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

Abstract

BackgroundUltrasound (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).MethodsA 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.ResultsDD+ 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).ConclusionsEarly 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.

Evaluation of Respiratory Muscle Strength and Diaphragm Ultrasound: Normative Values, Theoretical Considerations, and Practical Recommendations

“…These include patients with neuromuscular disorders [2] and, more recently, patients with heart failure [8]. In addition, diaphragm ultrasound has been applied in chronic pulmonary disease [9][10][11], and ultrasound measures of diaphragmatic dysfunction have been shown to correlate with morbidity and poor prognosis in mechanically ventilated patients and in patients with chronic obstructive pulmonary disease (COPD) [12][13][14].…”

Zwerchfell-Ultraschall durchführen und interpretieren – Schritt für Schritt

“…Chancen Die prognostische Relevanz der hier dargestellten und aus der Zwerchfell-Ultraschalluntersuchung abgeleiteten Marker konnte u. a. bei Patienten mit COPD (für Exazerbationen und den Bedarf einer Beatmungspflichtigkeit in der Zukunft sowie "Weaning Outcome" [6,7]) und neuromuskulären Erkrankungen (für den Bedarf einer Beatmungspflichtigkeit [8,9]) gezeigt werden. Die Funktion des Zwerchfells als maßgeb-lichem inspiratorischem Atemmuskel (das ca.…”

“…bei funktioneller Residualkapazität wurde eine enge Assoziation zur echten anatomischen Dicke nachgewiesen [8]. Eine sonografisch erfasste Zwerchfellatrophie (< 1,5 mm bei Männern und < 1,3 mm bei Frauen) prädiziert bei auf der Intensivstation beatmeten Patienten ein erschwertes Weaning und ein schlechteres Outcome [6]…”

Utility and validity of dynamic chest radiography in cystic fibrosis (dynamic CF): an observational, non-controlled, non-randomised, single-centre, prospective study

“…Diaphragmatic motion can be directly assessed by ultrasound, traditional fluoroscopy and MRI fluoroscopy. While ultrasound shows promise in areas such as weaning from mechanical ventilation 21 and predicting recovery from non-invasive ventilation in COPD, 22 or assessing the presence of diaphragm dysfunction during exacerbations of COPD, 23 it requires skilled technicians and is not in widespread clinical use for assessing non-ventilated individuals. MRI fluoroscopy has shown correlation between diaphragmatic movement with FEV 1 in people with COPD, 24 but it is both time-consuming and resourceconsuming to perform.…”