Mechanical Ventilation–induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes
Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown. To determine whether diaphragm atrophy developing during mechanical ventilation lead...
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| Published in | American journal of respiratory and critical care medicine Vol. 197; no. 2; pp. 204 - 213 |
|---|---|
| Main Authors | , , , , , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
United States
American Thoracic Society
15.01.2018
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| Subjects | |
| Online Access | Get full text |
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| Abstract | Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown.
To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation.
Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity.
Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation.
Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation. |
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| AbstractList | Rationale: Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown.Objectives: To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation.Methods: Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity.Measurements and Main Results: Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation.Conclusions: Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation. Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown.RATIONALEDiaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown.To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation.OBJECTIVESTo determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation.Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity.METHODSDiaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity.Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation.MEASUREMENTS AND MAIN RESULTSOf 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation.Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation.CONCLUSIONSDiaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation. Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown. To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation. Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity. Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation. Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation. |
| Author | Dres, Martin Brace, Deborah Murray, Alistair Reid, W. Darlene Goligher, Ewan C. Ferguson, Niall D. Kavanagh, Brian P. Slutsky, Arthur S. Brochard, Laurent J. Tomlinson, George Scales, Damon C. Lanys, Ashley Urrea, Cristian Rittayamai, Nuttapol Vorona, Stefannie Fan, Eddy Rubenfeld, Gordon D. Sklar, Michael C. Herridge, Margaret S. |
| Author_xml | – sequence: 1 givenname: Ewan C. surname: Goligher fullname: Goligher, Ewan C. organization: Interdepartmental Division of Critical Care Medicine, Department of Physiology, Department of Medicine, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 2 givenname: Martin surname: Dres fullname: Dres, Martin organization: Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada, Respiratory and Critical Care Department, Groupe Hospitalier Pitié Salpêtrière Charles Foix, Assistance Publique Hôpitaux de Paris, Paris, France – sequence: 3 givenname: Eddy surname: Fan fullname: Fan, Eddy organization: Interdepartmental Division of Critical Care Medicine, Department of Medicine, Institute for Health Policy, Management, and Evaluation, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 4 givenname: Gordon D. surname: Rubenfeld fullname: Rubenfeld, Gordon D. organization: Interdepartmental Division of Critical Care Medicine, Department of Medicine, Institute for Health Policy, Management, and Evaluation, Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Canada – sequence: 5 givenname: Damon C. surname: Scales fullname: Scales, Damon C. organization: Interdepartmental Division of Critical Care Medicine, Department of Medicine, Institute for Health Policy, Management, and Evaluation, Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Canada – sequence: 6 givenname: Margaret S. surname: Herridge fullname: Herridge, Margaret S. organization: Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada, Toronto General Research Institute, Toronto, Canada; and – sequence: 7 givenname: Stefannie surname: Vorona fullname: Vorona, Stefannie organization: Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 8 givenname: Michael C. surname: Sklar fullname: Sklar, Michael C. organization: Department of Anesthesia, and, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada – sequence: 9 givenname: Nuttapol surname: Rittayamai fullname: Rittayamai, Nuttapol organization: Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada – sequence: 10 givenname: Ashley surname: Lanys fullname: Lanys, Ashley organization: Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada – sequence: 11 givenname: Alistair surname: Murray fullname: Murray, Alistair organization: Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 12 givenname: Deborah surname: Brace fullname: Brace, Deborah organization: Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 13 givenname: Cristian surname: Urrea fullname: Urrea, Cristian organization: Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 14 givenname: W. Darlene surname: Reid fullname: Reid, W. Darlene organization: Department of Physical Therapy, University of Toronto, Toronto, Canada – sequence: 15 givenname: George surname: Tomlinson fullname: Tomlinson, George organization: Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada – sequence: 16 givenname: Arthur S. surname: Slutsky fullname: Slutsky, Arthur S. organization: Interdepartmental Division of Critical Care Medicine, Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada – sequence: 17 givenname: Brian P. surname: Kavanagh fullname: Kavanagh, Brian P. organization: Interdepartmental Division of Critical Care Medicine, Department of Physiology, Department of Anesthesia, and, Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada – sequence: 18 givenname: Laurent J. surname: Brochard fullname: Brochard, Laurent J. organization: Interdepartmental Division of Critical Care Medicine, Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada – sequence: 19 givenname: Niall D. surname: Ferguson fullname: Ferguson, Niall D. organization: Interdepartmental Division of Critical Care Medicine, Department of Physiology, Department of Medicine, Institute for Health Policy, Management, and Evaluation, Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/28930478$$D View this record in MEDLINE/PubMed https://hal.science/hal-03985853$$DView record in HAL |
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| Snippet | Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure... Rationale: Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm... |
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| SubjectTerms | Clinical outcomes Diaphragm (Anatomy) Intensive care Intubation Life Sciences Muscular system Ostomy Respiration Respiratory system Respiratory therapy Sepsis Ultrasonic imaging Ventilators |
| Title | Mechanical Ventilation–induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes |
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