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Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
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Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
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Roshdy A. Respiratory Monitoring During Mechanical Ventilation: The Present and the Future. J Intensive Care Med 2023; 38:407-417. [PMID: 36734248 DOI: 10.1177/08850666231153371] [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: 02/04/2023]
Abstract
The increased application of mechanical ventilation, the recognition of its harms and the interest in individualization raised the need for an effective monitoring. An increasing number of monitoring tools and modalities were introduced over the past 2 decades with growing insight into asynchrony, lung and chest wall mechanics, respiratory effort and drive. They should be used in a complementary rather than a standalone way. A sound strategy can guide a reduction in adverse effects like ventilator-induced lung injury, ventilator-induced diaphragm dysfunction, patient-ventilator asynchrony and helps early weaning from the ventilator. However, the diversity, complexity, lack of expertise, and associated cost make formulating the appropriate monitoring strategy a challenge for clinicians. Most often, a big amount of data is fed to the clinicians making interpretation difficult. Therefore, it is fundamental for intensivists to be aware of the principle, advantages, and limits of each tool. This analytic review includes a simplified narrative of the commonly used basic and advanced respiratory monitors along with their limits and future prospective.
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Affiliation(s)
- Ashraf Roshdy
- Critical Care Medicine Department, Faculty of Medicine, 54562Alexandria University, Alexandria, Egypt.,Critical Care Unit, North Middlesex University Hospital, London, UK
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Kaur A, Sharma S, Singh VP, Krishna MR, Gautam PL, Singh G. Sonographic assessment of diaphragmatic thickening and excursion as predictors of weaning success in the intensive care unit: A prospective observational study. Indian J Anaesth 2022; 66:776-782. [PMID: 36590197 PMCID: PMC9795502 DOI: 10.4103/ija.ija_312_22] [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: 04/04/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background and Aims Ultrasonographic assessment of diaphragmatic function can be a useful bedside tool in the weaning and extubation of mechanically ventilated patients, especially in patients with difficult weaning, in whom diaphragmatic weakness is suspected. Thus, this study was planned to assess the role of bedside sonographic assessment of diaphragmatic indices such as diaphragmatic thickening fraction (DTf) and diaphragmatic excursion (DE) in predicting successful extubation or extubation failure in weaning eligible patients by comparing the measurements with outcome. Methods This prospective observational study was conducted on 50 mechanically ventilated, weaning-ready patients during the spontaneous breathing trial (SBT). The DE and DTf of patients were noted along with conventional parameters of weaning. Probability value <0.05 was considered statistically significant. Receiver operating characteristic (ROC) curves were used for analysis. Area under the curve (AUC) was measured, and sensitivity and specificity for different cut-off values were estimated. Results Out of 50 patients, 15 (30%) had SBT failure and 4 had extubation failure. The group with SBT failure had significantly higher rapid shallow breathing index (RSBI) and airway occlusion pressure (P0.1s), whereas DE and DTf were lower compared to the SBT successful group. Strong correlation existed between RSBI, DTf, DE and P0.1s. DTf of nearly 24% (sensitivity 93.5%, specificity 94.7%) and DE of 1.10 cm (84% sensitivity, 89.5% specificity) were associated with best outcome. Conclusion Along with conventional parameters of weaning, sonographic assessment of diaphragmatic parameters can be useful in predicting the success of SBT and in avoiding unnecessary extubation failures and thereby help in achieving a successful weaning outcome.
