Diaphragm ultrasonography to estimate the work of breathing during non-invasive ventilation

PurposeUltrasonography allows the direct observation of the diaphragm. Its thickness variation measured in the zone of apposition has been previously used to diagnose diaphragm paralysis. We assessed the feasibility and accuracy of this method to assess diaphragmatic function and its contribution to respiratory workload in critically ill patients under non-invasive ventilation.MethodsThis was a preliminary physiological study in the intensive care unit of a university hospital. Twelve patients requiring planned non-invasive ventilation after extubation were studied while spontaneously breathing and during non-invasive ventilation at three levels of pressure support (5, 10 and 15 cmH2O). Diaphragm thickness was measured in the zone of apposition during tidal ventilation and the thickening fraction (TF) was calculated as (thickness at inspiration − thickness at expiration)/thickness at expiration. Diaphragmatic pressure–time product per breath (PTPdi) was measured from oesophageal and gastric pressure recordings.ResultsPTPdi and TF both decreased as the level of pressure support increased. A significant correlation was found between PTPdi and TF (ρ = 0.74, p < 0.001). The overall reproducibility of TF assessment was good but the coefficient of repeatability reached 18 % for inter-observer reproducibility.ConclusionsUltrasonographic assessment of the diaphragm TF is a non-invasive method that may prove useful in evaluating diaphragmatic function and its contribution to respiratory workload in intensive care unit patients.

[1]  S. Na,et al.  An Evaluation of Diaphragmatic Movement by M-Mode Sonography as a Predictor of Pulmonary Dysfunction After Upper Abdominal Surgery , 2010, Anesthesia and analgesia.

[2]  C. Gregoretti,et al.  Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients* , 2005, Critical care medicine.

[3]  Sairam Parthasarathy,et al.  Weaning prediction: esophageal pressure monitoring complements readiness testing. , 2005, American journal of respiratory and critical care medicine.

[4]  D. Kim.  A potential selection bias in the study of early combination antibiotic therapy versus monotherapy in septic shock. , 2011, Critical care medicine.

[5]  A. Beckett,et al.  AKUFO AND IBARAPA. , 1965, Lancet.

[6]  N. Pride,et al.  In vivo assessment of diaphragm contraction by ultrasound in normal subjects. , 1995, Thorax.

[7]  W. Yost,et al.  Diaphragmatic thickness-lung volume relationship in vivo. , 1989, Journal of applied physiology.

[8]  Gary C. Sieck,et al.  ATS/ERS Statement on respiratory muscle testing. , 2002, American journal of respiratory and critical care medicine.

[9]  S. Eveloff,et al.  Diaphragm thickening during inspiration. , 1997, Journal of applied physiology.

[10]  J. L. Gall,et al.  APACHE II--a severity of disease classification system. , 1986, Critical care medicine.

[11]  Svein Arne Aase,et al.  Reproducibility in echocardiographic assessment of the left ventricular global and regional function, the HUNT study. , 2010, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.

[12]  Jean-Yves Fagon,et al.  Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. , 2009, Chest.

[13]  P. Macklem,et al.  The oxygen cost of breathing in patients with cardiorespiratory disease. , 2015, The American review of respiratory disease.

[14]  Sang-Bum Hong,et al.  Diaphragm dysfunction assessed by ultrasonography: Influence on weaning from mechanical ventilation* , 2011, Critical care medicine.

[15]  P. Macklem,et al.  The respiratory muscles. , 1982, The New England journal of medicine.

[16]  J M Bland,et al.  Statistical methods for assessing agreement between two methods of clinical measurement , 1986 .

[17]  A. Feinstein,et al.  Clinical biostatistics: LIV. The biostatistics of concordance , 1981 .

[18]  R. Johnson,et al.  Patterns of shortening and thickening of the human diaphragm. , 1997, Journal of applied physiology.

[19]  A. Boussuges,et al.  Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. , 2009, Chest.

[20]  A. Feinstein,et al.  THE BIOSTATISTICS OF CONCORDANCE , 1981 .

