1
|
Peng L, Kang H, Chang H, Sun Y, Zhao Y, Zhao H. The ratio of parasternal intercostal muscle-thickening fraction-to-diaphragm thickening fraction for predicting weaning failure. J Crit Care 2024; 83:154847. [PMID: 38909540 DOI: 10.1016/j.jcrc.2024.154847] [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: 08/22/2023] [Revised: 05/22/2024] [Accepted: 06/14/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Diaphragm dysfunction is associated with weaning outcomes in mechanical ventilation patients, in the case of diaphragm dysfunction, the accessory respiratory muscles would be recruited. The main purpose of this study is to explore the performance of parasternal intercostal muscle thickening fraction in relation to diaphragmatic thickening fraction ratio (TFic1/TFdi2) for predicting weaning outcomes, and compare its accuracy with D-RSBI in predicting weaning failure. MATERIALS AND METHODS We prospectively enrolled consecutive patients from 7/2022-5/2023. We measured TFic, TFdi, and diaphragmatic excursion (DE3) by ultrasound and calculated the TFic/TFdi ratio and diaphragmatic rapid shallow breathing index (D-RSBI4). Receiver-operator characteristic (ROC5) curves evaluated the accuracy of the TFic/TFdi ratio and D-RSBI in predicting weaning failure. RESULTS 161 were included in the final analysis, 114 patients (70.8%) were successfully weaned from mechanical ventilation. The TFic/TFdi ratio (AUROC = 0.887 (95% CI: 0.821-0.953)) was superior to the D-RSBI (AUROC = 0.875 (95% CI: 0.807-0.944)) for predicting weaning failure. CONCLUSIONS The TFic/TFdi ratio predicted weaning failure with high accuracy and outperformed the D-RSBI.
Collapse
Affiliation(s)
- Li Peng
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hongshan Kang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Hairong Chang
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yue Sun
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Yuanyuan Zhao
- Department of Intensive Care Unit, Harrison International Peace Hospital, Hengshui 053000, Hebei, China
| | - Heling Zhao
- Department of Critical Care Medicine, Hebei Medical University, Shijiazhuang 050000, Hebei, China; Department of Intensive Care Unit, Hebei General Hospital, Shijiazhuang 050000, Hebei, China.
| |
Collapse
|
2
|
Siniscalchi C, Nouvenne A, Cerundolo N, Meschi T, Ticinesi A. Diaphragm Ultrasound in Different Clinical Scenarios: A Review with a Focus on Older Patients. Geriatrics (Basel) 2024; 9:70. [PMID: 38920426 PMCID: PMC11202496 DOI: 10.3390/geriatrics9030070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/08/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
Diaphragm muscle dysfunction is increasingly recognized as a fundamental marker of several age-related diseases and conditions including chronic obstructive pulmonary disease, heart failure and critical illness with respiratory failure. In older individuals with physical frailty and sarcopenia, the loss of muscle mass and function may also involve the diaphragm, contributing to respiratory dysfunction. Ultrasound has recently emerged as a feasible and reliable strategy to visualize diaphragm structure and function. In particular, it can help to predict the timing of extubation in patients undergoing mechanical ventilation in intensive care units (ICUs). Ultrasonographic evaluation of diaphragmatic function is relatively cheap, safe and quick and can provide useful information for real-time monitoring of respiratory function. In this review, we aim to present the current state of scientific evidence on the usefulness of ultrasound in the assessment of diaphragm dysfunction in different clinical settings, with a particular focus on older patients. We highlight the importance of the qualitative information gathered by ultrasound to assess the integrity, excursion, thickness and thickening of the diaphragm. The implementation of bedside diaphragm ultrasound could be useful for improving the quality and appropriateness of care, especially in older subjects with sarcopenia who experience acute respiratory failure, not only in the ICU setting.
Collapse
Affiliation(s)
- Carmine Siniscalchi
- Department of Continuity of Care and Multicomplexity, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (C.S.); (A.N.); (N.C.); (T.M.)
| | - Antonio Nouvenne
- Department of Continuity of Care and Multicomplexity, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (C.S.); (A.N.); (N.C.); (T.M.)
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Nicoletta Cerundolo
- Department of Continuity of Care and Multicomplexity, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (C.S.); (A.N.); (N.C.); (T.M.)
| | - Tiziana Meschi
- Department of Continuity of Care and Multicomplexity, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (C.S.); (A.N.); (N.C.); (T.M.)
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | - Andrea Ticinesi
- Department of Continuity of Care and Multicomplexity, Azienda Ospedaliero-Universitaria di Parma, Via Antonio Gramsci 14, 43126 Parma, Italy; (C.S.); (A.N.); (N.C.); (T.M.)
