 2006; 34:2530-5. [PMID: 16878032 DOI: 10.1097/01.ccm.0000236546.98861.25] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Weaning predictors are often incorporated in protocols to predict weaning outcome for patients on mechanical ventilation. The predictors are used as a decision point in protocols to determine whether a patient may advance to a spontaneous breathing trial. The impact of including predictors in a weaning protocol has not been previously studied. We designed a study to determine the effect of including a weaning predictor (frequency-tidal volume ratio, or f/Vt) in a weaning protocol. DESIGN Randomized, blinded controlled trial. SETTING Academic teaching hospitals. PATIENTS Three hundred and four patients admitted to intensive care units at three academic teaching hospitals. INTERVENTIONS Patients were screened daily for measures of oxygenation, cough and secretions, adequate mental status, and hemodynamic stability. Patients were randomized to two groups; in one group the f/Vt was measured but not used in the decision to wean (n = 151), but in the other group, f/Vt was measured and used, using a threshold of 105 breaths/min/L (n = 153). Patients passing the screen received a 2-hr spontaneous breathing trial. Patients passing the spontaneous breathing trial were eligible for an extubation attempt. MEASUREMENTS AND MAIN RESULTS Groups were similar with regard to gender, age, and Acute Physiology and Chronic Health Evaluation II score. The median duration for weaning time was significantly shorter in the group where the weaning predictor was not used (2.0 vs. 3.0 days, p = .04). There was no difference with regard to the extubation failure, in-hospital mortality rate, tracheostomy, or unplanned extubation. CONCLUSIONS Including a weaning predictor (f/Vt) in a protocol prolonged weaning time. In addition, the predictor did not confer survival benefit or reduce the incidence of extubation failure or tracheostomy. The results of this study indicate that f/Vt should not be used routinely in weaning decision making.
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Affiliation(s)
- Maged A Tanios
- UCLA School of Medicine, Pulmonary and Critical Care Medicine, St. Mary Medical Center Long Beach, California and Long Beach Memorial Medical Center, Long Beach, CA, USA
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Tobin MJ. Remembrance of weaning past: the seminal papers. Intensive Care Med 2006; 32:1485-93. [PMID: 16896845 DOI: 10.1007/s00134-006-0338-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 07/24/2006] [Indexed: 10/24/2022]
Abstract
The approach to ventilator weaning has changed considerably over the past 30 years. Change has resulted from research in three areas: pathophysiology, weaning-predictor testing, and weaning techniques. Physiology research illuminated the mechanisms of weaning failure. It also uncovered markers of weaning success. Through more reliable prediction, patients whose weaning would have been tedious in the 1970s are now weaned more rapidly. The weaning story offers several lessons in metascience: importance of creativity, the asking of heretical questions, serendipity, mental-set psychology, cross-fertilization, and the hazards of precocity. Weaning research also illustrates how Kuhnian normal (me-too) science dominates any field. Making the next quantum leap in weaning will depend on spending less time on normal science and more on the raising (and testing) of maverick ideas.
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Affiliation(s)
- Martin J Tobin
- Loyola University of Chicago Stritch School of Medicine, Edward Hines Jr. VA Hospital, Division of Pulmonary and Critical Care Medicine, 111N, 5th Avenue and Roosevelt Road, Hines, Illinois 601451, USA,
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Shahrizaila N, Lim WS, Robson DK, Kinnear WJ, Wills AJ. Tubular aggregate myopathy presenting with acute type II respiratory failure and severe orthopnoea. Thorax 2006; 61:89-90. [PMID: 16396955 PMCID: PMC2080694 DOI: 10.1136/thx.2004.028233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Acute hypercapnic respiratory failure (AHRF) is a common reason for hospital admission. Most patients have an underlying chronic lung disease such as chronic obstructive pulmonary disease. We report the case of a man who presented with AHRF secondary to tubular aggregate myopathy.
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Affiliation(s)
- N Shahrizaila
- Department of Neurology, Queen's Medical Centre, Nottingham NG7 1UH, UK.
