Diaphragm Atrophy During Pediatric Acute Respiratory Failure Is Associated With Prolonged Noninvasive Ventilation Requirement Following Extubation

Abstract

Objectives: Diaphragm atrophy is evident during invasive ventilation for pediatric acute respiratory failure, but with unknown significance. We hypothesized that diaphragm atrophy in pediatric acute respiratory failure is associated with prolonged noninvasive positive pressure ventilation following extubation. Design: Prospective observational study. Setting: Single-center academic PICU. Patients: Invasively ventilated children with acute respiratory failure. Interventions: Diaphragm ultrasound was performed within 36 hours after intubation and repeated within 48 hours preceding extubation. Rapid shallow breathing index at 15 and 30 minutes of a spontaneous breathing trial and negative inspiratory force were collected in a subset of patients concurrently with the ultrasound measurements. Measurements and Main Results: Diaphragm thickness at end-expiration was measured to assess for diaphragm atrophy during mechanical ventilation. Percentage change in diaphragm thickness at end-expiration was defined as baseline diaphragm thickness at end-expiration minus final, preextubation diaphragm thickness at end-expiration divided by baseline diaphragm thickness at end-expiration. The primary outcome measure was duration of noninvasive positive pressure ventilation following extubation with prolonged use defined as noninvasive positive pressure ventilation use for greater than 24 hours postextubation. Among 56 children, 47 (median age, 15.5 mo; interquartile range, 6–53 mo) had diaphragm thickness at end-expiration measured within 48 hours prior to extubation. Fourteen (30%) had prolonged noninvasive positive pressure ventilation use with median duration 110 hours (interquartile range, 52–130 hr). The median percentage change of diaphragm thickness at end-expiration from baseline among those with and without prolonged noninvasive positive pressure ventilation use was –20% (interquartile range, –32% to –10%) versus –7% (interquartile range, –21% to 0%) (p = 0.04). Conclusions: Diaphragm atrophy is associated with prolonged postextubation noninvasive positive pressure ventilation in children with acute respiratory failure. Serial bedside diaphragm ultrasound may identify children at risk for prolonged noninvasive positive pressure ventilation use after extubation.

Characteristics and Risk Factors of Children Requiring Prolonged Mechanical Ventilation vs. Non-prolonged Mechanical Ventilation in the PICU: A Prospective Single-Center Study

“…Prolonging the duration of mechanical ventilation causes many challenging complications, such as ventilator-associated pneumonia (VAP), pulmonary hemorrhage, tracheal injury, diaphragm atrophy, neuromuscular disorders, an increased length of ICU stay and an unfavorable discharge destination (5)(6)(7)(8). Moreover, there are no specialized weaning units for patients requiring PMV.…”

Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

“…Ultrasound determined diaphragmatic thickness and thickening fraction has shown that diaphragmatic atrophy is greater in patients on neuromuscular blockade and that diaphragmatic contractility was linearly correlated with patients' degree of spontaneous breathing ( 72 , 74 ). Ultrasound determined diaphragmatic atrophy has also been proven to be associated with prolonged post-extubation non-invasive positive pressure ventilation ( 73 ). These studies demonstrate the utility of diaphragmatic ultrasound as a tool to help identify patients who are at risk for diaphragmatic dysfunction-mediated morbidity.…”

“…Diaphragmatic dysfunction is a loss of the muscular force generation of the diaphragm that has been associated with longer duration of mechanical ventilation and extubation failure (71)(72)(73). Ultrasound determined diaphragmatic thickness and thickening fraction has shown that diaphragmatic atrophy is greater in patients on neuromuscular blockade and that diaphragmatic contractility was linearly correlated with patients' degree of spontaneous breathing (72,74).…”

A narrative review of diaphragmatic ultrasound in pediatric critical care

“…Histologic evaluation has demonstrated diaphragm atrophy in adults who had 18‐69 h of diaphragmatic inactivity while on MV, with a decrease in size of both slow‐twitch and fast‐twitch muscle fibers 16 . The effect of diaphragm atrophy and dysfunction must not be underestimated as it has been associated with prolonged MV and increased complications in both adults and children 47,48 . In a single‐center study involving 31 children, significant diaphragm atrophy was noted in the first 24–48 h of MV, with substantial reductions in DTF and DT 30 .…”