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Formenti P, Ruzza F, Pederzolli Giovanazzi G, Sabbatini G, Galimberti A, Gotti M, Pezzi A, Umbrello M. Exploring ultrasonographic diaphragmatic function in perioperative anesthesia setting: A comprehensive narrative review. J Clin Anesth 2024; 97:111530. [PMID: 38986431 DOI: 10.1016/j.jclinane.2024.111530] [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: 02/28/2024] [Revised: 05/16/2024] [Accepted: 06/11/2024] [Indexed: 07/12/2024]
Abstract
The ultrasound study of diaphragm function represents a valid method that has been extensively studied in recent decades in various fields, especially in intensive care, emergency, and pulmonology settings. Diaphragmatic function is pivotal in these contexts due to its crucial role in respiratory mechanics, ventilation support strategies, and overall patient respiratory outcomes. Dysfunction or weakness of the diaphragm can lead to respiratory failure, ventilatory insufficiency, and prolonged mechanical ventilation, making its assessment essential for patient management and prognosis in critical care and emergency medicine. While several studies have focused on diaphragmatic functionality in the context of intensive care, there has been limited attention within the field of anesthesia. The ultrasound aids in assessing diaphragmatic dysfunction (DD) by measuring muscle mass and contractility and their potential variations over time. Recent advancements in ultrasound imaging allow clinicians to evaluate diaphragm function and monitor it during mechanical ventilation more easily. In the context of anesthesia, early studies have shed light on the patho-physiological mechanisms of diaphragm function during general anesthesia. In contrast, more recent research has centered on evaluating diaphragmatic functionality at various phases of general anesthesia and by comparing diverse types of procedures or anatomical position during surgery. The objectives of this current review are to highlight the use of diaphragm ultrasound for the evaluation of diaphragmatic function during perioperative anesthesia and surgery. Specifically, we aim to examine the effects of anesthetic agents, surgical techniques, and anatomical positioning on diaphragmatic function. We explore how ultrasound aids in assessing DD by measuring muscle mass and contractility, as well as their potential variations over time. Additionally, we will discuss recent advancements in ultrasound imaging that allow clinicians to evaluate diaphragm function and monitor it during mechanical ventilation more easily.
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Affiliation(s)
- Paolo Formenti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo 20097, Milan, Italy.
| | - Francesca Ruzza
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy
| | | | - Giovanni Sabbatini
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo 20097, Milan, Italy
| | - Andrea Galimberti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo 20097, Milan, Italy
| | - Miriam Gotti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo 20097, Milan, Italy
| | - Angelo Pezzi
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo 20097, Milan, Italy
| | - Michele Umbrello
- Department of Intensive Care, New Hospital of Legnano: Ospedale Nuovo di Legnano, 20025, Legnano, Milan, Italy
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Liu F, Wen Q, Yang Y, Chen J, Jin G, Yu L, He J. Diaphragmatic dysfunction is associated with postoperative pulmonary complications in the aged patients underwent radical resection of esophageal cancer: a prospective observational study. J Thorac Dis 2024; 16:3623-3635. [PMID: 38983161 PMCID: PMC11228742 DOI: 10.21037/jtd-24-197] [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: 02/02/2024] [Accepted: 04/26/2024] [Indexed: 07/11/2024]
Abstract
Background Diaphragmatic dysfunction escalates the susceptibility to postoperative pulmonary complications (PPCs). Currently, no study reports the occurrence of diaphragmatic dysfunction correlated with PPCs following radical resection of esophageal cancer in aged patients. We aimed to diagnose diaphragmatic dysfunction via ultrasonography and analyze diaphragmatic dysfunction's relation with PPCs after radical resection of esophageal cancer surgery in aged patients. Methods This prospective observational study comprised 86 aged patients undergoing radical resection of esophageal cancer. Patient characteristics data and intraoperative details were collected. Ultrasonography was performed before (preoperative) and after (first, third, and fifth day postoperatively) surgery. Outcome measures included PPCs within seven days postoperative, occurrence of diaphragmatic dysfunction, and short-term prognosis. Results After excluding 14 patients, we finally analyzed clinical data from 72 patients. The prevalence of PPCs was higher in the patients with diaphragmatic dysfunction than those without (19 of 23, 83% vs. 21 of 49, 43%, P=0.004). Postoperative diaphragmatic dysfunction was positively correlated with PPCs in patients who underwent elective radical esophageal cancer surgery (r=0.37, P=0.001). Persistent diaphragmatic dysfunction, furthermore, was positively correlated with the development of multiple PPCs (r=0.43, P<0.001). The logistic regression analysis revealed that age, total open procedure, and postoperative diaphragmatic dysfunction were identified as significant risk factors for PPCs, while total open procedure was an independent risk factor for diaphragmatic dysfunction. Conclusions Postoperative diaphragmatic dysfunction positively correlates with developing PPCs. Continuous monitoring of postoperative diaphragmatic function can screen high-risk patients with PPCs, which has specific clinical significance. Age, total open procedure, and diaphragmatic dysfunction are identified as risk factors for developing PPCs, while total open procedure specifically increases the risk for postoperative diaphragmatic dysfunction.
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Affiliation(s)
- Fuqiang Liu
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Qian Wen
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
| | - Yiwen Yang
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Jiahui Chen
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Guangshan Jin
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Ling Yu
- Department of Ultrasound, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jianhua He
- Department of Anesthesiology, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, China
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, China
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Yao XY, Li HM, Sun BW, Zhang YY, Feng JG, Jia J, Liu L. Ultrasound assessment of diaphragmatic dysfunction in non-critically ill patients: relevant indicators and update. Front Med (Lausanne) 2024; 11:1389040. [PMID: 38957305 PMCID: PMC11217340 DOI: 10.3389/fmed.2024.1389040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/03/2024] [Indexed: 07/04/2024] Open
Abstract
Diaphragm dysfunction (DD) can be classified as mild, resulting in diaphragmatic weakness, or severe, resulting in diaphragmatic paralysis. Various factors such as prolonged mechanical ventilation, surgical trauma, and inflammation can cause diaphragmatic injury, leading to negative outcomes for patients, including extended bed rest and increased risk of pulmonary complications. Therefore, it is crucial to protect and monitor diaphragmatic function. Impaired diaphragmatic function directly impacts ventilation, as the diaphragm is the primary muscle involved in inhalation. Even unilateral DD can cause ventilation abnormalities, which in turn lead to impaired gas exchange, this makes weaning from mechanical ventilation challenging and contributes to a higher incidence of ventilator-induced diaphragm dysfunction and prolonged ICU stays. However, there is insufficient research on DD in non-ICU patients, and DD can occur in all phases of the perioperative period. Furthermore, the current literature lacks standardized ultrasound indicators and diagnostic criteria for assessing diaphragmatic dysfunction. As a result, the full potential of diaphragmatic ultrasound parameters in quickly and accurately assessing diaphragmatic function and guiding diagnostic and therapeutic decisions has not been realized.
