1. Am J Respir Crit Care Med. 2015 Jul 13.

[Epub ahead of print]

Evolution of Diaphragm Thickness During Mechanical Ventilation: Impact of
Inspiratory Effort.
Goligher EC(1,)(2), Fan E(3,)(4), Herridge MS(3,)(5), Murray A(6), Vorona S(7),
Brace D(8), Rittayamai N(9,)(10), Lanys A(11), Tomlinson G(12), Singh JM(3,)(13)
,
Bolz SS(14), Rubenfeld GD(3,)(15), Kavanagh BP(9,)(16,)(17), Brochard LJ(3,)(18)
,
Ferguson ND(19,)(9,)(20,)(21,)(22).
Author information:
(1)University of Toronto, Interdivisional Department of Critical Care , Toronto
Western Hospital , 399 Bathurst St., 2MCL-411Q , Toronto, Ontario, Canada , M5T
2S8 , 416-603-5800. (2)University Health Network, Department of Medicine,
Division of Respirology, Toronto, Ontario, Canada ;
ewan.goligher@mail.utoronto.ca. (3)University of Toronto, Interdepartmental
Division of Critical Care Medicine , Toronto General Hospital , 585 University
Avenue , 11C-1167 , Toronto, Ontario, Canada. (4)University Health Network,
Department of Medicine, Toronto, Ontario, Canada ; eddy.fan@uhn.ca. (5)Universit
y
Health Network, Department of Medicine, Toronto, Ontario, Canada ;
dr.margaret.herridge@uhn.ca. (6)University Health Network, Department of
Medicine, Toronto, Ontario, Canada ; alistair.murray@mail.mcgill.ca.
(7)University Health Network, Department of Medicine, Toronto, Ontario, Canada ;
stefannie.vorona@uhn.ca. (8)University Health Network, Department of Medicine,
Toronto, Ontario, Canada ; debbie.brace@mail.mcgill.ca. (9)University of Toronto
,
Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada.
(10)St. Michael's Hospital, Keenan Centre for Biomedical Research, Toronto,
Ontario, Canada ; rittayamain@smh.ca. (11)St. Michael's Hospital, Keenan Centre
for Biomedical Research, Toronto, Ontario, Canada ; ashleylanys@gmail.com.
(12)University Health Network, Department of Medicine, Toronto, Ontario, Canada
;
george.tomlinson@uhn.ca. (13)University Health Network, Department of Medicine,
Toronto, Ontario, Canada ; Jeff.Singh@uhn.ca. (14)University of Toronto,
Department of Physiology, Toronto, Ontario, Canada ; steffensebastian@me.com.
(15)Sunnybrook Health Sciences Centre, Department of Critical Careare, Toronto,
Ontario, Canada ; gordon.rubenfeld@sunnybrook.ca. (16)Hospital for Sick Children
,
Department of Critical Care Medicine, Toronto, Ontario, Canada. (17)University o
f
Toronto, Department of Anesthesia, Toronto, Ontario, Canada ;
brian.kavanagh@utoronto.ca. (18)St. Michael's Hospital, Keenan Centre for
Biomedical Research, Toronto, Ontario, Canada ; BrochardL@smh.ca. (19)University
Health Network, Department of Medicine, Division of Respirology, Toronto,
Ontario, Canada. (20)University of Toronto, Department of Physiology, Toronto,
Ontario, Canada. (21)University of Toronto, Institute for Health Policy,
Management and Evaluation, Toronto, Ontario, Canada. (22)University Health
Network, Toronto General Research Institute, Toronto, Ontario, Canada ;
niall.ferguson@uhn.ca.
Rationale Diaphragm atrophy and dysfunction have been reported in humans during
mechanical ventilation, but the prevalence, causes, and functional impact of
changes in diaphragm thickness during routine mechanical ventilation for
critically ill patients are unknown. Objectives To describe the evolution of

diaphragm thickness over time during mechanical ventilation, its impact on

diaphragm function, and the influence of inspiratory effort on this phenomenon.
Methods In 3 academic intensive care units, 107 patients were enrolled shortly
after initiating ventilation along with 10 non-ventilated ICU patients
(controls). Diaphragm thickness and contractile activity (quantified by the
inspiratory thickening fraction) were measured daily by ultrasound. Measurements
and Main Results Over the first week of ventilation, diaphragm thickness
decreased by more than 10% in 47 (44%), was unchanged in 47 (44%), and increased
by more than 10% in 13 (12%). Thickness did not vary over time following
extubation or in non-ventilated patients. Low diaphragm contractile activity was
associated with rapid decreases in diaphragm thickness while high contractile
activity was associated with increases in diaphragm thickness (p=0.002).
Contractile activity decreased with increasing ventilator driving pressure
(p=0.01) and controlled ventilator modes (p=0.02). Maximal thickening fraction (
a
measure of diaphragm function) was lower in patients with decreased or increased
diaphragm thickness (n=10) compared to patients with unchanged thickness (n=10,
p=0.05 for comparison). Conclusions Changes in diaphragm thickness are common
during mechanical ventilation and may be associated with diaphragmatic weakness.
Titrating ventilatory support to maintain normal levels of inspiratory effort ma
y
prevent changes in diaphragm configuration associated with mechanical
ventilation.
PMID: 26167730 [PubMed - as supplied by publisher]
2. J Intensive Care Med. 2015 May 14. pii: 0885066615583639. [Epub ahead of prin
t]
Ultrasonography for Screening and Follow-Up of Diaphragmatic Dysfunction in the
ICU: A Pilot Study.
Mariani LF(1), Bedel J(2), Gros A(2), Lerolle N(3), Milojevic K(4), Laurent V(2)
,
Hilly J(2), Troch G(2), Bedos JP(2), Planquette B(5).
Author information:
(1)Service de ranimation polyvalente, Versailles-Le Chesnay, France
luciefenet84@gmail.com. (2)Service de ranimation polyvalente, Versailles-Le
Chesnay, France. (3)Ranimation Mdicale et Mdicine Hyperbare, Centre
Hospitalier Universitaire Angers, Facult de Mdecine, Universit d'Angers,
Angers, France. (4)SAMU 78 SMUR de Versailles, Le Chesnay, France. (5)Service de
ranimation polyvalente, Versailles-Le Chesnay, France Service de pneumologie et
de soins intensifs, Hpital Europen Georges Pompidou-20 rue Leblanc, 75015
Paris, France.
PURPOSE: Reversibility and impact of diaphragmatic dysfunction (DD) are unknown.
The principal aim was to describe diaphragmatic function as assessed by
ultrasonography during weaning trials.
MATERIALS AND METHODS: The present study is a 6-month single-center prospective
study. All patients under mechanical ventilation for more than 7 days and
eligible for a spontaneous breathing trial (SBT) were enrolled prospectively.