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Gayan-Ramirez G, Testelmans D, Maes K, Rácz GZ, Cadot P, Zádor E, Wuytack F, Decramer M. Intermittent spontaneous breathing protects the rat diaphragm from mechanical ventilation effects. Crit Care Med 2006; 33:2804-9. [PMID: 16352963 DOI: 10.1097/01.ccm.0000191250.32988.a3] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Short-term mechanical ventilation has been proven to reduce diaphragm force and fiber dimensions. We hypothesized that intermittent spontaneous breathing during the course of mechanical ventilation would minimize the effects of mechanical ventilation on diaphragm force and expression levels of transcription factors (MyoD and myogenin). DESIGN Randomized, controlled experiment. SETTING Animal basic science laboratory. SUBJECTS Male Wistar rats, weighing 350-500 g. INTERVENTIONS Anesthetized and tracheotomized rats were submitted to either 24 hrs of spontaneous breathing (SB, n = 5), 24 hrs of continuous controlled mechanical ventilation (CMV, n = 7), or controlled mechanical ventilation with intermittent spontaneous breathing: 60 mins every 5 hrs of mechanical ventilation repeated four times (ISB60, n = 8) or 5 mins every 5 hrs 55 mins of mechanical ventilation repeated four times (SB5, n = 9). They were compared with control animals free from intervention (C, n = 5). MEASUREMENTS AND MAIN RESULTS The profile of the diaphragm force-frequency curve of the controls and SB group was significantly different from that of the ISB and CMV groups; especially, the mean asymptotic force was less in the ISB and CMV compared with controls and SB. CMV resulted in a significant decrease in the diaphragm type I (-26%, p < .05 vs. C) and type IIx/b (-39%, p < .005 vs. C and SB) cross-sectional area, whereas this was not observed in the ISB groups. Diaphragm MyoD protein expression was significantly decreased after ISB60 (-35%, p < .0001 vs. C and SB) and even more after CMV (-73%, p < .0001 vs. others). The same pattern was observed with myogenin protein levels. Positive relationships between diaphragm MyoD and myogenin protein levels and diaphragm force were observed. CONCLUSIONS The data demonstrated that intermittent spontaneous breathing during the course of mechanical ventilation may minimize the deleterious effect of controlled mechanical ventilation on diaphragm force, fiber dimensions, and expression of transcription factors.
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Affiliation(s)
- Ghislaine Gayan-Ramirez
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, Leuven Belgium
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Gayan-Ramirez GN, Decramer ML. Diaphragm antioxidant system in controlled mechanical ventilation in piglets: short term vs. prolonged mechanical ventilation response. Intensive Care Med 2005; 31:1303-5. [PMID: 16041523 DOI: 10.1007/s00134-005-2693-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2005] [Accepted: 06/27/2005] [Indexed: 11/29/2022]
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Tobin M, Brochard L, Rossi A. Exploration de la fonction des muscles respiratoires en réanimation. Rev Mal Respir 2004. [DOI: 10.1016/s0761-8425(04)71403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Supinski G, Fitting JW, Bellemare F. Évaluation de la fatigue des muscles respiratoires. Rev Mal Respir 2004. [DOI: 10.1016/s0761-8425(04)71398-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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El-Kabir DR, Polkey MI, Lyall RA, Williams AJ, Moxham J. The effect of treatment on diaphragm contractility in obstructive sleep apnea syndrome. Respir Med 2003; 97:1021-6. [PMID: 14509556 DOI: 10.1016/s0954-6111(03)00132-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In untreated obstructive sleep apnea syndrome (OSAS) inspiratory efforts are made against an occluded airway and diaphragm fatigue might therefore complicate OSAS. To test this hypothesis we measured twitch transdiaphragmatic pressure (Tw Pdi) in response to bilateral cervical magnetic stimulation of the phrenic nerve roots in nine patients with OSAS before and one month after successful therapy with nasal continuous positive airways pressure (nCPAP). The mean Tw Pdi before therapy was 23.2cm H2O and after therapy was 22.8cm H2O (P = 0.59); the mean change after initiation of nCPAP was 0.4cm H2O with 95% confidence intervals of -1.3cm H2O and +2.1 cm H2O. We conclude that low frequency diaphragm fatigue does not complicate untreated OSAS.
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Affiliation(s)
- Desiree R El-Kabir
- Lane Fox Respiratory Unit and Sleep Disorders Centre, St Thomas' Hospital, Guy's King's and St Thomas' School of Medicine, Lambeth Palace Road, London SE1 7EH, UK.
