Lerolle Nicolas, Guérot Emmanuel, Dimassi Saoussen, Zegdi Rachid, Faisy Christophe, Fagon Jean-Yves, Diehl Jean-Luc
Service de Réanimation Médicale, Hôopital Européen Georges Pompidou, Assistance Publique-Hôopitaux de Paris, Université Paris Descartes, Faculté de Médecine, Paris, France.
Service de Réanimation Médicale, Hôopital Européen Georges Pompidou, Assistance Publique-Hôopitaux de Paris, Université Paris Descartes, Faculté de Médecine, Paris, France.
Chest. 2009 Feb;135(2):401-407. doi: 10.1378/chest.08-1531. Epub 2008 Aug 27.
Severe diaphragmatic dysfunction can prolong mechanical ventilation after cardiac surgery. An ultrasonographic criterion for diagnosing severe diaphragmatic dysfunction defined by a reference technique such as transdiaphragmatic pressure measurements has never been determined.
Twenty-eight patients requiring mechanical ventilation > 7 days postoperatively were studied. Esophageal and gastric pressures were measured to calculate transdiaphragmatic pressure during maximal inspiratory effort and the Gilbert index, which evaluates the diaphragm contribution to respiratory pressure swings during quiet ventilation. Ultrasonography allowed measuring right and left hemidiaphragmatic excursions during maximal inspiratory effort. Best E is the greatest positive value from either hemidiaphragm. Twenty cardiac surgery patients with uncomplicated postoperative course were also evaluated with ultrasonography preoperatively and postoperatively. Measurements were performed in semirecumbent position.
Transdiaphragmatic pressure during maximal inspiratory effort was below normal value in 27 of the 28 patients receiving prolonged mechanical ventilation (median, 39 cm H(2)O; interquartile range [IQR] 28 cm H(2)O). Eight patients had Gilbert indexes <or= 0 indicating severe diaphragmatic dysfunction. Best E was lower in patients with Gilbert index <or= 0 than > 0 (30 mm; IQR, 10 mm; vs 19 mm; IQR, 7 mm, respectively; p = 0.001). Best E < 25 mm had a positive likelihood ratio of 6.7 (95% confidence interval [CI], 2.4 to 19) and a negative likelihood ratio of 0 (95% CI, 0 to 1.1) for having a Gilbert index <or= 0. None of the patients with uncomplicated course had Best E < 25 mm either preoperatively or postoperatively.
Ultrasonographic-based determination of hemidiaphragm excursions in patients requiring prolonged mechanical ventilation after cardiac surgery may help identify those with and without severe diaphragmatic dysfunction as defined by the Gilbert index.
严重的膈肌功能障碍可延长心脏手术后的机械通气时间。从未确定过一种通过参考技术（如跨膈压测量）来诊断严重膈肌功能障碍的超声标准。
对28例术后需要机械通气超过7天的患者进行研究。测量食管和胃内压力，以计算最大吸气努力时的跨膈压以及吉尔伯特指数，该指数评估安静通气期间膈肌对呼吸压力波动的贡献。超声检查可测量最大吸气努力时左右半膈肌的移动幅度。最佳E值是左右半膈肌中最大的正值。还对20例术后病程无并发症的心脏手术患者在术前和术后进行了超声检查评估。测量在半卧位进行。
在28例接受长时间机械通气的患者中，27例最大吸气努力时的跨膈压低于正常值（中位数为39 cm H₂O；四分位数间距[IQR]为28 cm H₂O）。8例患者的吉尔伯特指数≤0，表明存在严重的膈肌功能障碍。吉尔伯特指数≤0的患者的最佳E值低于指数>0的患者（分别为30 mm；IQR为10 mm；与19 mm；IQR为7 mm，p = 0.001）。最佳E<25 mm对于吉尔伯特指数≤0的阳性似然比为6.7（95%置信区间[CI]为2.4至19），阴性似然比为0（95%CI为0至1.1）。病程无并发症的患者在术前或术后均无最佳E<25 mm。
对于心脏手术后需要长时间机械通气的患者，基于超声测定半膈肌移动幅度可能有助于识别那些存在和不存在吉尔伯特指数所定义的严重膈肌功能障碍的患者。
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