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Wu H, Chasteen B. Rapid review of ventilator-induced diaphragm dysfunction. Respir Med 2024; 223:107541. [PMID: 38290603 DOI: 10.1016/j.rmed.2024.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/01/2024]
Abstract
Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of mechanical ventilation. Various noninvasive and invasive methods have been developed to assess diaphragm function. The implementation of diaphragm-protective ventilation strategies is crucial for preventing diaphragm injuries. Furthermore, diaphragm neurostimulation emerges as a promising and novel treatment option. In this rapid review, our objective is to discuss the current understanding of ventilator-induced diaphragm dysfunction, diagnostic approaches, and updates on strategies for prevention and management.
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Affiliation(s)
- Huimin Wu
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States; Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
| | - Bobby Chasteen
- Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
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Bureau C, Van Hollebeke M, Dres M. Managing respiratory muscle weakness during weaning from invasive ventilation. Eur Respir Rev 2023; 32:32/168/220205. [PMID: 37019456 PMCID: PMC10074167 DOI: 10.1183/16000617.0205-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 04/07/2023] Open
Abstract
Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH2O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising.
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
| | - Marine Van Hollebeke
- KU Leuven - University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Martin Dres
- Sorbonne Université, INSERM, UMR_S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation, Département R3S, Paris, France
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Gan XY, Zhang J, Xu P, Liu SJ, Guo ZL. Early passive orthostatic training prevents diaphragm atrophy and dysfunction in intensive care unit patients on mechanical ventilation: A retrospective case‒control study. Heart Lung 2023; 59:37-43. [PMID: 36709529 DOI: 10.1016/j.hrtlng.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation (MV), who are always bedridden, easily develop diaphragm atrophy and dysfunction. However, few studies have assessed diaphragmatic thickness and functional changes after early passive orthostatic training. OBJECTIVES This is the first study to investigate the efficacy of early passive orthostatic training in preventing diaphragm atrophy and dysfunction in ICU patients on MV. METHODS In this randomized retrospective case‒control study, 81 ICU patients on MV for 8 days or longer were enrolled. Forty-four patients received early passive orthostatic training initiated within 72 h of MV initiation (training group), and 37 patients did not receive training (no-training group). The protocol was performed for seven days, once a day for 30 min. The primary outcomes were diaphragmatic thickness and diaphragm contractile fraction (TFdi). The ventilatory parameters were secondary outcomes. RESULTS This study included 81 (45 male) ICU patients on MV [(mean ± SD) age = (60.63 ± 7.88) years]. The training group had a larger diaphragmatic thickness at end-expiration (Tdi,ee) and a smaller magnitude of decrease in Tdi,ee and TFdi (p = 0.001, 0.029, and <0.001, respectively) than the no-training group after 7 days of training. The mean arterial pressure, fraction of inspired oxygen, and white blood cell levels were decreased in the training group compared with the no-training group (p = 0.003, 0.001, and 0.026, respectively), but lactic acid levels decreased slightly in the training group with no significant difference (p = 0.708). CONCLUSIONS Early passive orthostatic training is suitable to ameliorate diaphragm atrophy and dysfunction in ICU patients on MV.
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Affiliation(s)
- Xin-Yu Gan
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China
| | - Jun Zhang
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China.
| | - Ping Xu
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China
| | - Si-Jin Liu
- Department of Nursing, Harbin Medical University, Daqing, Heilongjiang 163319, China
| | - Zhi-Lin Guo
- Department of Rehabilitation, Beidahuang Industry Group General Hospital, 235 Hashuang Road, Nangang District, Harbin, Heilongjiang 150000, China
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Rbm20 ΔRRM Mice, Expressing a Titin Isoform with Lower Stiffness, Are Protected from Mechanical Ventilation-Induced Diaphragm Weakness. Int J Mol Sci 2022; 23:ijms232415689. [PMID: 36555335 PMCID: PMC9779751 DOI: 10.3390/ijms232415689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Diaphragm weakness frequently develops in mechanically ventilated critically ill patients and is associated with increased morbidity, including ventilator weaning failure, mortality, and health care costs. The mechanisms underlying diaphragm weakness are incompletely understood but may include the elastic properties of titin, a giant protein whose layout in the muscle's sarcomeres makes it an ideal candidate to sense ventilation-induced diaphragm unloading, resulting in downstream signaling through titin-binding proteins. In the current study, we investigated whether modulating titin stiffness affects the development of diaphragm weakness during mechanical ventilation. To this end, we ventilated genetically engineered mice with reduced titin stiffness (Rbm20ΔRRM), and robust (TtnΔIAjxn) or severely (TtnΔ112-158) increased titin stiffness for 8 h, and assessed diaphragm contractility and protein expression of titin-binding proteins. Mechanical ventilation reduced the maximum active tension of the diaphragm in WT, TtnΔIAjxn and TtnΔ112-158 mice. However, in Rbm20ΔRRM mice maximum active tension was preserved after ventilation. Analyses of titin binding proteins suggest that muscle ankyrin repeat proteins (MARPs) 1 and 2 may play a role in the adaptation of the diaphragm to mechanical ventilation, and the preservation of diaphragm contractility in Rbm20ΔRRM mice. Thus, Rbm20ΔRRM mice, expressing titin isoforms with lower stiffness, are protected from mechanical ventilation-induced diaphragm weakness, suggesting that titin elasticity may modulate the diaphragm's response to unloading during mechanical ventilation.
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Villelabeitia-Jaureguizar K, Calvo-Lobo C, Rodríguez-Sanz D, Vicente-Campos D, Castro-Portal JA, López-Cañadas M, Becerro-de-Bengoa-Vallejo R, Chicharro JL. Low Intensity Respiratory Muscle Training in COVID-19 Patients after Invasive Mechanical Ventilation: A Retrospective Case-Series Study. Biomedicines 2022; 10:2807. [PMID: 36359327 PMCID: PMC9687222 DOI: 10.3390/biomedicines10112807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38−0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94−1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.
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Affiliation(s)
| | - César Calvo-Lobo
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - David Rodríguez-Sanz
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Davinia Vicente-Campos
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | | | | | | | - José López Chicharro
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Lecronier M, Jung B, Molinari N, Pinot J, Similowski T, Jaber S, Demoule A, Dres M. Severe but reversible impaired diaphragm function in septic mechanically ventilated patients. Ann Intensive Care 2022; 12:34. [PMID: 35403916 PMCID: PMC9001790 DOI: 10.1186/s13613-022-01005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Whether sepsis-associated diaphragm dysfunction may improve despite the exposure of mechanical ventilation in critically ill patients is unclear. This study aims at describing the diaphragm function time course of septic and non-septic mechanically ventilated patients. Methods Secondary analysis of two prospective observational studies of mechanically ventilated patients in whom diaphragm function was assessed twice: within the 24 h after intubation and when patients were switched to pressure support mode, by measuring the endotracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (Ptr,stim). Change in diaphragm function was expressed as the difference between Ptr,stim measured under pressure support mode and Ptr,stim measured within the 24 h after intubation. Sepsis was defined according to the Sepsis-3 international guidelines upon inclusion. In a sub-group of patients, the right hemidiaphragm thickness was measured by ultrasound. Results Ninety-two patients were enrolled in the study. Sepsis upon intubation was present in 51 (55%) patients. In septic patients, primary reason for ventilation was acute respiratory failure related to pneumonia (37/51; 73%). In non-septic patients, main reasons for ventilation were acute respiratory failure not related to pneumonia (16/41; 39%), coma (13/41; 32%) and cardiac arrest (6/41; 15%). Ptr,stim within 24 h after intubation was lower in septic patients as compared to non-septic patients: 6.3 (4.9–8.7) cmH2O vs. 9.8 (7.0–14.2) cmH2O (p = 0.004), respectively. The median (interquartile) duration of mechanical ventilation between first and second diaphragm evaluation was 4 (2–6) days in septic patients and 3 (2–4) days in non-septic patients (p = 0.073). Between first and second measurements, the change in Ptr,stim was + 19% (− 13–61) in septic patients and − 7% (− 40–12) in non-septic patients (p = 0.005). In the sub-group of patients with ultrasound measurements, end-expiratory diaphragm thickness decreased in both, septic and non-septic patients. The 28-day mortality was higher in patients with decrease or no change in diaphragm function. Conclusion Septic patients were associated with a more severe but reversible impaired diaphragm function as compared to non-septic patients. Increase in diaphragm function was associated with a better survival. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01005-9.
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Affiliation(s)
- Marie Lecronier
- Médecine Intensive - Réanimation (Département "R3S"), APHP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France. .,Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM-UMR S 1158, Sorbonne Université, Paris, France.
| | - Boris Jung
- Département de Médecine Intensive - Réanimation, CHU Montpellier, Montpellier, France.,Laboratoire de Physiologie et Médecine Expérimentale du cœur et des Muscles, INSERM U1046-CNRS UMR 9214, Université de Montpellier, Montpellier, France
| | - Nicolas Molinari
- Department of Medical Information, Hôpital Arnaud de Villeneuve, IMAG U5149, Université de Montpellier, Montpellier, France
| | - Jérôme Pinot
- Médecine Intensive - Réanimation (Département "R3S"), APHP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Médecine Intensive - Réanimation (Département "R3S"), APHP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM-UMR S 1158, Sorbonne Université, Paris, France
| | - Samir Jaber
- Département de Médecine Intensive - Réanimation, CHU Montpellier, Montpellier, France.,Laboratoire de Physiologie et Médecine Expérimentale du cœur et des Muscles, INSERM U1046-CNRS UMR 9214, Université de Montpellier, Montpellier, France
| | - Alexandre Demoule
- Médecine Intensive - Réanimation (Département "R3S"), APHP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM-UMR S 1158, Sorbonne Université, Paris, France
| | - Martin Dres
- Médecine Intensive - Réanimation (Département "R3S"), APHP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France.,Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM-UMR S 1158, Sorbonne Université, Paris, France
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Abstract
While the traditional lung function tests are used to assess lung capacity and pulmonary function, they cannot evaluate respiratory driving function and the integrity of the conduction pathway from the central nervous system to the respiratory motor neuron in the spinal cord and to the diaphragm. The inspiratory trigger is sent from the central nervous system through the phrenic nerve and drives the diaphragm to generate inspiratory movement. Therefore, phrenic nerve stimulation and diaphragmatic electromyography are two fundamental methods to assess respiratory function. There are several useful tools to assess respiratory motor system including electrical or magnetic phrenic nerve stimulation, diaphragmatic needle electromyography, and diaphragmatic ultrasound. By these means, physicians can assess current respiratory status in different neurological diseases that affect respiratory muscles, follow-up of the severity of respiratory impairment, help to predict the chance of successfully weaning from ventilatory support, and confirm clinical diagnoses such as diaphragmatic myoclonus. Although some of these tests require special training, applying these neurophysiological assessments in clinical practice is highly recommended.