- Department of Medicine and Surgery, University of Parma, Via Antonio Gramsci 14, 43126 Parma, Italy
| | | |
Collapse
|
3
|
Diao S, Li S, Dong R, Jiang W, Wang C, Chen Y, Wang J, He S, Wang Y, Du B, Weng L. The diaphragmatic electrical activity during spontaneous breathing trial in patients with mechanical ventilation: physiological description and potential clinical utility. BMC Pulm Med 2024; 24:263. [PMID: 38816810 PMCID: PMC11140881 DOI: 10.1186/s12890-024-03077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUNDS Increased respiratory drive has been demonstrated to correlate with weaning failure, which could be quantified by electrical activity of the diaphragm (EAdi). We described the physiological process of EAdi-based parameters during the spontaneous breathing trial (SBT) and evaluated the change of EAdi-based parameters as potential predictors of weaning failure. METHODS We conducted a prospective study in 35 mechanically ventilated patients who underwent a 2-hour SBT. EAdi and ventilatory parameters were continuously measured during the SBT. Diaphragm ultrasound was performed before the SBT and at the 30 min of the SBT. Three EAdi-based parameters were calculated: neuro-ventilatory efficiency, neuro-excursion efficiency and neuro-discharge per min. RESULTS Of the thirty 35 patients studied, 25 patients were defined as SBT success, including 22 patients weaning successfully and 3 patients reintubated. Before the SBT, neuro-excursion efficiency differed significantly between two groups and had the highest predictive value for SBT failure (AUROC 0.875, p < 0.01). Early increases in EAdi were observed in SBT, which are more prominent in SBT failure group. One minute, changes in EAdi and neuro-discharge per min also predicted weaning outcome (AUROCs 0.944 and 0.918, respectively). CONCLUSIONS EAdi-based parameters, especially neuro-excursion efficiency and changes in neuro-discharge per min, may detect impending weaning failure earlier than conventional indices. EAdi monitoring provides physiological insights and a more tailored approach to facilitate successful weaning. Further research should validate these findings and explore the utility of combined EAdi and diaphragm ultrasound assessment in weaning ICU patients from mechanical ventilation. TRIAL REGISTRATION Registered at ClinicalTrials.gov on 20 September 2022 (Identifier: NCT05632822).
Collapse
Affiliation(s)
- Shitong Diao
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Run Dong
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Jiang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunyao Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jingyi Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuhua He
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yifan Wang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| |
Collapse
|
4
|
Sartini S, Ferrari L, Cutuli O, Castellani L, Cristina ML, Arboscello E, Sartini M. The Role of POCUS to Face COVID-19: A Narrative Review. J Clin Med 2024; 13:2756. [PMID: 38792298 PMCID: PMC11121862 DOI: 10.3390/jcm13102756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
COVID-19 has been a challenging outbreak to face, with millions of deaths among the globe. Acute respiratory failure due to interstitial pneumonia was the leading cause of death other than prothrombotic activation and complications. Lung ultrasound (LUS) and point-of-care ultrasound (POCUS) are widely used not only to triage, to identify, and to monitor lungs involvement but also to assess hemodynamic status and thrombotic and hemorrhagic complications, mainly in critically ill patients. POCUS has gained growing consideration due to its bedside utilization, reliability, and reproducibility even in emergency settings especially in unstable patients. In this narrative review, we aim to describe LUS and POCUS utilization in COVID-19 infection based on the literature found on this topic. We reported the LUS patterns of COVID-19 pulmonary infection, the diagnostic accuracy with respect to CT lung scan, its prognostic value, the variety of scores and protocols proposed, and the utilization of POCUS to investigate the extra-lung complications.
