The Utility of Diaphragm Ultrasound in Reducing Time to Extubation

Diaphragmatic ultrasound: approach, emerging evidence, and future perspectives in non-ICU patients

Diaphragmatic dysfunction is an important contributor to hypercapnic respiratory failure, but its presence is often challenging to determine at the bedside. Diaphragm ultrasound provides an opportunity to evaluate the function of the diaphragm noninvasively by evaluating the following parameters that can help define diaphragmatic dysfunction: diaphragm excursion, diaphragm muscle thickness, and thickening fraction. Its evaluation has the potential to assist with diagnosis of respiratory failure, provide prognosis, and assist with patient monitoring and should be considered as part of an internal medicine physician's and emergency physician's skill set. This article provides an overview on how to perform diaphragm ultrasound, review its pitfalls, and discuss the evidence of its use in patients with neuromuscular disorders and chronic obstructive pulmonary disease. Finally, its potential emerging uses in the perioperative setting and for evaluation of acute heart failure are discussed.

Respiratory effort in mechanical ventilation weaning Prediction: An observational, case-control study

BACKGROUND

The diaphragm is crucial for ventilator weaning, but its specific impact on weaning indicators needs further clarification. This study investigated the variability in weaning outcomes across different diaphragm function populations and the value of respiratory drive and inspiratory effort in weaning.

METHODS

This observational case-control study enrolled patients on mechanical ventilation for more than 48 h and completed a 30-minute spontaneous breathing trial (SBT) with pressure-support ventilation for the first time. After the SBT, airway pressure at 100 ms during occlusion (P0.1), inspiratory effort, and diaphragmatic ultrasound were evaluated to predict weaning outcomes. Weaning failure was defined as re-intubation within 48 h of weaning, the need for therapeutic non-invasive ventilation, or death.

RESULTS

68 patients with a mean age of 63.21 ± 15.15 years were included. In patients with diaphragm thickness (DT) ≥ 2 mm, P0.1 (P=0.002), pressure-muscle index (PMI) (P=0.012), and occluded expiratory airway pressure swing (ΔPocc) (P=0.030) were significantly higher in those who failed weaning. Conversely, for patients with DT<2 mm, PMI (P=0.003) and ΔPocc (P=0.002) were lower in the weaning failure group. Additionally, within the DT≥2 mm group, P0.1 demonstrated a higher area under the curve (AUC) for weaning prediction (0.889 vs. 0.739) compared to those with DT<2 mm.

CONCLUSIONS

PMI and ΔPocc are predictive of weaning outcomes in patients with diaphragm thickness ≥ 2 mm, where the assessment value of P0.1 is notably higher. Diaphragm function significantly influences the accuracy of weaning predictions based on respiratory drive and inspiratory effort.

IMPLICATIONS FOR CLINICAL PRACTICE

Our findings indicate that the effectiveness of respiratory drive and inspiratory effort in predicting successful weaning from mechanical ventilation may vary across different patient populations. Diaphragm function plays a crucial role in weaning assessments, particularly when using P0.1, the pressure-muscle index (PMI), and occluded expiratory airway pressure swing (ΔPocc).

Review of Point-of-Care Diaphragmatic Ultrasound in Emergency Medicine: Background, Techniques, Achieving Competency, Research, and Recommendations

ABSTRACT

The diaphragm is the major muscle of inspiration accounting for approximately 70% of the inspired tidal volume. Point-of-care diaphragmatic ultrasound offers the ability to quantitatively assess diaphragmatic function, perform serial evaluations over time, and visualize structures above and below the diaphragm. Although interest in point-of-care ultrasound (POCUS) of the diaphragm is developing in the emergency medicine, assessment of the diaphragm and its function is not recognized as a core application by national organizations or expert guidelines. As a result, it is infrequently performed, and its potential value in research or clinical practice may not be fully appreciated. The purpose of this review is to describe the developmental aspects of the diaphragm as it pertains to POCUS, discuss the POCUS techniques for evaluating diaphragmatic function, address competency acquisition in this POCUS application, summarize relevant research in the ED, and provide a summary of recommendations for further research and clinical utilization of POCUS in diaphragm evaluation.

