Indian Journal of Respiratory Care

IJRC Email      Register      Login

VOLUME 13 , ISSUE 2 ( April-June, 2024 ) > List of Articles

Original Article

Reduced Diaphragmatic Thickness Index in Mechanically Ventilated Patients: Incidence, Risk Factors, and Impact on Weaning Outcome

Debasish Panda, Suresh Kumar Sundaramurthy, Lakshmi Ranganathan, Ramesh Venkataraman, Nagarajan Ramakrishnan, Raymond Dominic Savio

Keywords : Diaphragmatic dysfunction, Diaphragmatic thickness index, Diaphragmatic weakness, Mechanical ventilation, Spontaneous breathing trial, Weaning

Citation Information : Panda D, Sundaramurthy SK, Ranganathan L, Venkataraman R, Ramakrishnan N, Savio RD. Reduced Diaphragmatic Thickness Index in Mechanically Ventilated Patients: Incidence, Risk Factors, and Impact on Weaning Outcome. Indian J Respir Care 2024; 13 (2):95-100.

DOI: 10.5005/jp-journals-11010-1111

License: CC BY-NC 4.0

Published Online: 18-06-2024

Copyright Statement:  Copyright © 2024; The Author(s).


Background: Diaphragmatic weakness (DW) is common in an intensive care unit (ICU) and diaphragmatic thickness index (DTI) using ultrasound is used as a surrogate marker for DW despite many limitations. This study aims to identify the incidence and risk factors of reduced DTI (≤30%) among patients ventilated for >48 hours and its impact on outcome of first spontaneous breathing trial (SBT). Materials and methods: Single-center, prospective, observational study, conducted in a tertiary care ICU, over 4 months. Consecutive, eligible patients initiated on mechanical ventilation (MV) upon hospitalization and continued for >48 hours were included. Serial measurements of DTI were done once every 3 days until first SBT. Data pertaining to risk factors for DW and outcome of first SBT were documented. Results: Ninety-two patients were included in the final analysis of the study. DTI ≤30% was identified in 43.5% of patients. Sepsis on admission (p = 0.02) and use of neuromuscular blocking (NMB) agent infusion (p = 0.028) were significantly associated with reduced DTI. Failure of first SBT was observed in 82.5% of the patients with DTI ≤30%, whereas only 25% of those with DTI ≥31% were unsuccessful [relative risk (RR)—3.3; confidence interval (CI)—2.47–1.34]. Mean DTI was significantly higher among those who succeeded their first SBT (32.9 ± 8.9) vs those who failed (19.32 ± 11.89). Conclusion: Reduced DTI (≤30%) is common among patients mechanically ventilated for greater than 48 hours. Sepsis on admission and use of NMB agent infusion were identified as significant risk factors. DTI ≤30% was significantly associated with a failed first SBT.