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Affiliation(s)
- Yih-Chih Jacinta Kuo
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kai-Hsiang Stanley Chen
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.
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Ultrasound assessment of the diaphragm during the first days of mechanical ventilation compared to spontaneous respiration: a comparative study. LA TUNISIE MEDICALE 2021; 99:1055-1065. [PMID: 35288909 PMCID: PMC9390126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION In critically ill patients, the diaphragm is subject to several aggressions mainly those induced by mechanical ventilation (MV). Currently, diaphragmatic ultrasound has become the most useful bedside for the clinician to evaluate diaphragm contractility. AIM To examine the effects of MV on the diaphragm contractility during the first days of ventilation. METHODS Two groups of subjects were studied: a study group (n=30) of adults receiving MV versus a control group (n=30) of volunteers on spontaneous ventilation (SV). Using an ultrasound device, we compared the diaphragmatic thickening fraction (DTF). Secondly, we analysed the relationship between DTF and weaning. RESULTS comparatively to SV group, patients of MV group have a higher end expiratory diameter (EED) (2.09 ± 0.6 vs. 1.76 ± 0.32 mm, p=0.01) and a lower DTF (39.9 ± 12.5% vs. 49.0 ± 20.5%, p=0.043). Fourteen among the 30 ventilated patients successfully weaned. No significant correlation was shown between DTF and weaning duration (Rho= - 0.464, p=0.09). A DTF value > 33% was near to be significantly associated with weaning success (OR=2; 95% CI= [1.07-3.7], p=0.05) with a sensitivity at 85.7%. CONCLUSIONS diaphragmatic contractility was altered from the first days of MV. A DTF value >32,7% was associated to the weaning success and that may be useful to predict successful weaning with sensitivity at 85.7%.
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Supinski GS, Netzel PF, Westgate PM, Schroder EA, Wang L, Callahan LA. A randomized controlled trial to determine whether beta-hydroxy-beta-methylbutyrate and/or eicosapentaenoic acid improves diaphragm and quadriceps strength in critically Ill mechanically ventilated patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:308. [PMID: 34446067 PMCID: PMC8390080 DOI: 10.1186/s13054-021-03737-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/19/2021] [Indexed: 02/05/2023]
Abstract
Background Intensive care unit acquired weakness is a serious problem, contributing to respiratory failure and reductions in ambulation. Currently, there is no pharmacological therapy for this condition. Studies indicate, however, that both beta-hydroxy-beta-methylbutyrate (HMB) and eicosapentaenoic acid (EPA) increase muscle function in patients with cancer and in older adults. The purpose of this study was to determine whether HMB and/or EPA administration would increase diaphragm and quadriceps strength in mechanically ventilated patients. Methods Studies were performed on 83 mechanically ventilated patients who were recruited from the Medical Intensive Care Units at the University of Kentucky. Diaphragm strength was assessed as the trans-diaphragmatic pressure generated by supramaximal magnetic phrenic nerve stimulation (PdiTw). Quadriceps strength was assessed as leg force generated by supramaximal magnetic femoral nerve stimulation (QuadTw). Diaphragm and quadriceps thickness were assessed by ultrasound. Baseline measurements of muscle strength and size were performed, and patients were then randomized to one of four treatment groups (placebo, HMB 3 gm/day, EPA 2 gm/day and HMB plus EPA). Strength and size measurements were repeated 11 days after study entry. ANCOVA statistical testing was used to compare variables across the four experimental groups. Results Treatments failed to increase the strength and thickness of either the diaphragm or quadriceps when compared to placebo. In addition, treatments also failed to decrease the duration of mechanical ventilation after study entry. Conclusions These results indicate that a 10-day course of HMB and/or EPA does not improve skeletal muscle strength in critically ill mechanically ventilated patients. These findings also confirm previous reports that diaphragm and leg strength in these patients are profoundly low. Additional studies will be needed to examine the effects of other anabolic agents and innovative forms of physical therapy. Trial registration: ClinicalTrials.gov, NCT01270516. Registered 5 January 2011, https://clinicaltrials.gov/ct2/show/NCT01270516?term=Supinski&draw=2&rank=4. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03737-9.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, University of Kentucky, 740 South Limestone, L543, Lexington, KY, 40536-0284, USA
| | - Paul F Netzel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, University of Kentucky, 740 South Limestone, L543, Lexington, KY, 40536-0284, USA
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, 725 Rose Street, Lexington, KY, MDS 205B40536-0082, USA
| | - Elizabeth A Schroder
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, University of Kentucky, 740 South Limestone, L543, Lexington, KY, 40536-0284, USA
| | - Lin Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, University of Kentucky, 740 South Limestone, L543, Lexington, KY, 40536-0284, USA
| | - Leigh Ann Callahan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, University of Kentucky, 740 South Limestone, L543, Lexington, KY, 40536-0284, USA.
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Thompson AF, Moraes L, Rocha NN, Fernandes MVS, Antunes MA, Abreu SC, Santos CL, Capelozzi VL, Samary CS, de Abreu MG, Saddy F, Pelosi P, Silva PL, Rocco PRM. Impact of different frequencies of controlled breath and pressure-support levels during biphasic positive airway pressure ventilation on the lung and diaphragm in experimental mild acute respiratory distress syndrome. PLoS One 2021; 16:e0256021. [PMID: 34415935 PMCID: PMC8378704 DOI: 10.1371/journal.pone.0256021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 07/28/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We hypothesized that a decrease in frequency of controlled breaths during biphasic positive airway pressure (BIVENT), associated with an increase in spontaneous breaths, whether pressure support (PSV)-assisted or not, would mitigate lung and diaphragm damage in mild experimental acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 hours, animals were randomly assigned to: 1) BIVENT-100+PSV0%: airway pressure (Phigh) adjusted to VT = 6 mL/kg and frequency of controlled breaths (f) = 100 bpm; 2) BIVENT-50+PSV0%: Phigh adjusted to VT = 6 mL/kg and f = 50 bpm; 3) BIVENT-50+PSV50% (PSV set to half the Phigh reference value, i.e., PSV50%); or 4) BIVENT-50+PSV100% (PSV equal to Phigh reference value, i.e., PSV100%). Positive end-expiratory pressure (Plow) was equal to 5 cmH2O. Nonventilated animals were used for lung and diaphragm histology and molecular biology analysis. RESULTS BIVENT-50+PSV0%, compared to BIVENT-100+PSV0%, reduced the diffuse alveolar damage (DAD) score, the expression of amphiregulin (marker of alveolar stretch) and muscle atrophy F-box (marker of diaphragm atrophy). In BIVENT-50 groups, the increase in PSV (BIVENT-50+PSV50% versus BIVENT-50+PSV100%) yielded better lung mechanics and less alveolar collapse, interstitial edema, cumulative DAD score, as well as gene expressions associated with lung inflammation, epithelial and endothelial cell damage in lung tissue, and muscle ring finger protein 1 (marker of muscle proteolysis) in diaphragm. Transpulmonary peak pressure (Ppeak,L) and pressure-time product per minute (PTPmin) at Phigh were associated with lung damage, while increased spontaneous breathing at Plow did not promote lung injury. CONCLUSION In the ARDS model used herein, during BIVENT, the level of PSV and the phase of the respiratory cycle in which the inspiratory effort occurs affected lung and diaphragm damage. Partitioning of inspiratory effort and transpulmonary pressure in spontaneous breaths at Plow and Phigh is required to minimize VILI.
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Affiliation(s)
- Alessandra F. Thompson
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Copa D’Or Hospital, Rio de Janeiro, Brazil
| | - Lillian Moraes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Nazareth N. Rocha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Niterói, Brazil
| | - Marcos V. S. Fernandes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Mariana A. Antunes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Soraia C. Abreu
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Cintia L. Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Vera L. Capelozzi
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cynthia S. Samary
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Department of Physical Therapy, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcelo G. de Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany
- Outcomes Research Consortium, Cleveland, OH, United States of America
| | - Felipe Saddy
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- Copa D’Or Hospital, Rio de Janeiro, Brazil
- Pró-Cardíaco Hospital, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Pedro L. Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
- * E-mail:
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Aarab Y, Flatres A, Garnier F, Capdevila M, Raynaud F, Lacampagne A, Chapeau D, Klouche K, Etienne P, Jaber S, Molinari N, Gamon L, Matecki S, Jung B. Shear Wave Elastography, A New Tool for Diaphragmatic Qualitative Assessment. A Translational Study. Am J Respir Crit Care Med 2021; 204:797-806. [PMID: 34255974 DOI: 10.1164/rccm.202011-4086oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Prolonged mechanical ventilation (MV) is often associated either with a decrease (known atrophy) or an increase (supposed injury) in diaphragmatic thickness. Shear wave elastography is a non-invasive technique that measures shear modulus, a surrogate of tissue stiffness and mechanical properties. OBJECTIVES To describe changes in shear modulus (SM) during the ICU stay and the relationship with alterations in muscle thickness. To perform a comprehensive ultrasound-based characterization of histological and force production changes occurring in the diaphragm. METHODS Translational study using critically ill patients and mechanically ventilated piglets. Serial ultrasound examination of the diaphragm collecting thickness and SM was performed in both patients and piglets. Transdiaphragmatic pressure and diaphragmatic biopsies were collected in piglets. MEASUREMENTS AND MAIN RESULTS We enrolled 102 patients, 88 of whom were invasively mechanically ventilated. At baseline, SM was 14.3+/-4.3 kPa and diaphragm end-expiratory thickness was 2.0+/-0.5 mm. Decrease or increase by more than 10% from baseline was reported in 86% of the patients for thickness and in 92% of the patients for shear modulus. An increase in diaphragmatic thickness during the stay was associated with a decrease in SM (β=-9.34±4.41; p=0.03) after multivariable analysis. In the piglet sample, a decrease in SM over 3 days of MV was associated with loss of force production, slow and fast fiber atrophy and increased lipid droplets accumulation. CONCLUSIONS Increases in diaphragm thickness during critical illness is associated with decreased tissue stiffness as demonstrated by shear wave ultrasound elastography, consistent with the development of muscle injury and weakness.