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Affiliation(s)
- Xin-Yu Yao
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Hong-Mei Li
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Anesthesiology, Chengdu Fifth People’s Hospital, Chengdu, China
| | - Bo-Wen Sun
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Ying-Ying Zhang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Jian-Guo Feng
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Jing Jia
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, China
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Boussuges M, Blanc P, Bregeon F, Boussuges A. Interest of thoracic ultrasound after cardiac surgery or interventional cardiology. World J Cardiol 2024; 16:118-125. [PMID: 38576518 PMCID: PMC10989224 DOI: 10.4330/wjc.v16.i3.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 03/21/2024] Open
Abstract
Thoracic ultrasound has attracted much interest in detecting pleural effusion or pulmonary consolidation after cardiac surgery. In 2016, Trovato reported, in the World Journal of Cardiology, the interest of using, in addition to echocardiography, thoracic ultrasound. In this editorial, we highlight the value of assessing diaphragm function after cardiac surgery and interventional cardiology procedures. Various factors are able to impair diaphragm function after such interventions. Diaphragm motion may be decreased by chest pain secondary to sternotomy, pleural effusion or impaired muscle function. Hemidiaphragmatic paralysis may be secondary to phrenic nerve damage complicating cardiac surgery or atrial fibrillation ablation. Diagnosis may be delayed. Indeed, respiratory troubles induced by diaphragm dysfunction are frequently attributed to pre-existing heart disease or pulmonary complications secondary to surgery. In addition, elevated hemidiaphragm secondary to diaphragm dysfunction is sometimes not observed on chest X-ray performed in supine position in the intensive care unit. Analysis of diaphragm function by ultrasound during the recovery period appears essential. Both hemidiaphragms can be studied by two complementary ultrasound methods. The mobility of each hemidiaphragms is measured by M-mode ultrasonography. In addition, recording the percentage of inspiratory thickening provides important information about the quality of muscle function. These two approaches make it possible to detect hemidiaphragm paralysis or dysfunction. Such a diagnosis is important because persistent diaphragm dysfunction after cardiac surgery has been shown to be associated with adverse respiratory outcome. Early respiratory physiotherapy is able to improve respiratory function through strengthening of the inspiratory muscles i.e. diaphragm and accessory inspiratory muscles.
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Affiliation(s)
- Martin Boussuges
- Service de Pneumologie, Centre Hospitalier Universitaire Sud Reunion, Saint Pierre 97410, Ile de la Reunion, France
| | - Philippe Blanc
- Department of Cardiac and Pulmonary Rehabilitation, Ste Clotilde & YlangYlang Rehabilitation Center, Sainte Clotilde 97491, Ile de la Reunion, France
| | - Fabienne Bregeon
- Service d'Explorations Fonctionnelles Respiratoires, Centre Hospitalier Universitaire Nord, Assistance Publique des Hôpitaux de Marseille, Marseille 13015, France
- Institut Hospitalo-Universitaire-Méditerranée Infection, Aix Marseille Université, Marseille 13005, France
| | - Alain Boussuges
- Service d'Explorations Fonctionnelles Respiratoires, Centre Hospitalier Universitaire Nord, Assistance Publique des Hôpitaux de Marseille, Marseille 13015, France
- Center for Cardiovascular and Nutrition Research, Aix Marseille Université, Institut National de la Santé et de la Recherche Médicale, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Marseille 13005, France.
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Moury PH, Béhouche A, Bailly S, Durand Z, Dessertaine G, Pollet A, Jaber S, Verges S, Albaladejo P. Diaphragm thickness modifications and associated factors during VA-ECMO for a cardiogenic shock: a cohort study. Ann Intensive Care 2024; 14:38. [PMID: 38457010 PMCID: PMC10923772 DOI: 10.1186/s13613-024-01264-8] [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: 09/23/2023] [Accepted: 02/16/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The incidence, causes and impact of diaphragm thickness evolution in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock are unknown. Our study investigates its evolution during the first week of VA-ECMO and its relationship with sweep gas flow settings. METHODS We conducted a prospective monocentric observational study in a 12-bed ICU in France, enrolling patients on the day of the VA-ECMO implantation. The diaphragm thickness and the diaphragm thickening fraction (as index of contractile activity, dTF; dTF < 20% defined a low contractile activity) were daily measured for one week using ultrasound. Factors associated with diaphragm thickness evolution (categorized as increased, stable, or atrophic based on > 10% modification from baseline to the last measurement), early extubation role (< day4), and patients outcome at 60 days were investigated. Changes in diaphragm thickness, the primary endpoint, was analysed using a mixed-effect linear model (MLM). RESULTS Of the 29 included patients, seven (23%) presented diaphragm atrophy, 18 remained stable (60%) and 4 exhibited an increase (17%). None of the 13 early-extubated patients experienced diaphragm atrophy, while 7 (46%) presented a decrease when extubated later (p-value = 0.008). Diaphragm thickness changes were not associated with the dTF (p-value = 0.13) but with sweep gas flow (Beta = - 3; Confidence Interval at 95% (CI) [- 4.8; - 1.2]. p-value = 0.001) and pH (Beta = - 2; CI [- 2.9; - 1]. p-value < 0.001) in MLM. The dTF remained low (< 20%) in 20 patients (69%) at the study's end and was associated with sweep gas flow evolution in MLM (Beta = - 2.8; 95% CI [- 5.2; - 0.5], p-value = 0.017). Odds ratio of death at 60 days in case of diaphragm atrophy by day 7 was 8.50 ([1.4-74], p = 0.029). CONCLUSION In our study, diaphragm thickness evolution was frequent and not associated with the diaphragm thickening fraction. Diaphragm was preserved from atrophy in case of early extubation with ongoing VA-ECMO assistance. Metabolic disorders resulting from organ failures and sweep gas flow were linked with diaphragm thickness evolution. Preserved diaphragm thickness in VA-ECMO survivors emphasizes the importance of diaphragm-protective strategies, including meticulous sweep gas flow titration.
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Affiliation(s)
- Pierre-Henri Moury
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France.
