Duration of diaphragmatic inactivity after endotracheal intubation of critically ill patients

Michael Chaim Sklar, Fabiana Madotto, Annemijn Jonkman, Michela Rauseo, Ibrahim Soliman, L Felipe Damiani, Irene Telias, Sebastian Dubo, Lu Chen, Nuttapol Rittayamai, Guang-Qiang Chen, Ewan C Goligher, Martin Dres, Remi Coudroy, Tai Pham, Ricard M Artigas, Jan O Friedrich, Christer Sinderby, Leo Heunks, Laurent Brochard, Michael Chaim Sklar, Fabiana Madotto, Annemijn Jonkman, Michela Rauseo, Ibrahim Soliman, L Felipe Damiani, Irene Telias, Sebastian Dubo, Lu Chen, Nuttapol Rittayamai, Guang-Qiang Chen, Ewan C Goligher, Martin Dres, Remi Coudroy, Tai Pham, Ricard M Artigas, Jan O Friedrich, Christer Sinderby, Leo Heunks, Laurent Brochard

Abstract

Background: In patients intubated for mechanical ventilation, prolonged diaphragm inactivity could lead to weakness and poor outcome. Time to resume a minimal diaphragm activity may be related to sedation practice and patient severity.

Methods: Prospective observational study in critically ill patients. Diaphragm electrical activity (EAdi) was continuously recorded after intubation looking for resumption of a minimal level of diaphragm activity (beginning of the first 24 h period with median EAdi > 7 µV, a threshold based on literature and correlations with diaphragm thickening fraction). Recordings were collected until full spontaneous breathing, extubation, death or 120 h. A 1 h waveform recording was collected daily to identify reverse triggering.

Results: Seventy-five patients were enrolled and 69 analyzed (mean age ± standard deviation 63 ± 16 years). Reasons for ventilation were respiratory (55%), hemodynamic (19%) and neurologic (20%). Eight catheter disconnections occurred. The median time for resumption of EAdi was 22 h (interquartile range 0-50 h); 35/69 (51%) of patients resumed activity within 24 h while 4 had no recovery after 5 days. Late recovery was associated with use of sedative agents, cumulative doses of propofol and fentanyl, controlled ventilation and age (older patients receiving less sedation). Severity of illness, oxygenation, renal and hepatic function, reason for intubation were not associated with EAdi resumption. At least 20% of patients initiated EAdi with reverse triggering.

Conclusion: Low levels of diaphragm electrical activity are common in the early course of mechanical ventilation: 50% of patients do not recover diaphragmatic activity within one day. Sedatives are the main factors accounting for this delay independently from lung or general severity. Trial Registration ClinicalTrials.gov (NCT02434016). Registered on April 27, 2015. First patients enrolled June 2015.

Keywords: Critical care; Diaphragm; Electrical activity of the diaphragm; Mechanical ventilation; Sedation.

Conflict of interest statement

Laurent Brochard has indicated the following financial relationship: “LB's laboratory received research grants and/or equipment from Medtronic Covidien, Fisher Paykel, Philips, Sentec, Air Liquide and General Electric outside the scope of this study.” Irene Telias has indicated the following: "MBMed SA Argentina," "Covidien, Argentina," and "Canadian Institutes of Health Research". Ewan C. Goligher has indicated the following: "Getinge" and "Timpel". Ricard M. Artigas has indicated the following: "Medtronic". Leo Heunks has indicated the following: "Ventfree, USA" and "Getinge, Sweden". Christer Sinderby has indicated the following: Dr. Sinderby has made inventions related to neural control of mechanical ventilation that are patented. The patents are assigned to the academic institution(s) where inventions were made. The license for these patents belongs to Maquet Critical Care. Future commercial uses of this technology may provide financial benefit to Dr. Sinderby through royalties. Dr Sinderby owns 50% of Neurovent Research Inc (NVR). NVR is a research and development company that builds the equipment and catheters for research studies. NVR has a consulting agreement with Maquet Critical Care, which is a subsidiary of Getinge. Supported by the RS McLaughlin Foundation.

Figures

Fig. 1
Fig. 1
Flow chart of study population
Fig. 2
Fig. 2
Probability to have EAdi resumption during the study period (n = 69). Following intubation, the estimated mean time for resumption of a minimal EAdi was 35 h (standard error 5 h) and the estimated median (IQR) time was 22 (0–50) h. Note: probabilities were estimated with the Kaplan–Meier approach and patients with catheter disconnection were censored at time of EAdi catheter disconnection
Fig. 3
Fig. 3
Probability of EAdi resumption during the study period stratified according to: (1) the use of sedatives (a); (2) mode of ventilation at EAdi catheter connection (assisted, controlled) (b). Note: probabilities were estimated with the Kaplan–Meier approach and patients with catheter disconnection were censored at time of EAdi catheter disconnection
Fig. 4
Fig. 4
Probability of EAdi resumption during the study period stratified according to sedative drug: a propofol, b midazolam, c fentanyl

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Source: PubMed

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