Diaphragmatic Dynamics Assessed by Bedside Ultrasound Predict Extubation in the Intensive Care Unit: A Prospective Observational Study

Background

This study aims to evaluate the predictive value of bedside ultrasound evaluation of diaphragmatic dynamics in determining successful extubation outcomes for patients eligible for weaning.

Methods

This prospective observational study was conducted on patients who were mechanically ventilated and ready for weaning during the spontaneous breathing trial (SBT). The diaphragm contraction and motion-related parameters of patients such as end inspiratory diaphragm thickness (DT-insp), end respiratory diaphragm thickness (DT-exp), diaphragm thickening fraction (DTF), diaphragmatic thickening fraction rapid shallow breathing index (DTF-RSBI), diaphragmatic excursion (DE), diaphragmatic excursion rapid shallow breathing index (DE-RSBI) were recorded and the association with failure in ventilatory extubation was analyzed. A receiver operating characteristic (ROC) curve was conducted to analyze the prediction of successful weaning.

Results

Out of 95 patients, 14 (14.74%) died, and 68 (71.58%) were successfully extubated. There were significant differences between the two groups in all parameters except DT-exp. The results indicated that duration of mechanical ventilation (OR = 0.850, 95% CI: 0.770-0.938, P = 0.001), DTF (OR = 1.214, 95% CI: 1.108-1.330, P = 0.000), DTF-RSBI (OR = 0.917, 95% CI: 0.880-0.954, P = 0.000), DE (OR = 127.02, 95% CI: 15.004-1075.291, P = 0.000), DE-RSBI (OR = 0.752, 95% CI: 0.657-0.861, P = 0.000) had predictive value for weaning. DTF and DE had a high sensitivity of 91.18%, 100%, respectively. Whereas, duration of mechanical ventilation, DTF-RSBI, DE-RSBI showed a high specificity of 81.48,85.19%, 81.48%. Considering all the above factors, the sensitivity was 88.24% and the specificity was 88.89%.

Conclusion

Bedside ultrasound assessment of diaphragmatic parameters enables the detection of diaphragmatic dysfunction, thus proving valuable in predicting extubation success and facilitating a favorable weaning outcome.

Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis

BACKGROUND

Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures.

METHODS

Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients.

RESULTS

Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01).

CONCLUSIONS

DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted.

TRIAL REGISTRATION

PROSPERO CRD42020209295, October 15, 2020.

Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care: A Narrative Review

INTRODUCTION

Weaning failure is common in mechanically ventilated patients, and whether ultrasound (US) can predict weaning outcome remains controversial. This review aims to evaluate the diaphragmatic function measured by US as a predictor of weaning outcome.

METHODS

PubMed was searched to identify original articles about the use of diaphragmatic US in ICU patients. A total of 61 citations were retrieved initially; available data of 26 studies were included in this review.

RESULTS

To assess diaphragmatic dysfunction in adults, six studies evaluated excursion, five evaluated thickening fraction, and both in nine. Despite heterogeneity in the diagnostic accuracy of diaphragm US among the studies, the sonographic indices showed good diagnostic performance for predicting weaning outcome.

CONCLUSIONS

Diaphragmatic US can be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients and predict weaning outcome.

Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors

As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.

Value of Diaphragm Ultrasonography for Extubation: A Single-Blinded Randomized Clinical Trial

Introduction

Daily evaluation of mechanically ventilated (MV) patients is essential for successful extubation. Proper withdrawal prevents complications and reduces the cost of hospitalization in the intensive care unit (ICU). Diaphragm ultrasonography (DUS) has emerged as a potential instrument for determining whether a patient is ready to be extubated. This study compared the efficacy rate of extubation using a standard withdrawal protocol and DUS in patients with MV.