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Affiliation(s)
| | | | - Fanny Garnier
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, Montpellier, France
| | - Mathieu Capdevila
- Montpellier University and Montpellier Teaching Hospital,, Saint Eloi Anesthesiology and Critical Care Medicine, Montpellier University and Montpellier Teaching Hospital, Montpellier, France , Montpellier, France.,Montpellier Universite d'Excellence, 539031, PhyMedExp, Montpellier, France
| | | | - Alain Lacampagne
- PhyMedExp, Montpellier University, INSERM, CNRS, Montpellier, France
| | - David Chapeau
- Lapeyronie University Hospital, Intensive Care Unit, Montpellier, France
| | - Kada Klouche
- Lapeyronie University Hospital, Intensive Care Unit, Montpellier, France
| | - Pascal Etienne
- Laboratoire Charles Coulomb, 131799, Montpellier, France
| | - Samir Jaber
- University hospital. CHU de MONTPELLIER HOPITAL SAINT ELOI, Intensive Care Unit and transplantation-Departement of Anesthesiology DAR B, Montpellier Cedex 5, France
| | - Nicolas Molinari
- CHU Montpellier - Hôpital la Colombière, DIM, Montpellier, France
| | - Lucie Gamon
- Montpellier University and Montpellier Teaching Hospital,, Saint Eloi Anesthesiology and Critical Care Medicine, Montpellier University and Montpellier Teaching Hospital, Montpellier, France
| | - Stefan Matecki
- Universite de Montpellier, 27037, 4. Pediatric Functional Exploration Unit, University Hospital of Montpellier, Montpellier, France
| | - Boris Jung
- Centre Hospitalier Regional Universitaire de Montpellier, 26905, medical ICU, Montpellier, France;
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12
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Supinski GS, Schroder EA, Wang L, Morris AJ, Callahan LAP. Mitoquinone mesylate (MitoQ) prevents sepsis-induced diaphragm dysfunction. J Appl Physiol (1985) 2021; 131:778-787. [PMID: 34197233 DOI: 10.1152/japplphysiol.01053.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Sepsis-induced diaphragm dysfunction is a major contributor to respiratory failure in mechanically ventilated patients. There are no pharmacological treatments for this syndrome, but studies suggest that diaphragm weakness is linked to mitochondrial free radical generation. We hypothesized that administration of mitoquinone mesylate (MitoQ), a mitochondrially targeted free radical scavenger, would prevent sepsis-induced diaphragm dysfunction. We compared diaphragm function in 4 groups of male mice: 1) sham-operated controls treated with saline (0.3 mL ip), 2) sham-operated treated with MitoQ (3.5 mg/kg/day given intraperitoneally in saline), 3) cecal ligation puncture (CLP) mice treated with saline, and 4) CLP mice treated with MitoQ. Forty-eight hours after surgery, we assessed diaphragm force generation, myosin heavy chain content, state 3 mitochondrial oxygen consumption (OCR), and aconitase activity. We also determined effects of MitoQ in female mice with CLP sepsis and in mice with endotoxin-induced sepsis. CLP decreased diaphragm specific force generation and MitoQ prevented these decrements (e.g. maximal force averaged 30.2 ± 1.3, 28.0 ± 1.3, 12.8 ± 1.9, and 30.0 ± 1.0 N/cm2 for sham, sham + MitoQ, CLP, and CLP + MitoQ groups, respectively, P < 0.001). CLP also reduced diaphragm mitochondrial OCR and aconitase activity; MitoQ blocked both effects. Similar responses were observed in female mice and in endotoxin-induced sepsis. Moreover, delayed MitoQ treatment (by 6 h) was as effective as immediate treatment. These data indicate that MitoQ prevents sepsis-induced diaphragm dysfunction, preserving force generation. MitoQ may be a useful therapeutic agent to preserve diaphragm function in critically ill patients with sepsis.NEW & NOTEWORTHY This is the first study to show that mitoquinone mesylate (MitoQ), a mitochondrially targeted antioxidant, treats sepsis-induced skeletal muscle dysfunction. This biopharmaceutical agent is without known side effects and is currently being used by healthy individuals and in clinical trials in patients with various diseases. When taken together, our results suggest that MitoQ has the potential to be immediately translated into treatment for sepsis-induced skeletal muscle dysfunction.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Elizabeth A Schroder
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lin Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Andrew J Morris
- Division of Cardiovascular Medicine, The Gill Heart and Vascular Institute, University of Kentucky, Lexington, Kentucky.,Division of Cardiovascular Medicine, Veterans Affairs Medical Center, Lexington, Kentucky
| | - Leigh Ann P Callahan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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13
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Crulli B, Kawaguchi A, Praud JP, Petrof BJ, Harrington K, Emeriaud G. Evolution of inspiratory muscle function in children during mechanical ventilation. Crit Care 2021; 25:229. [PMID: 34193216 PMCID: PMC8243304 DOI: 10.1186/s13054-021-03647-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no universally accepted method to assess the pressure-generating capacity of inspiratory muscles in children on mechanical ventilation (MV), and no study describing its evolution over time in this population. METHODS In this prospective observational study, we have assessed the function of the inspiratory muscles in children on various modes of MV. During brief airway occlusion maneuvers, we simultaneously recorded airway pressure depression at the endotracheal tube (ΔPaw, force generation) and electrical activity of the diaphragm (EAdi, central respiratory drive) over five consecutive inspiratory efforts. The neuro-mechanical efficiency ratio (NME, ΔPaw/EAdimax) was also computed. The evolution over time of these indices in a group of children in the pediatric intensive care unit (PICU) was primarily described. As a secondary objective, we compared these values to those measured in a group of children in the operating room (OR). RESULTS In the PICU group, although median NMEoccl decreased over time during MV (regression coefficient - 0.016, p = 0.03), maximum ΔPawmax remained unchanged (regression coefficient 0.109, p = 0.50). Median NMEoccl at the first measurement in the PICU group (after 21 h of MV) was significantly lower than at the only measurement in the OR group (1.8 cmH2O/µV, Q1-Q3 1.3-2.4 vs. 3.7 cmH2O/µV, Q1-Q3 3.5-4.2; p = 0.015). Maximum ΔPawmax in the PICU group was, however, not significantly different from the OR group (35.1 cmH2O, Q1-Q3 21-58 vs. 31.3 cmH2O, Q1-Q3 28.5-35.5; p = 0.982). CONCLUSIONS The function of inspiratory muscles can be monitored at the bedside of children on MV using brief airway occlusions. Inspiratory muscle efficiency was significantly lower in critically ill children than in children undergoing elective surgery, and it decreased over time during MV in critically ill children. This suggests that both critical illness and MV may have an impact on inspiratory muscle efficiency.
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Affiliation(s)
- Benjamin Crulli
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Atsushi Kawaguchi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
- Pediatric Intensive Care Unit, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Basil J Petrof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Karen Harrington
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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14
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Moon DS, Huh JW, Hong SB, Koh Y, Lim CM. Dynamic inhomogeneity of aeration along the vertical axis of the lung may predict weaning failure regardless of diaphragm dysfunction. J Crit Care 2021; 65:186-191. [PMID: 34198210 DOI: 10.1016/j.jcrc.2021.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/17/2021] [Accepted: 06/12/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to investigate dynamic changes of lung aeration during a spontaneous breathing trial (SBT) in patients with diaphragm dysfunction (DD) and to predict weaning failure using electrical impedance tomography (EIT). MATERIALS AND METHODS We enrolled 40 adult patients who received mechanical ventilation over 48 h and were eligible for SBT with a T-piece. All patients were screened for DD using ultrasonography before SBT. EIT data, including global inhomogeneity index (an off-site parameter), and temporal skew of aeration (TSA) (an on-site parameter) were collected. RESULTS Sixteen (40%) patients had DD. During SBT, the tidal impedance variation decreased by 32% from baseline in patients with DD and by 14% in those without DD (p = 0.001). The global inhomogeneity index in the SBT failure group (n = 9) was 0.92 (median), and that of the SBT success group was 0.65 (p = 0.004). The TSA along the vertical axis of the lung was 12.0% and 2.0%, respectively (p = 0.001). With a vertical TSA cutoff of ≥4.35%, SBT failure was predicted with a sensitivity of 88.9% and specificity of 96.9% (area under the curve: 0.955). CONCLUSION Dynamic inhomogeneity of aeration along the vertical axis of the lung as assessed using TSA predicts SBT failure regardless of DD. TRIAL REGISTRATION This trial was retrospectively registered at cris.nih.go.kr (identifier: KCT003567; release date February 27, 2019).
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Affiliation(s)
- Do Sik Moon
- Department of Pulmonology and Critical Care Medicine, Chosun Universitiy Hospital, Gwangju, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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15
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Van Aerde N, Meersseman P, Debaveye Y, Wilmer A, Gunst J, Casaer MP, Wauters J, Wouters PJ, Gosselink R, Van den Berghe G, Hermans G. Five-year outcome of respiratory muscle weakness at intensive care unit discharge: secondary analysis of a prospective cohort study. Thorax 2021; 76:561-567. [PMID: 33712505 DOI: 10.1136/thoraxjnl-2020-216720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To assess the association between respiratory muscle weakness (RMW) at intensive care unit (ICU) discharge and 5-year mortality and morbidity, independent from confounders including peripheral muscle strength. METHODS Secondary analysis of the prospective 5-year follow-up of the EPaNIC cohort (ClinicalTrials.gov: NCT00512122), limited to 366 patients screened for respiratory and peripheral muscle strength in the ICU with maximal inspiratory pressure (MIP) after removal of the artificial airway, and the Medical Research Council sum score. RMW was defined as an absolute value of MIP <30 cmH2O. Associations between RMW at (or closest to) ICU discharge and all-cause 5-year mortality, and key measures of 5-year physical function, comprising respiratory muscle strength (MIP), hand-grip strength (HGF), 6 min walk distance (6MWD) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36), were assessed with Cox proportional hazards and linear regression models, adjusted for confounders including peripheral muscle strength. RESULTS RMW was present in 136/366 (37.2%) patients at ICU discharge. RMW was not independently associated with 5-year mortality (HR with 95% CI 1.273 (0.751 to 1.943), p=0.352). Among 156five-year survivors, those with, as compared with those without RMW demonstrated worse physical function (MIP (absolute value, cmH2O): 62(42-77) vs 94(78-109), p<0.001; HGF (%pred): 67(44-87) vs 96(68-110), p<0.001; 6MWD (%pred): 87(74-102) vs 99 (80-111), p=0.009; PF-SF-36 (score): 55 (30-80) vs 80 (55-95), p<0.001). Associations between RMW and morbidity endpoints remained significant after adjustment for confounders (effect size with 95% CI: MIP: -23.858 (-32.097 to -15.027), p=0.001; HGF: -18.591 (-30.941 to -5.744), p=0.001; 6MWD (transformed): -1587.007 (-3073.763 to -179.253), p=0.034; PF-SF-36 (transformed): 1.176 (0.144-2.270), p=0.036). CONCLUSIONS RMW at ICU discharge is independently associated with 5-year morbidity but not 5-year mortality.
