Abstract
BackgroundUltrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care. In this single-center prospective study, we investigated the impact of US-assessed DD on noninvasive ventilation (NIV) failure in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and its correlation with the transdiaphragmatic pressure assessed using the invasive sniff maneuver (Pdi sniff).MethodsA population of 75 consecutive patients with AECOPD with hypercapnic acidosis admitted to our respiratory intensive care unit (RICU) were enrolled. Change in diaphragm thickness (ΔTdi) < 20% during tidal volume was the predefined cutoff for identifying DD+/− status. Correlations between ΔTdi < 20% NIV failure and other clinical outcomes were investigated. Correlation between ΔTdi and Pdi sniff values was analyzed in a subset of ten patients.ResultsDD+ patients had a higher risk for NIV failure than DD− patients (risk ratio, 4.4; p < 0.001), and this finding was significantly associated with higher RICU, in-hospital, and 90-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer RICU stay. Huge increases in NIV failure (HR, 6.2; p < 0.0001) and 90-day mortality (HR, 4.7; p = 0.008) in DD+ patients were found by Kaplan-Meier analysis. ΔTdi highly correlated with Pdi sniff (Pearson’s r = 0.81; p = 0.004). ΔTdi < 20% showed better accuracy in predicting NIV failure than baseline pH value and early change in both arterial blood pH and partial pressure of carbon dioxide following NIV start (AUCs 0.84 to DTdi < 20%, 0.51 to pH value at baseline, 0.56 to early change in arterial blood pH following NIV start, and 0.54 to early change in partical pressure of carbon dioxide following NIV start, respectively; p < 0.0001).ConclusionsEarly and noninvasive US assessment of DD during severe AECOPD is reliable and accurate in identifying patients at major risk for NIV failure and worse prognosis.
Highlights
Ultrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care
Patients admitted to the intensive care unit (ICU) or respiratory intensive care unit (RICU) because of severe episodes of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have considerably high inhospital (24%) and 1-year (59%) mortality rates [1,2,3]
In a recently published pilot study, we reported that DD as assessed by a noninvasive ultrasound (US) technique is present in almost one-fourth of patients with AECOPD and admitted to the RICU for severe hypercapnic respiratory failure [9]
Summary
Ultrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care. In this single-center prospective study, we investigated the impact of US-assessed DD on noninvasive ventilation (NIV) failure in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and its correlation with the transdiaphragmatic pressure assessed using the invasive sniff maneuver (Pdi sniff). The use of noninvasive ventilation (NIV) in patients experiencing respiratory failure due to AECOPD is considered a first-line treatment but still has a failure rate between 5% and 40% [4]. Researchers in previous studies have observed that patients with chronic obstructive pulmonary disease (COPD) might have a higher rate of diaphragmatic dysfunction (DD) than to age- and sex-matched healthy control individuals [6]. The early collapse of terminal airways with air entrapment causes an intrinsic positive end-expiratory pressure (PEEPi) that behaves as an adjunctive load that the respiratory muscles must overcome before generating inspiratory flow [7]
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