Methods

A randomized, parallel, single-blind, controlled study was conducted on ICU patients undergoing MV. Patients were randomly assigned to either the control (conventional weaning protocol) group or intervention (DUS-guided weaning) group in a 1 : 1 ratio. The primary outcome measure was the rate of reintubation and hospital mortality.

Results

Forty patients were randomized to the trial. The mean age of the sample was 70 years, representing an older population. The extubation success rate was 90% in both groups. There was no reintubation in the first 48 hours and only two reintubations in both groups between the second and seventh days. The hospital mortality risk in patients with acute kidney injury was positively correlated with age and the need for hemodialysis. Discussion. This study demonstrates the usefulness of DUS measurement protocols for withdrawing MV. The rate of reintubation was low for both cessation methods. As a parameter, the diaphragm thickness fraction comprehensively evaluates the diaphragm function. The results demonstrate that DUS has the potential to serve as a noninvasive tool for guiding extubation decisions. In conclusion, using DUS in patients with respiratory failure revealed no difference in reintubation rates or mortality compared with the conventional method. Future research should concentrate on larger, multicentered, randomized trials employing a multimodal strategy that combines diaphragmatic parameters with traditional clinical withdrawal indices.

Clinical utility of diaphragmatic ultrasonography for mechanical ventilator weaning in adults: A study protocol for systematic review and meta-analysis

Background and Aims

Mechanical ventilation is associated with several risks, including barotrauma, ventilator-associated pneumonia, and ventilator-induced diaphragmatic dysfunction. A delay in weaning from mechanical ventilation increases these risks, and prolonged weaning has been shown to increase hospital mortality. Various tools have been used in clinical practice to predict successful weaning from mechanical ventilation; however, they have a low prognostic accuracy. The use of ultrasonography in intensive care units is an area of growing interest since it is a noninvasive, convenient, and safe modality. Since ultrasonography can provide real-time assessment of diaphragmatic morphology and function, it may have clinical utility in predicting successful mechanical ventilator weaning. This study aimed to describe a protocol to assess the effectiveness of diaphragmatic ultrasonography in the decision-making process for ventilator weaning in terms of its impact on clinical outcomes.

Methods

This systematic review of published analytical research will use an aggregative thematic approach according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will perform a comprehensive search for studies on the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. Two authors will independently perform abstract and full-text screening and data extraction. Additionally, a meta-analysis and the risk of bias evaluation will be conducted, as appropriate.

Conclusion

Systematic reviews on the effectiveness of diaphragmatic ultrasonography in the decision-making process for ventilator weaning in terms of its impact on clinical outcomes are lacking. The results of this systematic review may serve as a basis for future clinical trials. Systematic review registration: This protocol was registered with the Open Science Framework: https://osf.io/cn8xf.

Diaphragmatic Dynamics and Thickness Parameters Assessed by Ultrasonography Predict Extubation Success in Critically Ill Patients

INTRODUCTION

A frequent cause of weaning and extubation failure in critically ill mechanically ventilated patients is diaphragm muscle dysfunction. Ultrasound (US) evaluation of the diaphragm yields important data regarding its thickness (diaphragm thickening fraction [TFdi]) and its movement or excursion (diaphragmatic dynamics) that reveal the presence of diaphragmatic dysfunction.

METHODS

Cross-sectional study, which included patients older than 18 years with invasive mechanical ventilation with an expected duration of more than 48 h, in a tertiary referral center in Colombia. The excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi were evaluated by US. Prevalence and use of medications were evaluated, and the association with failure in ventilatory weaning and extubation was analyzed.

RESULTS

Sixty-one patients were included. The median age and APACHE IV score were 62.42 years and 78.23, respectively. The prevalence of diaphragmatic dysfunction (assessed by excursion and TFdi) was 40.98%. The sensibility, specificity, positive predictive value, and negative predictive value for TFdi < 20% was 86%, 24%, 75%, and 40%, respectively, with an area under the receiver operating characteristic (ROC) curve of 0.6. The ultrasonographic analysis of excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi (>20%) allow in its set and with normal values, predict success or failure for the extubation with an area under the ROC curve of 0.87.

