Point of care diaphragm ultrasound in mechanically ventilated children: A predictive tool to detect extubation failure

Abstract

Background: Children should be weaned from the ventilator once their clinical condition improves. Extubation failure is associated with poorer clinical outcomes in children. Predictive indicators of successful extubation are needed. This study aims to evaluate the predictive value of ultrasonographic diaphragm imaging could help predict weaning success. Methods: In this prospective, observational study conducted between March and December 2021, children between 1 month and 10 years of age who were mechanically ventilated for more than 48 h were included. Diaphragm ultrasound (DUS) examinations were performed at the end of 2-h extubation readiness test (ERT). The end-inspiratory thickness (DTi), end-expiratory thickness (DTe), diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), inspiratory slope (IS), and expiratory slope (ES) were evaluated.Results: Twenty-four (60%) patients were successfully extubated, while 16 (40%) required invasive or noninvasive mechanical ventilation support which were classified as failed extubation group. Three of the sixteen patients in the failed extubation group required reintubation. DTF was significantly greater in the successful weaning group (55.05 ± 23.75% vs. 30.9 ± 10.38%) (p < 0.001). DE was significantly greater in the successful weaning group (14 ± 4.4 mm vs. 11.05 ± 3.25 mm) (p < 0.001). DTF and DE were found to have a sensitivity and specificity of 91.67%, 87.50%, 83.33%, and 81.25%, respectively. Conclusion:Diaphragm ultrasound is a feasible and promising tool to guide physicians during weaning from invasive mechanical ventilation. Among all DUS measurements, the DE and DTF indexes showed better performance in extubation failure than other diaphragmatic parameters.

Accuracy of lung and diaphragm ultrasound in predicting infant weaning outcomes: a systematic review and meta-analysis

“…The possibility of patient selection bias was mostly related to the fact that four studies included patients who were either eligible for weaning or planned to be weaned rather than patients who were randomly selected ( 21 , 24 , 25 , 29 ). Index test poses a risk since they do not clearly reveal whether the ultrasound was performed without knowledge of the clinical outcomes ( 21 , 23 , 27 , 28 , 31 ). Furthermore, the reference standard poses a danger due to the low success rate of clinical weaning events and the omission to identify whether clinical weaning decisions were taken without knowledge of ultrasound findings ( 22 , 27 , 28 , 29 , 30 , 31 ).…”

“…Index test poses a risk since they do not clearly reveal whether the ultrasound was performed without knowledge of the clinical outcomes ( 21 , 23 , 27 , 28 , 31 ). Furthermore, the reference standard poses a danger due to the low success rate of clinical weaning events and the omission to identify whether clinical weaning decisions were taken without knowledge of ultrasound findings ( 22 , 27 , 28 , 29 , 30 , 31 ). The Deeks' test revealed no substantial publication bias in LUS, DE, or DTF, with all P values more than 0.05 ( Supplementary Figure S1 ).…”

“…DE and DTF worked well in adult studies, with greatest predictive values of 10–15 mm and 20%–36%, respectively ( 42 ). Except for one study, where the DTF cut-off point was chosen at 40.50% because the patients studied were generally healthy ( 28 ), the DTF cut-off values in the included studies were similar to those in adults. However, the ideal cut-off for DE in the studies we considered was often less than 10 mm, significantly smaller than the adult figure, with the exception of Gazi et al ( 28 ), who used a cut-off of 12.15 mm.…”

Ultrasound assessment of diaphragm thickness, contractility, and strain in healthy pediatric patients

“…Ultrasound is a noninvasive technology which can be used to measure end‐expiratory diaphragm thickness 3–6 (Tdi‐exp) and contractility with high inter‐rater reliability in adults 6 and children 3 . Initial pediatric literature suggests that diaphragm ultrasound may be utilized to help predict the need for respiratory support, 7 noninvasive ventilation failure 8 in infants with bronchiolitis, and extubation success in mechanically ventilated children 9 …”

“…3 Initial pediatric literature suggests that diaphragm ultrasound may be utilized to help predict the need for respiratory support, 7 noninvasive ventilation failure 8 in infants with bronchiolitis, and extubation success in mechanically ventilated children. 9 Traditional ultrasound measurements of diaphragm contractility include diaphragm excursion (DE) and diaphragm thickening fraction (DTF). DE measures the diaphragm's downward displacement during inspiration, whereas DTF quantifies the proportion of change in muscle thickness between the resting state (Tdi-exp) and maximal inspiration (Tdi-insp).…”