Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Annals of Intensive Care
Published in: Annals of Intensive Care 1/2020

Open Access 01-12-2020 | Haloperidol | Research

Recruitment pattern of the diaphragm and extradiaphragmatic inspiratory muscles in response to different levels of pressure support

Authors: L. H. Roesthuis, J. G. van der Hoeven, H. W. H. van Hees, W.-J. M. Schellekens, J. Doorduin, L. M. A. Heunks

Published in: Annals of Intensive Care | Issue 1/2020

Login to get access

Abstract

Background

Inappropriate ventilator assist plays an important role in the development of diaphragm dysfunction. Ventilator under-assist may lead to muscle injury, while over-assist may result in muscle atrophy. This provides a good rationale to monitor respiratory drive in ventilated patients. Respiratory drive can be monitored by a nasogastric catheter, either with esophageal balloon to determine muscular pressure (gold standard) or with electrodes to measure electrical activity of the diaphragm. A disadvantage is that both techniques are invasive. Therefore, it is interesting to investigate the role of surrogate markers for respiratory dive, such as extradiaphragmatic inspiratory muscle activity. The aim of the current study was to investigate the effect of different inspiratory support levels on the recruitment pattern of extradiaphragmatic inspiratory muscles with respect to the diaphragm and to evaluate agreement between activity of extradiaphragmatic inspiratory muscles and the diaphragm.

Methods

Activity from the alae nasi, genioglossus, scalene, sternocleidomastoid and parasternal intercostals was recorded using surface electrodes. Electrical activity of the diaphragm was measured using a multi-electrode nasogastric catheter. Pressure support (PS) levels were reduced from 15 to 3 cmH2O every 5 min with steps of 3 cmH2O. The magnitude and timing of respiratory muscle activity were assessed.

Results

We included 17 ventilated patients. Diaphragm and extradiaphragmatic inspiratory muscle activity increased in response to lower PS levels (36 ± 6% increase for the diaphragm, 30 ± 6% parasternal intercostals, 41 ± 6% scalene, 40 ± 8% sternocleidomastoid, 43 ± 6% alae nasi and 30 ± 6% genioglossus). Changes in diaphragm activity correlated best with changes in alae nasi activity (r2 = 0.49; P < 0.001), while there was no correlation between diaphragm and sternocleidomastoid activity. The agreement between diaphragm and extradiaphragmatic inspiratory muscle activity was low due to a high individual variability. Onset of alae nasi activity preceded the onset of all other muscles.

