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

Alessandro Marchioni, Ivana Castaniere, Roberto Tonelli, Riccardo Fantini, Matteo Fontana, Luca Tabbì, Andrea Viani, Francesco Giaroni, Valentina Ruggieri, Stefania Cerri, Enrico Clini, Alessandro Marchioni, Ivana Castaniere, Roberto Tonelli, Riccardo Fantini, Matteo Fontana, Luca Tabbì, Andrea Viani, Francesco Giaroni, Valentina Ruggieri, Stefania Cerri, Enrico Clini

Abstract

Background: Ultrasound (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).

Methods: A 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.

Results: DD+ 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).

Conclusions: Early 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.

Keywords: Diaphragmatic dysfunction; Noninvasive ventilation; Respiratory failure; Transdiaphragmatic pressure; Ultrasound.

Conflict of interest statement

Ethics approval and consent to participate

Approval from the local ethics committee of Modena was obtained (registered protocol number 839/C.E.). Written informed consent to participate was obtained from all enrolled patients or from their relatives, when appropriate.

Consent for publication

Consent for publication was obtained from all patients enrolled or from their relatives, when appropriate.

Competing interests

The authors declare that they have no competing interests with regard to any organization or entity with a financial interest in competition with the subject matter or materials discussed in this publication.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Study population diagram. AECOPD, NIV Noninvasive ventilation, RICU, ILD Interstitial lung disease, IOT, DD, Pdi, US Ultrasound
Fig. 2
Fig. 2
ROC analysis comparing predictors for noninvasive ventilation (NIV) failure at baseline and within 2 hours after NIV was started. ΔTdi Change in diaphragm thickness
Fig. 3
Fig. 3
a Correlation between change in diaphragm thickness (ΔTdi) and transdiaphragmatic pressure capacity measured at maximal inspiration using the sniff maneuver (Pdi sniff). b Accuracy of ΔTdi and Pdi sniff in identifying patients with diaphragmatic dysfunction (DD)
Fig. 4
Fig. 4
a Change in diaphragm thickness (ΔTdi) values at ultrasound testing and transdiaphragmatic pressure capacity measured at maximal inspiration using the sniff maneuver (Pdi sniff) values in the subgroup of ten patients tested with esophageal and gastric balloons. b Distribution of patients with ΔTdi < 20% or > 20% according to Pdi sniff. NIV Noninvasive ventilation
Fig. 5
Fig. 5
Probability of fail noninvasive ventilation (NIV) failure (a) and death (b) within the first 48 hours after admission according to the presence (+)/absence (−) of diaphragmatic dysfunction (DD) as assessed by ultrasound

