Acute and Critical Care

Original Articles

Pulmonary
Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India: Nupur B Patel, Gaurav Jain, Udit Chauhan, Ajeet Singh Bhadoria, Saurabh Chandrakar, Haritha Indulekha; Acute Crit Care. 2023;38(2):200-208. Published online May 25, 2023; DOI: https://doi.org/10.4266/acc.2022.01060

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Abstract PDF: Background
Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. Methods: In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. Results: In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. Conclusions: The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Pulmonary
The role of diaphragmatic thickness measurement in weaning prediction and its comparison with rapid shallow breathing index: a single-center experience: Lokesh Kumar Lalwani, Manjunath B Govindagoudar, Pawan Kumar Singh, Mukesh Sharma, Dhruva Chaudhry; Acute Crit Care. 2022;37(3):347-354. Published online July 25, 2022; DOI: https://doi.org/10.4266/acc.2022.00108

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Abstract PDF Supplementary Material: Background
Acute respiratory failure (ARF) is commonly managed with invasive mechanical ventilation (IMV). The majority of the time that a patient spends on IMV is in the process of weaning. Prediction of the weaning outcome is of paramount importance, as untimely/delayed extubation is associated with a high risk of mortality. Diaphragmatic ultrasonography is a promising tool in the intensive care unit, and its utility in predicting the success of weaning remains understudied.
Methods
In this prospective-observational study, we recruited 54 ARF patients on IMV, along with 50 healthy controls. During a spontaneous breathing trial, all subjects underwent diaphragmatic ultrasonography along with a rapid shallow breathing index (RSBI) assessment.
Results
The mean age was 41.8±17.0 and 37.6±10.5 years among the cases and control group, respectively. Demographic variables were broadly similar in the two groups. The most common cause of ARF was obstructive airway disease. The average duration of IMV was 5.41±2.81 days. Out of 54 subjects, 45 were successfully weaned, while nine patients failed weaning. Age, body mass index, and severity of disease were similar in the successful and failed weaning patients. The sensitivity in predicting successful weaning of percent change in diaphragmatic thickness (Δtdi%) >29.71% was high (93.33%), while specificity was 66.67%. The sensitivity and specificity of mean diaphragmatic thickness (tdi) end-expiratory >0.178 cm was 60.00% and 77.78%, respectively. RSBI at 1 minute of <93.75 had an equally high sensitivity (93.33%) but a lower specificity (22.22%). Similar results were also found for RSBI measured at 5 minutes.
Conclusions
During the weaning assessment, the purpose is to minimize both premature as well as delayed extubation. We found that diaphragmatic ultrasonography, in particular Δtdi%, is better than RSBI in predicting weaning outcomes.

Pulmonary
Diaphragm ultrasound as a better predictor of successful extubation from mechanical ventilation than rapid shallow breathing index: Mohammad Jhahidul Alam, Simanta Roy, Mohammad Azmain Iktidar, Fahmida Khatun Padma, Khairul Islam Nipun, Sreshtha Chowdhury, Ranjan Kumar Nath, Harun-Or Rashid; Acute Crit Care. 2022;37(1):94-100. Published online January 11, 2022; DOI: https://doi.org/10.4266/acc.2021.01354

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9 Citations

Abstract PDF

Background
In 3%–19% of patients, reintubation is needed 48–72 hours following extubation, which increases intensive care unit (ICU) morbidity, mortality, and expenses. Extubation failure is frequently caused by diaphragm dysfunction. Ultrasonography can be used to determine the mobility and thickness of the diaphragm. This study looked at the role of diaphragm excursion (DE) and thickening fraction in predicting successful extubation from mechanical ventilation.
Methods
Thirty-one patients were extubated with the advice of an ICU consultant using the ICU weaning regimen and diaphragm ultrasonography was performed. Ultrasound DE and thickening fraction were measured three times: at the commencement of the t-piece experiment, at 10 minutes, and immediately before extubation. All patients' parameters were monitored for 48 hours after extubation. Rapid shallow breathing index (RSBI) was also measured at the same time.
Results
Successful extubation was significantly correlated with DE (P=0.01). Receiver curve analysis for DE to predict successful extubation revealed good properties (area under the curve [AUC], 0.83; P<0.001); sensitivity, 77.8%; specificity, 84.6%, positive predictive value (PPV), 87.5%; negative predictive value (NPV), 73.3% while cut-off value, 11.43 mm. Diaphragm thickening fraction (DTF) also revealed moderate curve properties (AUC, 0.69; P=0.06); sensitivity, 61.1%; specificity, 84.6%; PPV, 87.5%; NPV, 61.1% with cut-off value 22.33% although former one was slightly better. RSBI could not reach good receiver operating characteristic value at cut-off points 100 b/min/L (AUC, 0.58; P=0.47); sensitivity, 66.7%; specificity, 53.8%; PPV, 66.7%; NPV, 53.8%).
Conclusions
To decrease the rate of reintubation, DE and DTF are better indicators of successful extubation. DE outperforms DTF.