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Affiliation(s)
- Amandeep Kaur
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Shruti Sharma
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Vikram P. Singh
- Department Of Cardiothoracic Vascular Surgery, Hero DMC Heart Institute, Ludhiana, Punjab, India,Address for correspondence: Dr. Vikram P. Singh, H. No 36-C, Rajguru Nagar, Ludhiana - 141 012, Punjab, India. E-mail:
| | - M. Ravi Krishna
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Parshotam L. Gautam
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Gagandeep Singh
- Department of Neurology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Alam MJ, Roy S, Iktidar MA, Padma FK, Nipun KI, Chowdhury S, Nath RK, Rashid HO. Diaphragm ultrasound as a better predictor of successful extubation from mechanical ventilation than rapid shallow breathing index. Acute Crit Care 2022; 37:94-100. [PMID: 35081706 PMCID: PMC8918710 DOI: 10.4266/acc.2021.01354] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background In 3%–19% of patients, reintubation is needed 48–72 hours following extubation, which increases intensive care unit (ICU) morbidity, mortality, and expenses. Extubation failure is frequently caused by diaphragm dysfunction. Ultrasonography can be used to determine the mobility and thickness of the diaphragm. This study looked at the role of diaphragm excursion (DE) and thickening fraction in predicting successful extubation from mechanical ventilation. Methods Thirty-one patients were extubated with the advice of an ICU consultant using the ICU weaning regimen and diaphragm ultrasonography was performed. Ultrasound DE and thickening fraction were measured three times: at the commencement of the T-piece experiment, at 10 minutes, and immediately before extubation. All patients' parameters were monitored for 48 hours after extubation. Rapid shallow breathing index (RSBI) was also measured at the same time. Results Successful extubation was significantly correlated with DE (P<0.001). Receiver curve analysis for DE to predict successful extubation revealed good properties (area under the curve [AUC], 0.83; P<0.001); sensitivity, 77.8%; specificity, 84.6%; positive predictive value (PPV), 84.6 %; negative predictive value (NPV), 73.3% while cut-off value, 11.43 mm. Diaphragm thickening fraction (DTF) also revealed moderate curve properties (AUC, 0.69; P=0.06); sensitivity, 61.1%; specificity, 84.6%; PPV, 87.5%; NPV, 61.1% with cut-off value 22.33% although former one was slightly better. RSBI could not reach good receiver operating characteristic value at cut-off points 100 breaths/min/L (AUC, 0.58; P=0.47); sensitivity, 66.7%; specificity, 53.8%; PPV, 66.7%; NPV, 53.8%). Conclusions To decrease the rate of reintubation, DE and DTF are better indicators of successful extubation. DE outperforms DTF.
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Yu T, Wu R, Yao L, Wang K, Wang G, Fan Z, Wu N, Fang X. Neurally adjusted ventilatory assist after surgical treatment of intracerebral hemorrhage: a randomized crossover study. J Int Med Res 2020; 48:300060520939837. [PMID: 32720550 PMCID: PMC7388128 DOI: 10.1177/0300060520939837] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the neuromechanical efficiency (NME), neuroventilatory efficiency (NVE), and diaphragmatic function effects between pressure support ventilation (PSV) and neutrally adjusted ventilatory assist (NAVA). METHODS Fifteen patients who had undergone surgical treatment of intracerebral hemorrhage were enrolled in this randomized crossover study. The patients were assigned to PSV for the first 24 hours and then to NAVA for the following 24 hours or vice versa. The monitored ventilatory parameters under the two ventilation models were compared. NME, NVE, and diaphragmatic function were compared between the two ventilation models. RESULTS One patient's illness worsened during the study. The study was stopped for this patient, and intact data were obtained from the other 14 patients and analyzed. The monitored tidal volume was significantly higher with PSV than NAVA (487 [443-615] vs. 440 [400-480] mL, respectively). NME, NVE, diaphragmatic function, and the partial pressures of arterial carbon dioxide and oxygen were not significantly different between the two ventilation models. CONCLUSION The tidal volume was lower with NAVA than PSV; however, the patients' selected respiratory pattern during NAVA did not change the NME, NVE, or diaphragmatic function.Clinical trial registration no. ChiCTR1900022861.