INTERVENTION: Two blinded ultrasonographers evaluated each hemidiaphragm during

SBT. Prevalence of DD among weaning failure and death and interobserver
reproducibility have been evaluated.
RESULTS: The 34 included patients had a mean Simplified Acute Physiology Score
version II of 55.7 14 and a median intensive care unit (ICU) stay length of 17
days (13-30). Diaphragmatic dysfunction was found in 13 (38%) patients, on both
sides in 8. Bilateral DD resolved before ICU discharge in 5 of the 7 reevaluated
patients. No weaning failures were recorded. The ICU mortality was higher
patients with DD (37% vs 5%, P = .048). Mean interobserver agreement rate
91%. Reproducibility was better with M-mode.
CONCLUSION: The ICU-acquired DD usually improves before ICU discharge but
constitute a marker for greater disease severity. The present preliminary
s
require confirmation in a larger prospective multicenter study.

in
was
might
result

The Author(s) 2015.

PMID: 25979406 [PubMed - as supplied by publisher]
3. Rev Mal Respir. 2015 Apr;32(4):370-80. doi: 10.1016/j.rmr.2014.08.013. Epub 2
014
Nov 6.
[Consequences of mechanical ventilation on diaphragmatic function].
[Article in French]
Jung B(1), Gleeton D(2), Daurat A(1), Conseil M(2), Mahul M(2), Rao G(2), Mateck
i
S(3), Lacampagne A(3), Jaber S(4).
Author information:
(1)Dpartement d'anesthsie-ranimation, hpital Saint-loi, CHU de Montpellier,
34295 Montpellier cedex 5, France; Inserm U-1046, universit Montpellier 1,
universit Montpellier 2, CHU Arnaud-de-Villeneuve, 34295 Montpellier cedex 5,
France. (2)Dpartement d'anesthsie-ranimation, hpital Saint-loi, CHU de
Montpellier, 34295 Montpellier cedex 5, France. (3)Inserm U-1046, universit
Montpellier 1, universit Montpellier 2, CHU Arnaud-de-Villeneuve, 34295
Montpellier cedex 5, France. (4)Dpartement d'anesthsie-ranimation, hpital
Saint-loi, CHU de Montpellier, 34295 Montpellier cedex 5, France; Inserm U-1046,
universit Montpellier 1, universit Montpellier 2, CHU Arnaud-de-Villeneuve,
34295 Montpellier cedex 5, France. Electronic address:
s-jaber@chu-montpellier.fr.
INTRODUCTION: Mechanical ventilation is associated with ventilator-induced
diaphragmatic dysfunction (VIDD) in animal models and also in humans.
BACKGROUND: The main pathophysiological pathways implicated in VIDD seems to be
related to muscle inactivity but may also be the consequence of high tidal
volumes. Systemic insults from side effects of medication, infection,
malnutrition and hypoperfusion also play a part. The diaphragm is caught in the
cross-fire of ventilation-induced and systemic-induced dysfunctions.
Intracellular consequences of VIDD include oxidative stress, proteolysis,
impaired protein synthesis, autophagy activation and excitation-contraction
decoupling. VIDD can be diagnosed at the bedside using non-invasive magnetic
stimulation of the phrenic nerves which is the gold standard. Other techniques
involve patient's participation such as respiratory function tests or ultrasound
examination.