Conclusions

Extradiaphragmatic inspiratory muscle activity increases in response to lower inspiratory support levels. However, there is a poor correlation and agreement with the change in diaphragm activity, limiting the use of surface electromyography (EMG) recordings of extradiaphragmatic inspiratory muscles as a surrogate for electrical activity of the diaphragm.
Appendix
Available only for authorised users
Literature
1.
Dres M, Goligher EC, Heunks LMA, Brochard LJ. Critical illness-associated diaphragm weakness. Intensive Care Med. 2017;43(10):1441–52.PubMedCrossRef
2.
Hooijman PE, Beishuizen A, Witt CC, de Waard MC, Girbes AR, Spoelstra-de Man AM, et al. Diaphragm muscle fiber weakness and ubiquitin-proteasome activation in critically ill patients. Am J Respir Crit Care Med. 2015;191(10):1126–38.PubMedPubMedCentralCrossRef
3.
Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med. 2011;183(3):364–71.PubMedCrossRef
4.
Hudson MBSAJ, Nelson WB, Bruells CS, Levine S, Powers SK. Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy. Crit Care Med. 2012;40:1254–60.PubMedPubMedCentralCrossRef
5.
Ebihara SHSNA, Danialou G, Cho W, Gottfried SB, Petrof BJ. Mechanical ventilation protects against diaphragm injury in sepsis. Am J Respir Crit Care Med. 2002;165:221–8.PubMedCrossRef
6.
Goligher ECFE, Herridge MS, Murray A, Vorona S, Brace D, Rittayamai N, Lanys A, Tomlinson G, Singh JM, Bolz S, Rubenfeld GD, Kavanagh BP, Brochard LJ, Ferguson ND. Evolution of diaphragm thickness during mechanical ventilation: impact of inspiratory effort. Am J Respir Crit Care Med. 2015;192:1080–8.PubMedCrossRef
7.
Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu BAJ, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SK, Shrager JB. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008;358(13):1327–35.PubMedCrossRef
8.
Reid WDHJ, Bryson S, Walker DC, Belcastro AN. Diaphragm injury and myofibrillar structure induced by resistive loading. J Appl Physiol. 1994;76:176–84.PubMedCrossRef
9.
Jiang TRWD, Road JD. Delayed diaphragm injury and diaphragm force production. Am J Respir Crit Care Med. 1998;157:736–42.PubMedCrossRef
10.
Bellani G, Pesenti A. Assessing effort and work of breathing. Curr Opin Crit Care. 2014;20(3):352–8.PubMedCrossRef
11.
Doorduin J, van Hees HW, van der Hoeven JG, Heunks LM. Monitoring of the respiratory muscles in the critically ill. Am J Respir Crit Care Med. 2013;187(1):20–7.PubMedCrossRef
12.
Heunks LM, Doorduin J, van der Hoeven JG. Monitoring and preventing diaphragm injury. Curr Opin Crit Care. 2015;21(1):34–41.PubMedCrossRef
13.
Goligher EC, Brochard LJ, Reid WD, Fan E, Saarela O, Slutsky AS, et al. Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. Lancet Respir Med. 2019;7(1):90–8.PubMedCrossRef
14.
Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, et al. The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014;189(5):520–31.PubMedCrossRef
15.
Mauri T, Yoshida T, Bellani G, Goligher EC, Carteaux G, Rittayamai N, et al. Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med. 2016;42(9):1360–73.PubMedCrossRef
16.
Bellani G, Mauri T, Coppadoro A, Grasselli G, Patroniti N, Spadaro S, et al. Estimation of patient’s inspiratory effort from the electrical activity of the diaphragm. Crit Care Med. 2013;41(6):1483–91.PubMedCrossRef
17.
Bellani G, Bronco A, Arrigoni Marocco S, Pozzi M, Sala V, Eronia N, et al. Measurement of diaphragmatic electrical activity by surface electromyography in intubated subjects and its relationship with inspiratory effort. Respir Care. 2018;63(11):1341–9.PubMedCrossRef
18.
Lin L, Guan L, Wu W, Chen R. Correlation of surface respiratory electromyography with esophageal diaphragm electromyography. Respir Physiol Neurobiol. 2019;259:45–52.PubMedCrossRef
19.
Dres M, Dube BP, Goligher EC, Vorona S, Demiri S, Brochard LJ, Similowsky T, Demoule A. Intercostal muscle ultrasound: a feasibility and physiological study in mechanically ventilated patients [abstract]. Am J Respir Crit Care Med. 2018;197:A5863.
20.
Oppersma E, Doorduin J, van der Heijden EHRM, van der Hoeven JG, Heunks LMA. Noninvasive ventilation and the upper airway: should we pay more attention? Crit Care. 2013;17(245):1–7.
21.
Strohl KPHMJ, Hallett M, Saunders NA, Ingram RH Jr. Activation of upper airway muscles before onset of inspiration in normal humans. J Appl Physiol. 1980;49:638–42.PubMedCrossRef
22.
Saboisky JP, Jordan AS, Eckert DJ, White DP, Trinder JA, Nicholas CL, et al. Recruitment and rate-coding strategies of the human genioglossus muscle. J Appl Physiol. 2010;109(6):1939–49.PubMedPubMedCentralCrossRef
23.
Hudson AL, Butler JE, Gandevia SC, De Troyer A. Interplay between the inspiratory and postural functions of the human parasternal intercostal muscles. J Neurophysiol. 2010;103(3):1622–9.PubMedCrossRef
24.
25.
Moore KL, Dalley AF, Agur AM. Chapter 8 Neck. Clinically oriented anatomy. 5th ed. 2006. p. 1052–78.
26.
Schmidt M, Kindler F, Gottfried SB, Raux M, Hug F, Similowski T, et al. Dyspnea and surface inspiratory electromyograms in mechanically ventilated patients. Intensive Care Med. 2013;39(8):1368–76.PubMedCrossRef
27.
