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 is to investigate the predictive value of diaphragm ultrasound for weaning outcomes in critically ill children. Methods: The study included 50 cases whose mechanical ventilation (MV) time was >48 h, and all eligibles were divided into either the weaning success group (n = 39) or the weaning failure group (n = 11). Diaphragm thickness, diaphragmatic excursion (DE), and diaphragmatic thickening fraction (DTF) 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 ≥0.86 cmH 2 O/kg for PImax with a sensitivity of 0.51 and a specificity of 0.82. The linear correlation analysis showed that DTF had significant correlation with PImax in children ( P = 0.003). Conclusions: Diaphragm ultrasound has great value in predicting the weaning outcome of critically ill children. DTF and PImax presented better performance than other diaphragmatic parameters. However, DE has limited value in predicting weaning outcomes of children with MV.

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 …”

Sonographic evaluation of diaphragmatic thickness and excursion as a predictor for successful extubation in mechanically ventilated preterm infants

“…However, we compensated for this by obtaining our Mmode measures over the most moving point of the hemidiaphragm on B-mode. Moreover, M-mode technique has been successfully used in previous studies to measure diaphragmatic thickness in excursion in adults and pediatric age groups [9,30]. A potential technical limitation to our study is the use of a micro-convex transducer rather than a high-frequency microlinear transducer for imaging.…”

A prospective observational study on critically ill children with diaphragmatic dysfunction: clinical outcomes and risk factors

“…The second cause may be that majority of adult patients suffered from chronic obstructive pulmonary disorder (COPD), where muscle fibers of the diaphragm undergo chronic oxidative remodeling, resulting in weakness in the ability of diaphragm compensation [26]. Third, the average time for ventilatory treatment was more the elderly than that in the children with DD [576 (374-850) hrs vs 360 (168-528)] [6,22]. In addition, in critically ill children, we observed that the time of ventilation is a risk factor independent of DD, similar to that observed in adult studies [2,27].…”