Association of Low Baseline Diaphragm Muscle Mass With Prolonged Mechanical Ventilation and Mortality Among Critically Ill Adults

Sklar, Michael C.; Dres, Martin; Fan, Eddy; Rubenfeld, Gordon D.; Scales, Damon C.; Herridge, Margaret S.; Rittayamai, Nuttapol; Harhay, Michael O.; Reid, W. Darlene; Tomlinson, George; Rozenberg, Dmitry; McClelland, William; Riegler, Stephen; Slutsky, Arthur S.; Brochard, Laurent; Ferguson, Niall D.; Goligher, Ewan C.

doi:10.1001/jamanetworkopen.2019.21520

Cited by 64 publications

(52 citation statements)

References 63 publications

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“…Diaphragm structure and function are known to deteriorate during mechanical ventilation. Both acute decreases and increases in diaphragm thickness during mechanical ventilation have been documented repeatedly using point-of-care ultrasound [13][14][15]; these sonographic findings are associated with poor clinical outcomes [16]. It is unknown whether diaphragm echodensity changes during mechanical ventilation and whether this provides additional independent information about clinically important changes in muscle structure and function during mechanical ventilation and critical illness.…”

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confidence: 99%

Diaphragm echodensity in mechanically ventilated patients: a description of technique and outcomes

et al. 2021

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Background Acute increases in muscle sonographic echodensity reflect muscle injury. Diaphragm echodensity has not been measured in mechanically ventilated patients. We undertook to develop a technique to characterize changes in diaphragm echodensity during mechanical ventilation and to assess whether these changes are correlated with prolonged mechanical ventilation. Methods Diaphragm ultrasound images were prospectively collected in mechanically ventilated patients and in 10 young healthy subjects. Echodensity was quantified based on the right-skewed distribution of grayscale values (50th percentile, ED50; 85th percentile, ED85). Intra- and inter-analyzer measurement reproducibility was determined. Outcomes recorded included duration of ventilation and ICU complications (including reintubation, tracheostomy, prolonged ventilation, or death). Results Echodensity measurements were obtained serially in 34 patients comprising a total of 104 images. Baseline (admission) diaphragm ED85 was increased in mechanically ventilated patients compared to younger healthy subjects (median 56, interquartile range (IQR) 42–84, vs. 39, IQR 36–52, p = 0.04). Patients with an initial increase in median echodensity over time (≥ + 10 in ED50 from baseline) had fewer ventilator-free days to day 60 (n = 13, median 46, IQR 0–52) compared to patients without this increase (n = 21, median 53 days, IQR 49–56, unadjusted p = 0.03). Both decreases and increases in diaphragm thickness during mechanical ventilation were associated with increases in ED50 over time (adjusted p = 0.03, conditional R2 = 0.80) and the association between increase in ED50 and outcomes persisted after adjusting for changes in diaphragm thickness. Conclusions Many patients exhibit increased diaphragm echodensity at the outset of mechanical ventilation. Increases in diaphragm echodensity during the early course of mechanical ventilation are associated with prolonged mechanical ventilation. Both decreases and increases in diaphragm thickness during mechanical ventilation are associated with increased echodensity.

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Diaphragm echodensity in mechanically ventilated patients: a description of technique and outcomes

et al. 2021

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“…Endexpiratory DT was measured on two consecutive breaths from two separate images. 3 Measurements were repeated until three values consistent within 10% were obtained and their mean was retained for analysis.…”

Section: Methodsmentioning

confidence: 99%

Low Diaphragm Muscle Mass Predicts Adverse Outcome in Patients Hospitalized for Covid-19 Pneumonia

Corradi

Isirdi

Brusasco

et al. 2020

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Purpose: The aim of this study was to evaluate whether measurement of diaphragm thickness by ultrasonography may be a clinically useful noninvasive method for identifying patients at risk of adverse outcomes defined as need of invasive mechanical ventilation or death. Methods: We retrospectively reviewed the records of consecutive of 77 patients with laboratory-confirmed Covid-19 infection admitted to our intermediate care unit in Pisa between March 5 and March 30, 2020, with follow up until hospital discharge or death. Logistic regression was used identify variables potentially associated with adverse outcomes and those P<0.10 were entered into a multivariate logistic regression model. Cumulative probability for lack of adverse outcomes in patients with or without low baseline diaphragm muscle mass was calculated with the Kaplan–Meier product-limit estimator.Results: The main findings of this study are that 1) patients who developed adverse outcomes had thinner diaphragm than those who did not (2.0 vs 2.2 mm, p:0.001), 2) DT and lymphocyte count were independent significant predictors of adverse outcomes, with end-expiratory DT being the strongest (-708, OR: 0.492, p: 0.018).Conclusion: Diaphragmatic ultrasound may be a valid tool to evaluate the risk of respiratory failure. Evaluating the need of mechanical ventilation treatment should be based not only on PaO2/FiO2, but on a more comprehensive assessment including DT because if the lungs become less compliant a thinner diaphragm, albeit free of intrinsic abnormality, may become exhausted, thus contributing to severe respiratory failure.