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Gayan-Ramirez G, de Paepe K, Cadot P, Decramer M. Detrimental effects of short-term mechanical ventilation on diaphragm function and IGF-I mRNA in rats. Intensive Care Med 2003; 29:825-33. [PMID: 12682716 DOI: 10.1007/s00134-003-1688-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2002] [Accepted: 01/21/2003] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Because respiratory muscle weakness appears to play an important role in weaning from mechanical ventilation, we developed an animal model of mechanical ventilation with appropriate controls in order to determine whether 24 h of mechanical ventilation already affected diaphragmatic function. DESIGN AND INTERVENTIONS Fifty-two male Wistar rats were randomized into three groups: a non-anesthetized control group (C, n=10), an anesthetized spontaneously breathing group (SB, n=9 out of 26), and an anesthetized and mechanically ventilated group (MV, n=12 out of 16). RESULTS After 24 h, in vitro diaphragmatic force was decreased in SB group but even more so in MV group (i.e., 80 Hz: -15% in SB, P<0.005 vs C and -34% in MV group, P<0.005 vs C and SB). This was associated with a significant decrease in the diaphragm type I and type IIa dimensions in the SB group, which was more pronounced in the MV group. Interestingly, diaphragm IGF-I mRNA was decreased in the SB group (-14%, P<0.05 vs C), but more so in MV group (-29%, P<0.001 vs C and P<0.01 vs SB). Moreover, there was a significant correlation between diaphragm force and IGF-I mRNA (at 80 Hz r=0.51, P=0.0056). CONCLUSIONS We conclude that 24 h of mechanical ventilation in rats, independently of anesthesia, already significantly reduced diaphragm force, fiber dimensions, and its IGF-I mRNA levels.
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Affiliation(s)
- Ghislaine Gayan-Ramirez
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Rehabilitation and Respiratory Division, University Hospitals, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
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Laghi F, Cattapan SE, Jubran A, Parthasarathy S, Warshawsky P, Choi YSA, Tobin MJ. Is weaning failure caused by low-frequency fatigue of the diaphragm? Am J Respir Crit Care Med 2003; 167:120-7. [PMID: 12411288 DOI: 10.1164/rccm.200210-1246oc] [Citation(s) in RCA: 216] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Because patients who fail a trial of weaning from mechanical ventilation experience a marked increase in respiratory load, we hypothesized that these patients develop diaphragmatic fatigue. Accordingly, we measured twitch transdiaphragmatic pressure using phrenic nerve stimulation in 11 weaning failure and 8 weaning success patients. Measurements were made before and 30 minutes after spontaneous breathing trials that lasted up to 60 minutes. Twitch transdiaphragmatic pressure was 8.9 +/- 2.2 cm H2O before the trials and 9.4 +/- 2.4 cm H2O after their completion in the weaning failure patients (p = 0.17); the corresponding values in the weaning success patients were 10.3 +/- 1.5 and 11.2 +/- 1.8 cm H2O (p = 0.18). Despite greater load (p = 0.04) and diaphragmatic effort (p = 0.01), the weaning failure patients did not develop low-frequency fatigue probably because of greater recruitment of rib cage and expiratory muscles (p = 0.004) and because clinical signs of distress mandating the reinstitution of mechanical ventilation arose before the development of fatigue. Twitch pressure revealed considerable diaphragmatic weakness in many weaning failure patients. In conclusion, in contrast to our hypothesis, weaning failure was not accompanied by low-frequency fatigue of the diaphragm, although many weaning failure patients displayed diaphragmatic weakness.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. Veterans Administration Hospital, Hines, Illinois 60141, USA.
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32
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Abstract
The study of patients being weaned from mechanical ventilation has offered new insights into the physiology of respiratory failure. Assessment of the balance between respiratory muscle strength, work and central drive is essential if difficulty in weaning occurs, and optimisation of these elements may improve the success of weaning. Psychological support of patients and the creation of units specialising in weaning have also resulted in a higher success rate.
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Affiliation(s)
- J Goldstone
- Department of Intensive Care Medicine, University College London Hospitals, The Middlesex Hospital, London, UK.
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Abstract
The contribution of respiratory muscle fatigue to the development of ventilatory failure has been the subject of considerable interest and has stimulated much research. Experimental studies in dogs have shown respiratory muscle fatigue to be a cause of ventilatory failure in both cardiogenic and septic shock models. In clinical conditions resulting in acute or chronic hypercapnia, respiratory muscle fatigue is believed to occur; however, the specific role of fatigue has been difficult to prove.
