Respiratory weakness after mechanical ventilation is associated with one-year mortality - a prospective study

Clément Medrinal, Guillaume Prieur, Éric Frenoy, Aurora Robledo Quesada, Antoine Poncet, Tristan Bonnevie, Francis-Edouard Gravier, Bouchra Lamia, Olivier Contal, Clément Medrinal, Guillaume Prieur, Éric Frenoy, Aurora Robledo Quesada, Antoine Poncet, Tristan Bonnevie, Francis-Edouard Gravier, Bouchra Lamia, Olivier Contal

Abstract

Background: Diaphragm dysfunction in mechanically ventilated patients is associated with poor outcome. Maximal inspiratory pressure (MIP) can be used to evaluate inspiratory muscle function. However, it is unclear whether respiratory weakness is independently associated with long-term mortality. The aim of this study was to determine if low MIP is independently associated with one-year mortality.

Methods: We conducted a prospective observational cohort study in an 18-bed ICU. Adults requiring at least 24 hours of mechanical ventilation with scheduled extubation and no evidence of pre-existing muscle weakness underwent MIP evaluation just before extubation. Patients were divided into two groups: low MIP (MIP ≤30 cmH2O) and high MIP (MIP >30 cmH2O). Mortality was recorded for one year after extubation. For the survival analysis, the effect of low MIP was assessed using the log-rank test. The independent effect of low MIP on post mechanical ventilation mortality was analyzed using a multivariable Cox regression model.

Results: One hundred and twenty-four patients underwent MIP evaluation (median age 66 years (25(th)-75(th) percentile 56-74), Simplified Acute Physiology Score (SAPS) 2 = 45 (33-57), duration of mechanical ventilation 7 days (4-10)). Fifty-four percent of patients had low MIP. One-year mortality was 31 % (95 % CI 0.21, 0.43) in the low MIP group and 7 % (95 % CI 0.02, 0.16) in the high MIP group. After adjustment for SAPS 2 score, body mass index and duration of mechanical ventilation, low MIP was independently associated with one-year mortality (hazard ratio 4.41, 95 % CI 1.5, 12.9, p = 0.007). Extubation failure was also associated with low MIP (relative risk 3.0, 95 % CI 1, -9.6; p = 0.03) but tracheostomy and ICU length of stay were not.

Conclusion: Low MIP is frequent in patients on mechanical ventilation and is an independent risk factor for long-term mortality in ICU patients requiring mechanical ventilation. MIP is easily evaluated at the patient's bedside.

Trial registration: This study was retrospectively registered in www.clinicaltrials.gov (NCT02363231) in February 2015.

Keywords: Diaphragm; ICU; Maximal inspiratory pressure; Mechanical ventilation; Mortality.

Figures

Fig. 1
Fig. 1
Flow chart. MIP maximal inspiratory pressure, SBT spontaneous breathing trial
Fig. 2
Fig. 2
Significant difference between survival curves, based on the log-rank test (p < 0.001). Proposition: difference between survival curves (log-rank test (p < 0.001)). MIP maximal inspiratory pressure

References

    1. Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med. 2000;161(5):1450–8. doi: 10.1164/ajrccm.161.5.9902018.
    1. Vassilakopoulos T, Petrof BJ. Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med. 2004;169(3):336–41. doi: 10.1164/rccm.200304-489CP.
    1. Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008;358(13):1327–35. doi: 10.1056/NEJMoa070447.
    1. Jaber S, Petrof BJ, Jung B, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med. 2011;183(3):364–71. doi: 10.1164/rccm.201004-0670OC.
    1. Powers SK, Kavazis AN, Levine S. Prolonged mechanical ventilation alters diaphragmatic structure and function. Crit Care Med. 2009;37(10 suppl):S347–353. doi: 10.1097/CCM.0b013e3181b6e760.
    1. Shanely RA, Van Gammeren D, Deruisseau KC, et al. Mechanical ventilation depresses protein synthesis in the rat diaphragm. Am J Respir Crit Care Med. 2004;170(9):994–9. doi: 10.1164/rccm.200304-575OC.
    1. Hermans G, Agten A, Testelmans D, Decramer M, Gayan-Ramirez G. Increased duration of mechanical ventilation is associated with decreased diaphragmatic force: A prospective observational study. Crit Care. 2010;14(4):R127. doi: 10.1186/cc9094.
    1. Demoule A, Jung B, Prodanovic H, et al. Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact-a prospective study. Am J Respir Crit Care Med. 2013;188(2):213–9. doi: 10.1164/rccm.201209-1668OC.
    1. Supinski GS, Callahan LA. Diaphragm weakness in mechanically ventilated critically ill patients. Crit Care. 2013;17(3):R120. doi: 10.1186/cc12792.
    1. De Jonghe B, Bastuji-Garin S, Durand MC, et al. Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med. 2007;35(9):2007–15. doi: 10.1097/01.ccm.0000281450.01881.d8.
    1. Conti G, Montini L, Pennisi MA, et al. A prospective, blinded evaluation of indexes proposed to predict weaning from mechanical ventilation. Intensive Care Med. 2004;30(5):830–6. doi: 10.1007/s00134-004-2230-8.
    1. Nemer SN, Barbas CS, Caldeira JB, et al. Evaluation of maximal inspiratory pressure, tracheal airway occlusion pressure, and its ratio in the weaning outcome. J Crit Care. 2009;24(3):441–6. doi: 10.1016/j.jcrc.2009.01.007.
    1. Savi A, Teixeira C, Silva JM, et al. Weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care. 2012;27(2):221. doi: 10.1016/j.jcrc.2011.07.079.
    1. Katz S, Akpom CA. Ameasure of primary sociobiological functions. Int J Health Serv. 1976;6(3):493–508. doi: 10.2190/UURL-2RYU-WRYD-EY3K.
    1. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033–56. doi: 10.1183/09031936.00010206.
    1. Caruso P, Friedrich C, Denari SD, Ruiz SA, Deheinzelin D. The unidirectional valve is the best method to determine maximal inspiratory pressure during weaning. Chest. 1999;115(4):1096–101. doi: 10.1378/chest.115.4.1096.
    1. American Thoracic Society/European Thoracic Society ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med. 2002;166(4):518–624. doi: 10.1164/rccm.166.4.518.
    1. Supinski GS, Westgate P, Callahan LA. Correlation of inspiratory pressure to transdiaphragmatic twitch pressure in intensive care unit patients. Crit Care. 2016;20:77. doi: 10.1186/s13054-016-1247-z.
    1. Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, Similowski T, Demoule A. Coexistence and impact of limb muscle and diaphragm weakness at time of liberation from mechanical ventilation in medical ICU patients. Am J Respir Crit Care Med. 2016; (in press).
    1. Thomas D, Maes K, Agten A, et al. Time course of diaphragm function recovery after controlled mechanical ventilation in rats. J Appl Physiol (1985) 2013;115(6):775–84. doi: 10.1152/japplphysiol.00302.2012.
    1. Bruells CS, Bergs I, Rossaint R, et al. Recovery of diaphragm function following mechanical ventilation in a rodent model. PLoS One. 2014;9(1):e87460. doi: 10.1371/journal.pone.0087460.
    1. Abhyankar S, Leishear K, Callaghan FM, Demner-Fushman D, McDonald CJ. Lower short- and long-term mortality associated with overweight and obesity in a large cohort study of adult intensive care unit patients. Crit Care. 2012;16(6):R235. doi: 10.1186/cc11903.

Source: PubMed

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