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Abstract
BackgroundIn intensive care unit (ICU) patients, diaphragmatic dysfunction (DD) can occur on admission or during the subsequent stay. The respective incidence of these two phenomena has not been previously studied in humans. The study was designed to describe temporal trends in diaphragm function in mechanically ventilated (MV) patients.MethodsAncillary study of a prospective, 6-month, observational cohort study conducted in two ICUs. MV patients were studied within 24 h following intubation (day-1) and every 48–72 h thereafter. Diaphragm function was assessed by twitch tracheal pressure (Ptr,stim) in response to bilateral anterior magnetic phrenic nerve stimulation. Diaphragm dysfunction was defined as Ptr,stim < 11 cmH2O. Patients who received MV for at least 5 days were retained, and the first and the last measures were analysed.ResultsForty-three patients were included. Overall, 79 % of patients developed DD at some point during their ICU stay: 23 (53 %) patients presented DD on initiation of mechanical ventilation, 14 (33 %) of whom had persistent DD, while diaphragm function improved in 9 (21 %). Among the remaining 20 (47 %) patients who did not present DD on initiation of MV, 11 (26 %) developed DD during the ICU stay, while 9 (21 %) did not. Mortality was higher in patients with DD either on initiation of mechanical ventilation or during the subsequent ICU stay than in those who never developed DD (35 vs. 0 %, p = 0.04). Duration of MV was higher in patients with DD on initiation of MV that subsequently persisted than in patients who never exhibited diaphragm dysfunction (18 vs. 5 days, p = 0.04). Factors associated with a change in Ptr,stim were: age [linear coefficient regression (Coeff.) −0.097, standard error (SD) 0.047, p = 0.046], PaO2/FiO2 ratio (Coeff. 0.014, SD 0.006, p = 0.0211) and the proportion of the time under MV with sedation (per 10 %, Coeff. −5.359, SD 2.451, p = 0.035).ConclusionsDD is observed in a large majority of MV patients ≥5 days at some point of their ICU stay. Various patterns of DD are observed, including DD on initiation of mechanical ventilation and ICU-acquired DD.Trial registration clinicaltrials.gov Identifier # NCT00786526
Highlights
In intensive care unit (ICU) patients, diaphragmatic dysfunction (DD) can occur on admission or during the subsequent stay
It can be a negative consequence of mechanical ventilation per se, which is associated with a time-dependent decrease of diaphragm strength called ventilator-induced diaphragm dysfunction (VIDD) [7]
Exclusion criteria were an expected duration of mechanical ventilation less than 48 h, contraindications to magnetic stimulation of the phrenic nerves, use of neuromuscular blocking agents within the 24 h preceding the first diaphragm function assessment, pre-existing neuromuscular disorders, cervical spine injury, factors possibly interfering with tracheal pressure measurements in response to phrenic stimulation
Summary
In intensive care unit (ICU) patients, diaphragmatic dysfunction (DD) can occur on admission or during the subsequent stay. Diaphragm function is a major determinant of weaning from mechanical ventilation in intensive care unit (ICU) patients and influences the duration of mechanical ventilation [1]. It has become a major concern in ICU patients and the subject of an increasing number of reports [2]. The diaphragm, like all organs, can be involved in the shockrelated generalized organ failure observed in many patients on admission to the ICU [3] This occurs in 64 % of patients, is determined by sepsis and the severity of the disease and is associated with higher mortality [3]. The study was designed to describe temporal trends in diaphragm function, identify putative clinical factors associated with diaphragm dysfunction and describe the subsequent impact of these changes on the patient’s outcome
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