[21]  Tomio Inoue,et al.  Influence of the distribution of emphysema on diaphragmatic motion in patients with chronic obstructive pulmonary disease , 2011, Japanese Journal of Radiology.

[22]  R. S. Harris,et al.  Normal ventilatory movement of the right hemidiaphragm studied by ultrasonography and pneumotachography. , 1983, Radiology.

[23]  D. Altman,et al.  Statistics Notes: Measurement error and correlation coefficients , 1996, BMJ.

[24]  J. Masip,et al.  Noninvasive ventilation in acute respiratory failure , 2014, International journal of chronic obstructive pulmonary disease.

[25]  C. K. Mahutte,et al.  Pressure-time product during continuous positive airway pressure, pressure support ventilation, and T-piece during weaning from mechanical ventilation. , 1991, The American review of respiratory disease.

[26]  S. Powers,et al.  Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. , 2008, The New England journal of medicine.

[27]  J. Houston,et al.  Comparison of ultrasound with fluoroscopy in the assessment of suspected hemidiaphragmatic movement abnormality. , 1995, Clinical radiology.

[28]  F. Mccool,et al.  Ultrasound evaluation of the paralyzed diaphragm. , 1997, American journal of respiratory and critical care medicine.

[29]  P. Chien,et al.  Evaluation of a clinical test. I: Assessment of reliability , 2001, BJOG : an international journal of obstetrics and gynaecology.

[30]  M. Aubier,et al.  Effects of mechanical ventilation on diaphragmatic contractile properties in rats. , 1994, American journal of respiratory and critical care medicine.

[31]  J. Nicolás,et al.  Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. , 2006, American journal of respiratory and critical care medicine.

[32]  L. Brochard,et al.  Expiratory muscle activity increases intrinsic positive end-expiratory pressure independently of dynamic hyperinflation in mechanically ventilated patients. , 1995, American journal of respiratory and critical care medicine.

[33]  Arthur S Slutsky,et al.  Compensation for increase in respiratory workload during mechanical ventilation. Pressure-support versus proportional-assist ventilation. , 2000, American journal of respiratory and critical care medicine.

[34]  D. Altman,et al.  STATISTICAL METHODS FOR ASSESSING AGREEMENT BETWEEN TWO METHODS OF CLINICAL MEASUREMENT , 1986, The Lancet.

[35]  T. Similowski,et al.  Clinically relevant diaphragmatic dysfunction after cardiac operations. , 1994, The Journal of thoracic and cardiovascular surgery.

[36]  P E Pepe,et al.  Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. , 1982, The American review of respiratory disease.

[37]  Gary C Sieck,et al.  Altered diaphragm contractile properties with controlled mechanical ventilation. , 2002, Journal of applied physiology.

[38]  Thomas Similowski,et al.  Reduced breathing variability as a predictor of unsuccessful patient separation from mechanical ventilation* , 2006, Critical care medicine.

[39]  M. Sebbane,et al.  Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. , 2011, American journal of respiratory and critical care medicine.

[40]  F. Mccool,et al.  Monitoring recovery from diaphragm paralysis with ultrasound. , 2008, Chest.

[41]  J I Peters,et al.  Effects of prolonged controlled mechanical ventilation on diaphragmatic function in healthy adult baboons. , 1997, Critical care medicine.

[42]  J Moxham,et al.  Weaning From Mechanical Ventilation , 2004 .

[43]  F. Maltais,et al.  Mechanical ventilation-induced diaphragm disuse in humans triggers autophagy. , 2010, American journal of respiratory and critical care medicine.

[44]  W A Zin,et al.  A simple method for assessing the validity of the esophageal balloon technique. , 2015, The American review of respiratory disease.

[45]  S. Loring.  "Three-dimensional reconstruction of the in vivo human diaphragm shape at different lung volumes". , 1994, Journal of applied physiology.

[46]  L. Brochard,et al.  Role of the respiratory muscles in acute respiratory failure of COPD: lessons from weaning failure. , 2009, Journal of applied physiology.