van Leuteren Ruud W, de Waal Cornelia G, de Jongh Frans H, Bem Reinout A, van Kaam Anton H, Hutten Gerard
Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
Pediatr Crit Care Med. 2021 Nov 1;22(11):950-959. doi: 10.1097/PCC.0000000000002828.
Swift extubation is important to prevent detrimental effects of invasive mechanical ventilation but carries the risk of extubation failure. Accurate tools to assess extubation readiness are lacking. This study aimed to describe the effect of extubation on diaphragm activity in ventilated infants and children. Our secondary aim was to compare diaphragm activity between failed and successfully extubated patients.
Prospective, observational study.
Single-center tertiary neonatal ICU and PICU.
Infants and children receiving invasive mechanical ventilation longer than 24 hours.
None.
Diaphragm activity was measured with transcutaneous electromyography, from 15 minutes before extubation till 180 minutes thereafter. Peak and tonic activity, inspiratory amplitude, inspiratory area under the curve, and respiratory rate were calculated from the diaphragm activity waveform. One hundred forty-seven infants and children were included (median postnatal age, 1.9; interquartile range, 0.9-6.7 wk). Twenty patients (13.6%) failed extubation within 72 hours. Diaphragm activity increased rapidly after extubation and remained higher throughout the measurement period. Pre extubation, peak (end-inspiratory) diaphragm activity and tonic (end-inspiratory) diaphragm activity were significantly higher in failure, compared with success cases (5.6 vs 7.0 μV; p = 0.04 and 2.8 vs 4.1 μV; p = 0.04, respectively). Receiver operator curve analysis showed the highest area under the curve for tonic (end-inspiratory) diaphragm activity (0.65), with a tonic (end-inspiratory) diaphragm activity greater than 3.4 μV having a combined sensitivity and specificity of 55% and 77%, respectively, to predict extubation outcome. After extubation, diaphragm activity remained higher in patients failing extubation.
Diaphragm activity rapidly increased after extubation. Patients failing extubation had a higher level of diaphragm activity, both pre and post extubation. The predictive value of the diaphragm activity variables alone was limited. Future studies are warranted to assess the additional value of electromyography of the diaphragm in combined extubation readiness assessment.
快速拔管对于预防有创机械通气的有害影响很重要，但存在拔管失败的风险。目前缺乏准确评估拔管准备情况的工具。本研究旨在描述拔管对接受机械通气的婴幼儿膈肌活动的影响。我们的次要目的是比较拔管失败和成功拔管患者的膈肌活动情况。
前瞻性观察性研究。
单中心三级新生儿重症监护病房和儿科重症监护病房。
接受有创机械通气超过24小时的婴幼儿。
无。
通过经皮肌电图测量膈肌活动，从拔管前15分钟至拔管后180分钟。根据膈肌活动波形计算峰值和张力活动、吸气幅度、曲线下吸气面积和呼吸频率。纳入147例婴幼儿（出生后年龄中位数为1.9周；四分位间距为0.9 - 6.7周）。20例患者（13.6%）在72小时内拔管失败。拔管后膈肌活动迅速增加，并在整个测量期间保持较高水平。拔管前，拔管失败组的峰值（吸气末）膈肌活动和张力（吸气末）膈肌活动显著高于成功组（分别为5.6 μV对7.0 μV；p = 0.04和2.8 μV对4.1 μV；p = 0.04）。受试者操作曲线分析显示，张力（吸气末）膈肌活动的曲线下面积最大（0.65），张力（吸气末）膈肌活动大于3.4 μV预测拔管结果的综合敏感性和特异性分别为55%和77%。拔管后，拔管失败患者的膈肌活动仍较高。
拔管后膈肌活动迅速增加。拔管失败患者在拔管前后的膈肌活动水平较高。仅膈肌活动变量的预测价值有限。有必要开展进一步研究，以评估膈肌肌电图在综合拔管准备情况评估中的附加价值。