CONCLUSION AND PERSPECTIVES: At this date, only spontaneous ventilatory cycles

and perhaps phrenic nerve stimulation appear to diminish the severity of VIDD in
humans but several pathways are currently being examined using animal models.
Specific pharmacological options are currently under investigation in animal
models.
Copyright 2014 SPLF. Published by Elsevier Masson SAS. All rights reserved.
PMID: 25496650 [PubMed - in process]
4. Minerva Med. 2014 Nov 14. [Epub ahead of print]
Clinical applications of diaphragm ultrasound: moving forward.
Zanforlin A(1), Bezzi M, Carlucci A, Di Marco F.
Author information:
(1)Multidisciplinary Area Medical Department San Luca Hospital Trecenta, Rovigo,
Italy - alessandro.zanforlin@gmail.com.
Establishing the correct time of weaning from mechanical ventilation is a crucia
l
issue in the clinical practice. The difficult process of weaning can be due to
pathological conditions that result in an imbalance between respiratory-muscle
strength and respiratory load. Recently it has been suggested that ultrasound
measurements of diaphragm muscle thickening in inspiration during weaning could
provide an estimation of extubation success. Bedside ultrasonography,
particularly sonographic evaluation of the diaphragm by measuring the percentage
variation of diaphragm thickness (tdi) between end-inspiration and end-expiratio
n
(tdi%), has become a valuable tool in the management of intensive care unit
patients. This non-invasive, low-cost and fast to perform technique seems to
predict with a good accuracy the extubation failure. Some limitations derive fro
m
the difficulty to determine the maximum (end inspiratory) and minimum (end
expiratory) tdi observing a dynamic image in B-mode, in particular in
non-collaborating patients. In addition, some dynamic situations causing
extubation failure could not be predicted by an ultrasound measure performed at
the beginning of the weaning trial. Nowadays the technique proposed remains a
useful tool for helping the prediction of extubation failure. It would be useful
in the future to set up multicentric studies with a standardised description of
the procedure and serial measurements in different timing during the weaning
trial. Furthermore, randomized controlled trials to evaluate the efficiency of
tdi% versus other indexes in predicting extubation failure are needed.
PMID: 25396686 [PubMed - as supplied by publisher]
5. Crit Ultrasound J. 2014 Jun 7;6(1):8. doi: 10.1186/2036-7902-6-8. eCollection
2014.
Diaphragm ultrasound as a new index of discontinuation from mechanical
ventilation.
Ferrari G(1), De Filippi G(1), Elia F(1), Panero F(1), Volpicelli G(2), Apr

F(1).
Author information:
(1)High Dependency Unit, San Giovanni Bosco Hospital, P.za Donatore del Sangue 3
,
Turin 10154, Italy. (2)Department of Emergency Medicine, San Luigi Gonzaga
University Hospital, Turin 10043, Italy.
BACKGROUND: Predictive indexes of weaning from mechanical ventilation are often
inaccurate. Among the many indexes used in clinical practice, the rapid shallow
breathing index is one of the most accurate. We evaluated a new weaning index
consisting in the diaphragm thickening fraction (DTF) assessed by ultrasound.
METHODS: Forty-six patients were prospectively enrolled. All patients were
ventilated in pressure support through a tracheostomy tube. Patients underwent a
spontaneous breathing trial (SBT) when they met all the following criteria:
FiO2 < 0.5, PEEP 5cmH2O, PaO2/FiO2 > 200, respiratory rate <30 breaths per
minute, absence of fever, alert and cooperative, and hemodynamic stability
without vaso-active therapy support. During the trial, the right hemi-diaphragm
was visualized in the zone of apposition using a 10-MHz linear ultrasound probe.
The patient was then instructed to perform breathing to total lung capacity (TLC
)
and then exhaling to residual volume (RV). Diaphragm thickness was recorded at
TLC and RV, and the DTF was calculated as percentage from the following formula:
Thickness at end inspiration - Thickness at end expiration / Thickness at end
expiration. Also, the rapid shallow breathing index (RSBI) was calculated.
Weaning failure was defined as the inability to maintain spontaneous breathing
for at least 48h, without any form of ventilatory support.
RESULTS: A significant difference between diaphragm thickness at TLC and RV was
observed both in patients who succeeded SBT and patients who failed. DTF was
significantly different between patients who failed and patients who succeeded
SBT. A cutoff value of a DTF >36% was associated with a successful SBT with a
sensitivity of 0.82, a specificity of 0.88, a positive predictive value (PPV) of
0.92, and a negative predictive value (NPV) of 0.75. By comparison, RSBI <105 ha
d
a sensitivity of 0.93, a specificity of 0.88, a PPV of 0.93, and a NPV of 0.88
for determining SBT success.
CONCLUSIONS: This study shows that in our cohort of patients, the assessment of
DTF by diaphragm ultrasound may perform similarly to other weaning indexes. If
validated by other studies, this method may be used in clinical practice.
PMCID: PMC4057909
PMID: 24949192 [PubMed]
6. Thorax. 2014 May;69(5):402-4. doi: 10.1136/thoraxjnl-2013-204920.
Measuring diaphragm shortening using ultrasonography to predict extubation
success.
Criner GJ.
PMID: 24727579 [PubMed - indexed for MEDLINE]
7. Curr Opin Crit Care. 2014 Jun;20(3):352-8. doi: 10.1097/MCC.0000000000000089.

Assessing effort and work of breathing.