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Affiliation(s)
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Yves Debaveye
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Alexander Wilmer
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Jan Gunst
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Michael P Casaer
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Flanders, Belgium
| | - Pieter J Wouters
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Rik Gosselink
- Rehabilitation Sciences, KU Leuven, Leuven, Flanders, Belgium
| | - Greet Van den Berghe
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Greet Hermans
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium .,Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
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16
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Ye X, Liu Z, Ma Y, Song Y, Hu L, Luo J, Xiao H. A Novel Normalized Cross-Correlation Speckle-Tracking Ultrasound Algorithm for the Evaluation of Diaphragm Deformation. Front Med (Lausanne) 2021; 8:612933. [PMID: 33777969 PMCID: PMC7994279 DOI: 10.3389/fmed.2021.612933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/22/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives: To develop a two-dimensional normalized cross-correlation (NCC)-based ultrasonic speckle-tracking algorithm for right diaphragm deformation analysis. Methods: Six healthy and eight mechanical ventilation patients were enrolled in this study. Images were acquired by a portable ultrasound system in three sections. DICOM data were processed with NCC to obtain the interframe/cumulative vertical and horizontal displacements, as well as the global strain of the right diaphragm, with continuous tracking and drift correction. Results: The NCC algorithm can track the contraction and relaxation of the right diaphragm by following the respiratory movement continuously. For all three sections, the interframe and accumulated horizontal displacements were both significantly larger than the corresponding vertical displacements (interframe p values: 0.031, 0.004, and 0.000; cumulative p values: 0.039, 0.001, and <0.0001). For the global strain of the right diaphragm, there was no significant difference between each pair of sections (all p > 0.05), regardless of whether the horizontal interval of the initial diaphragm point was 1, 3, 5, or 10 times in the sampling interval. Conclusions: This study developed a novel diaphragm deformation ultrasound imaging method. This method can be used to estimate the diaphragm interframe/accumulated displacement in the horizontal and vertical directions and the global strain on three different imaging planes, and it was found that the strain was not sensitive to the imaging plane.
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Affiliation(s)
- Xiong Ye
- School of Clinical Medicine, Shanghai University of Medicine & Health Sciences, Shanghai, China.,National Medical Products Administration (NMPA) Key Laboratory for Respiratory and Anaesthetic Equipment, Shanghai, China
| | - Zhi Liu
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Ying Ma
- Department of Ultrasound, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Ye Song
- Department of Ultrasound, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Lihua Hu
- Department of Ultrasound, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Jianwen Luo
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Hui Xiao
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiaotong University, Shanghai, China
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17
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Lieb S, Schumann S. Loss of muscular force in isolated rat diaphragms is related to changes in muscle fibre size. Physiol Meas 2021; 42:025003. [PMID: 33705356 DOI: 10.1088/1361-6579/abdf3a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Passivity of the diaphragm during prolonged mechanical ventilation can lead to ventilation-induced diaphragmatic dysfunction reasoned by a reduction of diaphragmatic muscle strength. Electrical stimulation may be utilised to modulate diaphragm muscle strength. Therefore we intended to investigate diaphragmatic muscle strength based on stimulation with electric impulses. APPROACH Diaphragms of Wistar rats were excised, embedded in various incubation solutions and placed in a diaphragm force measurement device. Pressure amplitudes generated by the diaphragm in dependency of the embedding solution, stimulation frequency and time (360 min) were determined. Furthermore, the diaphragms were histologically evaluated. MAIN RESULTS The ex vivo diaphragms evoked no pressure if embedded in incubation solutions with high potassium concentrations and up to >20 cmH2O if embedded in incubation solutions with extracellular potassium concentrations. Although vitality was well maintained after 360 min (78%) cultivation, the diaphragm's force dropped by 90.8% after 240 min. The decline in the diaphragm's force progressed faster if stimulation was performed every 20 min compared to every 120 min. The size of Type I muscle fibres was largest in diaphragms stimulated every 120 min. The fibre size of Type 2b/x muscle cells was lower in diaphragms after electrical stimulation compared to non-stimulated diaphragms. SIGNIFICANCE The force that the diaphragm can develop in ex vivo conditions depends on the incubation solution and the conditions of activation. Activity-related changes in the diaphragm's muscular force are accompanied by specific changes in muscle fibre size.
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Affiliation(s)
- Samuel Lieb
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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18
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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19
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Supinski GS, Wang L, Schroder EA, Callahan LAP. MitoTEMPOL, a mitochondrial targeted antioxidant, prevents sepsis-induced diaphragm dysfunction. Am J Physiol Lung Cell Mol Physiol 2020; 319:L228-L238. [PMID: 32460519 DOI: 10.1152/ajplung.00473.2019] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Clinical studies indicate that sepsis-induced diaphragm dysfunction is a major contributor to respiratory failure in mechanically ventilated patients. Currently there is no drug to treat this form of diaphragm weakness. Sepsis-induced muscle dysfunction is thought to be triggered by excessive mitochondrial free radical generation; we therefore hypothesized that therapies that target mitochondrial free radical production may prevent sepsis-induced diaphragm weakness. The present study determined whether MitoTEMPOL, a mitochondrially targeted free radical scavenger, could reduce sepsis-induced diaphragm dysfunction. Using an animal model of sepsis, we compared four groups of mice: 1) sham-operated controls, 2) animals with sepsis induced by cecal ligation puncture (CLP), 3) sham controls given MitoTEMPOL (10 mg·kg-1·day-1 ip), and 4) CLP animals given MitoTEMPOL. At 48 h after surgery, we measured diaphragm force generation, mitochondrial function, proteolytic enzyme activities, and myosin heavy chain (MHC) content. We also examined the effects of delayed administration of MitoTEMPOL (by 6 h) on CLP-induced diaphragm weakness. The effects of MitoTEMPOL on cytokine-mediated alterations on muscle cell superoxide generation and cell size in vitro were also assessed. Sepsis markedly reduced diaphragm force generation. Both immediate and delayed MitoTEMPOL administration prevented sepsis-induced diaphragm weakness. MitoTEMPOL reversed sepsis-mediated reductions in mitochondrial function, activation of proteolytic pathways, and decreases in MHC content. Cytokines increased muscle cell superoxide generation and decreased cell size, effects that were ablated by MitoTEMPOL. MitoTEMPOL and other compounds that target mitochondrial free radical generation may be useful therapies for sepsis-induced diaphragm weakness.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lin Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Elizabeth A Schroder
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Leigh Ann P Callahan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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Vetrugno L, Guadagnin GM, Brussa A, Orso D, Garofalo E, Bruni A, Longhini F, Bove T. Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 1. Ultrasound J 2020; 12:9. [PMID: 32166566 PMCID: PMC7067937 DOI: 10.1186/s13089-020-00161-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/06/2020] [Indexed: 12/11/2022] Open
Abstract
Although mechanical ventilation may be a patient’s vital ally during acute illness, it can quickly transform into an enemy during chronic conditions. The weaning process is the fundamental phase that enables the resumption of physiological respiratory function; however, it is also associated with a number of life-threatening complications, and a large percentage of critically ill patients never achieve airway device removal or require the resumption of mechanical ventilation just a few days post-weaning. Indeed, the weaning process is, at present, more of an art than a science. As such, there is urgent need for novel contributions from the scientific literature to abate the growing rates of morbidity and mortality associated with weaning failure. The physician attempting to wean a patient must integrate clinical parameters and common-sense criteria. Numerous studies have striven to identify single predictive factors of weaning failure and sought to standardize the weaning process, but the results are characterized by remarkable heterogeneity. Despite the lack of benchmarks, it is clear that the analysis of respiratory function must include a detailed overview of the five situations described below rather than a single aspect. The purpose of this two-part review is to provide a comprehensive description of these situations to clarify the “arena” physicians are entering when weaning critically ill patients from mechanical ventilation.