CONCLUSION

Diaphragmatic dynamics and thickness parameters together assessed by ultrasonography could predict the success of extubation in critically ill patients in Colombia, based on the finding of diaphragmatic dysfunction.

Diaphragmatic ultrasound in weaning ventilated patients: a reliable predictor?

Timely weaning of mechanical ventilation is clinically difficult, as both early and late discontinuations are associated with adverse events impeding the patient's favorable course in the critical care unit. Many parameters aid in judging whether the patient is going to be safely extubated; however, some remain deficient. We herein describe diaphragmatic ultrasound as a new modality for this purpose, detailing diaphragm excursion and thickness as means of it.

Diyafram ultrasonografisinin weaning başarısını tahmin etmedeki gücü

Amaç: Bu çalışmada amaç; diyafram kalınlığının weaning üzerine etkilerini ultrasonografi (USG) ile değerlendirmektir. Gereç ve Yöntem: Prospektif olarak yapılan bu çalışmada; hastaların demografik özellikleri, yoğun bakıma yatış ve mekanik ventilasyon endikasyonları, ek hastalıkları, diyafram kalınlığı, Sıralı Organ Yetmezliği Değerlendirmesi (SOFA) skoru ve Basitleştirilmiş Akut Fizyoloji Skoru (SAPS) II, mortalite oranı, periferik oksijen satürasyonu (SpO2), IMV süresi, dakika hacmi, solunum sayısı (RR), ekspiratuar hacimleri, RSBI değerleri kaydedildi.Hastalar invaziv mekanik ventilatör (IMV) basınç desteği (PS) modunda 30 dakika boyunca spontan olarak ventile edildi . Diyafram kalınlığı (DT), B moduna ayarlanmış 7-10 MHz lineer ultrason probu kullanılarak ölçüldü. Sağ hemidiyafram, 8. ve 10. interkostal boşluklar arasındaki midaksiller çizgide diyafram ve göğüs kafesinin birleştiği bölgede görüntülendi. Ölçümler sonrasında hastalar stabil hale geldikten sonra 1 saat boyunca T-tüpe alındı. T-tüpte spontan solunum denemeleri (SBT)'ni başarıyla tamamlayan hastalar ekstübe edildi. Hastalar başarılı ve başarısız weaning olmak üzere 2 gruba ayrıldı. Bulgular: Toplam 72 hasta çalışmaya dahil edilme kriterlerini sağlayarak değerlendirilmeye alındı. Hastaların 4 tanesi 24 saatten daha kısa süre IMV desteği aldığı için çalışma dışı bırakıldı. Diyafram kalınlık indeksi (DTI) ve diyafram kalınlaşma fraksiyonu (DTF) oranlarında gruplar arasında bir farklılık gözlenmedi. İnspirasyon sonunu diyafram kalınlığı (DTV) ve ekspirasyon sonunu diyafram kalınlığı (DFRV) olarak tanımlanan diyaframın kalınlık ölçümleri başarılı weaning grubunda daha yüksekti. Weaning başarısını tahmin etmek için DTV'nin en iyi eşik değeri 0.72, DFRV değeri 0.669 olarak bulundu. Sonuç: Weaning başarısı diyafram fonksiyonları, diyafram kalınlık parametreleri ve akciğer kapasiteleri ile yakından ilişkilidir. USG, diyaframı değerlendirmek için kullanılabilecek pratik, hasta başı uygulanabilen, noninvaziv bir yöntemdir. DTV ve DFRV weaning sürecinde başarıyı tahmin edebilecek parametreler arasındadır. DTF ve DTI weaning başarısını öngörmede yetersiz bulundu.

Diaphragm Ultrasound in Cardiac Surgery: State of the Art

In cardiac surgery, patients are at risk of phrenic nerve injury, which leads to diaphragm dysfunction and acute respiratory failure. Diaphragm dysfunction (DD) is relatively frequent in cardiac surgery and particularly affects patients after coronary artery bypass graft. The onset of DD affects patients’ prognosis in term of weaning from mechanical ventilation and hospital length of stay. The authors present a narrative review about diaphragm physiology, techniques used to assess diaphragm function, and the clinical application of diaphragm ultrasound in patients undergoing cardiac surgery.