Bellani G(1), Pesenti A.
Author information:
(1)aDepartment of Health Science, University of Milan-Bicocca bDepartment of
Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.
PURPOSE OF REVIEW: Spontaneous breathing has been shown to induce both positive
and negative effects on the function and on injury of lungs and diaphragm during
critical illness; thus, monitoring of the breathing effort generated by the
patient might be valuable for a better understanding of the mechanisms of diseas
e
and to set properly ventilation. The purpose of this review is to summarize the
recent findings on the different techniques available to measure the patient's
breathing effort, mainly during spontaneous assisted ventilation.
RECENT FINDINGS: Although esophageal pressure measurement remains the solid
reference technique to quantitate the breathing effort, other tools have been
developed and tested. These include the diaphragmatic electromyogram, whose
voltage is linearly related to the pressure generated by the diaphragm,
ultrasound, which relies on the measurement of diaphragmatic displacement or
thickening, and other approaches, which derive breathing effort solely from the
airway flow and pressure tracings.
SUMMARY: The development of measurement techniques and their introduction in
clinical practice will allow us to understand the role of spontaneous breathing
effort in the pathophysiology of lung injury and weaning failure, and how to
adjust the breathing workload in an individual patient.
PMID: 24722059 [PubMed - indexed for MEDLINE]
8. BMJ Case Rep. 2014 Jan 28;2014. pii: bcr2013202202. doi: 10.1136/bcr-2013-202
202.
Difficult to wean: think of the diaphragm.
Suryanarayana J(1), Varma M, Vidyasagar S, Vivek G.
Author information:
(1)Department of Medicine, Kasturba Medical College, Manipal University, Manipal
,
Karnataka, India.
A 65-year-old woman, treated for non-ST segment elevation myocardial infarction
and unexplained type 2 respiratory failure, was referred to our hospital in view
of difficulty in weaning off the ventilator. She was evaluated in detail for
persistent hypercapnia. Ultrasound of the diaphragm showed minimal excursion of
diaphragm while she was off the ventilator and fluoroscopy confirmed bilateral
diaphragmatic palsy. As extensive radiological, immunological and microbiologica
l
workup ruled out other possible aetiologies, a diagnosis of idiopathic Bell's
palsy of the diaphragm was made. She was treated with valacyclovir and steroids
after which she gradually recovered and was weaned off the ventilator.
PMID: 24473427 [PubMed - indexed for MEDLINE]
9. Thorax. 2014 May;69(5):423-7. doi: 10.1136/thoraxjnl-2013-204111. Epub 2013 D

ec
23.
Diaphragm ultrasound as a predictor of successful extubation from mechanical
ventilation.
DiNino E(1), Gartman EJ, Sethi JM, McCool FD.
Author information:
(1)Memorial Hospital of Rhode Island and Brown University, , Pawtucket, Rhode
Island, USA.
INTRODUCTION: The purpose of this study was to evaluate if ultrasound derived
measures of diaphragm thickening, rather than diaphragm motion, can be used to
predict extubation success or failure.
METHODS: Sixty-three mechanically ventilated patients were prospectively
recruited. Diaphragm thickness (tdi) was measured in the zone of apposition of
the diaphragm to the rib cage using a 7-10 MHz ultrasound transducer. The percen
t
change in tdi between end-expiration and end-inspiration (tdi%) was calculated
during either spontaneous breathing (SB) or pressure support (PS) weaning trials
.
A successful extubation was defined as SB for >48 h following endotracheal tube
removal.
RESULTS: Of the 63 subjects studied, 27 patients were weaned with SB and 36 were
weaned with PS. The combined sensitivity and specificity of tdi%30% for
extubation success was 88% and 71%, respectively. The positive predictive value
and negative predictive value were 91% and 63%, respectively. The area under the
receiver operating characteristic curve was 0.79 for tdi%.
CONCLUSIONS: Ultrasound measures of diaphragm thickening in the zone of
apposition may be useful to predict extubation success or failure during SB or P
S
trials.
PMID: 24365607 [PubMed - indexed for MEDLINE]
10. Korean J Anesthesiol. 2013 Jun;64(6):545-9. doi: 10.4097/kjae.2013.64.6.545.
Epub
2013 Jun 24.
Successful weaning from mechanical ventilation in the quadriplegia patient with
C2 spinal cord injury undergoing C2-4 spine laminoplasty -A case report-.
Chang JE(1), Park SH, Do SH, Song IA.
Author information:
(1)Department of Anesthesiology and Pain Medicine, Seoul National University
Hospital, Seoul, Korea.
In patients with cervical spine injuries, respiratory function requires careful
attention. Voluntary respiratory control is usually possible with lesions below
C4 level although paralysis of the abdominal musculature results in a decreased
ability to cough and to clear secretions, which may later lead to respiratory
insufficiency. Therefore, injuries above C5 usually necessitate long term
mechanical ventilation. Even though weaning criteria are not definitive for the
quadriplegic patient, M-mode ultrasonography of the diaphragm may be useful in
identifying patients at high risk of difficulty weaning. Diaphragmatic

dysfunction (vertical excursion < 10 mm or paradoxical movements) results in

frequent early and delayed weaning failures. We present our clinical experience
with successful weaning by using M-mode ultrasonography and a cough-assist devic
e
for secretion clearance after extubation in a quadriplegic patient undergoing
C2-4 spine laminoplasty.
PMCID: PMC3695255
PMID: 23814658 [PubMed]
11. Intensive Care Med. 2013 May;39(5):801-10. doi: 10.1007/s00134-013-2823-1. E
pub
2013 Jan 24.
Sonographic evaluation of the diaphragm in critically ill patients. Technique an
d
clinical applications.
Matamis D(1), Soilemezi E, Tsagourias M, Akoumianaki E, Dimassi S, Boroli F,
Richard JC, Brochard L.
Author information:
(1)Intensive Care Unit, Papageorgiou General Hospital, Thessaloniki, Greece.
dmatamis@gmail.com
Comment in
Intensive Care Med. 2013 May;39(5):986.
The use of ultrasonography has become increasingly popular in the everyday
management of critically ill patients. It has been demonstrated to be a safe and
handy bedside tool that allows rapid hemodynamic assessment and visualization of
the thoracic, abdominal and major vessels structures. More recently, M-mode
ultrasonography has been used in the assessment of diaphragm kinetics.
Ultrasounds provide a simple, non-invasive method of quantifying diaphragmatic
movement in a variety of normal and pathological conditions. Ultrasonography can
assess the characteristics of diaphragmatic movement such as amplitude, force an
d
velocity of contraction, special patterns of motion and changes in diaphragmatic
thickness during inspiration. These sonographic diaphragmatic parameters can
provide valuable information in the assessment and follow up of patients with
diaphragmatic weakness or paralysis, in terms of patient-ventilator interactions
during controlled or assisted modalities of mechanical ventilation, and can
potentially help to understand post-operative pulmonary dysfunction or weaning
failure from mechanical ventilation. This article reviews the technique and the
clinical applications of ultrasonography in the evaluation of diaphragmatic
function in ICU patients.
PMID: 23344830 [PubMed - indexed for MEDLINE]
12. Am J Respir Crit Care Med. 2013 Jan 1;187(1):20-7. doi:
10.1164/rccm.201206-1117CP. Epub 2012 Oct 26.
Monitoring of the respiratory muscles in the critically ill.