- Univ. Grenoble Alpes, Inserm, Grenoble Alpes University Hospital, HP2 Laboratory, Grenoble, France.
| | - Alexandre Béhouche
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
| | - Sébastien Bailly
- Univ. Grenoble Alpes, Inserm, Grenoble Alpes University Hospital, HP2 Laboratory, Grenoble, France
| | - Zoé Durand
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
| | | | - Angelina Pollet
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Anaesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Samuel Verges
- Univ. Grenoble Alpes, Inserm, Grenoble Alpes University Hospital, HP2 Laboratory, Grenoble, France
| | - Pierre Albaladejo
- Pôle Anesthésie-Réanimation, Grenoble Alpes University, Grenoble, France
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Olímpio Júnior H, Camilo GB, Marques JA, Xavier RS, Santos CE, Lopes AJ. Effects of transcutaneous electrical diaphragmatic stimulation in critically ill elderly patients: a randomized controlled trial. Physiother Theory Pract 2023:1-10. [PMID: 38044840 DOI: 10.1080/09593985.2023.2289053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/25/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Elderly patients under invasive mechanical ventilation (IMV) are more susceptible to muscle weakness. In the out-of-hospital environment, there are benefits to transcutaneous electrical diaphragmatic stimulation (TEDS), which is an easy-to-apply and low-cost technique. OBJECTIVE To evaluate the effect of TEDS on respiratory muscle strength, diaphragm thickness (DT), and IMV time in critically ill elderly patients. METHODS This was a randomized controlled trial in which patients were divided into an experimental group (EG) and a control group (CG). TEDS started 24 h after orotracheal intubation and lasted until the end of weaning. Both groups underwent the following assessments during the spontaneous breathing test after weaning from mechanical ventilation (MV): measurement of respiratory muscle strength by pressure gauge, analysis of DT by lung ultrasound, and extubation failure prevention checklist. RESULTS There were 23 participants in the EG and 21 in the CG. The median age was 66 (60-79) years. The mean values of the diaphragmatic thickening index in the EG and CG participants were 99.13 ± 26.75 and 66.88 ± 31.77, respectively (p = .001, Cohen's d = 1.094). The mean values of maximum inspiratory pressure in the EG and CG were 22.04 ± 3.41 and 19.34 ± 4.23 cmH2O, respectively (p = .005, Cohen's d = 0.698). The Tobin index and the integrative weaning index were similar between groups (p = .584 and p = .102, respectively). The duration of MV in the EG and CG was 6.28 ± 2.68 and 9.21 ± 2.76 days, respectively (p = .001, Cohen's d = -1.075). CONCLUSION Critically ill elderly patients receiving TEDS had shorter MV time, greater inspiratory muscle strength, and greater diaphragmatic contraction capacity according to their thickness fraction.
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Affiliation(s)
- Hebert Olímpio Júnior
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Gustavo Bittencourt Camilo
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
- Faculty of Medical and Health Sciences of Juiz de Fora (SUPREMA), Minas Gerais, Brazil
| | | | - Rosemere Saldanha Xavier
- Local Development Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
| | - Carlos Eduardo Santos
- Rehabilitation Sciences Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
- Local Development Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
- Rehabilitation Sciences Postgraduate Programme, Centro Universitario Augusto Motta (UNISUAM), Rio de Janeiro, Brazil
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Rizza V, Maranta F, Cianfanelli L, Cartella I, Alfieri O, Cianflone D. Imaging of the Diaphragm Following Cardiac Surgery: Focus on Ultrasonographic Assessment. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2481-2490. [PMID: 37357908 DOI: 10.1002/jum.16291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
Diaphragm dysfunction is a common complication following cardiac surgery. Its clinical impact is variable, ranging from the absence of symptoms to the acute respiratory failure. Post-operative diaphragm dysfunction may negatively affect patients' prognosis delaying the weaning from the mechanical ventilation (MV), extending the time of hospitalization and increasing mortality. Ultrasonography is a valid tool to evaluate diaphragmatic impairment in different settings, like the Intensive Care Unit, to predict successful weaning from the MV, and the Cardiovascular Rehabilitation Unit, to stratify patients in terms of risk of functional recovery failure. The aim of this review is to describe the pathophysiology of post-cardiac surgery diaphragm dysfunction, the techniques used for its diagnosis and the potential applications of diaphragm ultrasound.
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Affiliation(s)
| | - Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Vita-Salute San Raffaele University, Milan, Italy
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
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Moury PH, Pasquier V, Greco F, Arvieux JL, Alves-Macedo S, Richard M, Casez-Brasseur M, Skaare K, Jacon P, Durand M, Bedague D, Jaber S, Bosson JL, Albaladejo P. A randomized controlled trial of the intraoperative use of noninvasive ventilation versus supplemental oxygen by face mask for procedural sedation in an electrophysiology laboratory. Can J Anaesth 2023; 70:1182-1193. [PMID: 37268802 DOI: 10.1007/s12630-023-02495-2] [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: 07/26/2022] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 06/04/2023] Open
Abstract
PURPOSE The efficacy of noninvasive ventilation (NIV) during procedures that require sedation and analgesia has not been established. We evaluated whether NIV reduces the incidence of respiratory events. METHODS In this randomized controlled trial, we included 195 patients with an American Society of Anesthesiologists Physical Status of III or IV during electrophysiology laboratory procedures. We compared NIV with face mask oxygen therapy for patients under sedation. The primary outcome was the incidence of respiratory events determined by a computer-driven blinded analysis and defined by hypoxemia (peripheral oxygen saturation < 90%) or apnea/hypopnea (absence of breathing for 20 sec on capnography). Secondary outcomes included hemodynamic variables, sedation, patient safety (composite scores of major or minor adverse events), and adverse outcomes at day 7. RESULTS A respiratory event occurred in 89/98 (95%) patients in the NIV group and in 69/97 (73%) patients with face masks (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.13 to 1.47; P < 0.001). Hypoxemia occurred in 40 (42%) patients in the NIV group and in 33 (34%) patients with face masks (RR, 1.21; 95% CI, 0.84 to 1.74; P = 0.30). Apnea/hypopnea occurred in 83 patients (92%) in the NIV group vs 65 patients (70%) with face masks (RR, 1.32; 95% CI, 1.14 to 1.53; P < 0.001). Hemodynamic variables, sedation, major or minor safety events, and patient outcomes were not different between the groups. CONCLUSIONS Respiratory events were more frequent among patients receiving NIV without any safety or outcome impairment. These results do not support the routine use of NIV intraoperatively. STUDY REGISTRATION ClinicalTrials.gov (NCT02779998); registered 4 November 2015.
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Affiliation(s)
- Pierre-Henri Moury
- HP2 Laboratory, U1042, Grenoble Alpes University, Grenoble, France.
