Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients

Aurelien Flatres, Yassir Aarab, Stephanie Nougaret, Fanny Garnier, Romaric Larcher, Mathieu Amalric, Kada Klouche, Pascal Etienne, Gilles Subra, Samir Jaber, Nicolas Molinari, Stefan Matecki, Boris Jung, Aurelien Flatres, Yassir Aarab, Stephanie Nougaret, Fanny Garnier, Romaric Larcher, Mathieu Amalric, Kada Klouche, Pascal Etienne, Gilles Subra, Samir Jaber, Nicolas Molinari, Stefan Matecki, Boris Jung

Abstract

Background: Muscle weakness following critical illness is the consequence of loss of muscle mass and alteration of muscle quality. It is associated with long-term disability. Ultrasonography is a reliable tool to quantify muscle mass, but studies that evaluate muscle quality at the critically ill bedside are lacking. Shear wave ultrasound elastography (SWE) provides spatial representation of soft tissue stiffness and measures of muscle quality. The reliability and reproducibility of SWE in critically ill patients has never been evaluated.

Methods: Two operators tested in healthy controls and in critically ill patients the intra- and inter-operator reliability of the SWE using transversal and longitudinal views of the diaphragm and limb muscles. Reliability was calculated using the intra-class correlation coefficient and a bootstrap sampling method assessed their consistency.

Results: We collected 560 images. Longitudinal views of the diaphragm (ICC 0.83 [0.50-0.94]), the biceps brachii (ICC 0.88 [0.67-0.96]) and the rectus femoris (ICC 0.76 [0.34-0.91]) were the most reliable views in a training set of healthy controls. Intra-class correlation coefficient for inter-operator reproducibility and intra-operator reliability was above 0.9 for all muscles in a validation set of healthy controls. In critically ill patients, inter-operator reproducibility and intra-operator 1 and 2 reliability ICCs were respectively 0.92 [0.71-0.98], 0.93 [0.82-0.98] and 0.92 [0.81-0.98] for the diaphragm; 0.96 [0.86-0.99], 0.98 [0.94-0.99] and 0.99 [0.96-1] for the biceps brachii and 0.91 [0.51-0.98], 0.97 [0.93-0.99] and 0.99 [0.97-1] for the rectus femoris. The probability to reach intra-class correlation coefficient greater than 0.8 in a 10,000 bootstrap sampling for inter-operator reproducibility was respectively 81%, 84% and 78% for the diaphragm, the biceps brachii and the rectus femoris respectively.

Conclusions: SWE is a reliable technique to evaluate limb muscles and the diaphragm in both healthy controls and in critically ill patients.

Trial registration: The study was registered (ClinicalTrial NCT03550222).

Keywords: Cachexia; Diaphragmatic dysfunction; Intensive care unit acquired weakness; Sonoelastography.

Conflict of interest statement

The ultrasound equipment Aixplorer was made available for the study by SuperSonic Imagine S.A. (Aix-en-Provence, France). The SuperSonic company did not have any access to the study’s design, the results and the manuscript editing. The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
a–c Illustration showing the placement of the ultrasound probe
Fig. 2
Fig. 2
Representative elastograms for a diaphragm, b biceps brachii and c rectus femoris
Fig. 3
Fig. 3
Bland-Altman plot of the difference of shear modulus between operators in healthy subjects
Fig. 4
Fig. 4
Bland-Altman plot of the difference of shear modulus between operators in critical ill patients

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