The predictive value of diaphragm ultrasound for weaning outcomes in critically ill children

Abstract

Background: Multiple studies have shown that diaphragmatic ultrasound can better predict the outcome of weaning in adults. However, there are few studies focusing on children, leading to a lack of sufficient clinical evidence for the application of diaphragmatic ultrasound in children. The purpose of this study was to investigate the predictive value of diaphragm ultrasound for weaning outcomes in critically ill children. Methods: Study included 50 cases whose mechanical ventilation(MV) time > 48 h, and all eligibles were divided into either the weaning success group (n = 39) or the weaning failure group (n = 11). Diaphragm thickness and diaphragmatic excursion (DE) were measured in the zone of apposition. The maximum inspiratory pressure (PImax) was also recorded. Results: The ventilatory treatment time (P = 0.002) and length of PICU stay (P = 0.013) in the weaning failure group was longer than the success group. Cut-off values of diaphragmatic measures associated with successful weaning were ≥ 21% for DTF with a sensitivity of 0.82, and a specificity of 0.81, whereas it was ≥ 8.40 mm for DE with a sensitivity of 0.62, and a specificity of 0.91. The linear correlation analysis showed that DTF had no significant correlation with PImax in children (P = 0.31). Conclusions: Diaphragm ultrasound has great value in predicting the weaning outcome of critically ill children. DTF and DE presented better performance than other diaphragmatic parameters. However, PImax has limited value in terms of reflecting the inspiratory muscle function of children with MV. Trial Registration: The trial ‘Early rehabilitation intervention for critically ill children’ has been registered at http://www.chictr.org.cn/showproj.aspx?proj=23132. Registration number: ChiCTR1800020196. Key words: Paediatric; mechanical ventilation; diaphragm; ultrasound; weaning; PImax

Diaphragmatic atrophy and dysfunction in critically ill mechanically ventilated children

“…We could not find any difference in pre‐extubation DTF in children with successful extubation from failed extubation. Previously, a study in children reported DTF ≥ 21% as a predictor of successful extubation 4 . But a large multicentric adult study found no association of pre‐extubation DTF with extubation outcome 25 .…”

“…In patients requiring thoracic surgery, muscle biopsies of the diaphragm and latissimus dorsi demonstrated a 35% reduction in force‐generating capacity of the diaphragm within 2 h of surgery but not latissimus dorsi 3 . Diaphragm being the major respiratory drive muscle, VIDD has an adverse impact on weaning off and is associated with prolonged mechanical ventilation and hospital stay 4 . Conventional measures of diaphragmatic function such as phrenic nerve conduction study, transdiaphragmatic pressure measurement, pulmonary function testing, fluoroscopy, and diaphragmatic electrical activity, have limitations such as the need for special equipment, invasiveness, and exposure to ionizing radiations 5 .…”

“…Diaphragmatic thickening fraction (DTF) is an indicator of diaphragmatic function, assessed as a percentage change in diaphragmatic thickness between inspiration and expiration. Pre‐extubation DTF ≥ 21% has been shown as a good predictor of successful extubation in children 4 . Prolonged ventilation, drugs (steroids, neuromuscular blocking agents, and sedation), and malnutrition are commonly implicated predisposing factors for the development of VIDD 7 …”

Point-of-Care Ultrasound Measurement of Diaphragm Thickening Fraction as a Predictor of Successful Extubation in Critically Ill Children

“…They found that DTf less than 17% immediately postextubation was associated with extubation failure. Xue et al 15 in their study on 50 children who were ventilated for more than 48 hours found that DTf 21% was associated with successful extubation with a specificity of 0.81 and sensitivity of 0.82. Abdel Rahman et al 16 conducted a study on 106 children ventilated and showed that the best cutoff value of DTf for predicting weaning failure was 23.175% with an AUC of 0.932.…”

A narrative review of diaphragmatic ultrasound in pediatric critical care

“…In one study, positive end‐expiratory pressure (PEEP) of 5 cmH 2 O was provided, while PEEP was not specified in the other study. In a cohort of 50 children, DTF was significantly higher in patients that were successfully extubated 45 . The optimal cutoff value associated with successful extubation was a DTF > 21%, with a positive predictive value of 94% and a negative predictive value of 56%.…”