Moury Pierre-Henri, Cuisinier Adrien, Durand Michel, Bosson Jean-Luc, Chavanon Olivier, Payen Jean-François, Jaber Samir, Albaladejo Pierre
Department of Anesthesia and Intensive Care Medicine, Université Grenoble-Alpes, Grenoble University Hospital, Grenoble, France.
Department of Biostatistics, ThEMAS, TIMC, UMR, CNRS 5525, Université Grenoble Alpes, Grenoble University Hospital, Grenoble, France.
Ann Intensive Care. 2019 Apr 24;9(1):50. doi: 10.1186/s13613-019-0521-z.
Diaphragm paresis is common after cardiac surgery and may delay the weaning from the ventilator. Our objective was to evaluate diaphragm thickening during weaning and secondly the muscle thickness as a marker of myotrauma.
Patients undergoing elective cardiac surgery were prospectively included. Ultrasonic index of right hemidiaphragm thickening fraction (TF) was measured as a surrogate criterion of work of breathing. A TF < 20% was defined as a low diaphragm thickening. Measurements of TF were performed during three periods to study diaphragm thickening evolution defined by the difference between two consecutive time line point: preoperative (D - 1), during a spontaneous breathing trial (SBT) in the intensive care unit and postoperative (D + 1). We studied three patterns of diaphragm thickness at end expiration evolution from D - 1 to D + 1: > 10% decrease, stability and > 10% increase. Demographical data, length of surgery, type of surgery, ICU length of stay (LOS) and extubation failure were collected.
Of the 100 consecutively included patients, 75 patients had a low diaphragm thickening during SBT. Compared to TF values at D - 1 (36% ± 18), TF was reduced during SBT (17% ± 14) and D + 1 (12% ± 11) (P < 0.0001). Thickness and TF did not change according to the type of surgery or cooling method. TF at SBT was correlated to the length of surgery (both r = - 0.4; P < 0.0001). Diaphragm thickness as continuous variable did not change over time. Twenty-eight patients (42%) had a > 10% decrease thickness, 19 patients (29%) stability and 19 patients (28%) in > 10% increase, and this thickness evolution pattern was associated with: a longer LOS 3 days [2-5] versus 2 days [2-4] and 2 days [2], respectively (ANOVA P = 0.046), and diaphragm thickening evolution (ANOVA P = 0.02). Two patients experience extubation failure.
These findings indicate that diaphragm thickening is frequently decreased after elective cardiac surgery without impact on respiratory outcome, whereas an altered thickness pattern was associated with a longer length of stay in the ICU. Contractile activity influenced thickness evolution. Trial registry number ClinicalTrial.gov ID NCT02208479.
膈肌麻痹在心脏手术后很常见，可能会延迟呼吸机撤机。我们的目的是评估撤机过程中膈肌增厚情况，其次评估肌肉厚度作为肌损伤的标志物。
前瞻性纳入接受择期心脏手术的患者。测量右半侧膈肌增厚分数（TF）的超声指标，作为呼吸做功的替代标准。TF<20%被定义为膈肌增厚程度低。在三个时期进行TF测量，以研究由两个连续时间点之间的差异定义的膈肌增厚演变情况：术前（D-1）、重症监护病房的自主呼吸试验（SBT）期间和术后（D+1）。我们研究了从D-1到D+1呼气末膈肌厚度的三种演变模式：下降>10%、稳定和增加>10%。收集人口统计学数据、手术时长、手术类型、重症监护病房住院时长（LOS）和拔管失败情况。
在连续纳入的100例患者中，75例患者在SBT期间膈肌增厚程度低。与D-1时的TF值（36%±18）相比，SBT期间（17%±14）和D+1时（12%±11）TF降低（P<0.0001）。厚度和TF不因手术类型或降温方法而改变。SBT时的TF与手术时长相关（r均=-0.4；P<0.0001）。膈肌厚度作为连续变量未随时间变化。28例患者（42%）厚度下降>10%，19例患者（29%）稳定，19例患者（28%）增加>10%，这种厚度演变模式与以下因素相关：LOS分别为3天[2-5]、2天[2-4]和2天[2]，LOS更长（方差分析P=0.046），以及膈肌增厚演变（方差分析P=0.02）。2例患者拔管失败。
这些发现表明，择期心脏手术后膈肌增厚经常降低，对呼吸结局无影响，而厚度模式改变与在重症监护病房的住院时间延长有关。收缩活动影响厚度演变。试验注册号ClinicalTrial.gov ID NCT02208479。
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