- Pôle Anesthésie-Réanimation, Réanimation Cardiovasculaire et Thoracique, CHU Grenoble Alpes, CS 10217, Grenoble Cedex 9, France.
| | | | - Flora Greco
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | | | | | - Marion Richard
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | | | - Kristina Skaare
- Department of Biostatistics, Public Health, ThEMAS, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Peggy Jacon
- Department of Cardiology, CHU Grenoble Alpes, Grenoble, France
| | - Michel Durand
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Damien Bedague
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier, France
| | - Jean-Luc Bosson
- Department of Biostatistics, Public Health, ThEMAS, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
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Singh A, Mandal B, Negi S, Puri GD, Thingnam SKS. Ultrasonic prediction of weaning failure in children undergoing cardiac surgery: A prospective observational study. Ann Card Anaesth 2023; 26:281-287. [PMID: 37470526 PMCID: PMC10451141 DOI: 10.4103/aca.aca_113_22] [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: 06/28/2022] [Revised: 08/15/2022] [Accepted: 09/13/2022] [Indexed: 07/21/2023] Open
Abstract
Background and Aim To assess the utility of ultrasonic markers like B-line score (LUS), diaphragm thickness (DT), thickening fraction (DTF), and excursion (DE) as predictors of weaning outcomes in children on mechanical ventilation (MV) after cardiac surgery. Methods This was a prospective observational study done in postcardiac surgical intensive care unit (ICU) of a tertiary care hospital. Children aged 1 month to 18 years, on MV after cardiac surgery from January to November 2017, were included. They were extubated after satisfying institutional weaning criteria. Ultrasound for LUS, DT, DTF, and DE was performed preoperatively, during pressure support ventilation (PSV) before extubation and 4 h after extubation. Results Patients were divided into weaning failure and success groups based on reintubation within 48 h of extubation. Of the 50 evaluated patients, 43 (86%) were weaned successfully and 7 (14%) had weaning failure. The left DTF during PSV was lower in patients weaning failure (0.00%, interquartile range (IQR) 0.00-14.28 vs 16.67%, IQR 8.33-22.20, P = 0. 012). The left DTF≤ 14.64% during PSV (area under receiver's operating curve 0.795, P = 0.014), 85% sensitivity, and 57% specificity (positive likelihood ratio 1.97, negative likelihood ratio 0.25) could predict weaning failure. Conclusion The left DTF during PSV is a good predictor of weaning failure in children on MV in postoperative ICU after congenital cardiac surgery. Take home message In children on mechanical ventilation after cardiac surgery, left DTF during pressure support ventilation is a good predictor of weaning failure.
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Affiliation(s)
- Avneet Singh
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Banashree Mandal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunder Negi
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shyam Kumar Singh Thingnam
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Diaphragm function in patients with sepsis and septic shock: A longitudinal ultrasound study. Aust Crit Care 2023; 36:239-246. [PMID: 35272911 DOI: 10.1016/j.aucc.2022.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous literature on the determinants of diaphragm dysfunction in septic patients is limited. The goal of this study is to assess diaphragm dysfunction in terms of its prevalence and its potential associated factors in septic intensive care unit (ICU) patients. METHODS This prospective and observational study was conducted between June 2015 and July 2019. Ultrasound measures of diaphragm thickness were performed daily on septic patients. The primary outcome was the prevalence of diaphragm dysfunction at baseline and during the ICU stay. The secondary outcome was the diaphragm thickness. Possible associated factors were prospectively recorded. RESULTS Fifty patients were enrolled in the study. The prevalence of diaphragm dysfunction was 58%. No diaphragm atrophy was found during the ICU stay. Diaphragm dysfunction was associated with the alteration of consciousness, intra-abdominal sepsis, hypnotics and opioids, and mechanical ventilation. Administration of hypnotics, opioids, and steroids was associated with a decreased diaphragm thickening fraction. Diaphragm dysfunction had no impact on patient outcomes. CONCLUSIONS Our data reveal a high prevalence of diaphragm dysfunction in septic patients at the onset of sepsis. Administration of hypnotics, opioids, and steroids was associated with the alteration of diaphragm function as well as intra-abdominal sepsis.
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11
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Hennessey E, Bittner E, White P, Kovar A, Meuchel L. Intraoperative Ventilator Management of the Critically Ill Patient. Anesthesiol Clin 2023; 41:121-140. [PMID: 36871995 PMCID: PMC9985493 DOI: 10.1016/j.anclin.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.
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Affiliation(s)
- Erin Hennessey
- Stanford University - School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
| | - Edward Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peggy White
- University of Florida College of Medicine, Department of Anesthesiology, 1500 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA
| | - Alan Kovar
- Oregon Health and Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Lucas Meuchel
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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12
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Laghlam D, Naudin C, Srour A, Monsonego R, Malvy J, Rahoual G, Squara P, Nguyen LS, Estagnasié P. Persistent diaphragm dysfunction after cardiac surgery is associated with adverse respiratory outcomes: a prospective observational ultrasound study. Can J Anaesth 2023; 70:228-236. [PMID: 36513852 PMCID: PMC9747253 DOI: 10.1007/s12630-022-02360-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Transient diaphragm dysfunction is common during the first week after cardiac surgery; however, the precise incidence, risk factors, and outcomes of persistent diaphragm dysfunction are not well described. METHODS In a single-centre prospective cohort study, we included all consecutive patients over 18 yr who underwent elective cardiac surgery. Diaphragm function was evaluated with ultrasound (M-mode) by recording the excursion of both hemidiaphragms at two different time points: preoperatively and after the seventh postoperative day in patients breathing without assistance. Significant diaphragm dysfunction after the seventh day of the index cardiac surgery was defined as a decrease in diaphragm excursion below the lower limit of normal: at rest, < 9 mm for women and < 10 mm for men; after a sniff test, < 16 mm for women and < 18 mm for men. RESULTS Overall, 122 patients were included in the analysis. The median [interquartile range (IQR)] age was 69 [59-74] years and 96/122 (79%) were men. Ten (8%) patients had diaphragm dysfunction after the seventh postoperative day. We did not identify risk factors for persistent diaphragm dysfunction. Persistent diaphragm dysfunction was associated with a longer median [IQR] duration of noninvasive (8 [0-34] vs 0 [0-0] hr; difference in medians, 8 hr; 95% confidence interval [CI], 0 to 22; P < 0.001) and invasive mechanical ventilation (5 [3-257] vs 3[2-4] hr; difference in medians, 2 hr; 95% CI, 0.5 to 41; P = 0.008); a higher reintubation rate (4/10, 40% vs 1/112, 0.9%; relative risk, 45; 95% CI, 7.1 to 278; P < 0.0001), a higher incidence of pneumonia (4/10 [40%] vs 7/112 [6%]; relative risk, 6; 95% CI, 2 to 16; P < 0.001), and longer median [IQR] length of stay in the intensive care unit (8 [5-29] vs 4 [2-6] days; difference in medians, 4 days; 95% CI, 2 to 12; P = 0.002). CONCLUSION The incidence of persistent diaphragm dysfunction was 8% in patients undergoing elective cardiac surgery and was associated with adverse respiratory outcomes. STUDY REGISTRATION ClinicalTrials.gov (NCT04276844); prospectively registered 19 February 2020.
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Affiliation(s)
- Driss Laghlam
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France.
