Diaphragmatic atrophy and dysfunction in critically ill mechanically ventilated children

• Published in: Pediatric pulmonology Vol. 55; no. 12; pp. 3457 - 3464
• Main Authors: Mistri, Sabyasachi, Dhochak, Nitin, Jana, Manisha, Jat, Kana R., Sankar, Jhuma, Kabra, Sushil K., Lodha, Rakesh
• Format: Journal Article
• Language: English
• Published: United States Wiley Subscription Services, Inc 01.12.2020
• Subjects: Adolescent; Airway Extubation; Atrophy - etiology; Atrophy - pathology; Atrophy - physiopathology; Child; Child, Preschool; children; Cohort Studies; Critical Illness; Diaphragm - physiopathology; diaphragmatic atrophy; extubation failure; Female; Hospitalization; Humans; Infant; Intubation, Intratracheal; Male; Prospective Studies; Respiration, Artificial - adverse effects; Risk Factors; Ultrasonic imaging; Ultrasonography; ultrasound; Ventilation; Ventilators; extubation failure; children; ultrasound; ventilation; diaphragmatic atrophy
• ISSN: 8755-6863; 1099-0496
• DOI: 10.1002/ppul.25076

Rationale The extent of diaphragmatic atrophy and dysfunction in critically ill children from developing countries is not established. Objectives To estimate changes in ultrasound measurements of diaphragmatic thickness over the first week of mechanical ventilation. To assess magnitude and risk factors of diaphragmatic atrophy. Methods In an observational cohort study, children aged 1–18 years, requiring mechanical ventilation were included. Ultrasound measurements of diaphragmatic thickness at end‐expiration (DTe) and end‐inspiration (DTi), and diaphragmatic thickening fraction (DTF) were performed daily during the first week of admission, and pre‐ and post‐extubation. Diaphragmatic atrophy (%) and atrophy rate (rate of decline in DTe, % per day) were calculated. Measurements and Main Results Of 55 children (74.6% boys) enrolled, 20 (36.4%) died. Of 35 children with planned extubation, 5 (14.3%) required reintubation. Baseline median (interquartile range [IQR]) DTe, DTi, and DTF were 1.27 mm (1, 1.6), 1.76 mm (1.35, 2.10), and 33.75% (26.90, 44.60), respectively. There was a significant reduction in DTe over the first week of mechanical ventilation (p < .001), median (IQR) diaphragmatic atrophy and atrophy rate of 9.91% (5.26, 17.35) and 2.01% (1.08, 3.04) per day, respectively. Diaphragmatic atrophy rate was lower in pressure targeted ventilation (n = 44; 1.79% [1.03, 2.87]) than volume targeted ventilation (n = 11; 3.10% [1.31, 5.49]), p = .038. There was no difference in diaphragmatic parameters (atrophy rate, and peri‐extubation DTe and DTF) in extubation success versus failure. Conclusions The diaphragm undergoes progressive atrophy during the first week of mechanical ventilation in critically ill children. Future studies should evaluate ventilation strategies to reduce the diaphragmatic atrophy.