Pediatric Intensive Care Unit, University Regional Hospital of Málaga, Spain.
Pediatric Intensive Care Unit, University Regional Hospital of Málaga, Spain.
Paediatr Respir Rev. 2021 Dec;40:58-64. doi: 10.1016/j.prrv.2020.12.002. Epub 2021 Feb 23.
Ultrasonography has recently emerged as a promising technique that can rapidly estimate diaphragm function, especially during the weaning period. The aims of this study were to describe the evolution of diaphragmatic morphology and functional measurements by ultrasound in ventilated children.
This was a prospective, observational, single-center study. All the children admitted to our Pediatric Intensive Care Unit requiring mechanical ventilation for more than 48 h were included. Diaphragmatic thickness and the thickening fraction were assessed by ultrasound.
From June to December 2018, 47 patients (median age 3 months; interquartile range, 1-17) underwent 164 ultrasonographic evaluations. The median duration of mechanical ventilation was 168 h (interquartile range, 96-196). At the initial measurement, the thickness at end-inspiration was 2.2 mm (interquartile range, 1.8-2.5) and the thickness at end-expiration was 1.8 mm (interquartile range, 1.5-2.0) with a median decrease in thickness of -14% (interquartile range, -33% to -3%) and a -2% daily atrophy rate (interquartile range, -4.2% to 0%). Diaphragmatic atrophy was observed in 30/47 cases. Children who had been exposed to neuromuscular blockade infusion (n = 31) had a significantly lower mean thickness [-22% (interquartile range, -34% to -13%) vs. -6% (interquartile range, -12% to 0%); p = 0.009] and increased daily atrophy rate [-2.2% (interquartile range, -4.6 to 0%) vs. -1.4% (interquartile range, -2.6 to 0%); p = 0.049] compared to unexposed children. The decrease in thickness was significantly less in children ventilated for at least 12 hours with pressure support before extubation compared with those with shorter periods of spontaneous respiratory effort [-9.5% (interquartile range, -21 to 0%) vs. -26% (interquartile range, -37 to -12%); p = 0.011].
Point-of-care diaphragmatic ultrasound can detect diaphragmatic atrophy in mechanically ventilated children. Diaphragmatic atrophy was strongly associated with the use of mechanical ventilation and neuromuscular blockade. Diaphragmatic thickness also tended to decrease less in the pre-extubation stage with pressure support. We found no correlation between progressive diaphragm thinning, extubation failure, or an increased need for non-invasive ventilation post extubation.
超声检查最近已成为一种很有前途的技术，可以快速评估膈肌功能，尤其是在撤机期间。本研究的目的是描述超声在通气患儿中膈肌形态和功能测量的演变。
这是一项前瞻性、观察性、单中心研究。所有因需要机械通气超过 48 小时而入住我院儿科重症监护病房的患儿均被纳入研究。通过超声评估膈肌厚度和增厚分数。
2018 年 6 月至 12 月，47 例患儿（中位年龄 3 个月；四分位间距 1-17）共进行了 164 次超声评估。机械通气中位时间为 168 小时（四分位间距 96-196）。初始测量时，吸气末厚度为 2.2mm（四分位间距 1.8-2.5），呼气末厚度为 1.8mm（四分位间距 1.5-2.0），厚度减少中位数为-14%（四分位间距-33%至-3%），每日萎缩率为-2%（四分位间距-4.2%至 0%）。47 例患儿中有 30 例（64%）出现膈肌萎缩。接受神经肌肉阻滞剂输注的患儿（n=31）厚度减少更明显[平均厚度-22%（四分位间距-34%至-13%）比-6%（四分位间距-12%至 0%）；p=0.009]，每日萎缩率增加[2.2%（四分位间距-4.6 至 0%）比-1.4%（四分位间距-2.6 至 0%）；p=0.049]。与未接受神经肌肉阻滞剂输注的患儿相比，在拔管前接受至少 12 小时压力支持通气的患儿厚度减少明显较少[-9.5%（四分位间距-21 至 0%）比-26%（四分位间距-37 至-12%）；p=0.011]。
即时膈肌超声可检测出机械通气患儿的膈肌萎缩。膈肌萎缩与机械通气和神经肌肉阻滞剂的使用密切相关。在使用压力支持的拔管前阶段，膈肌厚度也趋于减少较少。我们发现膈肌进行性变薄与拔管失败或拔管后需要无创通气之间无相关性。