- CERIC, Clinique Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.
| | - Cecile Naudin
- Recherche et Innovation Clinique Ambroise Paré (RICAP), Neuilly-sur-Seine, France
| | - Alexandre Srour
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
| | - Raphael Monsonego
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
| | - Julien Malvy
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
| | - Ghilas Rahoual
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
| | - Pierre Squara
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
- CERIC, Clinique Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Lee S Nguyen
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
- CERIC, Clinique Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
| | - Philippe Estagnasié
- Department of Cardiology and Critical Care, Neuilly-sur-Seine, France
- CERIC, Clinique Ambroise Paré, 27 Boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France
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13
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Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure. Diagnostics (Basel) 2023; 13:diagnostics13030411. [PMID: 36766515 PMCID: PMC9914801 DOI: 10.3390/diagnostics13030411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying etiologies. In these cases, many factors related to systemic inflammation, prolonged use of steroids, and lung mechanical abnormalities (such as hyperinflation or increased elastic recoil due to pulmonary oedema or fibrosis) may act as synergic mechanisms leading to diaphragm dysfunction. The assessment of diaphragm function with ultrasound has been increasingly investigated in the emergency department and during hospital stay as a valuable tool for providing additional anatomical and functional information in many acute respiratory diseases. The diaphragmatic ultrasound is a noninvasive and repeatable bedside tool, has no contraindications, and allows the physician to rapidly assess the presence of diaphragmatic dysfunction; this evaluation may help in estimating the need for mechanical ventilation (and the risk of weaning failure), as well as the risk of longer hospital stay and higher mortality rate. This study presents an overview of the recent evidence regarding the evaluation of diaphragmatic function with bedside ultrasound and its clinical applications, including a discussion of real-life clinical cases.
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14
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[The perioperative role of high-flow cannula oxygen (HFNO)]. Rev Mal Respir 2023; 40:61-77. [PMID: 36496314 DOI: 10.1016/j.rmr.2022.11.004] [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: 02/01/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
High-flow nasal cannula oxygen (HFNO) is commonly used during the perioperative period. Its numerous physiological benefits, satisfactory tolerance and ease of use have led to its widespread application in intensive care and post-anesthesia care units. HFNO is also used in the operating theater in multiple indications: as oxygen supplementation (associated with pressurization) prior to orotracheal intubation; in digestive and bronchial endoscopies, especially in patients at risk of hypoxemia; and in intraoperative surgery requiring spontaneous ventilation (ENT, thoracic surgery…). During the postoperative period, HFNO can be used in a curative strategy for respiratory failure or in a prophylactic strategy to prevent reintubation. In a curative approach, HFNO seems of interest following cardiac or thoracic surgery but has not been evaluated in respiratory failure subsequent to abdominal surgery, in which case noninvasive ventilation remains the gold standard. The risk of respiratory complications depends on type of surgery and on patient comorbidities. As prophylaxis, HFNO is currently preferred to conventional oxygen therapy after cardiac or thoracic surgery, especially in patients at high risk of respiratory complications. For the clinician, it is important to acknowledge the limits of HFNO and to closely monitor patients receiving HFNO, the objective being to avoid delays in intubation that could lead to increased mortality.
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15
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Maranta F, Cianfanelli L, Rizza V, Cartella I, Pistoni A, Avitabile M, Meloni C, Castiglioni A, De Bonis M, Alfieri O, Cianflone D. Diaphragm Dysfunction after Cardiac Surgery: Insights from Ultrasound Imaging during Cardiac Rehabilitation. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1179-1189. [PMID: 35351317 DOI: 10.1016/j.ultrasmedbio.2022.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/31/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
Diaphragm dysfunction is common after cardiac surgery and can be evaluated with ultrasonography (US). We aimed at assessing with US the incidence of diaphragmatic dysfunction and the impact of cardiovascular rehabilitation (CR) on its recovery. A single-center cohort study was performed. Patients were enrolled after cardiac surgery. The 6-min walking test (6MWT) and diaphragm US were performed at CR admission and after 10 rehabilitative sessions. One hundred eighty-five patients were eligible for final analysis. One hundred thirty-one patients (70.8%) were found to have diaphragm dysfunction (excursion <2 cm). After CR, 68 patients regained normal diaphragmatic function; those with persistent dysfunction had a lower level of functional performance on the 6MWT (metabolic equivalents of tasks: 3.3 vs. 3.6, p = 0.013). The patients who underwent combined surgery (adjusted odds ratio [aOR] = 4.09, p = 0.001) and those with post-operative pneumothorax (aOR = 3.02, p = 0.042) were at increased risk of failure to improve diaphragmatic excursion. US parameters were more powerful tools in predicting diaphragmatic evolution compared with the 6MWT indexes: baseline diaphragm excursion and thickening fraction were associated with complete diaphragmatic functional recovery after CR (aOR = 9.101, p < 0.001, and aOR = 1.058, p = 0.020 respectively). US is a valuable tool for the assessment of post-operative diaphragmatic dysfunction and can identify patients at risk of diaphragmatic recovery failure.
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Affiliation(s)
- Francesco Maranta
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy.
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Iside Cartella
- School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - Anna Pistoni
- General Practitioner Lombardy Training Program, Pavia, Italy
| | - Maria Avitabile
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Meloni
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Castiglioni
- Vita-Salute San Raffaele University, Milan, Italy; Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Michele De Bonis
- Vita-Salute San Raffaele University, Milan, Italy; Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Ottavio Alfieri
- Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Cianflone
- Cardiac Rehabilitation Unit, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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16
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Genty T, Laverdure F, Peyrouset O, Rezaiguia-Delclaux S, Thès J, Stéphan F. Extubation Failure Prediction by Echography of the Diaphragm After Cardiothoracic Surgery: The EXPEDIA Study. Respir Care 2022; 67:308-315. [PMID: 34983832 PMCID: PMC9993501 DOI: 10.4187/respcare.09476] [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: 11/05/2022]
Abstract
BACKGROUND Successful extubation is difficult to predict. Ultrasound measurement of the diaphragm thickening fraction (DTF) might help predict weaning failure after cardiothoracic surgery. METHODS We assessed the predictive performance of diaphragm ultrasound in a derivation cohort of 50 prospectively included cardiothoracic surgery subjects ready for a weaning trial and in a validation cohort of 39 subjects ventilated for ≥ 48 h. DTF was assessed by ultrasound during pressure support ventilation (PSV) then during a T-piece spontaneous breathing trial (SBT). DTF was the percentage change in diaphragm thickness between expiration and inspiration and DTFmax, the higher DTF value of the 2 hemidiaphragms. DTFmax during SBT (static study) and the difference in DTFmax between PSV and SBT (dynamic study) were analyzed. RESULTS In the derivation cohort, DTFmax during SBT was 25.6 ± 17.3% in subjects with successful extubation and 65.2 ± 17.3% in those with weaning failure (difference 39.7 [95% CI 27.4-51.9], P < .01). During SBT, DTFmax ≥ 50% was associated with weaning failure (area under the receiver operating characteristic curve [AUC] 0.94 ± 0.05). In the dynamic study, a ≥ 40% DTFmax increase was associated with weaning failure (AUC 0.91 ± 0.06). In the validation cohort, DTFmax during SBT was 20.3 ± 17.1% in subjects with successful extubation and 82.0 ± 51.6% in those with weaning failure (difference 61.8 [95% CI 41.6-82.0], P < .01). During SBT, DTFmax ≥ 50% predicted weaning failure (AUC 0.99 ± 0.02). In the dynamic study, a ≥ 40% increase in DTFmax predicted weaning failure (AUC 0.81 ± 0.09). CONCLUSIONS Measuring DTFmax during SBT and the DTFmax change when switching from PSV to SBT may help predict weaning failure after cardiothoracic surgery. The study was registered on ANZCTR. CLINICAL TRIAL REGISTRATION NUMBER U1111-1180-1999.
