Evaluation of diaphragm thickness to predict intubation requirement and mortality in critical COVID-19 patients

Association of muscularity status with clinical and physical function outcomes in critically ill patients with COVID-19: A systematic review and meta-analysis

Pre-coronavirus disease 2019 (COVID-19) critical care research underscored the importance of muscularity on patient outcomes. This study investigates the association between skeletal muscle mass and quality with clinical and physical function outcomes in critically ill patients with COVID-19. We systematically searched MEDLINE, EMBASE, and CINAHL from database inception to April 24, 2024, for studies using objective methods to evaluate muscularity in critically ill adults with COVID-19, without language restrictions. Co-primary outcomes were overall mortality and muscle strength. Random-effect meta-analyses were performed in RevMan 5.4.1. We included 20 studies (N = 1818), assessing muscularity via computed tomography (twelve studies), ultrasound (seven studies), and bioelectrical impedance analysis (one study); none had low risk of bias. In analyses of high vs low muscularity, high muscle mass was significantly associated with lower overall mortality (nine studies; risk ratio = 0.74; 95% CI, 0.57-0.98; P = 0.03). When muscularity was analyzed as a continuous variable, COVID-19 survivors had higher skeletal muscle area (SMA) (13 studies; mean difference [MD] = 1.18; 95% CI, 0.03-2.33; P = 0.05) confirmed by sensitivity analysis using standardized MD (0.23, 95% CI 0.05-0.42, P = 0.01) and significantly higher muscle quality (five studies; standardized MD = 0.45; 95% CI, 0.20-0.70; P = 0.0004). Muscle strength findings were inconsistent: one study showed significant correlations between muscle strength with muscle mass parameters (r = 0.365-0.375, P < 0.001) whereas another found no association. In critically ill adults with COVID-19, high muscle mass was associated with lower mortality risk. Survivors had significantly higher SMA and muscle quality. Findings on physical function outcomes remain inconclusive (PROSPERO ID: CRD42022384155).

Diaphragm thickness and ICU admission risk in elderly COVID-19 patients: a CT-based analysis

BACKGROUND

The objective of this study was to examine the impact of diaphragm thickness (DT) on the prognosis of elderly patients infected with COVID-19, particularly with regard to the necessity of intensive care unit (ICU) admission.

METHODS

Between August 2020 and January 2021, 188 patients aged ≥ 65 years who were admitted to the internal medicine department of our hospital with a diagnosis of COVID-19 infection, were included in this study. The patients' DTs of the patients were measured by a radiologist using computed tomography (CT) scans from the right and left diaphragm dome level. DT was compared with the progression of respiratory distress and the necessity of intensive care. In statistical analysis, p < 0.05 was considered significant.

RESULTS

Right DT was higher in the group of patients with admission to the ICU (p = 0.11). According to multivariate logistic regression analysis, ferritin level (OR = 1; 95% CI = 1-1; p = 0.014), IL-6 level (OR = 1.004; 95% CI = 1-1.007; p = 0.045) and higher right DT (OR = 11.015; 95% CI = 3.739-32.447; p = 0.035) were found to be independent risk factors predicting the ICU admission in COVID-19 patients. There was no significant association with left DT. The predictive value of right DT for ICU requirement in COVID-19 patients was evaluated by ROC analysis. The ROC analysis showed a cut-off value > 1.8, AUC = 0.632, p = 0.009, 95% Cl (0.558-0.701). In correlation analysis, a positive correlation was found between right DT and ICU admission (r = 0.331, p < 0.001).

CONCLUSION

Our study is the first to evaluate dome-level DT with CT in elderly patients with COVID-19. In the elderly population, higher right DT levels have been observed to enhance the probability of ICU admission. This may be due to the fact that our sample group consists only of elderly people and the effects of COVID-19. We believe that further validation with more comprehensive studies is needed for DT assessment for clinical treatment decisions, particularly in COVID-19 patients. In addition, we think that the proposal for a standardized measurement site and method for DT measurement will be a guide for future studies.

CLINICAL TRIAL

Not applicable.