Schmidt MCL, Hug F, Demoule A, Similowski T. Surface electromyogram of inspiratory muscles: a possible routine monitoring tool in the intensive care unit. Br J Anaesth. 2011;106:913–4.PubMedCrossRef
28.
Cecchini JSM, Demoule A, Similowski T. Increased diaphragmatic contribution to inspiratory effort during neurally adjusted ventilatory assistance versus pressure support. Anesthesiology. 2014;121:1028–36.PubMedCrossRef
29.
Doorduin J, Nollet JL, Roesthuis LH, van Hees HW, Brochard LJ, Sinderby CA, et al. Partial neuromuscular blockade during partial ventilatory support in sedated patients with high tidal volumes. Am J Respir Crit Care Med. 2017;195(8):1033–42.PubMedCrossRef
30.
Doorduin J, Roesthuis LH, Jansen D, van der Hoeven JG, van Hees HWH, Heunks LMA. Respiratory muscle effort during expiration in successful and failed weaning from mechanical ventilation. Anesthesiology. 2018;129(3):490–501.PubMedCrossRef
31.
Doorduin J, Sinderby CA, Beck J, van der Hoeven JG, Heunks LM. Assisted ventilation in patients with acute respiratory distress syndrome: lung-distending pressure and patient–ventilator interaction. Anesthesiology. 2015;123(1):181–90.PubMedCrossRef
32.
Doorduin J, Sinderby CA, Beck J, van der Hoeven JG, Heunks LMA. Automated patient–ventilator interaction analysis during neurally adjusted non-invasive ventilation and pressure support ventilation in chronic obstructive pulmonary disease. Crit Care. 2014;18(5):550–7.PubMedPubMedCentralCrossRef
33.
Beck J, Gottfried SB, Navalesi P, Skrobik Y, Comtois N, Rossini M, et al. Electrical activity of the diaphragm during pressure support ventilation in acute respiratory failure. Am J Respir Crit Care Med. 2001;164(3):419–24.PubMedCrossRef
34.
Parthasarathy S, Jubran A, Laghi F, Tobin MJ. Sternomastoid, rib cage, and expiratory muscle activity during weaning failure. J Appl Physiol. 2007;103(1):140–7.PubMedCrossRef
35.
Falla DDAP, Rainoldi A, Merletti R, Jull G. Location of innervation zones of sternocleidomastoid and scalene muscles—a basis for clinical and research electromyography applications. Clin Neurophysiol. 2002;113:57–63.PubMedCrossRef
36.
Zhan C, Yeung LF, Yang Z. A wavelet-based adaptive filter for removing ECG interference in EMGdi signals. J Electromyogr Kinesiol. 2010;20(3):542–9.PubMedCrossRef
37.
Chiti L, Biondi G, Morelot-Panzini C, Raux M, Similowski T, Hug F. Scalene muscle activity during progressive inspiratory loading under pressure support ventilation in normal humans. Respir Physiol Neurobiol. 2008;164(3):441–8.PubMedCrossRef
38.
39.
Brochard LHA, Lorino H, Lemaire F. Inspiratory pressure support prevents diaphragmatic fatigue during weaning from mechanical ventilation. Am Rev Respir Dis. 1989;139:513–21.PubMedCrossRef
40.
Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory drive in critically ill patients: pathophysiology and clinical implications. Am J Respir Crit Care Med. 2019.
41.
Hug F, Raux M, Morelot-Panzini C, Similowski T. Surface EMG to assess and quantify upper airway dilators activity during non-invasive ventilation. Respir Physiol Neurobiol. 2011;178(2):341–5.PubMedCrossRef
42.
McKenzie DK, Butler JE, Gandevia SC. Respiratory muscle function and activation in chronic obstructive pulmonary disease. J Appl Physiol. 2009;107(2):621–9.PubMedCrossRef
43.
44.
Hudson AL, Gandevia SC, Butler JE. The effect of lung volume on the co-ordinated recruitment of scalene and sternomastoid muscles in humans. J Physiol. 2007;584(Pt 1):261–70.PubMedPubMedCentralCrossRef
45.
De Troyer AKPA, Wilson TA. Respiratory action of the intercostal muscles. Physiol Rev. 2005;85:717–56.PubMedCrossRef
46.
Saboisky JP, Gorman RB, De Troyer A, Gandevia SC, Butler JE. Differential activation among five human inspiratory motoneuron pools during tidal breathing. J Appl Physiol. 2007;102(2):772–80.PubMedCrossRef
47.
Hug F. Can muscle coordination be precisely studied by surface electromyography? J Electromyogr Kinesiol. 2011;21(1):1–12.PubMedCrossRef
Metadata
Title
Recruitment pattern of the diaphragm and extradiaphragmatic inspiratory muscles in response to different levels of pressure support
Authors
L. H. Roesthuis
J. G. van der Hoeven
H. W. H. van Hees
W.-J. M. Schellekens
J. Doorduin
L. M. A. Heunks
Publication date
01-12-2020
Publisher
Springer International Publishing
Keyword
Haloperidol
Published in
Annals of Intensive Care / Issue 1/2020
Electronic ISSN: 2110-5820
DOI
https://doi.org/10.1186/s13613-020-00684-6

Other articles of this Issue 1/2020

Annals of Intensive Care 1/2020 Go to the issue

Research

Multidisciplinary team approach in acute myocardial infarction patients undergoing veno-arterial extracorporeal membrane oxygenation

Letter to the Editor Response

Natural light exposure and delirium in ICU: does the dark side cloud everything?

Research

Rescue therapy with inhaled nitric oxide and almitrine in COVID-19 patients with severe acute respiratory distress syndrome

Letter to the Editor

Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province

Research

Ultrasound guidance and risk for intravascular catheter-related infections among peripheral arterial catheters: a post-hoc analysis of two large randomized-controlled trials

Letter to the Editor

Critically ill SARS-CoV-2-infected patients are not stratified as sepsis by the qSOFA