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Affiliation(s)
- Thibaut Genty
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France.
| | - Florent Laverdure
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Olivier Peyrouset
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Saïda Rezaiguia-Delclaux
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Jacques Thès
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - François Stéphan
- Department of Anesthesiology and Intensive Care, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris, France and University Paris Saclay Faculty of Medicine, Kremlin Bicêtre, France
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17
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Fayssoil A, Mansencal N, Nguyen LS, Orlikowski D, Prigent H, Bergounioux J, Annane D, Lofaso F. Diaphragm Ultrasound in Cardiac Surgery: State of the Art. MEDICINES 2022; 9:medicines9010005. [PMID: 35049938 PMCID: PMC8779362 DOI: 10.3390/medicines9010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/01/2022] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
In cardiac surgery, patients are at risk of phrenic nerve injury, which leads to diaphragm dysfunction and acute respiratory failure. Diaphragm dysfunction (DD) is relatively frequent in cardiac surgery and particularly affects patients after coronary artery bypass graft. The onset of DD affects patients’ prognosis in term of weaning from mechanical ventilation and hospital length of stay. The authors present a narrative review about diaphragm physiology, techniques used to assess diaphragm function, and the clinical application of diaphragm ultrasound in patients undergoing cardiac surgery.
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Affiliation(s)
- Abdallah Fayssoil
- Echo Lab, CHU de Raymond-Poincaré, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- INSERM U1179, END-ICAP, Université de Versailles-Saint Quentin, University of Paris-Saclay, 78180 Montigny-le-Bretonneux, France; (H.P.); (F.L.)
- Raymond Poincaré Hospital, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- Centre de Référence des Cardiomyopathies et des Troubles du Rythme Cardiaque Héréditaires ou Rares, Department of Cardiology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Université de Versailles-Saint Quentin, 92100 Boulogne, France;
- Correspondence:
| | - Nicolas Mansencal
- Centre de Référence des Cardiomyopathies et des Troubles du Rythme Cardiaque Héréditaires ou Rares, Department of Cardiology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Université de Versailles-Saint Quentin, 92100 Boulogne, France;
- INSERM U-1018, CESP, Épidémiologie Clinique, 94807 Villejuif, France
| | - Lee S. Nguyen
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, AP-HP, Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France;
- France Research and Innovation Department, CMC Ambroise Paré, RICAP, 27 bd Victor Hugo, 92200 Neuilly-sur-Seine, France
| | - David Orlikowski
- Service de Réanimation Médicale, CHU Raymond Poincaré, AP-HP, Université de Versailles Saint Quentin en Yvelines, 92380 Garches, France;
- Centre d’Investigation Clinique et Innovation Technologique CIC 14.29, INSERM, 92380 Garches, France
| | - Hélène Prigent
- INSERM U1179, END-ICAP, Université de Versailles-Saint Quentin, University of Paris-Saclay, 78180 Montigny-le-Bretonneux, France; (H.P.); (F.L.)
- Raymond Poincaré Hospital, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest—Site Raymond Poincaré—AP-HP, 92380 Garches, France
| | - Jean Bergounioux
- Pediatric Neurology and ICU, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond-Poincaré, 92380 Garches, France;
| | - Djillali Annane
- Laboratory Infection and Inflammation, Department of Critical Care, Raymond Poincaré Hospital (AP-HP), U1173, Faculty of Health Science Simone Veil, Université de Versailles-Saint Quentin, University Paris Saclay, INSERM, FHU SEPSIS, RHU RECORDS, 78180 Montigny-le-Bretonneux, France;
| | - Frédéric Lofaso
- INSERM U1179, END-ICAP, Université de Versailles-Saint Quentin, University of Paris-Saclay, 78180 Montigny-le-Bretonneux, France; (H.P.); (F.L.)
- Raymond Poincaré Hospital, AP-HP, Boulevard Raymond Poincaré, 92380 Garches, France
- Service de Physiologie et Explorations Fonctionnelles, GH Paris Ile de France Ouest—Site Raymond Poincaré—AP-HP, 92380 Garches, France
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18
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Bordoni B, Escher AR. Functional evaluation of the diaphragm with a noninvasive test. J Osteopath Med 2021; 121:835-842. [PMID: 34523291 DOI: 10.1515/jom-2021-0101] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022]
Abstract
Cardiac surgery with median sternotomy causes iatrogenic damage to the function of the diaphragm muscle that is both temporary and permanent. Myocardial infarction itself causes diaphragmatic genetic alterations, which lead the muscle to nonphysiological adaptation. The respiratory muscle area plays several roles in maintaining both physical and mental health, as well as in maximizing recovery after a cardiac event. The evaluation of the diaphragm is a fundamental step in the therapeutic process, including the use of instruments such as ultrasound, magnetic resonance imaging (MRI), and computed axial tomography (CT). This article reviews the neurophysiological relationships of the diaphragm muscle and the symptoms of diaphragmatic contractile dysfunction. The authors discuss a scientific basis for the use of a new noninstrumental diaphragmatic test in the hope of stimulating research.