Role of diaphragmatic dysfunction in extubation failure among patients at high risk of reintubation: A prospective cohort study

PURPOSE

This study aims to evaluate the role of diaphragmatic dysfunction in extubation failure among patients at high risk of reintubation.

MATERIAL AND METHODS

This prospective cohort study was carried out at a intensive care unit in China. Adult patients who had been intubated for more than 24 h and ready for extubation were included in the study if they exhibited a high risk of extubation failure. Diaphragm dysfunction was defined as a diaphragmatic thickening fraction <30 % or diaphragmatic excursion <10 mm. The primary outcome was defined as extubation failure, which includes either reintubation or death within the initial 7 days following extubation.

RESULTS

Out of the 113 patients, 27 (23.89 %) experienced extubation failure, with diaphragm dysfunction diagnosed in 63 (55.75 %) individuals. Patients who failed extubation were significantly more likely to have diaphragm dysfunction (85.19 % vs. 46.51 %, p < 0.01). In the Cox-proportional hazards regression analysis, diaphragm dysfunction and the Medical Research Council score were found to be associated with extubation failure. The adjusted hazard ratios were 4.56 [95 % CI: 1.56-13.33] and 0.93 [95 % CI: 0.88-0.99]. Both variables were closely correlated with extubation failure showing statistical significance.

CONCLUSION

Diaphragm dysfunction could contribute to an elevated extubation failure rate.

Diaphragm Ultrasound in Different Clinical Scenarios: A Review with a Focus on Older Patients

Diaphragm muscle dysfunction is increasingly recognized as a fundamental marker of several age-related diseases and conditions including chronic obstructive pulmonary disease, heart failure and critical illness with respiratory failure. In older individuals with physical frailty and sarcopenia, the loss of muscle mass and function may also involve the diaphragm, contributing to respiratory dysfunction. Ultrasound has recently emerged as a feasible and reliable strategy to visualize diaphragm structure and function. In particular, it can help to predict the timing of extubation in patients undergoing mechanical ventilation in intensive care units (ICUs). Ultrasonographic evaluation of diaphragmatic function is relatively cheap, safe and quick and can provide useful information for real-time monitoring of respiratory function. In this review, we aim to present the current state of scientific evidence on the usefulness of ultrasound in the assessment of diaphragm dysfunction in different clinical settings, with a particular focus on older patients. We highlight the importance of the qualitative information gathered by ultrasound to assess the integrity, excursion, thickness and thickening of the diaphragm. The implementation of bedside diaphragm ultrasound could be useful for improving the quality and appropriateness of care, especially in older subjects with sarcopenia who experience acute respiratory failure, not only in the ICU setting.

Prognostic Value of Diaphragm Diameter, Muscle Volume, and Bone Mineral Density in Critically Ill COVID-19 Patients

Objective: We aimed to analyze the prognostic value of muscle volume (MV), bone mineral density (BMD), and diaphragm diameter (DD) in COVID-19. Method: The study included 498 patients admitted to the intensive care unit (ICU) with a positive polymerase chain reaction test for COVID-19 from March 11, 2020, through August 31, 2022. The patients' laboratory and demographic data of the patients at the time of ICU admission were recorded. MV, DD, and BMD measurements were performed using computed tomography examinations. Muscle index (MI) was calculated as MV/height2. Quartiles were determined for all 4 measurements. Patients in the lowest quartile were recorded as having low MV, MI, DD, and BMD values. The parameters were evaluated for the whole group and compared according to gender and mortality. The multiple regression analysis was performed for the prediction of mortality. Results: In the mortality group, the male and female patients had significantly statistically lower values in MV (P < .001 and P = .002, respectively), MI (P < .001 and P = .005, respectively), DD (P < .001 and P < .001, respectively), and BMD (P = .002 and P < .001, respectively). In the multiple regression analysis, low MI (OR: 2.03, 95% CI: 1.14-3.61, P = .016) and DD (OR: 10.47, 95% CI: 5.59-19.59, P < .001) values remained significant for the prediction of mortality. Conclusion: BMD is a risk factor for mortality in patients with severe COVID-19, but cannot be used as an independent predictor. However, MI and DD can be used as independent predictors of mortality even in severe cases.