Title: Diaphragmatic dysfunction evaluation using ultrasonography as a predictor of weaning for patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease from mechanical ventilation
Authors: Akram Muhammad Fayed, Mohammed Samy Barakat, Emadeldin Mahmoud Zakaria
DOI: http://dx.doi.org/10.18535/jmscr/v4i6.44
Introduction: Diaphragmatic Excursion (DE) was used as a predictor for weaning of mechanical ventilation (MV) but not for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. Objectives: To correlate between Diaphragmatic dysfunction (DD) and outcome of mechanically ventilated AECOPD patients. Materials and Methods: 60 wean able mechanically ventilated patients with AECOPD were prospectively enrolled. M-mode U/S evaluation of the diaphragm was done using convex probe 3.5-5 MHZ in the supine position at the start of spontaneous breath trial on T-piece. Patients were randomized into two groups; DD (< 1 cm excursion) and non-DD (> 1 cm excursion). Outcomes of the ICU stay were determined. Results: Ten patients with DD had primary weaning failure versus two in the non-DD group, while six patients with DD had secondary weaning failure. There was significant reduction in duration of weaning, ICU and hospital length of stay in favor of non-DD group (2.5, 5 and 6 days, respectively; (p < 0.001)). For predicting weaning failure, the test showed 88.89% sensitivity, 97.62% specificity, 94.12% positive predictive value and 95.35% negative predictive value. Conclusions: DD detected by M-mode U/S was associated with prolonged duration of mechanical ventilation, ICU, hospital stay, and weaning failure in AECOPD patients. Key words: Acute exacerbation of COPD, Diaphragmatic dysfunction, Ultrasonography, Diaphragmatic excursion, weaning failure, and Rapid Shallow Breathing Index. 1. GOLD - the Global initiative for chronic Obstructive Lung Disease [Internet]. [Cited 2015 Oct 16]. Available from: http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html 2. Alía I, Esteban A. Weaning from mechanical ventilation. Crit Care. 2000 Feb 18;4(2):72. 3. Funk G-C, Anders S, Breyer M-K, Burghuber OC, Edelmann G, Heindl W, et al. Incidence and outcome of weaning from mechanical ventilation according to new categories. Eur Respir J. 2010 Jan;35(1):88–94. 4. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: A 28-day international study. JAMA. 2002 Jan 16; 287(3):345–55. 5. Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med. 1997 Mar 1;155(3):906–15. - 8 - 6. Zhu X, Heunks LMA, Machiels HA, Ennen L, Dekhuijzen PNR. Effects of modulation of nitric oxide on rat diaphragm isotonic contractility during hypoxia. J ApplPhysiol Bethesda Md 1985. 2003 Feb;94(2):612–20. 7. ONO1714, a New Inducible Nitric Oxide Synthase Inhibitor, At: Anesthesia & Analgesia [Internet]. [cited 2015 Oct 25]. Available from: http://journals.lww.com/ anesthesia-analgesia/Abstract/2001/04000/ ONO1714,_a_New_Inducible_Nitric_Oxide_Synthase.31.aspx 8. Ottenheijm CAC, Heunks LMA, Sieck GC, Zhan W-Z, Jansen SM, Degens H, et al. Diaphragm dysfunction in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005 Jul 15;172(2):200–5. 9. Stubbings AK, Moore AJ, Dusmet M, Goldstraw P, West TG, Polkey MI, et al. Physiological properties of human diaphragm muscle fibres and the effect of chronic obstructive pulmonary disease. J Physiol. 2008 May 15;586(10):2637–50. 10. Kabitz H-J, Windisch W, Schönhofer B. [Understanding ventilator-induced diaphra-gmmatic dysfunction (VIDD): progress and advances]. PneumolStuttg Ger. 2013 Aug;67(8):435–41. 11. Powers SK, Wiggs MP, Sollanek KJ, Smuder AJ. Ventilator-induced diaphragm dysfunction: cause and effect. Am J PhysiolRegulIntegr Comp Physiol. 2013 Sep;305(5):R464–77. 12. Bouhemad B, Zhang M, Lu Q, Rouby J-J. Clinical review: Bedside lung ultrasound in critical care practice. Crit Care. 2007 Feb 16;11(1):205. 13. Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM. DIaphragm muscle thinning in patients who are mechanically ventilated. Chest. 2012 Dec 1;142(6):1455–60. 14. Scott S, Fuld JP, Carter R, McEntegart M, MacFarlane NG. Diaphragm ultrasono-graphy as an alternative to whole-body plethysmography in pulmonary function testing. J Ultrasound Med Off J Am Inst Ultrasound Med. 2006 Feb;25(2):225–32. 15. Kim WY, Suh HJ, Hong S-B, Koh Y, Lim C-M. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011 Dec;39(12):2627–30. 16. Jiang J-R, Tsai T-H, Jerng J-S, Yu C-J, Wu H-D, Yang P-C. Ultrasonographic evaluation of liver/spleen movements and extubation outcome. Chest. 2004 Jul;126(1):179–85. 17. Gerscovich EO, Cronan M, McGahan JP, Jain K, Jones CD, McDonald C. Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med Off J Am Inst Ultrasound Med. 2001 Jun;20(6):597–604. 18. Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest. 2009 Feb;135(2):391–400. 19. Kantarci F, Mihmanli I, Demirel MK, Harmanci K, Akman C, Aydogan F, et al. Normal diaphragmatic motion and the effects of body composition: determination with M-mode sonography. J Ultrasound Med Off J Am Inst Ultrasound Med. 2004 Feb;23(2):255–60. 20. Houston JG, Angus RM, Cowan MD, McMillan NC, Thomson NC. Ultrasound assessment of normal hemidiaphragmatic movement: relation to inspiratory volume. Thorax. 1994 May;49(5):500–3.Abstract
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