Diaphragmatic atrophy and dysfunction in critically ill mechanically ventilated children

Abstract

Rationale The extent of diaphragmatic atrophy and dysfunction in critically ill children from developing countries is not established. Objectives To estimate changes in ultrasound measurements of diaphragmatic thickness over the first week of mechanical ventilation. To assess magnitude and risk factors of diaphragmatic atrophy. Methods In an observational cohort study, children aged 1–18 years, requiring mechanical ventilation were included. Ultrasound measurements of diaphragmatic thickness at end‐expiration (DTe) and end‐inspiration (DTi), and diaphragmatic thickening fraction (DTF) were performed daily during the first week of admission, and pre‐ and post‐extubation. Diaphragmatic atrophy (%) and atrophy rate (rate of decline in DTe, % per day) were calculated. Measurements and Main Results Of 55 children (74.6% boys) enrolled, 20 (36.4%) died. Of 35 children with planned extubation, 5 (14.3%) required reintubation. Baseline median (interquartile range [IQR]) DTe, DTi, and DTF were 1.27 mm (1, 1.6), 1.76 mm (1.35, 2.10), and 33.75% (26.90, 44.60), respectively. There was a significant reduction in DTe over the first week of mechanical ventilation (p < .001), median (IQR) diaphragmatic atrophy and atrophy rate of 9.91% (5.26, 17.35) and 2.01% (1.08, 3.04) per day, respectively. Diaphragmatic atrophy rate was lower in pressure targeted ventilation (n = 44; 1.79% [1.03, 2.87]) than volume targeted ventilation (n = 11; 3.10% [1.31, 5.49]), p = .038. There was no difference in diaphragmatic parameters (atrophy rate, and peri‐extubation DTe and DTF) in extubation success versus failure. Conclusions The diaphragm undergoes progressive atrophy during the first week of mechanical ventilation in critically ill children. Future studies should evaluate ventilation strategies to reduce the diaphragmatic atrophy.

Comparing ventilation modes by electrical impedance segmentography in ventilated children

“…Optimized strategies for patient-oriented mechanical ventilation are an important and frequently discussed topic in daily pediatric intensive care and scientific studies. Various ventilation modes have been established over the years, but have repeatedly shown undesirable side effects for children [1][2][3][4]. Synchronized intermittent mandatory ventilation (SIMV) has been shown to be a lung-protective strategy in pediatric intensive care [5].…”

“…Due to this asynchrony increased doses of sedation in ventilated children are required as documented in a study by Baez Hernandez et al [7]. Furthermore, several studies have described diaphragmatic atrophy caused by mechanical mandatory ventilation in pediatric patients [1][2][3].…”

Diaphragmatic Thickening Fraction by Ultrasound in Mechanically Ventilated Pediatric Patients: Pilot Observations During Spontaneous Breathing Trials

“…6 Patients on prolonged MV experience changes in diaphragm thickness (DT), mainly atrophy, which has been seen in 44%-47% of intubated pediatric patients 7,8 with percent decline occurring at a rate ranging from 2.01% to 3.4% per day. [8][9][10] and was associated with prolonged postextubation noninvasive positive pressure ventilation (NIPPV). 11 Recognizing the potential application of bedside diaphragmatic ultrasound in objectively assessing weaning outcomes, we sought to determine the utility of using ultrasound to assess diaphragmatic characteristics during SBTs.…”

Diaphragm ultrasound to predict weaning outcome: systematic review and meta-analysis

“…Similarly, in another study, Goligher et al [45] used a different US measurement index defined as the thickness of the diaphragm (TDI); although it indicated diaphragm thinning in patients with MV, no significant correlation was detected between TDI and weaning outcomes. Afterwards, Mistri et al [47] showed that diaphragm atrophy during MV is associated with a decrease in DTF value in patients admitted to a paediatric ICU. Additionally, increased DTF was suggested as a potential predictor of successful extubation.…”