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Affiliation(s)
- Luigi Vetrugno
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy.
| | - Giovanni Maria Guadagnin
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy.
| | - Alessandro Brussa
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Daniele Orso
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Clinic, Department of Medicine, University of Udine, Via Colugna 50, 33100, Udine, Italy
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21
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Supinski GS, Wang L, Schroder EA, Callahan LAP. SS31, a mitochondrially targeted antioxidant, prevents sepsis-induced reductions in diaphragm strength and endurance. J Appl Physiol (1985) 2020; 128:463-472. [PMID: 31944887 PMCID: PMC7099438 DOI: 10.1152/japplphysiol.00240.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis-induced diaphragm dysfunction contributes to respiratory failure and mortality in critical illness. There are no treatments for this form of diaphragm weakness. Studies show that sepsis-induced muscle dysfunction is triggered by enhanced mitochondrial free radical generation. We tested the hypothesis that SS31, a mitochondrially targeted antioxidant, would attenuate sepsis-induced diaphragm dysfunction. Four groups of mice were studied: 1) sham-operated controls, 2) sham-operated+SS31 (10 mg·kg-1·day-1), 3) cecal ligation puncture (CLP), and 4) CLP+SS31. Forty-eight hours postoperatively, diaphragm strips with attached phrenic nerves were isolated, and the following were assessed: muscle-field-stimulated force-frequency curves, nerve-stimulated force-frequency curves, and muscle fatigue. We also measured calpain activity, 20S proteasomal activity, myosin heavy chain (MHC) levels, mitochondrial function, and aconitase activity, an index of mitochondrial superoxide generation. Sepsis markedly reduced diaphragm force generation; SS31 prevented these decrements. Diaphragm-specific force generation averaged 30.2 ± 1.4, 9.4 ± 1.8, 25.5 ± 2.3, and 27.9 ± 0.6 N/cm2 for sham, CLP, sham+SS31, and CLP+SS31 groups (P < 0.001). Similarly, with phrenic nerve stimulation, CLP depressed diaphragm force generation, effects prevented by SS31. During endurance trials, force was significantly reduced with CLP, and SS31 prevented these reductions (P < 0.001). Sepsis also increased diaphragm calpain activity, increased 20S proteasomal activity, decreased MHC levels, reduced mitochondrial function (state 3 rates and ATP generation), and reduced aconitase activity; SS31 prevented each of these sepsis-induced alterations (P ≤ 0.017 for all indices). SS31 prevents sepsis-induced diaphragm dysfunction, preserving force generation, endurance, and mitochondrial function. Compounds with similar mechanisms of action may be useful therapeutically to preserve diaphragm function in patients who are septic and critically ill.NEW & NOTEWORTHY Sepsis-induced diaphragm dysfunction is a major contributor to mortality and morbidity in patients with critical illness in intensive care units. Currently, there is no proven pharmacological treatment for this problem. This study provides the novel finding that administration of SS31, a mitochondrially targeted antioxidant, preserves diaphragm myosin heavy chain content and mitochondrial function, thereby preventing diaphragm weakness and fatigue in sepsis.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lin Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Elizabeth A Schroder
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Leigh Ann P Callahan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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Li SP, Zhou XL, Zhao Y. Sedation with midazolam worsens the diaphragm function than dexmedetomidine and propofol during mechanical ventilation in rats. Biomed Pharmacother 2019; 121:109405. [PMID: 31810122 DOI: 10.1016/j.biopha.2019.109405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is identified as an independent contributor to diaphragmatic atrophy and contractile dysfunction. Appropriate sedation is also essential during MV, and anesthetics may have direct adverse effects on the diaphragm. However, there is a lack of research into the effects of different anesthetics on diaphragm function during MV. OBJECTIVES In the present study, we aim to examine the effect of midazolam, dexmedetomidine, and propofol on diaphragm function during MV. DESIGN Animal study. SETTING University research laboratory. SUBJECTS Male Wistar rats. INTERVENTIONS Animals were experienced 12 h of MV or spontaneous breathing (SB) with continuous anesthetics infusion. Diaphragm contractile properties, cross-sectional areas, microcirculation, oxidative stress, and proteolysis were examined. MEASUREMENTS AND MAIN RESULTS Diaphragmatic specific force was markedly reduced in the midazolam group compared with the dexmedetomidine (-60.4 ± 3.01%, p < 0.001) and propofol group (-58.3 ± 2.60%, p < 0.001) after MV. MV sedated with midazolam induced more atrophy of type II fibers compared with dexmedetomidine (-21.8 ± 2.11%, p = 0.0001) and propofol (-8.2 ± 1.53%, p = 0.003). No significant differences of these indices were found in the midazolam, dexmedetomidine, and propofol groups under SB condition (all p > 0.05, respectively). Twelve hours of MV resulted in a time dependent reduction in diaphragmatic functional capillary density (PB -25.1%, p = 0.0001; MZ -21.6%, p = 0.0003; DD -15.2%, p = 0.022; PP -24.8%, p = 0.0001, respectively), which did not occur in the gastrocnemius muscle. The diaphragmatic lipid peroxidation adducts 4-HNE and HIF-1α levels were significantly lower in dexmedetomidine group and propofol group compared to midazolam group (p < 0.05, respectively). Meanwhile, the catalase and SOD levels were also relatively lower (p < 0.05, respectively) in midazolam group compared to dexmedetomidine group and propofol group. CONCLUSIONS Twelve hours of mechanical ventilation during midazolam sedation led to a more severe diaphragm dysfunction than dexmedetomidine and propofol, possibly caused by its relative weaker antioxidant capacity.
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Affiliation(s)
- Shao-Ping Li
- 169 Donghu Road, Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Xian-Long Zhou
- 169 Donghu Road, Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Yan Zhao
- 169 Donghu Road, Emergency Center, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China.
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23
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Khemani RG, Hotz JC, Klein MJ, Kwok J, Park C, Lane C, Smith E, Kohler K, Suresh A, Bornstein D, Elkunovich M, Ross PA, Deakers T, Beltramo F, Nelson L, Shah S, Bhalla A, Curley MAQ, Newth CJL. A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management). Contemp Clin Trials 2019; 88:105893. [PMID: 31740425 DOI: 10.1016/j.cct.2019.105893] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/05/2019] [Accepted: 11/14/2019] [Indexed: 11/18/2022]
Abstract
Lung Protective Mechanical Ventilation (MV) of critically ill adults and children is lifesaving but it may decrease diaphragm contraction and promote Ventilator Induced Diaphragm Dysfunction (VIDD). An ideal MV strategy would balance lung and diaphragm protection. Building off a Phase I pilot study, we are conducting a Phase II controlled clinical trial that seeks to understand the evolution of VIDD in critically ill children and test whether a novel computer-based approach (Real-time Effort Driven ventilator management (REDvent)) can balance lung and diaphragm protective ventilation to reduce time on MV. REDvent systematically adjusts PEEP, FiO2, inspiratory pressure, tidal volume and rate, and uses real-time measures from esophageal manometry to target normal levels of patient effort of breathing. This trial targets 276 children with pulmonary parenchymal disease. Patients are randomized to REDvent vs. usual care for the acute phase of MV (intubation to first Spontaneous Breathing Trial (SBT)). Patients in either group who fail their first SBT will be randomized to REDvent vs usual care for weaning phase management (interval from first SBT to passing SBT). The primary clinical outcome is length of weaning, with several mechanistic outcomes. Upon completion, this study will provide important information on the pathogenesis and timing of VIDD during MV in children and whether this computerized protocol targeting lung and diaphragm protection can lead to improvement in intermediate clinical outcomes. This will form the basis for a larger, Phase III multi-center study, powered for key clinical outcomes such as 28-day ventilator free days. Clinical Trials Registration: NCT03266016.
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Affiliation(s)
- Robinder G Khemani
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America.
| | - Justin C Hotz
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Margaret J Klein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Jeni Kwok
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Caron Park
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Christianne Lane
- University of Southern California, Keck School of Medicine, Department of Preventative Medicine, United States of America
| | - Erin Smith
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Kristen Kohler
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Anil Suresh
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Dinnel Bornstein
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America
| | - Marsha Elkunovich
- University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America; Children's Hospital of Los Angeles, Department of Emergency Medicine, United States of America
| | - Patrick A Ross
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Timothy Deakers
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Fernando Beltramo
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Lara Nelson
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Shilpa Shah
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Anoopindar Bhalla
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
| | - Martha A Q Curley
- Children's Hospital Philadelphia, University of Pennsylvania, United States of America
| | - Christopher J L Newth
- Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care, United States of America; University of Southern California, Keck School of Medicine, Department of Pediatrics, United States of America
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24
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain. .,Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.,Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain.,Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.,Universidad Europea, Madrid, Spain
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25
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26
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Khalil Y, Mustafa EED, Youssef A, Imam MH, Behiry AFE. Neuromuscular dysfunction associated with delayed weaning from mechanical ventilation in patients with respiratory failure. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Yehia Khalil
- Department of Chest, Faculty of Medicine , Alexandria University, Egypt
| | | | - Ahmed Youssef
- Department of Chest, Faculty of Medicine , Alexandria University, Egypt
| | - Mohamed Hassan Imam
- Department of Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University, Egypt
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27
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Carámbula A, Visca A, D’Amico S, Angulo M. Respiratory and Peripheral Muscle Assessment in the Intensive Care Unit. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.arbr.2019.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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28
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Ruiz Ferrón F, Serrano Simón J. La monitorización convencional no es suficiente para valorar el esfuerzo respiratorio durante la ventilación asistida. Med Intensiva 2019; 43:197-206. [DOI: 10.1016/j.medin.2018.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/25/2018] [Accepted: 02/14/2018] [Indexed: 12/28/2022]
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29
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van der Pijl RJ, Granzier HL, Ottenheijm CAC. Diaphragm contractile weakness due to reduced mechanical loading: role of titin. Am J Physiol Cell Physiol 2019; 317:C167-C176. [PMID: 31042425 DOI: 10.1152/ajpcell.00509.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The diaphragm, the main muscle of inspiration, is constantly subjected to mechanical loading. Only during controlled mechanical ventilation, as occurs during thoracic surgery and in the intensive care unit, is mechanical loading of the diaphragm arrested. Animal studies indicate that the diaphragm is highly sensitive to unloading, causing rapid muscle fiber atrophy and contractile weakness; unloading-induced diaphragm atrophy and contractile weakness have been suggested to contribute to the difficulties in weaning patients from ventilator support. The molecular triggers that initiate the rapid unloading atrophy of the diaphragm are not well understood, although proteolytic pathways and oxidative signaling have been shown to be involved. Mechanical stress is known to play an important role in the maintenance of muscle mass. Within the muscle's sarcomere, titin is considered to play an important role in the stress-response machinery. Titin is a giant protein that acts as a mechanosensor regulating muscle protein expression in a sarcomere strain-dependent fashion. Thus titin is an attractive candidate for sensing the sudden mechanical arrest of the diaphragm when patients are mechanically ventilated, leading to changes in muscle protein expression. Here, we provide a novel perspective on how titin and its biomechanical sensing and signaling might be involved in the development of mechanical unloading-induced diaphragm weakness.
