The Utility of Diaphragm Ultrasound in Reducing Time to Extubation

Abstract

Purpose Prediction of optimal timing for extubation of mechanically ventilated patients is challenging. Ultrasound measures of diaphragm thickness or diaphragm dome excursion have been used to aid in predicting extubation success or failure. The aim of this study was to determine if incorporating results of diaphragm ultrasound into usual ICU care would shorten the time to extubation. Methods We performed a prospective, randomized, controlled study at three Brown University teaching hospitals. Included subjects underwent block randomization to either usual care (Control) or usual care enhanced with ultrasound measurements of the diaphragm (Intervention). The primary outcome was the time to extubation after ultrasound, and the secondary outcome was the total days on the ventilator. Only intensivists in the Intervention group would have the ultrasound information on the likelihood of successful extubation available to incorporate with traditional clinical and physiologic measures to determine the timing of extubation. Results A total of 32 subjects were studied; 15 were randomized into the Control group and 17 into the Intervention group. The time from ultrasound to extubation was significantly reduced in the Intervention group compared to the Control group in patients with a ∆tdi% ≥ 30% (4.8 ± 8.4 vs 35.0 ± 41.0 h, p = 0.04). The time from ultrasound to extubation was shorter in subjects with a normally functioning diaphragm (∆tdi% ≥ 30%) compared to those with diaphragm dysfunction (∆tdi% < 30%) (23.2 ± 35.2 vs 57.3 ± 52.0 h p = 0.046). When combining the Intervention and Control groups, a value of ∆tdi% ≥ 30% for extubation success at 24 h provided a sensitivity, specificity, PPV and NPV of 90.9%, 86.7%, 90.9%, and 86.7%, respectively. Conclusions Diaphragm ultrasound evaluation of ∆tdi% aids in reducing time to extubation.

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

“…In mechanically ventilated adults, McCool and colleagues [17] showed that the duration of mechanical ventilation was significantly shorter in patients diagnosed with normal diaphragmatic function as assessed by ultrasound measurement of diaphragmatic thickness and excursion. The authors stated that normal diaphragmatic function as assessed by ultrasound shows 90.9% sensitivity, 86.7% specificity, 90.9% positive predictive value, and 86.7% negative predictive value in predicting successful extubation from mechanical ventilation [17].…”

Early rehabilitation relieves diaphragm dysfunction induced by prolonged mechanical ventilation: a randomised control study

“…Accumulating evidence has shown that ultrasonographic detection of the diaphragm is feasible, reproducible, and highly reliable [ 10 , 11 ]. Recently, US measurement of the diaphragm has been suggested to be valuable for predicting the optimal time for extubation in mechanically ventilated patients [ 12 ].…”

Diaphragm Ultrasound in Cardiac Surgery: State of the Art

“…In patients with diaphragm dysfunction documented with ultrasound, spontaneous breathing trial (SBT) must be cautious, and CPAP (continuous positive airway pressure) can be proposed to support the respiratory status after extubation. The use of diaphragm ultrasound may reduce the time to extubation, according to a recent randomized trial [55]. In fact, using a cut-off of diaphragm TF ≥ 30% in ICU patients undergoing SBT, Mc Cool et al [55] reported a significant reduction of the time from ultrasound to extubation in an interventional group in comparison with a group receiving usual care.…”