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Affiliation(s)
- Linda Barton
- Animal Medical Center, 510 East 62nd Street, New York, NY 10021, USA.
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Kyroussis D, Johnson LC, Hamnegard CH, Polkey MI, Moxham J. Inspiratory muscle maximum relaxation rate measured from submaximal sniff nasal pressure in patients with severe COPD. Thorax 2002; 57:254-7. [PMID: 11867831 PMCID: PMC1746274 DOI: 10.1136/thorax.57.3.254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Slowing of the inspiratory muscle maximum relaxation rate (MRR) is a useful index of severe inspiratory muscle loading and potential fatigue and has been measured from the oesophageal pressure during sniffs in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to investigate whether it is possible to measure MRR and detect slowing using sniff nasal pressure in patients with COPD and to investigate the relationship between sniff oesophageal and sniff nasal MRR. METHODS Eight patients with severe COPD (mean FEV1 0.7 l; 26% predicted) were studied. Each subject performed submaximal sniff manoeuvres before and after walking to a state of severe dyspnoea on a treadmill. Oesophageal and gastric pressures were measured using balloon tipped catheters and nasal pressure was measured using an individually modelled nasal cast. MRR (% pressure fall/10 ms) was determined for each sniff and any change following exercise was reported as percentage of baseline to allow comparison of sniff nasal and oesophageal MRR. RESULTS At rest the mean (SE) sniff Poes MRR was 7.1 (0.3) and the mean Pnasal MRR was 8.6 (0.1). At 1 minute following exercise there was a mean decrease in sniff Poes MRR of 33.7% (range 20.7-53.4%) and a mean decrease in sniff Pnasal MRR of 28.2% (range 8.1-52.8%). The degree of slowing and time course of recovery was similar, with both returning to baseline values within 5-10 minutes. A separate analysis of the sniff pressures using only the nasal pressure traces demonstrated a similar pattern of slowing and recovery. CONCLUSIONS It is possible to detect slowing of the inspiratory muscles non-invasively using sniff nasal pressures in patients with COPD. This could be a useful technique with which to measure severe and potentially fatiguing inspiratory muscle loading, both in clinical settings and during exercise studies.
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Affiliation(s)
- D Kyroussis
- Respiratory Muscle Laboratory, Royal Brompton Hospital, London, UK
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36
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Hughes PD, Hart N, Hamnegård CH, Green M, Coats AJ, Moxham J, Polkey MI. Inspiratory Muscle Relaxation Rate Slows during Exhaustive Treadmill Walking in Patients with Chronic Heart Failure. Am J Respir Crit Care Med 2001; 163:1400-3. [PMID: 11371408 DOI: 10.1164/ajrccm.163.6.2003082] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Exercise intolerance is a feature of chronic heart failure (CHF). We hypothesized that excessive loading of the respiratory muscle pump might contribute to exertional breathlessness. One marker of excessive muscle-loading is slowing of maximum relaxation rate (MRR) and, therefore, to test our hypothesis, we investigated the effect of exhaustive treadmill walking on inspiratory muscle MRR in patients with CHF. We studied eight stable patients with mild-moderate CHF walking on a treadmill until termination because of severe dyspnea. Inspiratory muscle MRR was determined from esophageal pressure (Pes) change during submaximal sniffs (Sn) before and immediately after exercise to a mean (SD) minute ventilation of 77 () L/min. For comparison, nine healthy subjects performed a similar protocol; exercise was terminated either by severe dyspnea or when minute ventilation reached 100 L/min. There were no significant differences in terms of heart rate, respiratory rate, tidal volume, or inspiratory duty cycle at cessation of exercise. The mean slowing of Sn Pes MRR in the first minute after termination of exercise in the CHF group was 22.4% and in the normal control group it was 2.8% (p < 0.01). Our data show that slowing of inspiratory muscle relaxation rate occurs in patients with CHF walking to severe breathlessness. We conclude that severe loading of the inspiratory muscles is a feature of exertional dyspnea in CHF.