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Affiliation(s)
- Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona
| | - Coen A C Ottenheijm
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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30
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Association Between Muscle Wasting and Muscle Strength in Patients Who Developed Severe Sepsis And Septic Shock. Shock 2019; 51:312-320. [DOI: 10.1097/shk.0000000000001183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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31
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Lozano-García M, Estrada L, Jané R. Performance Evaluation of Fixed Sample Entropy in Myographic Signals for Inspiratory Muscle Activity Estimation. ENTROPY 2019; 21:e21020183. [PMID: 33266898 PMCID: PMC7514665 DOI: 10.3390/e21020183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 11/16/2022]
Abstract
Fixed sample entropy (fSampEn) has been successfully applied to myographic signals for inspiratory muscle activity estimation, attenuating interference from cardiac activity. However, several values have been suggested for fSampEn parameters depending on the application, and there is no consensus standard for optimum values. This study aimed to perform a thorough evaluation of the performance of the most relevant fSampEn parameters in myographic respiratory signals, and to propose, for the first time, a set of optimal general fSampEn parameters for a proper estimation of inspiratory muscle activity. Different combinations of fSampEn parameters were used to calculate fSampEn in both non-invasive and the gold standard invasive myographic respiratory signals. All signals were recorded in a heterogeneous population of healthy subjects and chronic obstructive pulmonary disease patients during loaded breathing, thus allowing the performance of fSampEn to be evaluated for a variety of inspiratory muscle activation levels. The performance of fSampEn was assessed by means of the cross-covariance of fSampEn time-series and both mouth and transdiaphragmatic pressures generated by inspiratory muscles. A set of optimal general fSampEn parameters was proposed, allowing fSampEn of different subjects to be compared and contributing to improving the assessment of inspiratory muscle activity in health and disease.
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Affiliation(s)
- Manuel Lozano-García
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), UPC Campus Diagonal-Besòs, Av. d’Eduard Maristany 10–14, 08930 Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), 08028 Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, 08028 Barcelona, Spain
| | - Luis Estrada
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), UPC Campus Diagonal-Besòs, Av. d’Eduard Maristany 10–14, 08930 Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), 08028 Barcelona, Spain
| | - Raimon Jané
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), UPC Campus Diagonal-Besòs, Av. d’Eduard Maristany 10–14, 08930 Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), 08028 Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, 08028 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-401-25-38
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Inspiratory Muscle Training in Patients with Prolonged Mechanical Ventilation: Narrative Review. Cardiopulm Phys Ther J 2019; 30:44-50. [PMID: 31105474 DOI: 10.1097/cpt.0000000000000092] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients with impending respiratory failure often require mechanical ventilation to optimize gas exchange. Although this form of assisted ventilation is required for survival, its persistent use results in diaphragm weakness and muscle fiber atrophy. There is strong evidence that mechanical ventilation alters the structure and function of the diaphragm, resulting in prolonged dependence on assisted ventilation and long-term consequences such as a delayed functional recovery, reduced quality of life and increased risk of mortality. This review summarizes the mechanisms underlying diaphragm dysfunction due to prolonged mechanical ventilation, highlights the role of inspiratory muscle exercise as a strategy to counter diaphragm weakness, and identifies the parameters of an evidence-supported exercise prescription for difficult to wean patients.
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Lozano-García M, Sarlabous L, Moxham J, Rafferty GF, Torres A, Jané R, Jolley CJ. Surface mechanomyography and electromyography provide non-invasive indices of inspiratory muscle force and activation in healthy subjects. Sci Rep 2018; 8:16921. [PMID: 30446712 PMCID: PMC6240075 DOI: 10.1038/s41598-018-35024-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/28/2018] [Indexed: 11/30/2022] Open
Abstract
The current gold standard assessment of human inspiratory muscle function involves using invasive measures of transdiaphragmatic pressure (Pdi) or crural diaphragm electromyography (oesEMGdi). Mechanomyography is a non-invasive measure of muscle vibration associated with muscle contraction. Surface electromyogram and mechanomyogram, recorded transcutaneously using sensors placed over the lower intercostal spaces (sEMGlic and sMMGlic respectively), have been proposed to provide non-invasive indices of inspiratory muscle activation, but have not been directly compared to gold standard Pdi and oesEMGdi measures during voluntary respiratory manoeuvres. To validate the non-invasive techniques, the relationships between Pdi and sMMGlic, and between oesEMGdi and sEMGlic were measured simultaneously in 12 healthy subjects during an incremental inspiratory threshold loading protocol. Myographic signals were analysed using fixed sample entropy (fSampEn), which is less influenced by cardiac artefacts than conventional root mean square. Strong correlations were observed between: mean Pdi and mean fSampEn |sMMGlic| (left, 0.76; right, 0.81), the time-integrals of the Pdi and fSampEn |sMMGlic| (left, 0.78; right, 0.83), and mean fSampEn oesEMGdi and mean fSampEn sEMGlic (left, 0.84; right, 0.83). These findings suggest that sMMGlic and sEMGlic could provide useful non-invasive alternatives to Pdi and oesEMGdi for the assessment of inspiratory muscle function in health and disease.
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Affiliation(s)
- Manuel Lozano-García
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain.
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain.
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain.
| | - Leonardo Sarlabous
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain
| | - John Moxham
- Faculty of Life Sciences & Medicine, King's College London, King's Health Partners, London, United Kingdom
| | - Gerrard F Rafferty
- King's College Hospital NHS Foundation Trust, King's Health Partners, London, United Kingdom
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, King's Health Partners, London, United Kingdom
| | - Abel Torres
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain
| | - Raimon Jané
- Biomedical Signal Processing and Interpretation group, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
- Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya (UPC)-Barcelona Tech, Barcelona, Spain
| | - Caroline J Jolley
- King's College Hospital NHS Foundation Trust, King's Health Partners, London, United Kingdom
- Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, King's Health Partners, London, United Kingdom
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Carámbula A, Visca A, D'Amico S, Angulo M. Respiratory and Peripheral Muscle Assessment in the Intensive Care Unit. Arch Bronconeumol 2018; 55:258-265. [PMID: 30454870 DOI: 10.1016/j.arbres.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/17/2018] [Accepted: 09/20/2018] [Indexed: 02/07/2023]
Abstract
Atrophy and weakness of the respiratory and peripheral muscles is a common problem in the intensive care unit (ICU). It is difficult to diagnose, particularly in the early stages of critical disease. Consequently, many cases are detected only in advanced stages, for example, when difficulties in mechanical ventilation weaning are encountered. The aim of this review is to describe the main tools that are currently available for evaluation of peripheral and respiratory muscles in the ICU. Techniques of varying complexity and specificity are discussed, and particular emphasis is placed on those with greater relevance in daily clinical practice, such as ultrasound.
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Affiliation(s)
- Agustín Carámbula
- Centro de Tratamiento Intensivo, Hospital Maciel, Montevideo, Uruguay
| | - Antonella Visca
- Centro de Tratamiento Intensivo, Hospital Maciel, Montevideo, Uruguay
| | - Silvana D'Amico
- Centro de Tratamiento Intensivo, Hospital Maciel, Montevideo, Uruguay
| | - Martín Angulo
- Centro de Tratamiento Intensivo, Hospital Maciel, Montevideo, Uruguay; Cátedra de Medicina Intensiva, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay; Departamento de Fisiopatología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.
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35
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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Jansen D, Jonkman AH, Roesthuis L, Gadgil S, van der Hoeven JG, Scheffer GJJ, Girbes A, Doorduin J, Sinderby CS, Heunks LMA. Estimation of the diaphragm neuromuscular efficiency index in mechanically ventilated critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:238. [PMID: 30261920 PMCID: PMC6161422 DOI: 10.1186/s13054-018-2172-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/28/2018] [Indexed: 12/27/2022]
Abstract
Background Diaphragm dysfunction develops frequently in ventilated intensive care unit (ICU) patients. Both disuse atrophy (ventilator over-assist) and high respiratory muscle effort (ventilator under-assist) seem to be involved. A strong rationale exists to monitor diaphragm effort and titrate support to maintain respiratory muscle activity within physiological limits. Diaphragm electromyography is used to quantify breathing effort and has been correlated with transdiaphragmatic pressure and esophageal pressure. The neuromuscular efficiency index (NME) can be used to estimate inspiratory effort, however its repeatability has not been investigated yet. Our goal is to evaluate NME repeatability during an end-expiratory occlusion (NMEoccl) and its use to estimate the pressure generated by the inspiratory muscles (Pmus). Methods This is a prospective cohort study, performed in a medical-surgical ICU. A total of 31 adult patients were included, all ventilated in neurally adjusted ventilator assist (NAVA) mode with an electrical activity of the diaphragm (EAdi) catheter in situ. At four time points within 72 h five repeated end-expiratory occlusion maneuvers were performed. NMEoccl was calculated by delta airway pressure (ΔPaw)/ΔEAdi and was used to estimate Pmus. The repeatability coefficient (RC) was calculated to investigate the NMEoccl variability. Results A total number of 459 maneuvers were obtained. At time T = 0 mean NMEoccl was 1.22 ± 0.86 cmH2O/μV with a RC of 82.6%. This implies that when NMEoccl is 1.22 cmH2O/μV, it is expected with a probability of 95% that the subsequent measured NMEoccl will be between 2.22 and 0.22 cmH2O/μV. Additional EAdi waveform analysis to correct for non-physiological appearing waveforms, did not improve NMEoccl variability. Selecting three out of five occlusions with the lowest variability reduced the RC to 29.8%. Conclusions Repeated measurements of NMEoccl exhibit high variability, limiting the ability of a single NMEoccl maneuver to estimate neuromuscular efficiency and therefore the pressure generated by the inspiratory muscles based on EAdi. Electronic supplementary material The online version of this article (10.1186/s13054-018-2172-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Diana Jansen
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands
| | - Lisanne Roesthuis
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suvarna Gadgil
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Gert-Jan J Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Armand Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands
| | - Jonne Doorduin
- Department of Neurology, Donders Institute, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christer S Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Postbox 7057, 1007, MB, Amsterdam, The Netherlands.
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Diaphragm Weakness in the Critically Ill: Basic Mechanisms Reveal Therapeutic Opportunities. Chest 2018; 154:1395-1403. [PMID: 30144420 DOI: 10.1016/j.chest.2018.08.1028] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 12/11/2022] Open
Abstract
The diaphragm is the primary muscle of inspiration. Its capacity to respond to the load imposed by pulmonary disease is a major determining factor both in the onset of ventilatory failure and in the ability to successfully separate patients from ventilator support. It has recently been established that a very large proportion of critically ill patients exhibit major weakness of the diaphragm, which is associated with poor clinical outcomes. The two greatest risk factors for the development of diaphragm weakness in critical illness are the use of mechanical ventilation and the presence of sepsis. Loss of force production by the diaphragm under these conditions is caused by a combination of defective contractility and reduced diaphragm muscle mass. Importantly, many of the same molecular mechanisms are implicated in the diaphragm dysfunction associated with both mechanical ventilation and sepsis. This review outlines the primary cellular mechanisms identified thus far at the nexus of diaphragm dysfunction associated with mechanical ventilation and/or sepsis, and explores the potential for treatment or prevention of diaphragm weakness in critically ill patients through therapeutic manipulation of these final common pathway targets.