Doorduin J(1), van Hees HW, van der Hoeven JG, Heunks LM.
Author information:
(1)Department of Critical Care Medicine, Radboud University Nijmegen Medical
Centre, The Netherlands.
Evidence has accumulated that respiratory muscle dysfunction develops in
critically ill patients and contributes to prolonged weaning from mechanical
ventilation. Accordingly, it seems highly appropriate to monitor the respiratory
muscles in these patients. Today, we are only at the beginning of routinely
monitoring respiratory muscle function. Indeed, most clinicians do not evaluate
respiratory muscle function in critically ill patients at all. In our opinion,
however, practical issues and the absence of sound scientific data for clinical
benefit should not discourage clinicians from having a closer look at respirator
y
muscle function in critically ill patients. This perspective discusses the lates
t
developments in the field of respiratory muscle monitoring and possible
implications of monitoring respiratory muscle function in critically ill
patients.
PMID: 23103733 [PubMed - indexed for MEDLINE]
13. Dtsch Med Wochenschr. 2012 Mar;137(13):644-7. doi: 10.1055/s-0031-1299035. E
pub
2012 Mar 20.
[Weaning from mechanical ventilation - new aspects].
[Article in German]
Pfeifer M(1), Schnhofer B.
Author information:
(1)Klinik Donaustauf - Zentrum fr Pneumologie. michael.pfeifer@ukr.de
PMID: 22434172 [PubMed - indexed for MEDLINE]
14. Crit Care Med. 2011 Dec;39(12):2760-1. doi: 10.1097/CCM.0b013e31822a55e9.
Ultrasonographic evaluation of diaphragmatic function.
Lerolle N, Diehl JL.
Comment on
Crit Care Med. 2011 Dec;39(12):2627-30.
PMID: 22094504 [PubMed - indexed for MEDLINE]
15. Crit Care Med. 2011 Dec;39(12):2627-30. doi: 10.1097/CCM.0b013e3182266408.
Diaphragm dysfunction assessed by ultrasonography: influence on weaning from
mechanical ventilation.
Kim WY(1), Suh HJ, Hong SB, Koh Y, Lim CM.

Author information:
(1)Department of Emergency Medicine, Ulsan University College of Medicine, Asan
Medical Center, Seoul, Korea.
Comment in
Crit Care Med. 2011 Dec;39(12):2760-1.
OBJECTIVE: To determine the prevalence of diaphragmatic dysfunction diagnosed by
M-mode ultrasonography (vertical excursion <10 mm or paradoxic movements) in
medical intensive care unit patients and to assess the influence of diaphragmati
c
dysfunction on weaning outcome.
DESIGN: Prospective, observational study.
SETTING: Twenty-eight-bed medical intensive care unit in a university-affiliated
hospital.
PATIENTS: Eighty-eight consecutive patients in the medical intensive care unit
who required mechanical ventilation over 48 hrs and met the criteria for a
spontaneous breathing trial were assessed. Patients with a history of
diaphragmatic or neuromuscular disease or evidence of pneumothorax or
pneumomediastinum were excluded.
INTERVENTIONS: During spontaneous breathing trial, each hemidiaphragm was
evaluated by M-mode ultrasonography using the liver and spleen as windows with
the patient supine. Rapid shallow breathing index was simultaneously calculated
at the bedside.
MEASUREMENTS AND MAIN RESULTS: The prevalence of ultrasonographic diaphragmatic
dysfunction among the eligible 82 patients was 29% (n = 24). Patients with
diaphragmatic dysfunction had longer weaning time (401 [range, 226-612] hrs vs.
90 [range, 24-309] hrs, p < .01) and total ventilation time (576 [range, 374-850
]
hrs vs. 203 [range, 109-408] hrs, p < .01) than patients without diaphragmatic
dysfunction. Patients with diaphragmatic dysfunction also had higher rates of
primary (20 of 24 vs. 34 of 58, p < .01) and secondary (ten of 20 vs. ten of 46,
p = .01) weaning failures than patients without diaphragmatic dysfunction. The
area under the receiver operating characteristics curve of ultrasonographic
criteria in predicting weaning failure was similar to that of rapid shallow
breathing index.
CONCLUSIONS: Using M-mode ultrasonography, diaphragmatic dysfunction was found i
n
a substantial number of medical intensive care unit patients without histories o
f
diaphragmatic disease. Patients with such diaphragmatic dysfunction showed
frequent early and delayed weaning failures. Ultrasonography of the diaphragm ma
y
be useful in identifying patients at high risk of difficulty weaning.
PMID: 21705883 [PubMed - indexed for MEDLINE]
16. Iran J Pediatr. 2011 Mar;21(1):116-20.
Early surgical intervention for diaphragmatic paralysis in a neonate; report of
a
case and literature review.
Ahmadpour-Kacho M(1), Zahedpasha Y, Hadipoor A, Akbarian-Rad Z.