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“…-Muscle function of diaphragm: the muscle function of the diaphragm was assessed through the thickness of diaphragm measured by ultrasound. 38,39 The LOGIQe device (GE Healthcare, Chicago, USA) was used, with a linear transducer (ML6-15 from 5 to 15 MHz and 9L 2-8 MHz). The measurement was performed with the patient in the supine position.…”

Section: Secondary Outcomesmentioning

confidence: 99%

“…Measurements were repeated at least once until consistently within 10%; the mean of all 4 measurement was used for analysis. 39 The measurement was obtained at baseline (up to 24 hours after the initiation of invasive mechanical ventilation), 10 days after randomization and in the last test before discharge or death from any cause, whichever came first (within 24 hours).…”

Section: Secondary Outcomesmentioning

confidence: 99%

Effects of photobiomodulation therapy combined with static magnetic field (PBMT-sMF) in patients with severe COVID-19 requiring intubation: a pragmatic randomized placebo-controlled trial

Marchi

Frâncio

Ferlito

et al. 2020

Preprint

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BackgroundPhotobiomodulation therapy (PBMT) when used isolated or combined with static magnetic field (PBMT-sMF) has been proven benefits on skeletal muscle increasing performance and reducing fatigue, increasing oxygen saturation, and modulating inflammatory process. However, it is unknown whether the effects observed with this therapy on respiratory muscles will be similar to the effects previously observed on skeletal muscles.ObjectiveWe aimed to investigate whether PBMT-sMF is able to decrease the length of stay in the intensive care unit (ICU) and to reduce the mortality rate of patients with severe COVID-19 requiring invasive mechanical ventilation, increasing the respiratory function and modulating the inflammatory process.MethodsWe conducted a prospectively registered, pragmatic, triple-blinded (patients, therapists and outcome assessors), randomized, placebo-controlled trial of PBMT-sMF in patients with severe COVID-19, requiring invasive mechanical ventilation, admitted to the ICU. Patients were randomly assigned to receive either PBMT-sMF (6 sites at the lower thorax – 189 J total, and 2 sites at the neck area – 63 J total) or placebo PBMT-sMF daily during all the ICU stay. The primary outcome was length of stay in the ICU defined by either discharge or death. The secondary outcomes were survival rate, muscle function of diaphragm, change in blood tests, change in mechanical ventilation parameters and change in arterial blood gas analysis.ResultsA total of 30 patients underwent randomization (with 15 assigned to PBMT-sMF and 15 to placebo) and were analyzed. The length of stay in the ICU for the placebo group was 23.06 days while for the PBMT-sMF group was 16.26. However, there was no statistically difference between groups for the length of stay in the ICU (mean difference - MD = - 6.80; 95% CI = - 18.71 to 5.11). Regarding the secondary outcomes were observed statistically differences in favor of PBMT-sMF for diaphragm thickness, fraction of inspired oxygen, partial pressure of oxygen/fraction of inspired oxygen ratio, C-reactive protein, lymphocytes count, and hemoglobin (p<0.05).ConclusionAmong patients with severe COVID-19 requiring invasive mechanical ventilation, PBMT-sMF was not statistically different than placebo to the length of stay in the ICU. However, it is important to highlight that our sample size was underpowered to detect statistical differences to the primary outcome. In contrast, PBMT-sMF increased muscle function of diaphragm, improved ventilatory parameters, decreased C-reactive protein levels and hemoglobin count, and increased lymphocytes count.

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Association of Low Baseline Diaphragm Muscle Mass With Prolonged Mechanical Ventilation and Mortality Among Critically Ill Adults

Cited by 64 publications

References 63 publications

Diaphragm echodensity in mechanically ventilated patients: a description of technique and outcomes

Diaphragm echodensity in mechanically ventilated patients: a description of technique and outcomes

Low Diaphragm Muscle Mass Predicts Adverse Outcome in Patients Hospitalized for Covid-19 Pneumonia

Effects of photobiomodulation therapy combined with static magnetic field (PBMT-sMF) in patients with severe COVID-19 requiring intubation: a pragmatic randomized placebo-controlled trial

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