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Lindqvist J, van den Berg M, van der Pijl R, Hooijman PE, Beishuizen A, Elshof J, de Waard M, Girbes A, Spoelstra-de Man A, Shi ZH, van den Brom C, Bogaards S, Shen S, Strom J, Granzier H, Kole J, Musters RJP, Paul MA, Heunks LMA, Ottenheijm CAC. Positive End-Expiratory Pressure Ventilation Induces Longitudinal Atrophy in Diaphragm Fibers. Am J Respir Crit Care Med 2018; 198:472-485. [PMID: 29578749 PMCID: PMC6118031 DOI: 10.1164/rccm.201709-1917oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 03/26/2018] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Diaphragm weakness in critically ill patients prolongs ventilator dependency and duration of hospital stay and increases mortality and healthcare costs. The mechanisms underlying diaphragm weakness include cross-sectional fiber atrophy and contractile protein dysfunction, but whether additional mechanisms are at play is unknown. OBJECTIVES To test the hypothesis that mechanical ventilation with positive end-expiratory pressure (PEEP) induces longitudinal atrophy by displacing the diaphragm in the caudal direction and reducing the length of fibers. METHODS We studied structure and function of diaphragm fibers of mechanically ventilated critically ill patients and mechanically ventilated rats with normal and increased titin compliance. MEASUREMENTS AND MAIN RESULTS PEEP causes a caudal movement of the diaphragm, both in critically ill patients and in rats, and this caudal movement reduces fiber length. Diaphragm fibers of 18-hour mechanically ventilated rats (PEEP of 2.5 cm H2O) adapt to the reduced length by absorbing serially linked sarcomeres, the smallest contractile units in muscle (i.e., longitudinal atrophy). Increasing the compliance of titin molecules reduces longitudinal atrophy. CONCLUSIONS Mechanical ventilation with PEEP results in longitudinal atrophy of diaphragm fibers, a response that is modulated by the elasticity of the giant sarcomeric protein titin. We postulate that longitudinal atrophy, in concert with the aforementioned cross-sectional atrophy, hampers spontaneous breathing trials in critically ill patients: during these efforts, end-expiratory lung volume is reduced, and the shortened diaphragm fibers are stretched to excessive sarcomere lengths. At these lengths, muscle fibers generate less force, and diaphragm weakness ensues.
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Affiliation(s)
- Johan Lindqvist
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | | | - Robbert van der Pijl
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
- Department of Physiology
| | | | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands; and
| | | | | | | | | | - Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | | | | | - Shengyi Shen
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | - Joshua Strom
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | - Henk Granzier
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | | | | | - Marinus A. Paul
- Department of Cardiothoracic Surgery, Vrije Universiteit Medical Center, Amsterdam, the Netherlands
| | | | - Coen A. C. Ottenheijm
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
- Department of Physiology
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Dres M, Goligher EC, Dubé BP, Morawiec E, Dangers L, Reuter D, Mayaux J, Similowski T, Demoule A. Diaphragm function and weaning from mechanical ventilation: an ultrasound and phrenic nerve stimulation clinical study. Ann Intensive Care 2018; 8:53. [PMID: 29687276 PMCID: PMC5913054 DOI: 10.1186/s13613-018-0401-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/16/2018] [Indexed: 01/28/2023] Open
Abstract
Background Diaphragm dysfunction is defined by a value of twitch tracheal pressure in response to magnetic phrenic stimulation (twitch pressure) amounting to less than 11 cmH2O. This study assessed whether this threshold or a lower one would predict accurately weaning failure from mechanical ventilation. Twitch pressure was compared to ultrasound measurement of diaphragm function. Methods In patients undergoing a first spontaneous breathing trial, diaphragm function was evaluated by twitch pressure and by diaphragm ultrasound (thickening fraction). Receiver operating characteristics curves were computed to determine the best thresholds predicting failure of spontaneous breathing trial. Results Seventy-six patients were evaluated, 48 (63%) succeeded and 28 (37%) failed the spontaneous breathing trial. The optimal thresholds of twitch pressure and thickening fraction to predict failure of the spontaneous breathing trial were, respectively, 7.2 cmH2O and 25.8%, respectively. The receiver operating characteristics curves were 0.80 (95% CI 0.70–0.89) for twitch pressure and 0.82 (95% CI 0.73–0.93) for thickening fraction. Both receiver operating characteristics curves were similar (p = 0.83). A twitch pressure value lower than 11 cmH2O (the traditional cutoff for diaphragm dysfunction) predicted failure of the spontaneous breathing trial with a sensitivity of 89% (95% CI 72–98%) and a specificity of 45% (95% CI 30–60%). Conclusions Failure of spontaneous breathing trial can be predicted with a lower value of twitch pressure than the value defining diaphragm dysfunction. Twitch pressure and thickening fraction had similar strong performance in the prediction of failure of the spontaneous breathing trial. Electronic supplementary material The online version of this article (10.1186/s13613-018-0401-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Dres
- UPMC Univ Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, Paris, France. .,Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France.
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Bruno-Pierre Dubé
- UPMC Univ Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, Paris, France.,Département de Médecine, Service de Pneumologie, Hôpital Hôtel-Dieu, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
| | - Elise Morawiec
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Laurence Dangers
- UPMC Univ Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, Paris, France.,Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Danielle Reuter
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Julien Mayaux
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Thomas Similowski
- UPMC Univ Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, Paris, France.,Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France
| | - Alexandre Demoule
- UPMC Univ Paris 06, INSERM, UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Universités, Paris, France.,Service de Pneumologie et Réanimation Médicale (Département "R3S"), AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, 47-83 boulevard de l'Hôpital, 75013, Paris, France
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40
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Dres M, Demoule A. Diaphragm dysfunction during weaning from mechanical ventilation: an underestimated phenomenon with clinical implications. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:73. [PMID: 29558983 PMCID: PMC5861656 DOI: 10.1186/s13054-018-1992-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Martin Dres
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ″R3S″), Paris, France.
| | - Alexandre Demoule
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ″R3S″), Paris, France
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41
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The Combination of SAT and SBT Protocols May Help Reduce the Incidence of Ventilator-Associated Pneumonia in the Burn Intensive Care Unit. J Burn Care Res 2018; 38:e574-e579. [PMID: 27755248 DOI: 10.1097/bcr.0000000000000451] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There are few published reports on the unique nature of burn patients using a paired spontaneous awakening and spontaneous breathing protocol. A combined protocol was implemented in our burn intensive care unit (ICU) on January 1, 2012. This study evaluates the impact of this protocol on patient outcomes in a burn ICU. We performed a retrospective review of our burn registry over 4 years, including all patients placed on mechanical ventilation. In the latter 2 years, patients meeting criteria underwent daily spontaneous awakening trial; if successful, spontaneous breathing trial was performed. Patient data included age, burn size, percent full-thickness burn, tracheostomy, and inhalation injury. Outcome measures included ventilator days, ICU and hospital lengths of stay, pneumonia, and disposition. Data were analyzed using Graphpad Prism and IBM SPSS software, with statistical significance defined as P < .05. There were 171 admissions in the preprotocol period and 136 after protocol implementation. Protocol patients had greater percent full-thickness burns, but did not differ in other characteristics. The protocol group had significantly shorter ICU length of stay, fewer ventilator days, and lower pneumonia incidence. Hospital length of stay, disposition, and mortality were not significantly different. Among patients with inhalation injuries, the protocol group exhibited fewer ventilator and ICU days. Protocol implementation in a burn ICU was accompanied by decreased ventilator days and a reduced incidence of pneumonia. A combined spontaneous awakening and breathing protocol is safe and may improve clinical practice in the burn ICU.
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van den Berg M, Hooijman PE, Beishuizen A, de Waard MC, Paul MA, Hartemink KJ, van Hees HWH, Lawlor MW, Brocca L, Bottinelli R, Pellegrino MA, Stienen GJM, Heunks LMA, Wüst RCI, Ottenheijm CAC. Diaphragm Atrophy and Weakness in the Absence of Mitochondrial Dysfunction in the Critically Ill. Am J Respir Crit Care Med 2017; 196:1544-1558. [PMID: 28787181 DOI: 10.1164/rccm.201703-0501oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE The clinical significance of diaphragm weakness in critically ill patients is evident: it prolongs ventilator dependency and increases morbidity, duration of hospital stay, and health care costs. The mechanisms underlying diaphragm weakness are unknown, but might include mitochondrial dysfunction and oxidative stress. OBJECTIVES We hypothesized that weakness of diaphragm muscle fibers in critically ill patients is accompanied by impaired mitochondrial function and structure, and by increased markers of oxidative stress. METHODS To test these hypotheses, we studied contractile force, mitochondrial function, and mitochondrial structure in diaphragm muscle fibers. Fibers were isolated from diaphragm biopsies of 36 mechanically ventilated critically ill patients and compared with those isolated from biopsies of 27 patients with suspected early-stage lung malignancy (control subjects). MEASUREMENTS AND MAIN RESULTS Diaphragm muscle fibers from critically ill patients displayed significant atrophy and contractile weakness, but lacked impaired mitochondrial respiration and increased levels of oxidative stress markers. Mitochondrial energy status and morphology were not altered, despite a lower content of fusion proteins. CONCLUSIONS Critically ill patients have manifest diaphragm muscle fiber atrophy and weakness in the absence of mitochondrial dysfunction and oxidative stress. Thus, mitochondrial dysfunction and oxidative stress do not play a causative role in the development of atrophy and contractile weakness of the diaphragm in critically ill patients.