Author information:
(1)Department of Pediatrics, Non-Communicable Pediatric Disease Research Center,
Amirkola Children's Hospital, Babol University of Medical Sciences, Babol, Iran.
BACKGROUND: Diaphragmatic paralysis in newborns is related to brachial plexus
palsy. It can cause respiratory failure necessitating prolonged mechanical
ventilation and subsequent extubation failure.
CASE PRESENTATION: We present a two-hour-old male newborn with a birth weight of
4500 grams who had a right-sided brachial plexus palsy and right diaphragmatic
paralysis due to shoulder dystocia. He developed respiratory distress due to
isolated paralysis of the right hemi diaphragm. The clinical course was
progressive, his condition worsening despite oxygen application. Physical
examination, chest X-rays and M-mode ultrasonography of the diaphragm confirmed
the diagnosis diaphragmatic paralysis. Surgical plication of diaphragm was done
earlier than the usual time because of recurrent extubation failure.
Diaphragmatic plication led to rapid improvement of pulmonary function and
allowed discontinuation of mechanical ventilation in less than 3 days.
CONCLUSION: Early diaphragmatic plication enhances weaning process and may
prevent or minimize the morbidity associated with long-term mechanical
ventilation in a neonate with diaphragmatic paralysis.
PMCID: PMC3446119
PMID: 23056776 [PubMed]
17. Ultrasound Obstet Gynecol. 2006 Jan;27(1):84-8; discussion 88.
Fetoscopic and ultrasound-guided decompression of the fetal trachea in a human
fetus with Fraser syndrome and congenital high airway obstruction syndrome
(CHAOS) from laryngeal atresia.
Kohl T(1), Hering R, Bauriedel G, Van de Vondel P, Heep A, Keiner S, Mller A,
Franz A, Bartmann P, Gembruch U.
Author information:
(1)German Center for Fetal Surgery & Minimally-Invasive Therapy, Department of
Obstetrics & Prenatal Medicine, University of Bonn, Bonn, Germany.
thomas.kohl@ukb.uni-bonn.de
Congenital high airway obstruction syndrome (CHAOS) from laryngeal atresia bears
a poor prognosis for hydropic fetuses owing to cardiac failure. We attempted
percutaneous fetoscopic and ultrasound-guided tracheal decompression in a
hydropic human fetus with CHAOS associated with Fraser syndrome. Percutaneous
fetoscopic and ultrasound-guided tracheal decompression was performed using thre
e
trocars under general materno-fetal anesthesia at 19 + 5 weeks of gestation.
Abnormal fetoplacental blood flow normalized within hours as a result of the
intervention. Furthermore, a normalization of lung : heart size and lung
echogenicity was observed within days. Resolution of hydrops was complete within
3 weeks. Premature rupture of membranes and premature contractions prompted
emergency delivery of the fetus by ex-utero intrapartum treatment (EXIT) at 28 +
2 weeks of gestation. Following delivery, the lungs could be ventilated at low
pressures and ambient oxygen concentration. Weaning from ventilation was achieve
d
at 18 days of postnatal life. Our experience indicated that percutaneous

fetoscopic and ultrasound-guided decompression of the fetal trachea is feasible

and may permit normalization of hemodynamics in hydropic human fetuses with CHAO
S
from laryngeal atresia. The procedure may also result in normalization of heart
:
lung size and provide the time needed to regain the function of the overstretche
d
diaphragm in this grave fetal condition.
Copyright 2005 ISUOG.
PMID: 16308883 [PubMed - indexed for MEDLINE]
18. Chest. 2004 Jul;126(1):179-85.
Ultrasonographic evaluation of liver/spleen movements and extubation outcome.
Jiang JR(1), Tsai TH, Jerng JS, Yu CJ, Wu HD, Yang PC.
Author information:
(1)Department of Internal Medicine, Yun Lin Hospital, Executive Yuan, Taiwan.
INTRODUCTION: The diaphragm plays a pivotal role in weaning and successful
extubation. We hypothesized that ultrasonographic evaluation of the movements of
the diaphragm by measuring liver/spleen displacement during spontaneous breathin
g
trials is a good predictor for extubation outcome.
PATIENTS AND METHODS: The studied subjects were intubated patients receiving
mechanical ventilation who were scheduled to be extubated. The displacement of
liver/spleen was measured by ultrasonography before extubation. The patients wer
e
classified into a success group (SG) or failure group according to the extubatio
n
outcome. The baseline data and organ displacements in these two groups were
analyzed. The sensitivity and specificity for the mean organ displacements and
weaning parameters to predict successful extubation were calculated.
RESULTS: We included 55 patients, 32 of whom (58%) were in the SG. The baseline
data are similar for these two groups, but the mean values of liver and spleen
displacements were higher in the SG. Using a cutoff value of 1.1 cm, the
sensitivity and specificity to predict successful extubation were 84.4% and
82.6%, respectively, better than traditional weaning parameters in this study.
CONCLUSION: The displacement of the liver/spleen, measured by ultrasonography, i
s
a good predictor for extubation outcome.
PMID: 15249460 [PubMed - indexed for MEDLINE]
19. Transpl Int. 1998;11(4):281-3.
Diaphragmatic nerve palsy in young children following liver transplantation.
Successful treatment by plication of the diaphragm.
Smyrniotis V(1), Andreani P, Muiesan P, Mieli-Vergani G, Rela M, Heaton ND.
Author information:
(1)Liver Transplant Surgical Service, King's College Hospital, London, UK.