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Affiliation(s)
- Tao Yu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Rongrong Wu
- Department of Education, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Lin Yao
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Kui Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Guiliang Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Zhen Fan
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Nianlong Wu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Xinggen Fang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
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Chong WH, Saha B, Jones DM, Beegle S. Respiratory Failure Secondary to Diaphragmatic Paralysis from Acute Exacerbation of Dermatomyositis. Am J Med Sci 2020; 361:659-665. [PMID: 32736829 DOI: 10.1016/j.amjms.2020.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/28/2020] [Accepted: 06/29/2020] [Indexed: 11/26/2022]
Abstract
Dermatomyositis (DM) is an idiopathic inflammatory disorder that presents with proximal muscle weakness and typical DM skin changes. DM can involve other organs such as the lung, esophagus, and heart. Diaphragmatic muscle paralysis is an unrecognized clinical presentation of acute DM exacerbation. A 58-year-old man with a history of DM presented to the hospital after sustaining a cardiorespiratory arrest. Before arrest, he had been suffering from progressive dyspnea and muscle weakness. Immunosuppressive therapy of tacrolimus for DM was recently discontinued due to renal toxicity. Bedside ultrasound of the diaphragm while intubated revealed evidence of bilateral diaphragmatic paralysis. After extubation, supine and upright pulmonary function tests (PFT) and sniff test results strengthened the diagnosis of diaphragmatic paralysis. The patient was worked up for an acute DM exacerbation as the likely etiology of the severe diaphragmatic muscle weakness (diaphragmatic paralysis) and ventilatory failure. Skin and muscle biopsy confirmed the diagnosis of active DM. The patient was treated with high dose steroids and mycophenolate mofetil, following which he soon recovered.
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Affiliation(s)
- Woon H Chong
- Department of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, New York.
| | - Biplab Saha
- Department of Pulmonary and Critical Care, Ozarks Medical Center, West Plains, Missouri
| | - David M Jones
- Department of Pathology, Albany Medical Center, Albany, New York
| | - Scott Beegle
- Department of Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, New York
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Abdelhafeez RM, Abumossalam AM, Arram EO, Elshafey MM, Abushehata ME. Diaphragm and weaning from mechanical ventilation: anticipation and outcome. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_13_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Shahshahani A, Laverdiere C, Bhadra S, Zilic Z. Ultrasound Sensors for Diaphragm Motion Tracking: An Application in Non-Invasive Respiratory Monitoring. SENSORS (BASEL, SWITZERLAND) 2018; 18:E2617. [PMID: 30096945 PMCID: PMC6111564 DOI: 10.3390/s18082617] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 12/30/2022]
Abstract
This paper introduces a novel respiratory detection system based on diaphragm wall motion tracking using an embedded ultrasound sensory system. We assess the utility and accuracy of this method in evaluating the function of the diaphragm and its contribution to respiratory workload. The developed system is able to monitor the diaphragm wall activity when the sensor is placed in the zone of apposition (ZOA). This system allows for direct measurements with only one ultrasound PZT5 piezo transducer. The system generates pulsed ultrasound waves at 2.2 MHz and amplifies reflected echoes. An added benefit of this system is that due to its design, the respiratory signal is less subject to motion artefacts. Promising results were obtained from six subjects performing six tests per subject with an average respiration detection sensitivity and specificity of 84% and 93%, respectively. Measurements were compared to a gold standard commercial spirometer. In this study, we also compared our measurements to other conventional methods such as inertial and photoplethysmography (PPG) sensors.
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Affiliation(s)
- Amirhossein Shahshahani
- Department of Electrical and Computer Engineering, McGill university, Montreal, QC H3A 0E9, Canada.
| | - Carl Laverdiere
- Faculty of Medicine, McGill University, Montreal, QC H3A 0E9, Canada.
| | - Sharmistha Bhadra
- Department of Electrical and Computer Engineering, McGill university, Montreal, QC H3A 0E9, Canada.
| | - Zeljko Zilic
- Department of Electrical and Computer Engineering, McGill university, Montreal, QC H3A 0E9, Canada.
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