References

    1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available from: .
    1. Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. 2003;326(7382):185.
    1. Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;117(5 Suppl 2):398S–401S. doi: 10.1378/chest.117.5_suppl_2.398S.
    1. Brochard L, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817–822. doi: 10.1056/NEJM199509283331301.
    1. Demoule A, et al. Benefits and risks of success or failure of noninvasive ventilation. Intensive Care Med. 2006;32(11):1756–1765. doi: 10.1007/s00134-006-0324-1.
    1. Unal O, et al. Evaluation of diaphragmatic movement with MR fluoroscopy in chronic obstructive pulmonary disease. Clin Imaging. 2000;24(6):347–350. doi: 10.1016/S0899-7071(00)00245-X.
    1. Gayan-Ramirez G, Decramer M. Mechanisms of striated muscle dysfunction during acute exacerbations of COPD. J Appl Physiol. 2013;114(9):1291–9. doi: 10.1152/japplphysiol.00847.2012.
    1. De Troyer A, Wilson TA. Effect of acute inflation on the mechanics of the inspiratory muscles. J Appl Physiol. 2009;107:315–323. doi: 10.1152/japplphysiol.91472.2008.
    1. Antenora F, et al. Prevalence and outcomes of diaphragmatic dysfunction assessed by ultrasound technology during acute exacerbation of chronic obstructive pulmonary disease: a pilot study. Respirology. 2017;22(2):338–344. doi: 10.1111/resp.12916.
    1. Davidson AC, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016;71(Suppl 2):ii1–i35. doi: 10.1136/thoraxjnl-2015-208209.
    1. Dellinger RP, et al. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637. doi: 10.1097/CCM.0b013e31827e83af.
    1. Fantini R, Mandrioli J, Zona S, Antenora F, Iattoni A, Monelli M, Fini N, Tonelli R, Clini E, Marchioni A. Ultrasound assessment of diaphragmatic function in patients with amyotrophic lateral sclerosis. Respirology. 2016;21(5):932–938. doi: 10.1111/resp.12759.
    1. Ambrosino N, Foglio K, Rubini F, Clini E, Nava S, Vitacca M. Non-invasive mechanical ventilation in acute respiratory failure due to chronic obstructive pulmonary disease: correlates for success. Thorax. 1995;50(7):755–757. doi: 10.1136/thx.50.7.755.
    1. Higgs BD, Behrakis PK, Bevan DR, Milic-Emili J. Measurement of pleural pressure with esophageal balloon in anesthetized humans. Anesthesiology. 1983;59(4):340–343. doi: 10.1097/00000542-198310000-00012.
    1. Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J. A simple method for assessing the validity of the esophageal balloon technique. Am Rev Respir Dis. 1982;126(5):788–791.
    1. Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary. Am J Respir Crit Care Med. 2017;195:557–582. doi: 10.1164/rccm.201701-0218PP.
    1. Similowski T, et al. Contractile properties of the human diaphragm during chronic hyperinflation. N Engl J Med. 1991;325:917–23.
    1. Bellamare F, et al. Effects of emphysema and lung volume reduction surgery on transdiaphragmatic pressure and diaphragm length. Chest. 2002;121:1898–910.
    1. Polkey MI, et al. Diaphragm strength in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1996;154:1310–7.
    1. Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med. 1997;155:906–15.
    1. Crul T, et al. Gene expression profiling in vastus lateralis muscle during an acute exacerbation of COPD. Cell Physiol Biochem. 2010;25:491–500. doi: 10.1159/000303054.
    1. Arthurton L, et al. Membrane glucocorticoid receptors are localised in the extracellular matrix and signal through the MAPK pathway in mammalian skeletal muscle fibres. J Physiol. 2015;593(12):2679–2692. doi: 10.1113/JP270502.
    1. Maes K, et al. Effects of acute administration of corticosteroids during mechanical ventilation on rat diaphragm. Am J Respir Crit Care Med. 2008;178:1219–1226. doi: 10.1164/rccm.200702-296OC.
    1. Dirks-Naylor AJ, Griffiths CL. Glucocorticoid-induced apoptosis and cellular mechanisms of myopathy. J Steroid Biochem Mol Biol. 2009;117:1–7. doi: 10.1016/j.jsbmb.2009.05.014.
    1. Gottesman E, McCool ED. Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med. 1997;55:1734–1739.
    1. Baria MR, et al. B-mode ultrasound assessment of diaphragm structure and function in patients with COPD. Chest. 2014;146(3):680–685. doi: 10.1378/chest.13-2306.
    1. Orozco-Levi M, et al. Injury of the human diaphragm associated with exertion and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;164:1734–1739. doi: 10.1164/ajrccm.164.9.2011150.
    1. Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627–2630. doi: 10.1097/CCM.0b013e3182266408.
    1. Seneff MG, et al. Hospital and 1- year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA. 1995;274(23):1852–7.
    1. Confalonieri M, Garuti G, Cattaruzza MS, Osborn JF, Antonelli M, Conti G, Kodric M, Resta O, Marchese S, Gregoretti C, Rossi A. Italian noninvasive positive pressure ventilation (NPPV) study group. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J. 2005;25(2):348–355. doi: 10.1183/09031936.05.00085304.
    1. Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet. 2000;355:1931–1935. doi: 10.1016/S0140-6736(00)02323-0.
    1. Chandra D, Stamm JA, Taylor B, Ramos RM, Satterwhite L, Krishnan JA, Mannino D, Sciurba FC, Holguín F. Outcomes of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease in the United States, 1998–2008. Am J Respir Crit Care Med. 2012;185(2):152–159. doi: 10.1164/rccm.201106-1094OC.
    1. Khan J, et al. Early development of critical illness myopathy and neuropathy in patients with severe sepsis. Neurology. 2006;67(8):1421–1425. doi: 10.1212/01.wnl.0000239826.63523.8e.

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