Collapse
Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Lorenzo Ferrari
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy;
| | - Ombretta Cutuli
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Luca Castellani
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;
- Hospital Hygiene, E.O. Ospedali Galliera, Via Alessandro Volta 8, 16128 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;
- Hospital Hygiene, E.O. Ospedali Galliera, Via Alessandro Volta 8, 16128 Genoa, Italy
| |
Collapse
|
5
|
Fritsch SJ, Siemer AG, Dreher M, Simon TP, Marx G, Bickenbach J. Diaphragm ultrasound in patients with prolonged weaning from mechanical ventilation. Quant Imaging Med Surg 2024; 14:3248-3263. [PMID: 38720844 PMCID: PMC11074767 DOI: 10.21037/qims-23-1712] [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: 12/01/2023] [Accepted: 03/18/2024] [Indexed: 05/12/2024]
Abstract
Background Several publications have examined diaphragmatic ultrasound using two-dimensional (2D) parameters in the context of weaning from mechanical ventilation (MV) and extubation. However, the studied cohorts had rather short duration of ventilation. Examinations on patients with prolonged weaning after long-term ventilation were missing. It was the aim of this study to assess of the diaphragm and peripheral musculature of patients undergoing prolonged weaning creating a chronological sequence of ultrasonic parameters during the course of weaning. Methods This study was carried out as a monocentric, prospective observational cross-sectional study. Patients in prolonged weaning who were transferred to a specialized weaning unit were eligible for inclusion if they were ventilated invasively by means of an endotracheal tube or tracheal cannula and if their expected treatment period was at least 5 days. Diaphragmatic function and one representative peripheral muscle were examined in 50 patients between March 2020 and April 2021. The 2D sonographic parameters of diaphragm and diaphragmatic function consisted of diaphragmatic thickness (Tdi) at the end of inspiration and expiration, the fractional thickening (FT) and the diaphragmatic excursion. Additionally, the M. quadriceps femoris was sonographically assessed at two locations. The difference of measurements between the first and the last measuring timepoint were examined using the Wilcoxon signed-rank test. For a longer chronological sequence, the Friedman's rank sum test with subsequent Wilcoxon-Nemenyi-McDonald-Thompson test for multiple comparisons was carried out. Results Fifty patients with prolonged weaning were included. The median duration of MV before transfer to the weaning unit was 11.5 [interquartile range (IQR) 10] days. Forty-one patients could be assessed over the full course of weaning, with 38 successfully weaned. Within these 41 patients, the sonographic parameters of the diaphragm slightly increased over the course of weaning indicating an increase in thickness and mobility. Especially parameters which represented an active movement reached statistical significance, i.e., inspiratory Tdi when assessed under spontaneous breathing [begin 3.41 (0.99) vs. end 3.43 (1.31) mm; P=0.01] and diaphragmatic excursion [begin 0.7 (0.8) vs. end 0.9 (0.6) cm; P=0.01]. The presence of positive end-expiratory pressure (PEEP) and pressure support did not influence the sonographic parameters significantly. The M. quadriceps femoris, in contrast, decreased slightly but constantly over the time [lower third: begin 1.36 (0.48) vs. end 1.28 (0.36) cm; P=0.054]. Conclusions The present study is the first one to longitudinally analyse diaphragmatic ultrasound in patients with prolonged weaning. Sonographic assessment showed that Tdi and excursion increased over the course of prolonged weaning, while the diameter of a representative peripheral muscle decreased. However, the changes are rather small, and data show a wide dispersion. To allow a potential, standardized use of diaphragm ultrasound for diagnostic decision support in prolonged weaning, further studies in this specific patient group are required.
Collapse
Affiliation(s)
- Sebastian Johannes Fritsch
- Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
- Jülich Supercomputing Centre, Forschungszentrum Jülich, Jülich, Germany
| | - Anna Große Siemer
- Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
- Department of Neurology, Protestant Hospital Oldenburg, Oldenburg, Germany
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
| |
Collapse
|
6
|
Vetrugno L, Deana C, Spadaro S, Cammarota G, Grieco DL, Tullio A, Bove T, Di Loreto C, Maggiore SM, Orsaria M, Study Group D. Diaphragmatic morphological post-mortem findings in critically ill COVID-19 patients: an observational study. Monaldi Arch Chest Dis 2024. [PMID: 38656318 DOI: 10.4081/monaldi.2024.2829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Our study investigates the post-mortem findings of the diaphragm's muscular structural changes in mechanically ventilated COVID-19 patients. Diaphragm samples of the right side from 42 COVID-19 critically ill patients were analyzed and correlated with the type and length of mechanical ventilation (MV), ventilatory parameters, prone positioning, and use of sedative drugs. The mean number of fibers was 550±626. The cross-sectional area was 4120±3280 μm2, while the muscular fraction was 0.607±0.126. The overall population was clustered into two distinct populations (clusters 1 and 2). Cluster 1 showed a lower percentage of slow myosin fiber and higher fast fiber content than cluster 2, 68% versus 82%, p<0.00001, and 29.8% versus 18.8%, p=0.00045 respectively. The median duration of MV was 180 (41-346) hours. In cluster 1, a relationship between assisted ventilation and fast myosin fiber percentage (R2=-0.355, p=0.014) was found. In cluster 2, fast fiber content increased with increasing the length of the controlled MV (R2=0.446, p=0.006). A high grade of fibrosis was reported. Cluster 1 was characterized by fibers' atrophy and cluster 2 by hypertrophy, supposing different effects of ventilation on the diaphragm but without excluding a possible direct viral effect on diaphragmatic fibers.
Collapse
Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, Gabriele d'Annunzio University of Chieti Pescara, Chieti; Department of Anesthesiology, Critical Care Medicine and Emergency, Annunziata Hospital, Chieti.