Citations

Citations to this article as recorded by

Ultrasonographic Assessment of Diaphragmatic Function and Its Clinical Application in the Management of Patients with Acute Respiratory Failure
Marina Saad, Stefano Pini, Fiammetta Danzo, Francesca Mandurino Mirizzi, Carmine Arena, Francesco Tursi, Dejan Radovanovic, Pierachille Santus
Diagnostics.2023; 13(3): 411. CrossRef
The ratio of respiratory rate to diaphragm thickening fraction for predicting extubation success
Dararat Eksombatchai, Chalermwut Sukkratok, Yuda Sutherasan, Detajin Junhasavasdikul, Pongdhep Theerawit
BMC Pulmonary Medicine.2023;[Epub] CrossRef
Effectiveness of diaphragmatic ultrasound as a predictor of successful weaning from mechanical ventilation: a systematic review and meta-analysis
Henry M. Parada-Gereda, Adriana L. Tibaduiza, Alejandro Rico-Mendoza, Daniel Molano-Franco, Victor H. Nieto, Wanderley A. Arias-Ortiz, Purificación Perez-Terán, Joan R. Masclans
Critical Care.2023;[Epub] CrossRef
Role of diaphragm ultrasound in weaning mechanically ventilated patients: A prospective observational study
Ravi Saravanan, Krishnamurthy Nivedita, Krishnamoorthy Karthik, Rajagopalan Venkatraman
Indian Journal of Anaesthesia.2022; 66(8): 591. CrossRef
The role of diaphragmatic thickness measurement in weaning prediction and its comparison with rapid shallow breathing index: a single-center experience
Lokesh Kumar Lalwani, Manjunath B Govindagoudar, Pawan Kumar Singh, Mukesh Sharma, Dhruva Chaudhry
Acute and Critical Care.2022; 37(3): 347. CrossRef
Diaphragm ultrasound in weaning from mechanical ventilation: a last step to predict successful extubation?
Domenica Di Costanzo, Mariano Mazza, Antonio Esquinas
Acute and Critical Care.2022; 37(4): 681. CrossRef
Sonographic assessment of diaphragmatic thickening and excursion as predictors of weaning success in the intensive care unit: A prospective observational study
Amandeep Kaur, Shruti Sharma, VikramP Singh, MRavi Krishna, ParshotamL Gautam, Gagandeep Singh
Indian Journal of Anaesthesia.2022; 66(11): 776. CrossRef
Comparison of assessment of diaphragm function using speckle tracking between patients with successful and failed weaning: a multicentre, observational, pilot study
Qiancheng Xu, Xiao Yang, Yan Qian, Chang Hu, Weihua Lu, Shuhan Cai, Bo Hu, Jianguo Li
BMC Pulmonary Medicine.2022;[Epub] CrossRef
Ultrasonographic assessment of diaphragmatic function in preterm infants on non-invasive neurally adjusted ventilatory assist (NIV-NAVA) compared to nasal intermittent positive-pressure ventilation (NIPPV): a prospective observational study
Mohamed Elkhouli, Liran Tamir-Hostovsky, Jenna Ibrahim, Nehad Nasef, Adel Mohamed
European Journal of Pediatrics.2022; 182(2): 731. CrossRef

Case Reports

Cardiology/Pediatric
Extracorporeal Membrane Oxygenation Cannula Malposition in the Azygos Vein in a Neonate with Right-Sided Congenital Diaphragmatic Hernia: Seung Jun Choi, Chun-Soo Park, Won Kyoung Jhang, Seong Jong Park; Korean J Crit Care Med. 2016;31(2):152-155. Published online May 31, 2016; DOI: https://doi.org/10.4266/kjccm.2016.31.2.152

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4 Citations

Abstract PDF

Malposition of the extracorporeal membrane oxygenation (ECMO) venous cannula in the azygos vein is not frequently reported. We hereby present such a case, which occurred in a neonate with right-sided congenital diaphragmatic hernia. Despite ECMO application, neither adequate flow nor sufficient oxygenation was achieved. On the cross-table lateral chest radiograph, the cannula tip was identified posterior to the heart silhouette, which implied malposition of the cannula in the azygos vein. After repositioning the cannula, the target flow and oxygenation were successfully achieved. When sufficient venous flow is not achieved, as in our case, clinicians should be alerted so they can identify the cannula tip location on lateral chest radiograph and confirm whether malposition in the azygos vein is the cause of the ineffective ECMO.

