Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure

Goligher, Ewan C.; Brochard, Laurent; Reid, W. Darlene; Fan, Eddy; Saarela, Olli; Slutsky, Arthur S.; Kavanagh, Brian P.; Rubenfeld, Gordon D.; Ferguson, Niall D.

doi:10.1016/s2213-2600(18)30366-7

Cited by 173 publications

(138 citation statements)

References 74 publications

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“…US may help by approximating diaphragm mass by measuring thickness as well as approximating diaphragm contractile activity by measuring the excursion and the thickening fraction [41]. A pioneer study by Goligher has reported that during critical illness and mechanical ventilation, the diaphragm thickness may decrease (supposedly because of atrophy), but may not change during the stay or may increase (supposedly because of myotrauma) [30,42]. Since diaphragmatic shear modulus has been associated with diaphragmatic function in spontaneously breathing volunteers [43], shear modulus analysis of the diaphragm in the critically ill may pave the way towards a non-invasive better understanding of diaphragm quality changes during critical illness.…”

Section: Discussionmentioning

confidence: 99%

Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients

et al. 2020

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Background: Muscle weakness following critical illness is the consequence of loss of muscle mass and alteration of muscle quality. It is associated with long-term disability. Ultrasonography is a reliable tool to quantify muscle mass, but studies that evaluate muscle quality at the critically ill bedside are lacking. Shear wave ultrasound elastography (SWE) provides spatial representation of soft tissue stiffness and measures of muscle quality. The reliability and reproducibility of SWE in critically ill patients has never been evaluated.Methods: Two operators tested in healthy controls and in critically ill patients the intra-and inter-operator reliability of the SWE using transversal and longitudinal views of the diaphragm and limb muscles. Reliability was calculated using the intra-class correlation coefficient and a bootstrap sampling method assessed their consistency. Results: We collected 560 images. Longitudinal views of the diaphragm (ICC 0.83 [0.50-0.94]), the biceps brachii (ICC 0.88 [0.67-0.96]) and the rectus femoris (ICC 0.76 [0.34-0.91]) were the most reliable views in a training set of healthy controls. Intra-class correlation coefficient for inter-operator reproducibility and intra-operator reliability was above 0.9 for all muscles in a validation set of healthy controls. In critically ill patients, inter-operator reproducibility and intra-operator 1 and 2 reliability ICCs were respectively 0.92 [0.71-0.98], 0.93 [0.82-0.98] and 0.92 [0.81-0.98] for the diaphragm; 0.96 [0.86-0.99], 0.98 [0.94-0.99] and 0.99 [0.96-1] for the biceps brachii and 0.91 [0.51-0.98], 0.97 [0.93-0.99] and 0. 99 [0.97-1] for the rectus femoris. The probability to reach intra-class correlation coefficient greater than 0.8 in a 10,000 bootstrap sampling for inter-operator reproducibility was respectively 81%, 84% and 78% for the diaphragm, the biceps brachii and the rectus femoris respectively.Conclusions: SWE is a reliable technique to evaluate limb muscles and the diaphragm in both healthy controls and in critically ill patients. Trial registration: The study was registered (ClinicalTrial NCT03550222).

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Section: Discussionmentioning

confidence: 99%

Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients

et al. 2020

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“…The main strength of this study lies in the ability of clearly separating the phases in which patient's inspiratory effort is present or absent, enabling to investigate the specific consequences of the mode of ventilation on diaphragm thickness and activity. We acknowledge that the consequences of ventilation on myotrauma need to be further analysed [38], even if a "lung-protective ventilation" during assisted modes, which mainly consists in the strict monitoring of respiratory mechanics and effort is the main key to improve outcome [10] bringing also to a smooth training of the diaphragm while weaning the lungs.…”

Section: Discussionmentioning

confidence: 99%

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study

et al. 2020

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Background: Diaphragm atrophy and dysfunction are consequences of mechanical ventilation and are determinants of clinical outcomes. We hypothesize that partial preservation of diaphragm function, such as during assisted modes of ventilation, will restore diaphragm thickness. We also aim to correlate the changes in diaphragm thickness and function to outcomes and clinical factors. Methods: This is a prospective, multicentre, observational study. Patients mechanically ventilated for more than 48 h in controlled mode and eventually switched to assisted ventilation were enrolled. Diaphragm ultrasound and clinical data collection were performed every 48 h until discharge or death. A threshold of 10% was used to define thinning during controlled and recovery of thickness during assisted ventilation. Patients were also classified based on the level of diaphragm activity during assisted ventilation. We evaluated the association between changes in diaphragm thickness and activity and clinical outcomes and data, such as ventilation parameters. Results: Sixty-two patients ventilated in controlled mode and then switched to the assisted mode of ventilation were enrolled. Diaphragm thickness significantly decreased during controlled ventilation (1.84 ± 0.44 to 1.49 ± 0.37 mm, p < 0.001) and was partially restored during assisted ventilation (1.49 ± 0.37 to 1.75 ± 0.43 mm, p < 0.001). A diaphragm thinning of more than 10% was associated with longer duration of controlled ventilation (10 [5, 15] versus 5 [4, 8.5] days, p = 0.004) and higher PEEP levels (12.6 ± 4 versus 10.4 ± 4 cmH 2 O, p = 0.034). An increase in diaphragm thickness of more than 10% during assisted ventilation was not associated with any clinical outcome but with lower respiratory rate (16.7 ± 3.2 versus 19.2 ± 4 bpm, p = 0.019) and Rapid Shallow Breathing Index (37 ± 11 versus 44 ± 13, p = 0.029) and with higher Pressure Muscle Index (2 [0.5, 3] versus 0.4 [0, 1.9], p = 0.024). Change in diaphragm thickness was not related to diaphragm function expressed as diaphragm thickening fraction. Conclusion: Mode of ventilation affects diaphragm thickness, and preservation of diaphragmatic contraction, as during assisted modes, can partially reverse the muscle atrophy process. Avoiding a strenuous inspiratory work, as measured by Rapid Shallow Breathing Index and Pressure Muscle Index, may help diaphragm thickness restoration.

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“…The inappropriate use of mechanical ventilation can injure not only the lung (barotrauma and volutrauma) but also respiratory muscles (myotrauma). Mechanical ventilation causes myotrauma by various mechanisms, leading to a final common pathway of VIDD [5].…”

Section: Diaphragm Injury During Spontaneous Breathing: Myotraumamentioning

confidence: 99%

“…Vigorous spontaneous inspiratory effort can cause both lung injury (patient self-inflicted lung injury [P-SILI]) [1,2] and diaphragm injury (myotrauma) [3,4]. These injuries lead to prolonged ventilation, difficult weaning, and increased morbidity and mortality [5][6][7]. Safe spontaneous breathing presents a complex challenge because one must aim to minimize the volume and transpulmonary pressure (P L ) to avoid P-SILI while also maintaining an appropriate level of patient respiratory effort to avoid diaphragm atrophy.…”

Section: Introductionmentioning

confidence: 99%

Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation

2020

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This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from During spontaneous breathing, vigorous patient respiratory efforts can cause lung injury (P-SILI) through different mechanisms (Fig. 2).Excessive global lung stress. As already discussed, patient respiratory efforts can increase tidal volume and P L above safe limits when respiratory drive is elevated.

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Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure

Cited by 173 publications

References 74 publications

Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients

Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients

Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study

Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation

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