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara; Intensive Care Unit, Azienda Ospedaliera Universitaria Sant'Anna, Ferrara.
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara; Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara.
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome.
| | - Annarita Tullio
- Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine; Department of Medicine, University of Udine.
| | - Carla Di Loreto
- Department of Medicine, University of Udine; Institute of Anatomic Pathology, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, Annunziata Hospital, Chieti; Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti Pescara, Chieti.
| | - Maria Orsaria
- Institute of Anatomic Pathology, Health Integrated Agency Friuli Centrale, Academic Hospital of Udine.
| | | |
Collapse
|
7
|
Le Stang V, Latronico N, Dres M, Bertoni M. Critical illness-associated limb and diaphragmatic weakness. Curr Opin Crit Care 2024; 30:121-130. [PMID: 38441088 PMCID: PMC10919276 DOI: 10.1097/mcc.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). RECENT FINDINGS In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. SUMMARY This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.
Collapse
Affiliation(s)
- Valentine Le Stang
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- ‘Alessandra BONO’ Interdepartmental University Research Center on LOng Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive –Réanimation (Département ‘R3S’), Paris, France
| | - Michele Bertoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
| |
Collapse
|
8
|
Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [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: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
Collapse
Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| |
Collapse
|
9
|
Wang Y, Yi Y, Zhang F, Yao YY, Chen YX, Wu CM, Wang RY, Yan M. Lung Ultrasound Score as a Predictor of Failure to Wean COVID-19 Elderly Patients off Mechanical Ventilation: A Prospective Observational Study. Clin Interv Aging 2024; 19:313-322. [PMID: 38404479 PMCID: PMC10887876 DOI: 10.2147/cia.s438714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/06/2024] [Indexed: 02/27/2024] Open
Abstract
Background The lung ultrasound score was developed for rapidly assessing the extent of lung ventilation, and it can predict failure to wean various types of patients off mechanical ventilation. Whether it is also effective for COVID-19 patients is unclear. Methods This single-center, prospective, observational study was conducted to assess the ability of the 12-region lung ultrasound score to predict failure to wean COVID-19 patients off ventilation. In parallel, we assessed whether right hemidiaphragmatic excursion or previously published predictors of weaning failure can apply to these patients. Predictive ability was assessed in terms of the area under the receiver operating characteristic curve (AUC). Results The mean age of the 35 patients in the study was (75 ± 9) years and 12 patients (37%) could not be weaned off mechanical ventilation. The lung ultrasound score predicted these failures with an AUC of 0.885 (95% CI 0.770-0.999, p < 0.001), and a threshold score of 10 provided specificity of 72.7% and sensitivity of 92.3%. AUCs were lower for previously published predictors of weaning failure, and right hemidiaphragmatic excursion did not differ significantly between the two groups. Conclusion The lung ultrasound score can accurately predict failure to wean critically ill COVID-19 patients off mechanical ventilation, whereas assessment of right hemidiaphragmatic excursion does not appear helpful in this regard. Trial Registration https://clinicaltrials.gov/ct2/show/NCT05706441.
Collapse
Affiliation(s)
- Ying Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
| | - Yu Yi
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
| | - Fan Zhang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
| | - Yuan-Yuan Yao
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Yue-Xiu Chen
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Chao-Min Wu
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Rui-Yu Wang
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| | - Min Yan
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, 221004, People’s Republic of China
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310016, People’s Republic of China
| |
Collapse
|
10
|
Marques MR, Pereira JM, Paiva JA, de Casasola-Sánchez GG, Tung-Chen Y. Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care: A Narrative Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:223-236. [PMID: 37915259 DOI: 10.1002/jum.16363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Weaning failure is common in mechanically ventilated patients, and whether ultrasound (US) can predict weaning outcome remains controversial. This review aims to evaluate the diaphragmatic function measured by US as a predictor of weaning outcome. METHODS PubMed was searched to identify original articles about the use of diaphragmatic US in ICU patients. A total of 61 citations were retrieved initially; available data of 26 studies were included in this review. RESULTS To assess diaphragmatic dysfunction in adults, six studies evaluated excursion, five evaluated thickening fraction, and both in nine. Despite heterogeneity in the diagnostic accuracy of diaphragm US among the studies, the sonographic indices showed good diagnostic performance for predicting weaning outcome. CONCLUSIONS Diaphragmatic US can be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients and predict weaning outcome.
