Positive End-Expiratory Pressure Ventilation Induces Longitudinal Atrophy in Diaphragm Fibers

Lindqvist, Johan; Berg, Marloes van den; Pijl, Robbert van der; Hooijman, Pleuni E.; Beishuizen, Albertus; Elshof, Judith; Waard, Monique de; Girbes, Armand R. J.; Man, Angélique M. E. de; Shi, Zhong-Hua; Brom, Charissa E. van den; Bogaards, Sylvia J. P.; Shen, Shengyi; Strom, Joshua; Granzier, Henk; Kole, Jeroen; Musters, René J.P.; Paul, Marinus A.; Heunks, Leo; Ottenheijm, Coen A.C.

doi:10.1164/rccm.201709-1917oc

Cited by 81 publications

(87 citation statements)

References 50 publications

(56 reference statements)

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“…A decrease in Tdi was shown to be associated with longer periods of mechanical ventilation, and it occurs early after intubation [2,25]. The higher levels of PEEP in patients with diaphragm thinning during CMV could be in line with the recent evidences regarding myofibre longitudinal atrophy due to PEEP [6]. To our knowledge, no studies until now described the relation between the prealbumin levels, as an index of nutritional status [17], and diaphragm thickness.…”

Section: Discussionsupporting

confidence: 64%

“…Ultrasound (US) is becoming a reference to assess diaphragmatic injury and to detect changes in diaphragmatic thickness over time; both an increase and a decrease of diaphragmatic thickness are associated with diaphragm activity and ventilation outcome [1,2]. Starting from experimental and clinical studies, four mechanisms of diaphragmatic injury (myotrauma) have been identified: disuse atrophy due to over-assistance [3], excessive load due to under-assistance [1,4], eccentric myotrauma from diaphragm contraction during expiration [5] or asynchronies, and longitudinal atrophy, due to high level of positive end-expiratory pressure (PEEP) [6]. Therefore, the need to set "protective" mechanical ventilation not only for the lungs but also for the diaphragm was recently advocated [7].…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionsupporting

confidence: 64%

Section: Introductionmentioning

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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“…On the other hand, preliminary experimental evidence suggests that if the diaphragm is maintained at a shorter length during acute mechanical ventilation, the diaphragm muscle fibers could adapt to the reduced length by absorbing sarcomeres in series (i.e., longitudinal atrophy) [ 52 ]. This may result in fibers overstretching with the release of PEEP during a T-tube weaning trial or after extubation.…”

Section: Clinical Strategies To Facilitate Lung and Diaphragm-protectmentioning

confidence: 99%

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

et al. 2020

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Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO 2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.

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“…Excessive PEEP. Preliminary experimental evidence suggests that maintaining the diaphragm at a shorter length with the use of excessive PEEP may cause sarcomeres to "drop out" of the muscle and shorten its length (longitudinal atrophy) [18]. This could theoretically disadvantage the length-tension characteristics of the muscle once PEEP is reduced, impairing diaphragm performance.…”

Section: Diaphragm Injury During Spontaneous Breathing: Myotraumamentioning

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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Positive End-Expiratory Pressure Ventilation Induces Longitudinal Atrophy in Diaphragm Fibers

Cited by 81 publications

References 50 publications

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

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

Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

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

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