Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study

Umbrello, Michele; Formenti, Paolo; Longhi, D.; Galimberti, Andrea; Piva, Ilaria; Pezzi, Annalisa; Mistraletti, Giovanni; Marini, John J.; Iapichino, G.

doi:10.1186/s13054-015-0894-9

Cited by 256 publications

(242 citation statements)

References 43 publications

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“…However, all of these studies were performed in spontaneously breathing subjects, whereas the role of excursion in the functional evaluation of diaphragm contractile activity during patient-triggered mechanical ventilation is far less clear. Work from our group 90 showed how this measurement was uncorrelated to any other index of inspiratory effort during patient-triggered mechanical ventilation. Indeed, diaphragm excursion during an assisted breath represents the sum of 2 forces acting in the same direction: the force of the diaphragm contraction by itself and the passive displacement of the diaphragm by the pressure provided by the ventilator, thus dismissing the role of this index as a measure of diaphragm contractile activity during assisted mechanical ventilation.…”

Section: Diaphragm Displacementmentioning

confidence: 89%

“…Assessment of displacement is easily performed, even if its role in the functional assessment of diaphragm dysfunction in patients undergoing patient-triggered mechanical ventilation has recently been questioned. 90 Diaphragm thickness and thickening during breathing, despite being slightly more difficult to assess, overcome the limitations of displacement and are increasingly been performed in the critical care setting. In conclusion, the increased routine use of ultrasonography in the ICU as a fast, inexpensive, and noninvasive test is expected to lead to a timely identification of patients with diaphragm dysfunction, potentially leading to a better tailoring of patient-triggered mechanical ventilation and to an improved assessment of recovery from diaphragm weakness.…”

Section: Discussionmentioning

confidence: 99%

“…87 A number of recent studies have employed ultrasound to measure diaphragm thickness and inspiratory thickening in ventilated subjects. Some of them focused on the feasibility and reproducibility of the technique, 88,89 whereas another 90 showed how with increasing levels of pressure support ventilation, parallel reductions were found between diaphragm thickening and both the diaphragm and esophageal pressure-time product, suggesting that diaphragm thickening is a reliable indicator of respiratory effort. Fig.…”

Section: Bedside Ultrasonography In Critically Ill Patientsmentioning

confidence: 99%

“…Other authors reported how left hemidiaphragm measurements could not be consistently obtained, whereas right hemidiaphragm thickness measurements are highly reproducible, particularly after marking the location of the probe. 87 Some authors evaluated the variation of thickness at different lung volumes from RV to TLC in normal subjects, [90][91][92][93] suggesting the use of this maximal contractile capacity of the diaphragm. Another study measured diaphragm thickness in subjects with diaphragm paralysis to monitor recovery of the muscle over time.…”

Section: B-modementioning

confidence: 99%

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Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects

Umbrello

Formenti

2016

Respir Care

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The majority of patients admitted to the ICU require mechanical ventilation as a part of their process of care. However, mechanical ventilation itself or the underlying disease can lead to dysfunction of the diaphragm, a condition that may contribute to the failure of weaning from mechanical ventilation. However, extended time on the ventilator increases health-care costs and greatly increases patient morbidity and mortality. Nevertheless, symptoms and signs of muscle disease in a bedridden (or bed rest-only) ICU patient are often difficult to assess because of concomitant confounding factors. Conventional assessment of diaphragm function lacks specific, noninvasive, time-saving, and easily performed bedside tools or requires patient cooperation. Recently, the use of ultrasound has raised great interest as a simple, noninvasive method of quantification of diaphragm contractile activity. In this review, we discuss the physiology and the relevant pathophysiology of diaphragm function, and we summarize the recent findings concerning the evaluation of its (dys)function in critically ill patients, with a special focus on the role of ultrasounds. We describe how to assess diaphragm excursion and diaphragm thickening during breathing and the meaning of these measurements under spontaneous or mechanical ventilation as well as the reference values in health and disease. The spread of ultrasonographic assessment of diaphragm function may possibly result in timely identification of patients with diaphragm dysfunction and to a potential improvement in the assessment of recovery from diaphragm weakness.