Collapse
Affiliation(s)
- Marta Rafael Marques
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Manuel Pereira
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Artur Paiva
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Alfonso X, Villanueva de la Cañada, Madrid, Spain
| |
Collapse
|
11
|
Chua MT, Boon Y, Yeoh CK, Li Z, Goh CJM, Kuan WS. Point-of-care ultrasound use in COVID-19: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2024; 12:13. [PMID: 38304913 PMCID: PMC10777239 DOI: 10.21037/atm-23-1403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/25/2023] [Indexed: 02/03/2024]
Abstract
Background and Objective The coronavirus disease 2019 (COVID-19) pandemic that began in early 2020 resulted in significant mortality from respiratory tract infections. Existing imaging modalities such as chest X-ray (CXR) lacks sensitivity in its diagnosis while computed tomography (CT) scan carries risks of radiation and contamination. Point-of-care ultrasound (POCUS) has the advantage of bedside testing with higher diagnostic accuracy. We aim to describe the various applications of POCUS for patients with suspected severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in the emergency department (ED) and intensive care unit (ICU). Methods We performed literature search on the use of POCUS in the diagnosis and management of COVID-19 in MEDLINE, Embase and Scopus databases using the following search terms: "ultrasonography", "ultrasound", "COVID-19", "SARS-CoV-2", "SARS-CoV-2 variants", "emergency services", "emergency department" and "intensive care units". Search was performed independently by two reviewers with any discrepancy adjudicated by a third member. Key Content and Findings Lung POCUS in patients with COVID-19 shows different ultrasonographic features from pulmonary oedema, bacterial pneumonia, and other viral pneumonia, thus useful in differentiating between these conditions. It is more sensitive than CXR, and more accessible and widely available than CT scan. POCUS can be used to diagnose COVID-19 pneumonia, screen for COVID-19-related pulmonary and extrapulmonary complications, and guide management of ICU patients, such as timing of ventilator weaning based on lung POCUS findings. Conclusions POCUS is a useful and rapid point-of-care modality that can be used to aid in diagnosis, management, and risk stratification of COVID-19 patients in different healthcare settings.
Collapse
Affiliation(s)
- Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yuru Boon
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chew Kiat Yeoh
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Zisheng Li
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Carmen Jia Man Goh
- Emergency Department, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
12
|
Skaarup SH, Juhl-Olsen P, Grundahl AS, Løgstrup BB. Replacement of fluoroscopy by ultrasonography in the evaluation of hemidiaphragm function, an exploratory prospective study. Ultrasound J 2024; 16:1. [PMID: 38189895 PMCID: PMC10774234 DOI: 10.1186/s13089-023-00355-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Dysfunction of the diaphragm may ultimately lead to respiratory insufficiency and compromise patient outcome. Evaluation of diaphragm function is cumbersome. Fluoroscopy has been the gold standard to measure diaphragmatic excursion. Ultrasonography can visualize diaphragm excursion and holds many advantages such as no radiation exposure, increased portability and accessibility. However, correlation between fluoroscopy and ultrasonography has never been studied. We aimed to compare fluoroscopic and ultrasound measures of diaphragm excursion to determine if ultrasonography can replace fluoroscopy. METHODS We performed ultrasound and fluoroscopy simultaneously during sniff inspiration and at total inspiratory capacity in patients with chronic obstructive pulmonary disease, heart failure and in healthy volunteers. Cranio-caudal excursion was measured by fluoroscopy and compared directly to M-mode excursion, B-mode excursion, area change, resting thickness, thickening fraction and contraction velocity measured by ultrasonography. RESULTS Forty-two participants were included. The Pearson correlation between M-mode and fluoroscopy excursion was 0.61. The slope was 0.9 (90%CI 0.76-1.04) in a regression analysis. Using the Bland-Altman method, the bias was - 0.39 cm (95% CI - 1.04-0.26), p = 0.24. The Pearson correlation between fluoroscopy and B-mode and area change ultrasonography was high; low for thickness and fraction. All correlations were lower during sniff inspiration compared with inspiratory capacity breathing. CONCLUSION Ultrasonography has an acceptable correlation and bias compared to fluoroscopy and can thus be used as the primary tool to evaluate diaphragm excursion.
