Qualitative and quantitative muscle ultrasound changes in patients with COVID-19-related ARDS

Michele Umbrello, Luigi Guglielmetti, Paolo Formenti, Edoardo Antonucci, Sergio Cereghini, Clelia Filardo, Giulia Montanari, Stefano Muttini, Michele Umbrello, Luigi Guglielmetti, Paolo Formenti, Edoardo Antonucci, Sergio Cereghini, Clelia Filardo, Giulia Montanari, Stefano Muttini

Abstract

Objectives: Severe forms of the novel coronavirus-19 (COVID-19) are associated with systemic inflammation and hypercatabolism. The aims of this study were to compare the time course of the size and quality of both rectus femoris and diaphragm muscles between critically ill, COVID-19 survivors and non-survivors and to explore the correlation between the change in muscles size and quality with the amount of nutritional support delivered and the cumulative fluid balance.

Methods: This was a prospective observational study in the general intensive care unit (ICU) of a tertiary care hospital for COVID-19. The right rectus femoris cross-sectional area and the right diaphragm thickness, as well as their echo densities were assessed within 24 h from ICU admission and on day 7. We recorded anthropometric and biochemical data, respiratory mechanics and gas exchange, daily fluid balance, and the number of calories and proteins administered.

Results: Twenty-eight patients were analyzed (65 ± 10 y of age; 80% men, body mass index 30 ± 7.8 kg/m2). Rectus femoris and diaphragm sizes were significantly reduced at day 7 (median = -26.1 [interquartile ratio [IQR], = -37.8 to -15.2] and -29.2% [-37.8% to -19.6%], respectively) and this reduction was significantly higher in non-survivors. Both rectus femoris and diaphragm echo density were significantly increased at day 7, with a significantly higher increase in non-survivors. The change in both rectus femoris and diaphragm size at day 7 was related to the cumulative protein deficit (R = 0.664, P < 0.001 and R = 0.640, P < 0.001, respectively), whereas the change in rectus femoris and diaphragm echo density was related to the cumulative fluid balance (R = 0.734, P < 0.001 and R = 0.646, P < 0.001, respectively).

Conclusions: Early changes in muscle size and quality seem related to the outcome of critically ill COVID-19 patients, and to be influenced by nutritional and fluid management strategies.

Keywords: ARDS; COVID-19; Catabolism; Diaphragm ultrasound; Muscle ultrasound; Nitrogen Balance.

Copyright © 2021 Elsevier Inc. All rights reserved.

Figures

Fig. 1
Fig. 1
Muscle ultrasound images at ICU admission (A) and on day 7 (B) from a representative patient. A and B show the rectus femoris and diaphragm, respectively, at ICU admission in a representative patient. C and D show the same muscles in the same patient on day 7 after ICU admission. The area enclosed in the white dashed line is the rectus femoris cross-sectional area; the arrowhead line indicates the diaphragm thickness. The histogram of muscle echo density is shown on the top right corner of each panel. d, diaphragm; f, femur; l, liver; rf, rectus femoris; vi, vastus intermedius.
Fig. 2
Fig. 2
Time course of energy and protein intake during the first 7 d of stay in ICU survivors and non-survivors. White circles represent energy intake in ICU survivors, black circles represent energy intake in non-survivors; white squares represent protein intake in ICU survivors, and black squares represent protein intake in ICU non-survivors. The analysis was performed with factorial analysis of variance, see the methods section for further details. ICU, intensive care unit.
Fig. 3
Fig. 3
Evolution of muscle mass (RF CSA and diaphragm thickness) and echo density over time. The figure shows the median (box), first and third quartile of each variable. Data were analyzed with two-way analysis of variance, see the methods section for further details. AU, arbitrary unit; RF CSA, rectus femoris cross-sectional area.
Fig. 4
Fig. 4
Correlation between the change in muscle size over the first week and the cumulative protein deficit (A and B), and the change in muscle echo density over the first week and the cumulative fluid balance. RF CSA, rectus femoris cross-sectional area.

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