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Critical Care
Published in: Critical Care 1/2018

Open Access 01-12-2018 | Research

Ultrasound-assessed diaphragmatic impairment is a predictor of outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease undergoing noninvasive ventilation

Authors: Alessandro Marchioni, Ivana Castaniere, Roberto Tonelli, Riccardo Fantini, Matteo Fontana, Luca Tabbì, Andrea Viani, Francesco Giaroni, Valentina Ruggieri, Stefania Cerri, Enrico Clini

Published in: Critical Care | Issue 1/2018

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Abstract

Background

Ultrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care. In this single-center prospective study, we investigated the impact of US-assessed DD on noninvasive ventilation (NIV) failure in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and its correlation with the transdiaphragmatic pressure assessed using the invasive sniff maneuver (Pdi sniff).

Methods

A population of 75 consecutive patients with AECOPD with hypercapnic acidosis admitted to our respiratory intensive care unit (RICU) were enrolled. Change in diaphragm thickness (ΔTdi) < 20% during tidal volume was the predefined cutoff for identifying DD+/− status. Correlations between ΔTdi < 20% NIV failure and other clinical outcomes were investigated. Correlation between ΔTdi and Pdi sniff values was analyzed in a subset of ten patients.

Results

DD+ patients had a higher risk for NIV failure than DD− patients (risk ratio, 4.4; p <  0.001), and this finding was significantly associated with higher RICU, in-hospital, and 90-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer RICU stay. Huge increases in NIV failure (HR, 6.2; p < 0.0001) and 90-day mortality (HR, 4.7; p = 0.008) in DD+ patients were found by Kaplan-Meier analysis. ΔTdi highly correlated with Pdi sniff (Pearson’s r = 0.81; p = 0.004). ΔTdi < 20% showed better accuracy in predicting NIV failure than baseline pH value and early change in both arterial blood pH and partial pressure of carbon dioxide following NIV start (AUCs 0.84 to DTdi < 20%, 0.51 to pH value at baseline, 0.56 to early change in arterial blood pH following NIV start, and 0.54 to early change in partical pressure of carbon dioxide following NIV start, respectively; p < 0.0001).

Conclusions

Early and noninvasive US assessment of DD during severe AECOPD is reliable and accurate in identifying patients at major risk for NIV failure and worse prognosis.
Literature
1.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available from: http://​goldcopd.​org/​.
2.
Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. 2003;326(7382):185.
3.
Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;117(5 Suppl 2):398S–401S.CrossRefPubMed
4.
Brochard L, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817–22.CrossRefPubMed
5.
Demoule A, et al. Benefits and risks of success or failure of noninvasive ventilation. Intensive Care Med. 2006;32(11):1756–65.CrossRefPubMed
6.
Unal O, et al. Evaluation of diaphragmatic movement with MR fluoroscopy in chronic obstructive pulmonary disease. Clin Imaging. 2000;24(6):347–50.CrossRefPubMed
7.
Gayan-Ramirez G, Decramer M. Mechanisms of striated muscle dysfunction during acute exacerbations of COPD. J Appl Physiol. 2013;114(9):1291–9.CrossRefPubMed
8.
De Troyer A, Wilson TA. Effect of acute inflation on the mechanics of the inspiratory muscles. J Appl Physiol. 2009;107:315–23.CrossRefPubMed
9.
Antenora F, et al. Prevalence and outcomes of diaphragmatic dysfunction assessed by ultrasound technology during acute exacerbation of chronic obstructive pulmonary disease: a pilot study. Respirology. 2017;22(2):338–44.CrossRefPubMed
10.
Davidson AC, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016;71(Suppl 2):ii1–35.CrossRefPubMed
11.
Dellinger RP, et al. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637.CrossRefPubMed
12.
Fantini R, Mandrioli J, Zona S, Antenora F, Iattoni A, Monelli M, Fini N, Tonelli R, Clini E, Marchioni A. Ultrasound assessment of diaphragmatic function in patients with amyotrophic lateral sclerosis. Respirology. 2016;21(5):932–8.CrossRefPubMed
13.
Ambrosino N, Foglio K, Rubini F, Clini E, Nava S, Vitacca M. Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax. 1995;50(7):755–7.CrossRefPubMedPubMedCentral
14.
Higgs BD, Behrakis PK, Bevan DR, Milic-Emili J. Measurement of pleural pressure with esophageal balloon in anesthetized humans. Anesthesiology. 1983;59(4):340–3.CrossRefPubMed
15.
Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J. A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis. 1982;126(5):788–91.PubMed
16.
Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary. Am J Respir Crit Care Med. 2017;195:557–82.CrossRefPubMed
17.
Similowski T, et al. Contractile properties of the human diaphragm during chronic hyperinflation. N Engl J Med. 1991;325:917–23.
18.
Bellamare F, et al. Effects of emphysema and lung volume reduction surgery on transdiaphragmatic pressure and diaphragm length. Chest. 2002;121:1898–910.
19.
Polkey MI, et al. Diaphragm strength in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1996;154:1310–7.
20.
Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med. 1997;155:906–15.
21.
Crul T, et al. Gene expression profiling in vastus lateralis muscle during an acute exacerbation of COPD. Cell Physiol Biochem. 2010;25:491–500.CrossRefPubMed
22.
Arthurton L, et al. Membrane glucocorticoid receptors are localised in the extracellular matrix and signal through the MAPK pathway in mammalian skeletal muscle fibres. J Physiol. 2015;593(12):2679–92.CrossRefPubMedPubMedCentral
23.
Maes K, et al. Effects of acute administration of corticosteroids during mechanical ventilation on rat diaphragm. Am J Respir Crit Care Med. 2008;178:1219–26.CrossRefPubMedPubMedCentral
24.
Dirks-Naylor AJ, Griffiths CL. Glucocorticoid-induced apoptosis and cellular mechanisms of myopathy. J Steroid Biochem Mol Biol. 2009;117:1–7.CrossRefPubMed
25.
Gottesman E, McCool ED. Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med. 1997;55:1734–9.
26.
27.
Orozco-Levi M, et al. Injury of the human diaphragm associated with exertion and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;164:1734–9.CrossRefPubMed
28.
Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627–30.CrossRefPubMed
29.
Seneff MG, et al. Hospital and 1- year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA. 1995;274(23):1852–7.
30.
Confalonieri M, Garuti G, Cattaruzza MS, Osborn JF, Antonelli M, Conti G, Kodric M, Resta O, Marchese S, Gregoretti C, Rossi A. Italian noninvasive positive pressure ventilation (NPPV) study group. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J. 2005;25(2):348–55.CrossRefPubMed
31.
Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355:1931–5.CrossRefPubMed
32.
Chandra D, Stamm JA, Taylor B, Ramos RM, Satterwhite L, Krishnan JA, Mannino D, Sciurba FC, Holguín F. Outcomes of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008. Am J Respir Crit Care Med. 2012;185(2):152–9.CrossRefPubMedPubMedCentral
33.
Khan J, et al. Early development of critical illness myopathy and neuropathy in patients with severe sepsis. Neurology. 2006;67(8):1421–5.CrossRefPubMed
Metadata
Title
Ultrasound-assessed diaphragmatic impairment is a predictor of outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease undergoing noninvasive ventilation
Authors
Alessandro Marchioni
Ivana Castaniere
Roberto Tonelli
Riccardo Fantini
Matteo Fontana
Luca Tabbì
Andrea Viani
Francesco Giaroni
Valentina Ruggieri
Stefania Cerri
Enrico Clini
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2018
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-018-2033-x

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