Collapse
Affiliation(s)
- Søren Helbo Skaarup
- Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Sofie Grundahl
- Department of Emergency Medicine, Randers Regional Hospital, Randers, Denmark
| | | |
Collapse
|
13
|
Laghi F. Clarifying the Role of Diaphragm Ultrasound Imaging in the Discontinuation of Mechanical Ventilation. Anesthesiology 2024; 140:4-7. [PMID: 38085158 DOI: 10.1097/aln.0000000000004810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois; Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| |
Collapse
|
14
|
Pu H, Doig GS, Lv Y, Wu X, Yang F, Zhang S, Liang Z, Zhou Y, Kang Y. Modifiable risk factors for ventilator associated diaphragmatic dysfunction: a multicenter observational study. BMC Pulm Med 2023; 23:343. [PMID: 37700263 PMCID: PMC10498609 DOI: 10.1186/s12890-023-02633-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Diaphragmatic dysfunction is known to be associated with difficulties weaning from invasive mechanical ventilation and is related to worse patient outcomes yet our understanding of how to prevent diaphragmatic dysfunction remains incomplete. We examined potentially modifiable risk factors for diaphragmatic dysfunction and attempted to estimate benefits attributable to altering these modifiable risk factors. METHODS This prospective multicenter observational study was undertaken in the general ICUs of two tertiary care teaching hospitals. Critically ill adults expected to receive invasive mechanical ventilation for at least 48 h were enrolled. Diaphragm function was assessed by ultrasound each study day, with dysfunction defined as thickening fraction less than 20%. RESULTS From January to December 2019, 856 patients were screened and 126 patients were enrolled. Overall, 40.5% (51/126) of patients experienced diaphragmatic dysfunction during invasive mechanical ventilation. Patients with diaphragmatic dysfunction were more likely to develop ventilator associated pneumonia (risk difference [RD] + 12.9%, 95% Confidence Interval [CI] 1.4 to 24.4%, P = 0.028), were more likely to experience extubation failure (RD + 8.5%, 95% CI 0.4 to 16.6%, P = 0.039) and required a longer duration of invasive mechanical ventilation (RD + 1.3 days, 95% CI 0.1 to 2.5 days, P = 0.035). They also required a longer hospital stay (RD + 1.2 days, 95% CI 0.04 to 2.4 days, P = 0.041) and were more likely to die before hospital discharge (RD + 18.1%, 95% CI 3.7 to 32.5%, P = 0.014). Multivariable analysis considered the impact of age, sex, pre-existing nutritional status, caloric intake, amino acid intake, acute disease severity, modes of mechanical ventilation, measures of respiratory status, sedation, pain control and baseline diaphragm thickness. Only SOFA score (P = 0.008) and early amino acid intake (P = 0.001) remained significant independent risk factors for the onset of diaphragmatic dysfunction. Causal path modeling suggested early amino acid intake may significantly reduce diaphragmatic dysfunction (RRR 29%, 95% CI 10% to 48%, P = 0.003) and may also reduce mortality (RRR 49%, 95% CI 25% to 73%, P < 0.0001). CONCLUSIONS Amino acid intake during the first 24 h of ICU stay may represent an important, modifiable risk factor for diaphragmatic dysfunction and may have a direct causal effect on mortality. We recommend additional research on this topic.
Collapse
Affiliation(s)
- Hong Pu
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Gordon S Doig
- Northern Clinical School Intensive Care Research Unit, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Yu Lv
- Healthcare-Associated Infection Control Center, Sichuan Academy of Medical Sciences, School of Medicine, Sichuan People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Xiaoxiao Wu
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences, School of Medicine, Sichuan People's Hospital, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Fu Yang
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Shurong Zhang
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan Zhou
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan Kang
- Department of Critical Care Medicine, West China Medical School, West China Hospital, Sichuan University, Chengdu, PR China
| |
Collapse
|
15
|
Castillo Sánchez I, Camarasa JT, Barbeta Sánchez E, Oliveira VR. Clinical and functional status of patients with severe COVID-19 pneumonia: an observational study at 2-3 months following discharge. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1248869. [PMID: 37671070 PMCID: PMC10475945 DOI: 10.3389/fresc.2023.1248869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023]
Abstract
Introduction Critically ill COVID-19 patients present long-term sequelae that affect their everyday life. This study aimed to describe the clinical and functional status of patients with severe COVID-19 pneumonia at 2-3 months post discharge from a Spanish critical care unit. Methods We collected retrospective data from 58 patients admitted to the critical care unit with diagnosis of severe respiratory failure due to COVID-19. Only patients who required invasive (IMV) or noninvasive ventilation (NIV) during their hospital stay were included. The following data were collected 2-3 months after hospital discharge: respiratory signs and symptoms, lung ultrasound (LUS) and diaphragm ultrasound images, blood test analysis, lung function parameters (spirometry and DLCO), exercise capacity (6 min walk test and sit-to-stand test), level of physical activity and health-related quality of life. Results We found clinical symptoms and lung structural alterations in LUS images of 26 patients (48.1%). Those presenting LUS abnormalities had longer length of stay in hospital (p = 0.026), functional alterations in spirometry (p < 0.01) and decreased diaphragm excursion (p = 0.029). No significant alterations were observed in blood test analysis, exercise capacity, level of physical activity and health-related quality of life. Conclusions A significant part of the patients admitted to a critical care unit continue to present clinical symptoms, pulmonary morphological abnormalities, and lung function alterations 2-3 months post discharge. This study corroborates that assessing the functional status of the survivors is essential to monitor the evolution of pulmonary sequelae.