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Affiliation(s)
- P D Hughes
- Respiratory Muscle Laboratory, Royal Brompton Hospital, Fulham Rd., London SW3 6NP, United Kingdom
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Polkey MI, Moxham J. Clinical aspects of respiratory muscle dysfunction in the critically ill. Chest 2001; 119:926-39. [PMID: 11243977 DOI: 10.1378/chest.119.3.926] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- M I Polkey
- Respiratory Muscle Laboratory, Royal Brompton Hospital, National Heart & Lung Institute, London, UK.
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38
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Abstract
Exacerbations of COPD are a leading indication for MV in the intensive care unit. A thorough understanding of the pathophysiology of AVF in COPD is critical for physicians caring for these patients. In particular, physicians should understand DHI and use the ventilator and ancillary techniques to minimize its impact. Noninvasive positive-pressure ventilation should be considered strongly in relatively stable patients with an adequate mental status and manageable secretions. Once AVF resolves, patients should be removed from the ventilator as soon as is safe to do so to minimize the adverse effects of prolonged MV. An organized approach to weaning and identifying patients capable of independent breathing is crucial. Most patients with COPD and AVF benefit from MV and generally return to or approach their premorbid functional status. A significant subset, however, will not benefit from, or choose not to undergo, MV. Deciding upon appropriate therapeutic options for these patients relies heavily on effective communication between physician and patient. Comprehensive discussions before the development of AVF can assist decision-making after respiratory failure develops.
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Affiliation(s)
- J M Sethi
- Department of Medicine, Section of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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39
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Abstract
Relaxation is the process by which, after contraction, the muscle actively returns to its initial conditions of length and load. In rhythmically active muscles such as diaphragm, relaxation is of physiological importance because diaphragm must return to a relatively constant resting position at the end of each contraction-relaxation cycle. Rapid and complete relaxation of the diaphragm is likely to play an important role in adaptation to changes in respiratory load and breathing frequency. Regulation of diaphragm relaxation at the molecular and cellular levels involves Ca(2+) removal from the myofilaments, active Ca(2+) pumping by the sarcoplasmic reticulum (SR), and decrease in the number of working cross bridges. The relative contribution of these mechanisms mainly depends on sarcomere length, muscle tension, and the intrinsic contractile function. Increased capacity of SR to take up Ca(2+) can arise from increased density of active SR pumping sites or in slow-twitch fibers from phosphorylation of phospholamban, whereas impaired coupling between ATP hydrolysis and Ca(2+) transport into the SR or intracellular acidosis reduces SR Ca(2+) pump activity. In experimental conditions of decreased contractile performance, slowed, enhanced, or unchanged relaxation rates have been reported in vitro. In vivo, a slowing in the rate of decline of the respiratory pressure is generally considered an early reliable index of respiratory muscle fatigue. Impaired relaxation rate may, in turn, favor mismatch between blood flow and metabolic demand, especially at high breathing frequencies.
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Affiliation(s)
- C Coirault
- Laboratoire d'Optique Appliquée, Ecole Nationale Supérieure des Techniques Avancées, Ecole Polytechnique, Institut National de la Santé et de la Recherche Médicale U 451, Batterie de l'Yvette, 91761 Palaiseau Cedex, France
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Abstract
For most mechanically ventilated patients, weaning can be accomplished quickly and easily. However, there is a smaller group of ventilated patients who fail to wean and remain ventilator-dependent. These patients account for a significant amount of health care costs and pose a great challenge for clinicians. Detailed knowledge of the etiology and pathophysiology of weaning failure is very important for the "treatment" of difficult to wean patients, and is thoroughly presented in this article. Based on this physiological background, strategies and techniques are proposed that are useful for the gradual transition to spontaneous ventilation.
