Change in diaphragm and intercostal muscle thickness in mechanically ventilated patients: a prospective observational ultrasonography study

Nobuto Nakanishi, Jun Oto, Yoshitoyo Ueno, Emiko Nakataki, Taiga Itagaki, Masaji Nishimura, Nobuto Nakanishi, Jun Oto, Yoshitoyo Ueno, Emiko Nakataki, Taiga Itagaki, Masaji Nishimura

Abstract

Background: Diaphragm atrophy is observed in mechanically ventilated patients. However, the atrophy is not investigated in other respiratory muscles. Therefore, we conducted a two-center prospective observational study to evaluate changes in diaphragm and intercostal muscle thickness in mechanically ventilated patients.

Methods: Consecutive adult patients who were expected to be mechanically ventilated longer than 48 h in the ICU were enrolled. Diaphragm and intercostal muscle thickness were measured on days 1, 3, 5, and 7 with ultrasonography. The primary outcome was the direction of change in muscle thickness, and the secondary outcomes were the relationship of changes in muscle thickness with patient characteristics.

Results: Eighty patients (54 males and 26 females; mean age, 68 ± 14 years) were enrolled. Diaphragm muscle thickness decreased, increased, and remained unchanged in 50 (63%), 15 (19%), and 15 (19%) patients, respectively. Intercostal muscle thickness decreased, increased, and remained unchanged in 48 (60%), 15 (19%), and 17 (21%) patients, respectively. Decreased diaphragm or intercostal muscle thickness was associated with prolonged mechanical ventilation (median difference (MD), 3 days; 95% CI (confidence interval), 1-7 and MD, 3 days; 95% CI, 1-7, respectively) and length of ICU stay (MD, 3 days; 95% CI, 1-7 and MD, 3 days; 95% CI, 1-7, respectively) compared with the unchanged group. After adjusting for sex, age, and APACHE II score, they were still associated with prolonged mechanical ventilation (hazard ratio (HR), 4.19; 95% CI, 2.14-7.93 and HR, 2.87; 95% CI, 1.53-5.21, respectively) and length of ICU stay (HR, 3.44; 95% CI, 1.77-6.45 and HR, 2.58; 95% CI, 1.39-4.63, respectively) compared with the unchanged group.

Conclusions: Decreased diaphragm and intercostal muscle thickness were frequently seen in patients under mechanical ventilation. They were associated with prolonged mechanical ventilation and length of ICU stay.

Trial registration: UMIN000031316. Registered on 15 February 2018.

Keywords: Atrophy; Diaphragm; Intercostal muscle; Ultrasonography.

Conflict of interest statement

Competing interestsThe authors declare that they have no competing interests

© The Author(s). 2019.

Figures

Fig. 1
Fig. 1
Time course of the diaphragm and intercostal muscle thickness. Time course for the measurement of the diaphragm and intercostal muscle thickness over the first 7 days of mechanical ventilation. The horizontal line represents the time from admission to the intensive care unit (ICU), and the vertical line represents the change in diaphragm and intercostal muscle thickness. Solid lines represent the changes in diaphragm muscle thickness, and dotted lines represent the changes in intercostal muscle thickness. Data are expressed as means and 95% confidence intervals
Fig. 2
Fig. 2
The relationship of changes in muscle thickness between the diaphragm and the intercostal muscles. Among groups stratified according to changes in diaphragm thickness, the percentages of patients with decreased, increased, or unchanged intercostal muscle thickness are shown by a bar graph. Numbers indicate the number of patients in each group. Changes in diaphragm and intercostal muscles thickness were associated with a kappa value 0.28 (95% confidence interval, 0.14–0.41, p < 0.001), suggesting a poor association
Fig. 3
Fig. 3
Cumulative incidence of liberation from mechanical ventilation by diaphragm or intercostal muscle thickness changes during the first week. Data were compared using Gray’s test with Bonferroni correction for two pairwise comparisons (significant at p < 0.025 vs. unchanged group). Death was treated as a competing risk. The horizontal line represents the time from admission to the intensive care unit (ICU), and the vertical line represents the cumulative incidence of liberation from mechanical ventilation. a Diaphragm: compared with unchanged, those with decreased or increased diaphragm thickness had a lower cumulative incidence of liberation from mechanical ventilation (p < 0.01 in both group). b Intercostal muscle: compared with unchanged, those with decreased diaphragm thickness had a lower cumulative incidence of liberation from mechanical ventilation (p = 0.018). VS, versus. *Significant at < 0.025 vs. unchanged group by Bonferroni correction

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