Collapse
Affiliation(s)
- Inmaculada Castillo Sánchez
- Pneumology Department, Granollers General Hospital, Barcelona, Spain
- Faculty of Health Sciences and Welfare, Universitat de Vic–Universitat Central de Catalunya (UVic-UCC), Vic, Spain
| | - Julia Tárrega Camarasa
- Pneumology Department, Granollers General Hospital, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
| | | | - Vinicius Rosa Oliveira
- Faculty of Health Sciences and Welfare, Universitat de Vic–Universitat Central de Catalunya (UVic-UCC), Vic, Spain
- Research Group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O), UVic-UCC, Vic, Spain
| |
Collapse
|
16
|
Temporal evolution of diaphragm thickness and diaphragm excursion among subjects hospitalized with COVID-19: A prospective observational study. Respir Med Res 2023; 83:100960. [PMID: 36563547 PMCID: PMC9770987 DOI: 10.1016/j.resmer.2022.100960] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has an affinity for the angiotensin-converting enzyme 2 (ACE2) receptors, which are present abundantly on the diaphragm. This study aims to describe temporal changes in diaphragmatic thickness and excursion using ultrasonography in subjects with acute COVID-19. METHODS This prospective observational study included adults hospitalized with COVID-19 in the past 48 hours. The diaphragm thickness at end-expiration (DTE), diaphragm thickening fraction (DTF), and diaphragm excursion during tidal breathing (DE) and maximal inspiration (DEmax) were measured using ultrasonography daily for 5 days. The changes in DTE, DTF, DE, and Demax from day 1 to day 5 were assessed. RESULTS This study included 64 adults (62.5% male) with a mean (SD) age of 50.2 (17.5) years. A majority (91%) of the participants had mild or moderate illness. The median (IQR) DTE, DTF (%), DE and Demax on day 1 were 2.2 (1.9, 3.0) mm, 21.5% (14.2, 31.0), 19.2 (16.5, 24.0) mm, and 26.7 (22.0, 30.2) mm, respectively. On day 5, there was a significant reduction in the DTE (p=0.002) with a median (IQR) percentage change of -15.7% (-21.0, 0.0). The DTF significantly increased on day 5 with a median (IQR) percentage change of 25.0% (-19.2, 98.4), p=0.03. There was no significant change in DE and Demax from day 1 to day 5, with a median (IQR) percentage change of 3.6% (-5.2, 15) and 0% (-6.7, 5.9), respectively. CONCLUSIONS Non-intubated patients with COVID-19 exhibited a temporal decline in diaphragm thickness with increase in thickening fraction over 5 days of hospital admission. Further research is warranted to assess the impact of COVID-19 pneumonia on diaphragmatic function.
Collapse
|
17
|
Vetrugno L, Deana C, Castaldo N, Fantin A, Belletti A, Sozio E, De Martino M, Isola M, Palumbo D, Longhini F, Cammarota G, Spadaro S, Maggiore SM, Bassi F, Tascini C, Patruno V. Barotrauma during Noninvasive Respiratory Support in COVID-19 Pneumonia Outside ICU: The Ancillary COVIMIX-2 Study. J Clin Med 2023; 12:jcm12113675. [PMID: 37297869 DOI: 10.3390/jcm12113675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Noninvasive respiratory support (NIRS) has been extensively used during the COVID-19 surge for patients with acute respiratory failure. However, little data are available about barotrauma during NIRS in patients treated outside the intensive care unit (ICU) setting. METHODS COVIMIX-2 was an ancillary analysis of the previous COVIMIX study, a large multicenter observational work investigating the frequencies of barotrauma (i.e., pneumothorax and pneumomediastinum) in adult patients with COVID-19 interstitial pneumonia. Only patients treated with NIRS outside the ICU were considered. Baseline characteristics, clinical and radiological disease severity, type of ventilatory support used, blood tests and mortality were recorded. RESULTS In all, 179 patients were included, 60 of them with barotrauma. They were older and had lower BMI than controls (p < 0.001 and p = 0.045, respectively). Cases had higher respiratory rates and lower PaO2/FiO2 (p = 0.009 and p < 0.001). The frequency of barotrauma was 0.3% [0.1-1.3%], with older age being a risk factor for barotrauma (OR 1.06, p = 0.015). Alveolar-arterial gradient (A-a) DO2 was protective against barotrauma (OR 0.92 [0.87-0.99], p = 0.026). Barotrauma required active treatment, with drainage, in only a minority of cases. The type of NIRS was not explicitly related to the development of barotrauma. Still, an escalation of respiratory support from conventional oxygen therapy, high flow nasal cannula to noninvasive respiratory mask was predictive for in-hospital death (OR 15.51, p = 0.001). CONCLUSIONS COVIMIX-2 showed a low frequency for barotrauma, around 0.3%. The type of NIRS used seems not to increase this risk. Patients with barotrauma were older, with more severe systemic disease, and showed increased mortality.
