Prevalence and time-course of diaphragmatic dysfunction following lung resection: A repeated ultrasonic assessment

Matthieu Daniel,Elodie Lang,Thi Mum Huynh,Julien Martin,Myriam Brebion,Karim Guessous,Diane Zlotnik,Laura Gouzien,Oussama Chaouch,Paul Delval,Arnaud Ferraris,Françoise Le Pimpec-Barthes,Bernard Cholley

doi:10.1016/j.accpm.2022.101024

Abstract

PurposeUltrasound (US) allows non-invasive repeated assessments of diaphragmatic excursion (DE) and thickening fraction (DTF) at the bedside, reflecting diaphragmatic dysfunction (DD). We aimed at determining the prevalence and time-course of DD following elective thoracic surgery and the association with postoperative complications. Material and methodsProspective, single-centre, observational study with consecutive patients undergoing thoracic surgery. DE/DTF were measured by two observers blinded to each other at 3 different time-points: prior to surgery, immediately after extubation and on postoperative day 3. The changes in DE/DTF of both hemi-diaphragms over time were compared according to the side (operated/non-operated) using a two-way-ANOVA. The association with postoperative complications was assessed using logistic regression. ResultsFifty patients, 60% males, aged 60 ± 15 years were included. Surgical procedures included lobectomy (n = 30), wedge-resection (n = 17) or pneumonectomy (n = 3). On the operated side, we observed a decrease in DE/DTF at D0 (−0.71 ± 0.12 mm, P < 0.05; −44 ± 30%, P < 0.05) and D3 (−0.82 ± 0.19 mm, P < 0.05; −39 ± 19%, P < 0.05) with respect to preoperative and non-operated side values over the study period. Persistent DD on the operated side was associated with an increased risk of lung infection (OR: 9.0, 95% CI [1.92–65.93], P = 0.001), ICU-admission (OR: 3.9, 95% CI [1.10–15.53], P = 0.04) according to univariate analysis and a prolonged length in hospital (OR: 1.3, 95% CI [1.1–1.7], P = 0.016) according to multivariate analysis. ConclusionsThoracic surgery generates DD mainly observed on the operated side, which persists at least up to postoperative D3 and is associated with an increase in hospital stay.

Highlights

There is little information regarding diaphragmatic dysfunction (DD) following thoracic surgery
DD was highly prevalent after thoracic surgery and was observed on the operated side in, at least, 68% of patients immediately after surgery (D0)
Two patients were excluded from the final analysis: one withdrew consent and the other died of a massive hemorrhage precluding the possibility of ultrasound assessment

Summary

Introduction

There is little information regarding diaphragmatic dysfunction (DD) following thoracic surgery. Ultrasound allows for non-invasive repeated assessments of diaphragmatic excursion (DE) and thickening fraction (DTF) at the bedside, reflecting DD. The monitoring of trans-diaphragmatic pressures (Pdi) combined with electromyographic recordings under supramaximal electrical (or magnetic) phrenic nerve stimulations [1, 2] remains the gold standard. This method is burdened with a specific complexity and invasiveness, making it poorly accessible on a routine and rather falls within the physiological research field in specialized centers. It has been demonstrated that DTF correlates with trans-diaphragmatic pressures [14, 15] but the measurement of DE is easier to acquire and more reproducible on spontaneously breathing patients during the postoperative period [16, 17]

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Discussion

Conclusion