Diaphragmatic paralysis was identified in four children after liver

transplantation. All presented with persistent right upper lobe atelectasis,
pleural effusion and recurrent respiratory infections and could not be weaned
from mechanical ventilatory support. Fluoroscopy and real-time ultrasound
confirmed paradoxical right diaphragmatic movements. Diaphragmatic plication was
undertaken and enabled rapid and sustained weaning from respiratory support in
all four cases. Vascular clamping of the suprahepatic vena cava seems to be the
cause. Diaphragmatic plication allows optimal recruitment of the respiratory
muscles with a favourable impact on lung mechanics and gas exchange.
PMID: 9704392 [PubMed - indexed for MEDLINE]
20. J Cardiothorac Vasc Anesth. 1995 Dec;9(6):670-5.
Clinical estimation of left and right ventricular volume with open chest compare
d
with transesophageal echocardiography and fast-response thermodilution.
Samuelsson S(1), Ehrenberg J, Settergren G.
Author information:
(1)Department of Cardiothoracic Anaesthetics, Karolinska Hospital, Stockholm,
Sweden.
OBJECTIVE: A clinical measure--inspection of the relation of the heart (acute
margin) to the diaphragm--has shown a strong positive correlation to
transesophageal echocardiographic (TEE) determination of left ventricular
end-diastolic area (LVEDA) during weaning from cardiopulmonary bypass (CPB). The
present study examines the correlation between right ventricular end-diastolic
volumes (RVEDV) before and after CPB when using the same clinical measure of lef
t
ventricular dimension.
DESIGN: Prospective study.
SETTING: Operating room, university hospital.
PARTICIPANTS: Patients scheduled for elective coronary artery bypass grafting.
INTERVENTIONS: After induction of anesthesia and endotracheal intubation, a
transesophageal echo-probe was inserted. A pulmonary artery right ventricular
ejection fraction/volumetric TD catheter was placed in the pulmonary artery.
MEASUREMENTS AND MAIN RESULTS: Before going on CPB, a mark was made with cautery
at the line of contact between the acute margin and the diaphragm. After CPB, th
e
patients were transfused to the same level. At these two times, TEE recordings o
f
the LVEDA and hemodynamic measurements including calculations of RVEDV were
obtained. The LVEDA before and after CPB showed a positive correlation, r = 0.81
,
p < 0.001. The RVEDV after CPB showed a weak correlation, r = 0.54, p < 0.05, to
RVEDV before CPB. There were no significant changes in right ventricular (RV)
wall tension calculated as right atrial pressure x RVEDV and pulmonary artery
systolic pressure x right ventricular end-systolic volume products. The only
significant change regarding hemodynamic parameters was a decrease in mean
arterial pressure.
CONCLUSIONS: It is concluded that there is only a weak correlation regarding
RVEDV before and after CPB when the patient is transfused to the line of contact
,

whereas this clinical measure correlates well with LVEDA.

PMID: 8664458 [PubMed - indexed for MEDLINE]
21. Pediatr Pulmonol. 1994 Sep;18(3):187-93.
Diaphragmatic paralysis in children: a review of 11 cases.
Commare MC(1), Kurstjens SP, Barois A.
Author information:
(1)Pediatric Intensive Care Unit, Raymond Poincar Hospital, Garches, France.
We reviewed 11 pediatric cases of diaphragmatic paralysis related to
nonspinal-cord injury which were managed in our Intensive Care Unit over the pas
t
10 years. Three cases were secondary to birth trauma, 7 followed surgical
procedures for congenital heart disease, and 1 occurred in association with
injuries sustained in a motor vehicle accident. The paralysis was bilateral in 8
children. The diagnosis was initially suspected on clinical grounds because of
respiratory distress, impossibility of weaning from the ventilator, and
paradoxical abdominal respiratory movements. Confirmatory investigations include
d
chest radiography, which revealed elevation of the affected hemidiaphragm,
fluoroscopy and ultrasound, both of which demonstrated diminished diaphragmatic
movement. Electromyography exhibited a failure of diaphragmatic response to
phrenic nerve stimulation in 8 patients. All patients were mechanically
ventilated; tracheostomy was required in 5 patients. Physiotherapy was considere
d
a beneficial adjuvant measure. Diaphragmatic plication was attempted without
success in 3 children. Seven children recovered without sequelae: Partial
respiratory autonomy was achieved after an average of 2.6 months, complete
autonomy after an average of 5.4 months. Two patients developed chronic lung
disease; one of them remains unresponsive, and one child died following
accidental extubation. We conclude that the diagnosis of diaphragmatic paralysis
is predominantly clinical, and that the outcome of patients treated by adequate
endotracheal mechanical ventilation is usually favorable.
PMID: 7800436 [PubMed - indexed for MEDLINE]
22. J Cardiothorac Vasc Anesth. 1993 Jun;7(3):290-3.
Comparison of clinical and echocardiographic determinations of left ventricular
dimension during weaning from cardiopulmonary bypass.
Settergren G(1), Samuelson S, Owall A, Brodin LA, Juhlin-Dannfelt A, Liska J.
Author information:
(1)Department of Cardiothoracic Anaesthetics and Intensive Care, Karolinska
Hospital, Stockholm, Sweden.
Twenty patients (age 45 to 78 years) were studied with ethical committee approva
l
and informed patient consent during coronary artery bypass grafting.
Transesophageal echocardiography (TEE) was used to validate a clinical measure o
f