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Affiliation(s)
| | | | - Albertus Beishuizen
- 2 Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Marinus A Paul
- 4 Department of Cardiothoracic Surgery, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - Koen J Hartemink
- 5 Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Michael W Lawlor
- 7 Division of Pediatric Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Roberto Bottinelli
- 8 Department of Molecular Medicine.,10 Interdepartmental Center for Biology and Sport Medicine, and.,9 Fondazione Salvatore Maugeri (IRCCS), Scientific Institute of Pavia, Pavia, Italy
| | - Maria A Pellegrino
- 8 Department of Molecular Medicine.,10 Interdepartmental Center for Biology and Sport Medicine, and.,11 Interuniversity Institute of Myology, University of Pavia, Pavia, Italy
| | - Ger J M Stienen
- 1 Department of Physiology, Amsterdam Cardiovascular Sciences.,12 Faculty of Science, Department of Physics and Astronomy, VU Amsterdam, Amsterdam, the Netherlands
| | | | - Rob C I Wüst
- 1 Department of Physiology, Amsterdam Cardiovascular Sciences.,13 Laboratory Genetic Metabolic Diseases, Academic Medical Center, Amsterdam, the Netherlands; and
| | - Coen A C Ottenheijm
- 1 Department of Physiology, Amsterdam Cardiovascular Sciences.,14 Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
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43
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Laghi F, Sassoon CS. Weakness in the Critically Ill: "Captain of the Men of Death" or Sign of Disease Severity? Am J Respir Crit Care Med 2017; 195:7-9. [PMID: 28035864 DOI: 10.1164/rccm.201606-1318ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Franco Laghi
- 1 Stritch School of Medicine, Loyola University Chicago Maywood, Illinois.,2 Edward Hines Jr. Veterans Affairs Hospital Hines, Illinois
| | - Catherine S Sassoon
- 3 University of California, Irvine Irvine, California and.,4 Veterans Affairs Long Beach Healthcare System Long Beach, California
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Vassilakopoulos T, Petrof BJ. A Stimulating Approach to Ventilator-induced Diaphragmatic Dysfunction. Am J Respir Crit Care Med 2017; 169:336-41. [PMID: 14739134 DOI: 10.1164/rccm.200304-489cp] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Critical illness-associated diaphragm weakness. Intensive Care Med 2017; 43:1441-1452. [DOI: 10.1007/s00134-017-4928-4] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 08/31/2017] [Indexed: 11/26/2022]
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Supinski GS, Morris PE, Dhar S, Callahan LA. Diaphragm Dysfunction in Critical Illness. Chest 2017; 153:1040-1051. [PMID: 28887062 DOI: 10.1016/j.chest.2017.08.1157] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 12/14/2022] Open
Abstract
The diaphragm is the major muscle of inspiration, and its function is critical for optimal respiration. Diaphragmatic failure has long been recognized as a major contributor to death in a variety of systemic neuromuscular disorders. More recently, it is increasingly apparent that diaphragm dysfunction is present in a high percentage of critically ill patients and is associated with increased morbidity and mortality. In these patients, diaphragm weakness is thought to develop from disuse secondary to ventilator-induced diaphragm inactivity and as a consequence of the effects of systemic inflammation, including sepsis. This form of critical illness-acquired diaphragm dysfunction impairs the ability of the respiratory pump to compensate for an increased respiratory workload due to lung injury and fluid overload, leading to sustained respiratory failure and death. This review examines the presentation, causes, consequences, diagnosis, and treatment of disorders that result in acquired diaphragm dysfunction during critical illness.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Peter E Morris
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Sanjay Dhar
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Leigh Ann Callahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY.
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Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength. Crit Care Med 2017; 45:e798-e805. [PMID: 28437378 DOI: 10.1097/ccm.0000000000002433] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Respiratory muscle weakness frequently develops during mechanical ventilation, although in children there are limited data about its prevalence and whether it is associated with extubation outcomes. We sought to identify risk factors for pediatric extubation failure, with specific attention to respiratory muscle strength. DESIGN Secondary analysis of prospectively collected data. SETTING Tertiary care PICU. PATIENTS Four hundred nine mechanically ventilated children. INTERVENTIONS Respiratory measurements using esophageal manometry and respiratory inductance plethysmography were made preextubation during airway occlusion and on continuous positive airway pressure of 5 and pressure support of 10 above positive end-expiratory pressure 5 cm H2O, as well as 5 and 60 minutes postextubation. MEASUREMENTS AND MAIN RESULTS Thirty-four patients (8.3%) were reintubated within 48 hours of extubation. Reintubation risk factors included lower maximum airway pressure during airway occlusion (aPiMax) preextubation, longer length of ventilation, postextubation upper airway obstruction, high respiratory effort postextubation (pressure rate product, pressure time product, tension time index), and high postextubation phase angle. Nearly 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cm H2O) at the time of extubation, and were nearly three times more likely to be reintubated than those with preserved strength (aPiMax > 30 cm H2O; 14% vs 5.5%; p = 0.006). Reintubation rates exceeded 20% when children with low aPiMax had moderately elevated effort after extubation (pressure rate product > 500), whereas children with preserved aPiMax had reintubation rates greater than 20% only when postextubation effort was very high (pressure rate product > 1,000). When children developed postextubation upper airway obstruction, reintubation rates were 47.4% for those with low aPiMax compared to 15.4% for those with preserved aPiMax (p = 0.02). Multivariable risk factors for reintubation included acute neurologic disease, lower aPiMax, postextubation upper airway obstruction, higher preextubation positive end-expiratory pressure, higher postextubation pressure rate product, and lower height. CONCLUSIONS Neuromuscular weakness at the time of extubation was common in children and was independently associated with reintubation, particularly when postextubation effort was high.
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Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, Similowski T, Demoule A. Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients. Am J Respir Crit Care Med 2017; 195:57-66. [PMID: 27310484 DOI: 10.1164/rccm.201602-0367oc] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Intensive care unit (ICU)- and mechanical ventilation (MV)-acquired limb muscle and diaphragm dysfunction may both be associated with longer length of stay and worse outcome. Whether they are two aspects of the same entity or have a different prevalence and prognostic impact remains unclear. OBJECTIVES To quantify the prevalence and coexistence of these two forms of ICU-acquired weakness and their impact on outcome. METHODS In patients undergoing a first spontaneous breathing trial after at least 24 hours of MV, diaphragm dysfunction was evaluated using twitch tracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (a pressure <11 cm H2O defined dysfunction) and ultrasonography (thickening fraction [TFdi] and excursion). Limb muscle weakness was defined as a Medical Research Council (MRC) score less than 48. MEASUREMENTS AND MAIN RESULTS Seventy-six patients were assessed at their first spontaneous breathing trial: 63% had diaphragm dysfunction, 34% had limb muscle weakness, and 21% had both. There was a significant but weak correlation between MRC score and twitch pressure (ρ = 0.26; P = 0.03) and TFdi (ρ = 0.28; P = 0.01), respectively. Low twitch pressure (odds ratio, 0.60; 95% confidence interval, 0.45-0.79; P < 0.001) and TFdi (odds ratio, 0.84; 95% confidence interval, 0.76-0.92; P < 0.001) were independently associated with weaning failure, but the MRC score was not. Diaphragm dysfunction was associated with higher ICU and hospital mortality, and limb muscle weakness was associated with longer duration of MV and hospital stay. CONCLUSIONS Diaphragm dysfunction is twice as frequent as limb muscle weakness and has a direct negative impact on weaning outcome. The two types of muscle weakness have only limited overlap.
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Affiliation(s)
- Martin Dres
- 1 Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,2 AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Bruno-Pierre Dubé
- 1 Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,3 Département de Médecine, Service de Pneumologie, Hôpital Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Julien Mayaux
- 2 AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Julie Delemazure
- 2 AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Danielle Reuter
- 2 AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Laurent Brochard
- 4 Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada; and.,5 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Similowski
- 1 Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,2 AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Alexandre Demoule
- 1 Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,2 AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
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Jones AYM, Ngai SPC, Ying MTC, Morris NR, Laakso EL, Lee SWY, Parry SM. Sonographic evaluation of diaphragmatic function during breathing control. Physiother Theory Pract 2017; 33:560-567. [DOI: 10.1080/09593985.2017.1323363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- A. Y. M. Jones
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - S. P. C. Ngai
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - M. T. C. Ying
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - N. R. Morris
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - E. L. Laakso
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - S. W. Y. Lee
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - S. M. Parry
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
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Dubé BP, Dres M, Mayaux J, Demiri S, Similowski T, Demoule A. Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications. Thorax 2017; 72:811-818. [PMID: 28360224 DOI: 10.1136/thoraxjnl-2016-209459] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 02/17/2017] [Accepted: 02/22/2017] [Indexed: 11/04/2022]
Abstract
RATIONALE In intensive care unit (ICU) patients, diaphragm dysfunction is associated with adverse clinical outcomes. Ultrasound measurements of diaphragm thickness, excursion (EXdi) and thickening fraction (TFdi) are putative estimators of diaphragm function, but have never been compared with phrenic nerve stimulation. Our aim was to describe the relationship between these variables and diaphragm function evaluated using the change in endotracheal pressure after phrenic nerve stimulation (Ptr,stim), and to compare their prognostic value. METHODS Between November 2014 and June 2015, Ptr,stim and ultrasound variables were measured in mechanically ventilated patients <24 hours after intubation ('initiation of mechanical ventilation (MV)', under assist-control ventilation, ACV) and at the time of switch to pressure support ventilation ('switch to PSV'), and compared using Spearman's correlation and receiver operating characteristic curve analysis. Diaphragm dysfunction was defined as Ptr,stim <11 cm H2O. RESULTS 112 patients were included. At initiation of MV, Ptr,stim was not correlated to diaphragm thickness (p=0.28), EXdi (p=0.66) or TFdi (p=0.80). At switch to PSV, TFdi and EXdi were respectively very strongly and moderately correlated to Ptr,stim, (r=0.87, p<0.001 and 0.45, p=0.001), but diaphragm thickness was not (p=0.45). A TFdi <29% could reliably identify diaphragm dysfunction (sensitivity and specificity of 85% and 88%), but diaphragm thickness and EXdi could not. This value was associated with increased duration of ICU stay and MV, and mortality. CONCLUSIONS Under ACV, diaphragm thickness, EXdi and TFdi were uncorrelated to Ptr,stim. Under PSV, TFdi was strongly correlated to diaphragm strength and both were predictors of remaining length of MV and ICU and hospital death.
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Affiliation(s)
- Bruno-Pierre Dubé
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,Département de médecine, service de pneumologie, Hôpital Hôtel-Dieu du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Martin Dres
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), F-75013, Paris, France
| | - Julien Mayaux
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), F-75013, Paris, France
| | - Suela Demiri
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), F-75013, Paris, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), F-75013, Paris, France
| | - Alexandre Demoule
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), F-75013, Paris, France
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