Ultrasonographic Assessment of Diaphragmatic Inspiratory Amplitude and Its Association with Postoperative Pulmonary Complications in Upper Abdominal Surgery: A Prospective, Longitudinal, Observational Study.

BACKGROUND

Diaphragmatic dysfunction following upper abdominal surgery is less recognized due to a lack of diagnostic modality for bedside evaluation. We used point-of-care ultrasound to evaluate the diaphragmatic inspiratory amplitude (DIA) in upper abdominal surgery for cancer. Our primary hypothesis was DIA would be reduced in the immediate postoperative period in patients with postoperative pulmonary complications (PPCs). Our aim was to identify an optimal cutoff of DIA for the diagnosis of PPCs.

METHODS

We conducted a prospective, observational study in patients aged 18-75 years undergoing elective, upper abdominal oncological surgeries under combined general and epidural anesthesia. Ultrasound evaluation of the diaphragm was done by measuring the DIA in the right and left hemidiaphragms during quiet and deep breathing on the day before surgery and postoperative days (PODs) 1, 2, and 3. Patients were followed up for PPCs until POD 7. The linear mixed-effects model examined the association between DIA and PPCs and other perioperative factors. Receiver-operating characteristics analysis was done to determine the optimal cutoff of DIA in diagnosing PPCs.

RESULTS

DIA measured in the 162 patients showed a significant decrease in their absolute values postoperatively from its preoperative baseline measurement. This decrease in DIA was significantly associated with PPC [right hemidiaphragm, = -0.17, 95% confidence interval (CI) -0.31 to -0.02, = 0.001 during quiet breathing; left hemidiaphragm, = -0.24, 95% CI = -0.44 to -0.04, = 0.018 and = -0.40, 95% CI = -0.71 to -0.09, = 0.012 during quiet and deep breathing, respectively]. A cutoff value of DIA of left hemidiaphragm at 1.3 cm during quiet breathing and 1.6 cm during deep breathing had a sensitivity of 77 and 75%, respectively, in their ability to diagnose PPCs [left hemidiaphragm quiet breathing, area under the curve (AUC): 0.653, 95% CI 0.539-0.768, = 0.015; left hemidiaphragm deep breathing, AUC: 0.675, 95% CI 0.577-0.773, = 0.007].

CONCLUSION

Following upper abdominal surgery, the DIA is decreased and associated with PPCs. DIA of left hemidiaphragm less than 1.3 cm during quiet breathing and 1.6 cm during deep breathing has a sensitivity of 77 and 75%, respectively, in diagnosing PPCs following upper abdominal surgery.

HOW TO CITE THIS ARTICLE

Vanamail PV, Balakrishnan K, Prahlad S, Chockalingam P, Dash R, Soundararajan DK. Ultrasonographic Assessment of Diaphragmatic Inspiratory Amplitude and Its Association with Postoperative Pulmonary Complications in Upper Abdominal Surgery: A Prospective, Longitudinal, Observational Study. Indian J Crit Care Med 2021;25(9):1031-1039.