Citations

Citations to this article as recorded by

Inadvertent cannulation of the azygos vein during eCPR
Shelina M. Jamal, Deborah S. Fruitman, Kevin M. Lichtenstein, Darren H. Freed, Natalie L. Yanchar
Journal of Pediatric Surgery Case Reports.2021; 71: 101941. CrossRef
Identification of Inadvertent Azygous Vein Cannulation Using Transthoracic Echocardiography During Venoarterial Extracorporeal Membrane Oxygenation Initiation
Bethany G. Runkel, Jason D. Fraser, John M. Daniel, Karina M. Carlson
CASE.2019; 3(2): 67. CrossRef
Successful Extracorporeal Membrane Oxygenation After Incidental Azygos Vein Cannulation in a Neonate With Right-Sided Congenital Diaphragmatic Hernia Interruption of the Inferior Vena Cava and Azygos Continuation
Alessandra Mayer, Genny Raffaeli, Federico Schena, Valeria Parente, Gabriele Sorrentino, Francesco Macchini, Anna Maria Colli, Lucia Mauri, Simona Neri, Irene Borzani, Ernesto Leva, Fabio Mosca, Giacomo Cavallaro
Frontiers in Pediatrics.2019;[Epub] CrossRef
The Future of Research on Extracorporeal Membrane Oxygenation (ECMO)
Ji Young Lee
Korean Journal of Critical Care Medicine.2016; 31(2): 73. CrossRef

A Chronic Traumatic Diaphragmatic Hernia Presenting 36 Years after Preceding Injury: A Case Report: Kyung Hwa Kim, Ja Hong Kuh, Tae Yoon Kim; Korean J Crit Care Med. 2010;25(3):199-202.; DOI: https://doi.org/10.4266/kjccm.2010.25.3.199

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Abstract PDF: We report a distinctive case of a large traumatic diaphragmatic hernia (TDH) that presented 36-years after the preceding injury. We believe this case represents the most delayed (TDH) presentation ever reported in Korea. This paper describes the particular presentation, including the operative and postoperative management of this patient. We also review the management of long delayed TDH presentation and the postoperative issues concerning thoracic cavity dead space and propensity of the repaired diaphragm for developing abdominal compartment syndrome.

Original Articles

Development and Experimental Evaluation of Respiratory Assist Device by Use of Right Thoracic Negative Pressure Ventilation: Joong Hwan Oh, Sang Hun Lee, Hyun Kyo Lim, Young Hee Lee, Sung Hoon Kim; Korean J Crit Care Med. 2005;20(2):165-169.

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Abstract PDF: BACKGROUND
A diaphragm pacing with electrical stimulation is a new respiratory assist device which has advantages over mechanical ventilation. Unilateral phrenic nerve stimulation makes uneven distribution of intrathoracic negative pressure and most likely relates to paradoxical motion of the diaphragm. Our purpose is to investigate a respiratory effect of right phrenic nerve pacing after thoracotomy compared with bilateral pacing. METHODS: Five dogs were examined under the general anesthesia. Right 5th intercostal space was opened. Two pacing leads were placed around the phrenic nerve and connected to the stimulator. Chest wall was closed after chest tube insertion. Ventilator was off without self respiration. Swan-Ganz catheter was introduced to the pulmonary artery, cardiac output, central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP). Arterial blood gases (PO2 & PCO2), end-tidal PCO2 (PETCO2) and tidal volume were measured with nerve stimulation. Left phrenic nerve was managed as the same manner. RESULTS: Right phrenic nerve pacing resulted in a tidal volume of 186+/-5 ml, PETCO2 of 55.0+/-2.3 mmHg, Arterial PO2 of 115+/-12 mmHg, PCO2 of 59+/-4 mmHg, Cardiac output of 2.3+/-0.5 L/min, CVP of 12.0+/-2.3 mmHg, PCWP of 14.2+/-2.5 mmHg. Bilateral phrenic nerve pacing resulted in a tidal volume of 418+/-3 ml, PETCO2 of 47.0+/-2.7 mmHg, PO2 of 289+/-10 mmHg, PCO2 of 42+/-3 mmHg, Cardiac output of 3.1+/-0.4 L/min, CVP of 10.2+/-2.5 mmHg, PCWP of 14.5+/-2.7 mmHg. Right phrenic nerve pacing showed significantly lower tidal volume, PO2 and higher PETCO2 and arterial blood PCO2 (p<0.05).
CONCLUSIONS
Right phrenic nerve pacing plays a role to develop respiratory assist. However the effect is less than the bilateral pacing.

Successful Weaning after Diaphragmatic Plication in an Infant with Phrenic Nerve Palsy Resulting from Removal of Cavernous Lymphangioma: Jang Ho Roh, Dong Woo Han, Shin Ok Koh, Yong Taek Nam; Korean J Crit Care Med. 2001;16(2):156-159.

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Abstract PDF: Phrenic nerve palsy is a well-known complication following cardiac surgery in children. The incidence is approximately 1~2%. In infants and young children, it often causes a life-threatening respiratory distress. They must be treated with mechanical ventilation in the ICU. Many patients with phrenic nerve injury who is impossible to wean from a ventilator are candidates of diaphragmatic plication. Diaphragmatic plication is performed to restore the normal pulmonary parenchymal volume by replacing the diaphragm to its proper location. This is a case of 2-months-old infant who had phrenic nerve palsy after the removal of cavernous lymphangioma of the chest. He underwent 4 operations to remove the mass and to have pericardiotomy. We tried to wean him from the ventilator but failed several times in the ICU. After 4th operation, right diaphragmatic elevation was noted from the chest X ray. Phrenic nerve palsy was confirmed with fluoroscopy and he underwent diaphragmatic plication on 42 days after his 4th operation. Three days after the diaphragmatic plication, weaning was successfully carried out.

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