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Section: Diaphragm Displacementmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Section: Bedside Ultrasonography In Critically Ill Patientsmentioning

confidence: 99%

Section: B-modementioning

confidence: 99%

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Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects

Umbrello

Formenti

2016

Respir Care

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“…Diaphragm thickness is measured laterally at the zone of apposition at the lower intercostal spaces [106]. The diaphragm thickening fraction is calculated as (end-inspiratory thickness minus end-expiratory thickness)/end-inspiratory thickness and has been used to assess diaphragm activity [107,108].…”

Section: Diaphragm Abnormalitiesmentioning

confidence: 99%

The efficacy of bedside chest ultrasound: from accuracy to outcomes

Hew

Tay

2016

Eur Respir Rev

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For many respiratory physicians, point-of-care chest ultrasound is now an integral part of clinical practice. The diagnostic accuracy of ultrasound to detect abnormalities of the pleura, the lung parenchyma and the thoracic musculoskeletal system is well described. However, the efficacy of a test extends beyond just diagnostic accuracy. The true value of a test depends on the degree to which diagnostic accuracy efficacy influences decision-making efficacy, and the subsequent extent to which this impacts health outcome efficacy. We therefore reviewed the demonstrable levels of test efficacy for bedside ultrasound of the pleura, lung parenchyma and thoracic musculoskeletal system.For bedside ultrasound of the pleura, there is evidence supporting diagnostic accuracy efficacy, decisionmaking efficacy and health outcome efficacy, predominantly in guiding pleural interventions. For the lung parenchyma, chest ultrasound has an impact on diagnostic accuracy and decision-making for patients presenting with acute respiratory failure or breathlessness, but there are no data as yet on actual health outcomes. For ultrasound of the thoracic musculoskeletal system, there is robust evidence only for diagnostic accuracy efficacy.We therefore outline avenues to further validate bedside chest ultrasound beyond diagnostic accuracy, with an emphasis on confirming enhanced health outcomes. @ERSpublicationsThe next challenge in bedside chest ultrasound is to refocus from diagnostic accuracy toward patient outcomes http://ow.ly/NyNR3027WLU

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Alterations in diaphragmatic function assessed by ultrasonography in mechanically ventilated patients with sepsis

et al. 2019

J of Clinical Ultrasound

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Purpose To assess alteration of diaphragmatic function by ultrasonography in a population of mechanically ventilated patients with or without sepsis. Methods We performed a prospective, 6‐month, single‐center, observational cohort study. Mechanically ventilated septic and nonseptic patients were studied within 24 hours following intubation and before the moment of ventilator liberation. Diaphragm thickness and contractile activity (quantified by diaphragmatic thickening fraction, DTF) were measured by ultrasonography at the zone of apposition. Intraobserver and interobserver reproducibility were measured. Results Fifty‐two critically ill patients were included, 28 with sepsis and 24 without sepsis. Upon initiation of ventilation, DTF was lower in septic than that in nonseptic patients (P = 0.03). No difference was observed between septic and nonseptic patients for diaphragm thickness. Mean 188 ± 111 hours after the first measurement, both diaphragm thickness and DTF decreased significantly compared with first measurements in septic and nonseptic patients, all P < 0.001. Diaphragm thickness decreased by 9.1 ± 10.7% in nonseptic and by 16.0 ± 13.5% in septic patients, P = 0.049. DTF decreased by 15.2 ± 21.3% in nonseptic and by 30.7 ± 22.0% in septic patients, P = 0.013. Conclusions Mechanically ventilated patients with sepsis were associated with an earlier and more severe diaphragm dysfunction compared with patients without sepsis.

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Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study

Cited by 256 publications

References 43 publications

Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects

Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects

The efficacy of bedside chest ultrasound: from accuracy to outcomes

Alterations in diaphragmatic function assessed by ultrasonography in mechanically ventilated patients with sepsis

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