CORRELATION BETWEEN DIAPHRAGM EXCURSION WITH BOTH THE QUALITY OF LIFE AND EXERCISE CAPACITY FOR PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE STUDIED BY ULTRASOUND

Objective: To study the correlation between diaphragm excursion and both the quality of life and exercise capacity in patients with chronic obstructive pulmonary disease (COPD) by ultrasound and to reveal the factors affecting diaphragm excursion. Methods: A total of 42 COPD patients who were treated in our hospital from October 2015 to March 2020 and 42 healthy volunteers (control group) were included in the present study. The participants’ height, weight, and diaphragm excursion (the amplitude of diaphragm movement during deep breathing measured by M-mode ultrasound ([Formula: see text])), diaphragm movement time, degree of airflow obstruction (the forced expiratory volume in one second (FEV1) as a percentage of its predicted level, FEV1%pred), and exercise capacity (six-minute walk distance, 6MWD) were measured. The St. George’s Respiratory Questionnaire (SGRQ) was used to evaluate the patients’ quality of life. The correlation between the amplitude of diaphragm movement and lung function was analyzed. The receiver operating characteristics (ROC) curve was used to determine the COPD diagnosis efficacy of M-mode ultrasound, and its influencing factors were further analyzed. Results: During tidal breathing, the movement amplitudes of both hemidiaphragms in the COPD group were greater than those in the control group. During deep breathing, the movement amplitudes of both hemidiaphragms in the control group were greater than those in the COPD group. Moreover, during both tidal and deep breathing, the movement time of the right hemidiaphragm in the control group was longer than that in the COPD group (all P < 0.001). During deep breathing, the amplitude of diaphragm movement was positively correlated with FEV1 and FEV1%pred (both P < 0.001). During both tidal and deep breathing, the area under the ROC curve (AUC) for the diagnosis of COPD according to the diaphragm movement amplitude was 0.833 and 0.887, respectively, and the AUC for the diagnosis of COPD according to the diaphragm movement time was 0.625 and 0.732, respectively. The [Formula: see text] was correlated with the SGRQ score, symptom score, impact score, activity score, and 6MWD, with correlation coefficients of −0.474, −0.416, −0.432, −0.502, and 0.536, respectively. The factors affecting the [Formula: see text] were height ([Formula: see text], P < 0.001) and FEV1%pred ([Formula: see text], P < 0.001). Conclusion: The diaphragm excursion in COPD was closely related to patients’ quality of life. Height and FEV1%pred had the greatest impact on diaphragm excursion. The lower the diaphragm excursion of the patient, the worse their quality of life and the lower their exercise capacity.

Early rehabilitation relieves diaphragm dysfunction induced by prolonged mechanical ventilation: a randomised control study

BACKGROUND

Prolonged mechanical ventilation (MV) induces diaphragm dysfunction in patients in the intensive care units (ICUs). Our study aimed to explore the therapeutic efficacy of early rehabilitation therapy in patients with prolonged MV in the ICU.

METHODS

Eighty eligible patients who underwent MV for > 72 h in the ICU from June 2019 to March 2020 were enrolled in this prospective randomised controlled trial. The patients were randomly divided into a rehabilitation group (n = 39) and a control group (n = 41). Rehabilitation therapy included six levels of rehabilitation exercises. Diaphragm function was determined using ultrasound (US).

RESULTS

Diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) were significantly decreased in all patients in both groups after prolonged MV (p < 0.001). The rehabilitation group had significantly higher DTF (p = 0.008) and a smaller decrease in DTF (p = 0.026) than the control group after 3 days of rehabilitation training. The ventilator duration and intubation duration were significantly shorter in the rehabilitation group than in the control group (p = 0.045 and p = 0.037, respectively). There were no significant differences in the duration of ICU stay, proportion of patients undergoing tracheotomy, and proportion of recovered patients between the two groups.