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Affiliation(s)
- Bruno Bordoni
- Foundation Don Carlo Gnocchi IRCCS, Department of Cardiology, Institute of Hospitalization and Care with Scientific, Milan, Italy
| | - Allan R Escher
- Anesthesiology/Pain Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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19
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Fritsch SJ, Hatam N, Goetzenich A, Marx G, Autschbach R, Heunks L, Bickenbach J, Bruells CS. Speckle tracking ultrasonography as a new tool to assess diaphragmatic function: a feasibility study. Ultrasonography 2021; 41:403-415. [PMID: 34749444 PMCID: PMC8942740 DOI: 10.14366/usg.21044] [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: 02/25/2021] [Accepted: 08/17/2021] [Indexed: 12/04/2022] Open
Abstract
A reliable method of measuring diaphragmatic function at the bedside is still lacking. Widely used two-dimensional (2D) ultrasonographic measurements, such as diaphragm excursion, diaphragm thickness, and fractional thickening (FT) have failed to show clear correlations with diaphragmatic function. A reason for this is that 2D ultrasonographic measurements, like FT, are merely able to measure the deformation of muscular diaphragmatic tissue in the transverse direction, while longitudinal measurements in the direction of contracting muscle fibres are not possible. Speckle tracking ultrasonography, which is widely used in cardiac imaging, overcomes this disadvantage and allows observations of movement in the direction of the contracting muscle fibres, approximating muscle deformation and the deformation velocity. Several studies have evaluated speckle tracking as a promising method to assess diaphragm contractility in healthy subjects. This technical note demonstrates the feasibility of speckle tracking ultrasonography of the diaphragm in a group of 20 patients after an aortocoronary bypass graft procedure. The results presented herein suggest that speckle tracking ultrasonography is able to depict alterations in diaphragmatic function after surgery better than 2D ultrasonographic measurements.
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Affiliation(s)
| | - Nima Hatam
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Andreas Goetzenich
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
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20
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Laghi FA, Saad M, Shaikh H. Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction. BMC Pulm Med 2021; 21:85. [PMID: 33722215 PMCID: PMC7958108 DOI: 10.1186/s12890-021-01441-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/19/2021] [Indexed: 12/25/2022] Open
Abstract
Diaphragm muscle dysfunction is increasingly recognized as an important element of several diseases including neuromuscular disease, chronic obstructive pulmonary disease and diaphragm dysfunction in critically ill patients. Functional evaluation of the diaphragm is challenging. Use of volitional maneuvers to test the diaphragm can be limited by patient effort. Non-volitional tests such as those using neuromuscular stimulation are technically complex, since the muscle itself is relatively inaccessible. As such, there is a growing interest in using imaging techniques to characterize diaphragm muscle dysfunction. Selecting the appropriate imaging technique for a given clinical scenario is a critical step in the evaluation of patients suspected of having diaphragm dysfunction. In this review, we aim to present a detailed analysis of evidence for the use of ultrasound and non-ultrasound imaging techniques in the assessment of diaphragm dysfunction. We highlight the utility of the qualitative information gathered by ultrasound imaging as a means to assess integrity, excursion, thickness, and thickening of the diaphragm. In contrast, quantitative ultrasound analysis of the diaphragm is marred by inherent limitations of this technique, and we provide a detailed examination of these limitations. We evaluate non-ultrasound imaging modalities that apply static techniques (chest radiograph, computerized tomography and magnetic resonance imaging), used to assess muscle position, shape and dimension. We also evaluate non-ultrasound imaging modalities that apply dynamic imaging (fluoroscopy and dynamic magnetic resonance imaging) to assess diaphragm motion. Finally, we critically review the application of each of these techniques in the clinical setting when diaphragm dysfunction is suspected.
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Affiliation(s)
- Franco A Laghi
- Department of Internal Medicine, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA
| | - Marina Saad
- Department of Biomedical and Clinical Sciences (DIBIC), Division of Pulmonary Diseases, University of Milan, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, V. G.B. Grassi, 74, 20157, Milan, Italy
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N), 5th Avenue and Roosevelt Road, Hines, IL, 60141, USA. .,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL, 60153, USA.
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21
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Laghlam D, Lê MP, Srour A, Monsonego R, Estagnasié P, Brusset A, Squara P. Diaphragm Dysfunction After Cardiac Surgery: Reappraisal. J Cardiothorac Vasc Anesth 2021; 35:3241-3247. [PMID: 33736912 DOI: 10.1053/j.jvca.2021.02.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The aim of this study was to re-investigate the incidence, risk factors, and outcomes of postoperative diaphragmatic dysfunction (DD) with actual cardiac surgery procedures. DESIGN Single-center, retrospective, observational study based on a prospectively collected database. SETTING Tertiary care cardiac surgery center. PARTICIPANTS Patients who underwent cardiac surgery between January 2016 and September 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The DD group included patients with clinically perceptible diaphragmatic paralysis, which was confirmed by chest ultrasound (amplitude of the diaphragm movement in time-motion mode at rest, after a sniff test). The primary endpoint was the incidence of DD. Among 3,577 patients included, the authors found 272 cases of DD (7.6%). Individuals with DD had more arterial hypertension (64.3% v 52.6%; p < 0.0001), higher body mass index (BMI) (28 [25-30] kg/m2v 26 [24-29] kg/m2; p < 0.0002), and higher incidence of coronary bypass grafting (CABG) (58.8% v 46.6%; p = 0.0001). DD was associated with more postoperative pneumonia (23.9% v 8.7%; p < 0.0001), reintubation (8.8% v 2.9%; p < 0.0001), tracheotomy (3.3% v 0.3%; p < 0.0001), noninvasive ventilation (45.6% v 5.4%; p < 0.0001), duration of mechanical ventilation (five [four-11] hours v four [three-six] hours; p < 0.0001), and intensive care unit and hospital stays (14 [11-17] days v 13 [11-16] days; p < 0.0001). In multivariate analysis, DD was associated with CABG (odds ratio [OR] 1.9 [1.5-2.6]; p = 0.0001), arterial hypertension (OR 1.4 [1.1-1.9]; p = 0.008), and BMI (OR per point 1.04 [1.01-1.07] kg/m2; p = 0.003). CONCLUSIONS The incidence of symptomatic DD after cardiac surgery was 7.6%, leading to respiratory complications and increased ICU stay. CABG was the principal factor associated with DD.
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Affiliation(s)
- Driss Laghlam
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France.
| | - Minh Pierre Lê
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Alexandre Srour
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Raphael Monsonego
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Philippe Estagnasié
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Alain Brusset
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Pierre Squara
- Department of Cardiology and Critical Care, Clinique Ambroise Paré, Neuilly-sur-Seine, France
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Bruni A, Garofalo E, Pasin L, Serraino GF, Cammarota G, Longhini F, Landoni G, Lembo R, Mastroroberto P, Navalesi P. Diaphragmatic Dysfunction After Elective Cardiac Surgery: A Prospective Observational Study. J Cardiothorac Vasc Anesth 2020; 34:3336-3344. [DOI: 10.1053/j.jvca.2020.06.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/31/2022]
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Abstract
PURPOSE OF REVIEW To review the clinical problem of diaphragm function in critically ill patients and describes recent advances in bedside monitoring of diaphragm function. RECENT FINDINGS Diaphragm weakness, a consequence of diaphragm dysfunction and atrophy, is common in the ICU and associated with serious clinical consequences. The use of ultrasound to assess diaphragm structure (thickness, thickening) and mobility (caudal displacement) appears to be feasible and reproducible, but no large-scale 'real-life' study is available. Diaphragm ultrasound can also be used to evaluate diaphragm muscle stiffness by means of shear-wave elastography and strain by means of speckle tracking, both of which are correlated with diaphragm function in healthy. Electrical activity of the diaphragm is correlated with diaphragm function during brief airway occlusion, but the repeatability of these measurements exhibits high within-subject variability. SUMMARY Mechanical ventilation is involved in the pathogenesis of diaphragm dysfunction, which is associated with severe adverse events. Although ultrasound and diaphragm electrical activity could facilitate monitoring of diaphragm function to deliver diaphragm-protective ventilation, no guidelines concerning the use of these modalities have yet been published. The weaning process, assessment of patient-ventilator synchrony and evaluation of diaphragm function may be the most clinically relevant indications for these techniques.
