Relationships between double cycling and inspiratory effort with diaphragm thickness during the early phase of mechanical ventilation: A prospective observational study

Abstract

Background Increased and decreased diaphragm thickness during mechanical ventilation is associated with poor outcomes. Some types of patient-ventilator asynchrony theoretically cause myotrauma of the diaphragm. However, the effects of double cycling on structural changes in the diaphragm have not been previously evaluated. Hence, this study aimed to investigate the relationship between double cycling during the early phase of mechanical ventilation and changes in diaphragm thickness, and the involvement of inspiratory effort in the occurrence of double cycling. Methods We evaluated adult patients receiving invasive mechanical ventilation for more than 48 h. The end-expiratory diaphragm thickness (Tdiee) was assessed via ultrasonography on days 1, 2, 3, 5 and 7 after the initiation of mechanical ventilation. Then, the maximum rate of change from day 1 (ΔTdiee%) was evaluated. Concurrently, we recorded esophageal pressure and airway pressure on days 1, 2 and 3 for 1 h during spontaneous breathing. Then, the waveforms were retrospectively analyzed to calculate the incidence of double cycling (double cycling index) and inspiratory esophageal pressure swing (ΔPes). Finally, the correlation between double cycling index as well as ΔPes and ΔTdiee% was investigated using linear regression models. Results In total, 19 patients with a median age of 69 (interquartile range: 65–78) years were enrolled in this study, and all received pressure assist-control ventilation. The Tdiee increased by more than 10% from baseline in nine patients, decreased by more than 10% in nine and remained unchanged in one. The double cycling indexes on days 1, 2 and 3 were 2.2%, 1.3% and 4.5%, respectively. There was a linear correlation between the double cycling index on day 3 and ΔTdiee% (R2 = 0.446, p = 0.002). The double cycling index was correlated with the ΔPes on days 2 (R2 = 0.319, p = 0.004) and 3 (R2 = 0.635, p < 0.001). Conclusions Double cycling on the third day of mechanical ventilation was associated with strong inspiratory efforts and, possibly, changes in diaphragm thickness.

Diaphragm-protective mechanical ventilation in acute respiratory failure

“…Monitoring of Pes and EAdi has advantages for diaphragm-protective mechanical ventilation in terms of both detection of asynchronous events and evaluation of inspiratory effort. In our prospective study (70), double triggering on the third day of mechanical ventilation was associated with strong inspiratory effort and may increase diaphragm thickness. Hence, the incidence of double triggering, which is the most lung-injurious asynchrony (71), may function as a surrogate indicator of a diaphragm-injurious breathing pattern.…”

Flow starvation during square-flow assisted ventilation detected by supervised deep learning techniques

“…Flow starvation leads to an additional load on patients and an elevated energy consumption by the respiratory muscles that can cause patient self-inflicted lung injury and concentric load-induced diaphragm injury [ 4 , 5 ] due to increased transpulmonary pressures, lung strain and stress. Moreover, insufficient airflow produces dyspnea, particularly air hunger which is the most distressing type of dyspnea [ 6 ], and could induce harmful asynchronies like double triggering [ 7 , 8 ]. Air hunger and dyspnea cause patient discomfort, increase anxiety, often leading to higher sedative doses, promoting delirium, and increased duration of IMV, intensive care unit (ICU) and hospital stay [ 9 , 10 ].…”