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Affiliation(s)
- T Vassilakopoulos
- Department of Critical Care and Pulmonary Services, Athens University Medical School, Evangelismos Hospital, Greece
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Kagawa T, Maekawa N, Mikawa K, Nishina K, Yaku H, Obara H. The Effect of Halothane and Sevoflurane on Fatigue-Induced Changes in Hamster Diaphragmatic Contractility. Anesth Analg 1998. [DOI: 10.1213/00000539-199802000-00033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kagawa T, Maekawa N, Mikawa K, Nishina K, Yaku H, Obara H. The effect of halothane and sevoflurane on fatigue-induced changes in hamster diaphragmatic contractility. Anesth Analg 1998; 86:392-7. [PMID: 9459255 DOI: 10.1097/00000539-199802000-00033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The purpose of this study was to examine the effect of halothane and sevoflurane on fatigue-induced changes in diaphragmatic contractility. Forty-two hamster diaphragm strips were randomly allocated according to anesthetics (no anesthesia control, 1%-3% halothane, 2%-6% sevoflurane) and stimulated directly in an organ bath. Under the influence of the anesthetics, muscle fatigue was induced by repetitive tetanic contraction, and diaphragmatic contractilities (i.e., peak twitch and tetanic tension, twitch contraction time, and half-relaxation time) were measured before and after fatigue. Neither halothane nor sevoflurane changed tension generation before or after fatigue, but each anesthetic significantly enhanced fatigue-induced prolongations of the contraction time and half-relaxation time after fatigue. Specifically, the half-relaxation times after fatigue in the 3% halothane, 4% sevoflurane, and 6% sevoflurane groups (225.6 +/- 37.6, 236.0 +/- 76.5, and 287.3 +/- 55.5 ms, respectively) were more than twice as long as those of the control group (104.7 +/- 19.7 ms, P < 0.05). We conclude that halothane and sevoflurane augment fatigue-induced prolongations of the contraction and relaxation times. Diaphragmatic function may deteriorate when there is a fatiguing task during the clinical administration of halothane or sevoflurane anesthesia. IMPLICATIONS This study implicates diaphragmatic fatigue during anesthesia. An in vitro hamster diaphragm muscle preparation was used to study the effect of halothane and sevoflurane on fatigue-induced change in contractility. Our findings suggest that increased load on the diaphragm during volatile anesthesia may lead to impaired diaphragmatic contractility.
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Affiliation(s)
- T Kagawa
- Department of Anesthesiology, Kobe University School of Medicine, Japan.
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Kyroussis D, Mills GH, Polkey MI, Hamnegard CH, Wragg S, Road J, Green M, Moxham J. Effect of maximum ventilation on abdominal muscle relaxation rate. Thorax 1996; 51:510-5. [PMID: 8711679 PMCID: PMC473596 DOI: 10.1136/thx.51.5.510] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND When the demand placed on the respiratory system is increased, the abdominal muscles become vigorously active to achieve expiration and facilitate subsequent inspiration. Abdominal muscle function could limit ventilatory capacity and a method to detect abdominal muscle fatigue would be of value. The maximum relaxation rate (MRR) of skeletal muscle has been used as an early index of the onset of the fatiguing process and precedes failure of force generation. The aim of this study was to measure MRR of abdominal muscles and to investigate whether it slows after maximum isocapnic ventilation (MIV). METHODS Five normal subjects were studied. Each performed short sharp expiratory efforts against a 3 mm orifice before and immediately after a two minute MIV. Gastric pressure (PGA) was recorded and MRR (% pressure fall/10 ms) for each PGA trace was determined. RESULTS Before MIV the mean (SD) maximum PGA MRR for the five subjects was 7.1 (0.8)% peak pressure fall/10 ms. Following MIV mean PGA MRR was decreased by 30% (range 25-35%), returning to control values within 5-10 minutes. CONCLUSIONS The MRR of the abdominal muscles, measured from PGA, is numerically similar to that described for the diaphragm and other skeletal muscles. After two minutes of maximal isocapnic ventilation abdominal muscle MRR slows, indicating that these muscles are sufficiently heavily loaded to initiate the fatiguing process.
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Affiliation(s)
- D Kyroussis
- Respiratory Muscle Laboratories, Royal Brompton and King's College Hospitals, London, UK
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44
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Affiliation(s)
- C Roussos
- Department of Critical Care, Medical School of Athens University, Evangelismos Hospital, Athens, Greece
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45
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46
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McKenzie DK, Bellemare F. Respiratory muscle fatigue. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1995; 384:401-14. [PMID: 8585468 DOI: 10.1007/978-1-4899-1016-5_32] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ventilatory failure may accompany a variety of pulmonary and neuromuscular diseases. There has been much controversy about whether this failure is due to respiratory muscle fatigue at peripheral sites or a failure of drive at sites within the central nervous system. The chapter reviews this topic.
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Affiliation(s)
- D K McKenzie
- Department of Respiratory Medicine, University of New South Wales, Sydney, Australia
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