Collapse
Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100 Chieti, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Venezia Giulia, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Nadia Castaldo
- Pulmonology Unit, Department of Cardio-Thoracic Surgery, Health Integrated Agency of Friuli Venezia Giulia, 33100 Udine, Italy
| | - Alberto Fantin
- Pulmonology Unit, Department of Cardio-Thoracic Surgery, Health Integrated Agency of Friuli Venezia Giulia, 33100 Udine, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Emanuela Sozio
- Infectious Disease Unit, Health Integrated Agency of Friuli Venezia Giulia, 33100 Udine, Italy
| | - Maria De Martino
- Department of Medical Area, University of Udine, 33100 Udine, Italy
| | - Miriam Isola
- Department of Medical Area, University of Udine, 33100 Udine, Italy
| | - Diego Palumbo
- Department of Radiology, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater, Domini, Magna Graecia University, 88100 Catanzaro, Italy
| | - Gianmaria Cammarota
- Anesthesiology and Intensive Care, Department of Translational medicine, Faculty of Medicine and Surgery, University of Ferrara, 44121 Ferrara, Italy
| | - Savino Spadaro
- Department of Medicine and Surgery, University of Perugia, 06123 Perugia, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, 66100 Chieti, Italy
- Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti Pescara, 66100 Chieti, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Venezia Giulia, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Carlo Tascini
- Infectious Disease Unit, Health Integrated Agency of Friuli Venezia Giulia, 33100 Udine, Italy
- Department of Medical Area, University of Udine, 33100 Udine, Italy
| | - Vincenzo Patruno
- Pulmonology Unit, Department of Cardio-Thoracic Surgery, Health Integrated Agency of Friuli Venezia Giulia, 33100 Udine, Italy
| |
Collapse
|
18
|
Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
Collapse
Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| |
Collapse
|
19
|
De Rosa S, Umbrello M, Pelosi P, Battaglini D. Update on Lean Body Mass Diagnostic Assessment in Critical Illness. Diagnostics (Basel) 2023; 13:diagnostics13050888. [PMID: 36900032 PMCID: PMC10000858 DOI: 10.3390/diagnostics13050888] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Acute critical illnesses can alter vital functions with profound biological, biochemical, metabolic, and functional modifications. Despite etiology, patient's nutritional status is pivotal to guide metabolic support. The assessment of nutritional status remains complex and not completely elucidated. Loss of lean body mass is a clear marker of malnutrition; however, the question of how to investigate it still remains unanswered. Several tools have been implemented to measure lean body mass, including a computed tomography scan, ultrasound, and bioelectrical impedance analysis, although such methods unfortunately require validation. A lack of uniform bedside measurement tools could impact the nutrition outcome. Metabolic assessment, nutritional status, and nutritional risk have a pivotal role in critical care. Therefore, knowledge about the methods used to assess lean body mass in critical illnesses is increasingly required. The aim of the present review is to update the scientific evidence regarding lean body mass diagnostic assessment in critical illness to provide the diagnostic key points for metabolic and nutritional support.
Collapse
Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences—CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, 38123 Trento, Italy
| | - Michele Umbrello
- S.C. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST dei Santi Paolo e Carlo, 20142 Milano, Italy
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, 16132 Genova, Italy
| | - Denise Battaglini
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Correspondence:
| |
Collapse
|
20
|
Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure. Diagnostics (Basel) 2023; 13:diagnostics13030411. [PMID: 36766515 PMCID: PMC9914801 DOI: 10.3390/diagnostics13030411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying etiologies. In these cases, many factors related to systemic inflammation, prolonged use of steroids, and lung mechanical abnormalities (such as hyperinflation or increased elastic recoil due to pulmonary oedema or fibrosis) may act as synergic mechanisms leading to diaphragm dysfunction. The assessment of diaphragm function with ultrasound has been increasingly investigated in the emergency department and during hospital stay as a valuable tool for providing additional anatomical and functional information in many acute respiratory diseases. The diaphragmatic ultrasound is a noninvasive and repeatable bedside tool, has no contraindications, and allows the physician to rapidly assess the presence of diaphragmatic dysfunction; this evaluation may help in estimating the need for mechanical ventilation (and the risk of weaning failure), as well as the risk of longer hospital stay and higher mortality rate. This study presents an overview of the recent evidence regarding the evaluation of diaphragmatic function with bedside ultrasound and its clinical applications, including a discussion of real-life clinical cases.
Collapse
|