CONCLUSIONS

Early rehabilitation is feasible and beneficial to ameliorate diaphragm dysfunction induced by prolonged MV and advance withdrawal from the ventilator and extubation in patients with MV. Diaphragm US is suggested for mechanically ventilated patients in the ICU. Trial registration Chinese Clinical Trial Registry, ID: ChiCTR1900024046, registered on 2019/06/23.

Decline in diaphragm thickness and clinical outcomes among patients with sepsis

BACKGROUND

The decline in the diaphragm thickness is common among patients with sepsis. The purpose of this study is to examine the relationship between the decline in diaphragm thickness as assessed by ultrasonography and various outcomes in septic patients.

METHODS

This prospective study included patients with sepsis whose diaphragm thickness was measured during inspiration (DTinsp) and expiration (DTexp) using ultrasonography on days 1, 3, 5, 7, 10, and 14 of admission in the ICU and thereafter weekly measurements until discharge or death.

RESULTS

The study included 70 (45 male) patients with sepsis [mean (SD) age = 55.91(14.08) years]. The mean (SD) DTinsp and DTexp (mm) on day-1 were 2.84 (0.32) and 2.33(0.27), respectively. During the hospital stay, there was a decline in DTinsp and DTexp. The decline in DTinsp and DTexp on days 3, 5, and 7 was significantly higher among patients with difficult weaning, non-survivors, and worse 90-day outcomes. Early decline (from day-1 to day-3) in diaphragm thickness predicted difficult weaning, in-hospital mortality, and worse 90-day outcome.

CONCLUSIONS

Among patients with sepsis, the decline in diaphragm thickness detected by ultrasonography is associated with worse in-hospital and short-term post-discharge outcomes. The role of early decline in diaphragm thickness on ultrasonography as a marker of worse outcomes needs further evaluation.

Sonographic evaluation of diaphragmatic thickness and excursion as a predictor for successful extubation in mechanically ventilated preterm infants

Sonographic assessment of diaphragmatic thickness and excursion has been found to be an accurate tool in predicting successful extubation of adult patients from invasive mechanical ventilation. We aimed to evaluate the accuracy of sonographic assessment of diaphragmatic thickness and excursion in predicting successful extubation of preterm infants from invasive conventional mechanical ventilation. Preterm infants less than 32 weeks gestation who required invasive conventional mechanical ventilation were evaluated by diaphragmatic sonography within 1 h of their planned extubation. Infants were classified into successful or failed extubation groups based on their ability to stay off invasive mechanical ventilation for 72 h after extubation. Inspiratory and expiratory thickness plus excursion of the right and left hemidiaphragm as well as diaphragmatic thickening fraction (DTF) measures were compared between groups. We included 43 eligible infants, of whom 34 infants succeeded and 9 infants failed extubation. Infants in the successful extubation group had a significantly higher expiratory thickness of the right and left hemidiaphragm, excursion of the right and left hemidiaphragm, inspiratory thickness of the left hemidiaphragm, and DTF of the left hemidiaphragm compared with infants who failed extubation. The receiver-operating characteristic curves showed that excursion of the right and left hemidiaphragm has the highest significant accuracy in predicting successful extubation of preterm infants among all diaphragmatic parameters (AUC is 0.98 and 0.96, respectively; p value < 0.001 for both).Conclusion: We conclude that diaphragmatic excursion is a useful indicator for successful extubation of preterm infants from mechanical ventilation. What is Known: • Invasive mechanical ventilation induces ventilator induced diaphragmatic dysfunction (VIDD) particularly when used for long time. • Assessment of diaphragmatic dimensions and functional activity has been a valuable tool in predicting successful extubation of adult patients from invasive mechanical ventilation. What is New: • Sonographic assessment of diaphragmatic dimensions can be used to predict successful extubation of preterm infants from mechanical ventilation. • Sonographic assessment of diaphragmatic excursion shows the highest sensitivity and specificity in predicting successful extubation of preterm infants.