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Utilidad de la ecografía diafragmática en la evaluación preoperatoria. Arch Bronconeumol 2020. [DOI: 10.1016/j.arbres.2020.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Moury PH, Zunarelli R, Bailly S, Durand Z, Béhouche A, Garein M, Durand M, Vergès S, Albaladejo P. Diaphragm Thickening During Venoarterial Extracorporeal Membrane Oxygenation Weaning: An Observational Prospective Study. J Cardiothorac Vasc Anesth 2020; 35:1981-1988. [PMID: 33218955 DOI: 10.1053/j.jvca.2020.10.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/01/2020] [Accepted: 10/23/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The respiratory workload, according to the diaphragm thickening fraction (TF) during sweep gas flow (SGF), decrease during weaning from venoarterial extracorporeal membrane oxygenation (VA ECMO) was evaluated for the present study. DESIGN Prospective observational study. SETTING Monocentric. PARTICIPANTS Patients were included if they were suitable for a first VA ECMO weaning trial and were breathing spontaneously. INTERVENTIONS SGF was set for 15 minutes when the TF was measured at 4 L/min, 2 L/min, and 1 L/min, with a 10-minute return to baseline between each step. Mechanical ventilation, when required, was set to pressure-support ventilation mode with 7 cmH2O (pressure support) and a positive end-expiratory pressure of 0 cmH2O. Diaphragm ultrasound was used to assess the TF at the end of each step. Demographics, left ventricular ejection fraction (LVEF), and outcome were collected. MEASUREMENTS AND MAIN RESULTS Fifteen patients were included. Ten patients were extubated, and five were ventilated. TF values were 6.3% [0-10] at 4 L/min, 13.3% [10-26] at 2 L/min, and 26.7% [22-44] at 1 L/min (analysis of variance: p < 0.001 between 4 L/min and 2 L/min and p = 0.03 between 2 L/min and 1 L/min). TF did not differ whether patients were or were not ventilated or whether they were or were not weaned successfully from ECMO. TF was correlated with LVEF at 1 L/min SGF (Pearson R 0.67 [0.21-0.88]; p = 0.009) and at 2 L/min (R 0.7 [0.27-0.89]; p = 0.005) but not at 4 L/min. SGF mitigated the relationship between LVEF and TF (analysis of covariance: p < 0.005). CONCLUSIONS Diaphragm TF was related to the SGF of the venoarterial ECMO settings and LVEF at the time of weaning.
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Affiliation(s)
- Pierre Henri Moury
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France; HP2 Laboratory, Grenoble Alpes University, Grenoble, France; Réanimation, CHT Gaston-Bourret Nouméa, Nouvelle-Calédonie, France.
| | - Romain Zunarelli
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Sébastien Bailly
- HP2 Laboratory, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, CHU Grenoble Alpes, Grenoble, France
| | - Zoé Durand
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | | | - Marina Garein
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Michel Durand
- Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Samuel Vergès
- HP2 Laboratory, Grenoble Alpes University, Grenoble, France
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Diaphragm ultrasound: A novel approach to assessing pulmonary function in patients with traumatic rib fractures. J Trauma Acute Care Surg 2020; 89:96-102. [PMID: 32282755 DOI: 10.1097/ta.0000000000002723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature. METHODS We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed. RESULTS A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC. CONCLUSION To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles. LEVEL OF EVIDENCE Diagnostic tests or criteria, Level III.
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Saccheri C, Morawiec E, Delemazure J, Mayaux J, Dubé BP, Similowski T, Demoule A, Dres M. ICU-acquired weakness, diaphragm dysfunction and long-term outcomes of critically ill patients. Ann Intensive Care 2020; 10:1. [PMID: 31900667 PMCID: PMC6942110 DOI: 10.1186/s13613-019-0618-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/16/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU)-acquired weakness and diaphragm dysfunction are frequent conditions, both associated with poor prognosis in critically ill patients. While it is well established that ICU-acquired weakness severely impairs long-term prognosis, the association of diaphragm dysfunction with this outcome has never been reported. This study investigated whether diaphragm dysfunction is associated with negative long-term outcomes and whether the coexistence of diaphragm dysfunction and ICU-acquired weakness has a particular association with 2-year survival and health-related quality of life (HRQOL). METHODS This study is an ancillary study derived from an observational cohort study. Patients under mechanical ventilation were enrolled at the time of their first spontaneous breathing trial. Diaphragm dysfunction was defined by tracheal pressure generated by phrenic nerve stimulation < 11 cmH2O and ICU-acquired weakness was defined by Medical Research Council (MRC) score < 48. HRQOL was evaluated with the SF-36 questionnaire. RESULTS Sixty-nine of the 76 patients enrolled in the original study were included in the survival analysis and 40 were interviewed. Overall 2-year survival was 67% (46/69): 64% (29/45) in patients with diaphragm dysfunction, 71% (17/24) in patients without diaphragm dysfunction, 46% (11/24) in patients with ICU-acquired weakness and 76% (34/45) in patients without ICU-acquired weakness. Patients with concomitant diaphragm dysfunction and ICU-acquired weakness had a poorer outcome with a 2-year survival rate of 36% (5/14) compared to patients without diaphragm function and ICU-acquired weakness [79% (11/14) (p < 0.01)]. Health-related quality of life was not influenced by the presence of ICU-acquired weakness, diaphragm dysfunction or their coexistence. CONCLUSIONS ICU-acquired weakness but not diaphragm dysfunction was associated with a poor 2-year survival of critically ill patients.
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Affiliation(s)
- Clément Saccheri
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Elise Morawiec
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Julie Delemazure
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Julien Mayaux
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France
| | - Bruno-Pierre Dubé
- Département de médecine, service de pneumologie, hôpital Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal - Carrefour de l'Innovation et de l'Évaluation en santé, Montreal, QC, Canada
| | - Thomas Similowski
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France.,UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Alexandre Demoule
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France.,UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Martin Dres
- Service de Pneumologie, Médecine intensive - Réanimation (Département "R3S"), AP-HP, Sorbonne Université, Groupe Hospitalier Universitaire Pitié-Salpêtrière Charles Foix, 75013, Paris, France. .,UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France.
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