Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Pediatr Crit Care Med. 2018 May;19(5):406-411. doi: 10.1097/PCC.0000000000001485.
Diaphragm atrophy is associated with delayed weaning from mechanical ventilation and increased mortality in critically ill adults. We sought to test for the presence of diaphragm atrophy in children with acute respiratory failure.
Prospective, observational study.
Single-center tertiary noncardiac PICU in a children's hospital.
Invasively ventilated children with acute respiratory failure.
Diaphragm thickness at end-expiration and end-inspiration were serially measured by ultrasound in 56 patients (median age, 17 mo; interquartile range, 5.5-52), first within 36 hours of intubation and last preceding extubation. The median duration of mechanical ventilation was 140 hours (interquartile range, 83-201). At initial measurement, thickness at end-expiration was 2.0 mm (interquartile range, 1.8-2.5) and thickness at end-inspiration was 2.5 mm (interquartile range, 2-2.8). The change in thickness at end-expiration during mechanical ventilation between first and last measurement was -13.8% (interquartile range, -27.4% to 0%), with a -3.4% daily atrophy rate (interquartile range, -5.6 to 0%). Thickening fraction = ([thickness at end-inspiration - thickness at end-expiration]/thickness at end-inspiration) throughout the course of mechanical ventilation was linearly correlated with spontaneous breathing fraction (beta coefficient, 9.4; 95% CI, 4.2-14.7; p = 0.001). For children with a period of spontaneous breathing fraction less than 0.5 during mechanical ventilation, those with exposure to a continuous neuromuscular blockade infusion (n = 15) had a significantly larger decrease in thickness at end-expiration compared with children with low spontaneous breathing fraction who were not exposed to a neuromuscular blockade infusion (n = 18) (-16.4%, [interquartile range, -28.4% to -7.0%] vs -7.3%; [interquartile range, -10.9% to -0%]; p = 0.036).
Diaphragm atrophy is present in children on mechanical ventilation for acute respiratory failure. Diaphragm contractility, measured as thickening fraction, is strongly correlated with spontaneous breathing fraction. The combination of exposure to neuromuscular blockade infusion with low overall spontaneous breathing fraction is associated with a greater degree of atrophy.
膈肌萎缩与机械通气撤机延迟和重症成人死亡率增加有关。我们试图在急性呼吸衰竭的儿童中检测膈肌萎缩的存在。
前瞻性观察研究。
儿童医院的单中心三级非心脏 PICU。
接受机械通气的急性呼吸衰竭儿童。
通过超声在 56 名患者（中位年龄 17 个月；四分位距 5.5-52）中连续测量呼气末和吸气末的膈肌厚度，第一次在插管后 36 小时内，最后一次在拔管前。机械通气的中位持续时间为 140 小时（四分位距 83-201）。在初始测量时，呼气末厚度为 2.0mm（四分位距 1.8-2.5），吸气末厚度为 2.5mm（四分位距 2-2.8）。机械通气期间，呼气末厚度在第一次和最后一次测量之间的变化为-13.8%（四分位距-27.4%至 0%），每日萎缩率为-3.4%（四分位距-5.6%至 0%）。在整个机械通气过程中，厚度增厚分数=[吸气末厚度-呼气末厚度/吸气末厚度]与自主呼吸分数呈线性相关（β系数为 9.4；95%置信区间，4.2-14.7；p = 0.001）。对于机械通气期间自主呼吸分数小于 0.5 的儿童，与未接受神经肌肉阻滞剂输注的自主呼吸分数低的儿童（n = 18）相比，接受连续神经肌肉阻滞剂输注的儿童（n = 15）的呼气末厚度下降幅度显著更大（-16.4%[四分位距，-28.4%至-7.0%]与-7.3%[四分位距，-10.9%至-0%]；p = 0.036）。
在因急性呼吸衰竭接受机械通气的儿童中存在膈肌萎缩。作为增厚分数测量的膈肌收缩力与自主呼吸分数密切相关。接受神经肌肉阻滞剂输注与整体自主呼吸分数低相结合与更大程度的萎缩有关。
