Disfunción diafragmática evaluada por ecografía como predictora del fracaso de la extubación: Revisión sistemática y metanálisis

Abstract

IntroductionThe evaluation of diaphragmatic dysfunction by ultrasound as a predictor of extubation failure lacks of standardization. MethodsWe performed a systematic review and meta-analysis of studies that included patients intubated on mechanical ventilation, and who received unilateral or bilateral diaphragmatic ultrasound to evaluate diaphragmatic dysfunction prior to extubation. We searched the Pubmed and Embase databases from January 1, 2010 to June 30, 2019 using the terms «diaphragm ultrasound, diaphragm ultrasonography», «weaning» and «extubation». We defined weaning failure as the need of intubation with invasive ventilacion or failure in spontaneous breathing trial (SBT). The echographic measures used for predicting weaning failure in intubated patients were diaphragmatic excursion (DE), diaphragm thickening fraction (DTF), time to peak inspiratory amplitude of the diaphragm (TPIA dia), modified lung ultrasound score (LUSm) y el excursion time index (ET index).We evaluated the usefulness of ultrasound-assessed diaphragmatic dysfunction to predict the primary outcome of weaning failure in intubated patients undergoing mechanical ventilation. Secondary outcomes were mortality, hospital stay and the need for noninvasive ventilation or high-flow oxygen therapy after weaning in this group of patients. Random effects model, odds ratio (OR), and 95% confidence intervals (CI) were used for data aggregation. The heterogeneity of the original studies was evaluated using the I2 statistic. In all analyses, significance levels were bilateral and p values < 0.05 were considered significant. ResultsWe included a total of 18 prospective studies that recruited 1 229 intubated patients on mechanical ventilation. Weaning failed in 254 of the 490 (52%) patients with diaphragmatic dysfunction, compared with 117 of the 739 (16%) patients without diaphragmatic dysfunction. The presence of ultrasound-assessed diaphragmatic dysfunction was significantly associated with weaning failure within 7 days after extubation (18 cohorts, 1 229 patients; odds ratio [OR] 8.2; 95% confidence interval [CI], 4.7-14,2; p < 0.0001; I2 = 66%). The results were consistent for studies that performed unilateral or bilateral assessment of diaphragmatic function. ConclusionsDiaphragmatic dysfunction evaluated by ultrasound is significantly associated with weaning failure in the first 7 days after extubation.