preload: inspection of the line of contact between the heart (acute margin) and
the diaphragm. Immediately before going on cardiopulmonary bypass (CPB), with th
e
cannulas and stay sutures in place, a small mark was made with the cautery on th
e
diaphragm at the line of contact. After CPB the patients were transfused from th
e
extracorporeal circuit to exactly the same level. At these two times, TEE
recordings of the short axis of the left ventricle were performed and stored on
videotape for later blinded evaluation off-line. The left ventricle short-axis
area in end-diastole measured after CPB showed a close correlation to that
measured before CPB, r = 0.88, P < 0.001. The regression line was close to the
line of identity. The conclusion was that inspection of the line of contact
between the heart and the diaphragm can be used clinically during weaning from
bypass to obtain the same left ventricular end-diastolic volume as before CPB.
PMID: 8518374 [PubMed - indexed for MEDLINE]
23. Acta Paediatr Scand. 1991 Mar;80(3):308-15.
The effect of aminophylline on the excursions of the diaphragm in preterm
neonates. A randomized double-blind controlled study.
Heyman E(1), Ohlsson A, Heyman Z, Fong K.
Author information:
(1)University of Toronto Regional Perinatal Unit, Ontario, Canada.
Aminophylline is used to treat apnoea and to facilitate weaning from assisted
ventilation in preterm infants. Aminophylline is thought to increase respiratory
drive centrally. We performed a randomized controlled double-blind study to
determine if aminophylline increases the excursions of the diaphragm indicating
a
possible direct peripheral effect. Twenty-two neonates were randomized to
treatment with intravenous aminophylline (n = 11) or to no treatment (n = 11). A
n
ultrasonographer, who was blinded to the group assignment, studied the
diaphragmatic excursions using a real time sector scanner. The posterior
one-third of the right hemidiaphragm was localized and M-mode was used to record
the diaphragmatic excursions on paper. The neonates were studied in an awake but
quiet state. Aminophylline resulted in an increase (43%) in the excursions of th
e
diaphragm (p = 0.012) with no change in respiratory rate or pCO2. These findings
indicate that aminophylline had a measurable effect on the diaphragmatic motion.
Further studies combining this technique with other techniques are needed to
determine if the main effect of aminophylline in the prevention of apnoea is
mainly central or peripheral.
PMID: 2035326 [PubMed - indexed for MEDLINE]
24. J Steroid Biochem Mol Biol. 1991;40(4-6):705-10.
Contraception with progestogens and progesterone during lactation.

Shaaban MM(1).
Author information:
(1)Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut
University, Egypt.
The growth and development of breastfed infants whose mothers used the
contraceptive implants Norplant containing levonorgestrel and the injectable
containing norethisterone enanthate were studied. Each group comprised of 120
women who initiated the use during the 5th to 7th week postpartum and were
compared with a similar number of IUD using mothers. The breastfeeding
performance did not differ between groups. The infants of the three groups
performed similarly as regards their physical growth and health as well as the
time of acquisition of the various milestones of psychomental development. A
vaginal ring releasing 10 mg of the "natural" progesterone per 24 h was tested i
n
breastfeeding mothers. The continuous use of the ring produced a serum level of
progesterone around 4 ng/ml. This was effective in augmenting lactational
infertility even through the later phases of breastfeeding when such an effect
starts to wane off. The use of the ring proved to be acceptable and had no
ill-effect on breastfeeding or infant growth or health. Using the natural
progesterone as a contraceptive adds a new measure of safety, since the amount o
f
the steroid secreted in the mother's milk will not be effectively absorbed from
the infant's gut. These studies suggest the possibility of using two new methods
for breastfeeding mothers; Norplant and the progesterone vaginal contraceptive
ring. These can be initiated early postpartum, whenever this is considered
needed.
PIP: Weight gain and psychomotor development of breastfed infants of Egyptian
mothers using Norplant, Cu T-380A IUDs, norethisterone enanthate injectables
(NET-EN), Depo Provera and a levonorgestrel minipill were compared in 2 trials.
First, groups of 120 women using Norplant and NET-EN were compared to a control
group using IUDs, beginning 5-7 weeks postpartum. There were no differences in
infant weight gain, mid-arm circumference, triceps-skin-fold thickness, or timin
g
of motor milestones. The mean growth curve of all 3 groups were close to that of
the 50th percentile for Egyptian infants. While timing of initiation of
supplements was similar in the 3 groups, complete weaning occurred first in the
IUD group, second in the Norplant group, and last in the NET-EN users. A second
trail compared progesterone implants injected with a trocar that resulted in a
blood level of 3 ng/ml for 5 months, with Population Council vaginal rings
releasing 10 progesterone/24 hours, and CuT-380A IUDs. Serum progesterone in the
ring users averaged 5.2 ng/ml for the 1st 2 weeks, then leveled off at about 4
ng/ml for about 2 months, falling to about 3 ng/ml for the last 3 weeks of use.
Each women used 4 rings per year. Evidence of ovulation by ultrasonic vaginal
probe and assay of estradiol and progesterone was apparent in 25% of vaginal rin
g
users, compared to 55.9% of controls in the 2nd 6 months postpartum. There was 1
pregnancy in a ring users. The continuation rates were 66.6% for rings and 85.5%
for IUDs. The reasons for discontinuation in vaginal ring continuation were
logistical problems and unfamiliarity.
PMID: 1835650 [PubMed - indexed for MEDLINE]