PDF Share
  1. Supinski GS, Morris PE, Dhar S, et al. Diaphragm dysfunction in critical illness. Chest 2018;153(4):1040–1051. DOI: 10.1016/j.chest.2017.08.1157
  2. Callahan LA, Supinski GS. Sepsis induces diaphragm electron transport chain dysfunction and protein depletion. Am J Respir Crit Care Med 2005;172(7):861–868. DOI: 10.1164/rccm.200410-1344OC
  3. Vassilakopoulos T, Zakynthinos S, Roussos C. Respiratory muscles and weaning failure. Eur Respir J 1996;9(11):2383–2400. DOI: 10.1183/09031936.96.09112383
  4. Vassilakopoulos T, Roussos C, Zakynthinos S. Weaning from mechanical ventilation. J Crit Care 1999;14(1):39–62. DOI: 10.1016/s0883-9441(99)90007-2
  5. Demoule A, Jung B, Prodanovic H, et al. Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact—a prospective study. Am J Respir Crit Care Med 2013;188(2):213–219. DOI: 10.1164/rccm.201209-1668OC
  6. Vassilakopoulos T, Zakynthinos S, Roussos C. The tension-time index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success. Am J Respir Crit Care Med 1998;158(2):378–385. DOI: 10.1164/ajrccm.158.2.9710084
  7. Kim WY, Suh HJ, Hong SB, et al. Diaphragm dysfunction assessed by ultrasonography: Influence on weaning from mechanical ventilation. Crit Care Med 2011;39(12):2627–2630. DOI: 10.1097/CCM.0b013e3182266408
  8. Adler D, Dupuis-Lozeron E, Richard JC, et al. Does inspiratory muscle dysfunction predict readmission after intensive care unit discharge? Am J Respir Crit Care Med 2014;190(3):347–350. DOI: 10.1164/rccm.201404-0655LE
  9. Dubé BP, Dres M, Mayaux J, et al. Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications. Thorax 2017;72(9):811–818. DOI: 10.1136/thoraxjnl-2016-209459
  10. Mills GH, Kyroussis D, Hamnegard CH, et al. Cervical magnetic stimulation of the phrenic nerves in bilateral diaphragm paralysis. Am J Respir Crit Care Med 1997;155(5):1565–1569. DOI: 10.1164/ajrccm.155.5.9154858
  11. Watson AC, Hughes PD, Louise Harris M, et al. Measurement of twitch transdiaphragmatic, esophageal, and endotracheal tube pressure with bilateral anterolateral magnetic phrenic nerve stimulation in patients in the intensive care unit. Crit Care Med 2001;29(7):1325–1331. DOI: 10.1097/00003246-200107000-00005
  12. Mier A, Brophy C, Moxham J, et al. Twitch pressures in the assessment of diaphragm weakness. Thorax 1989;44(12):990–996. DOI: 10.1136/thx.44.12.990
  13. Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest 2009;135(2):391–400. DOI: 10.1378/chest.08-1541
  14. Haji K, Royse A, Green C, et al. Interpreting diaphragmatic movement with bedside imaging, review article. J Crit Care 2016;34:56–65. DOI: 10.1016/j.jcrc.2016.03.006
  15. Francis CA, Hoffer JA, Reynolds S. Ultrasonographic evaluation of diaphragm thickness during mechanical ventilation in intensive care patients. Am J Crit Care 2016;25(1):e1–e8. DOI: 10.4037/ajcc2016563
  16. Bobbia X, Clément A, Claret PG, et al. Diaphragmatic excursion measurement in emergency patients with acute dyspnea: toward a new diagnostic tool? Am J Emerg Med 2016;34(8):1653–1657. DOI: 10.1016/j.ajem.2016.05.055
  17. Zambon M, Greco M, Bocchino S, et al. Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound: a systematic review. Intensive Care Med 2016;43(1):29–38. DOI: 10.1007/s00134-016-4524-z
  18. Llamas-Álvarez AM, Tenza-Lozano EM, Latour-Pérez J. Diaphragm and lung ultrasound to predict weaning outcome: systematic review and meta-analysis. Chest 2017;152(6):1140–1150. DOI: 10.1016/j.chest.2017.08.028
  19. Sarwal A, Walker FO, Cartwright MS. Neuromuscular ultrasound for evaluation of the diaphragm. Muscle Nerve 2013;47(3):319–329. DOI: 10.1002/mus.23671
  20. Gerscovich EO, Cronan M, McGahan JP, et al. Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med 2001;20(6):597–604. DOI: 10.7863/jum.2001.20.6.597
  21. American Thoracic Society/European Respiratory Society. ATS/ERS statement on respiratory muscle testing. Am J Respir Crit Care Med 2002;166(4):518–624. DOI: 10.1164/rccm.166.4.518
  22. Dres M, Dubé BP, Mayaux J, et al. Coexistence and impact of limb muscle and diaphragm weakness at time of liberation from mechanical ventilation in medical intensive care unit patients. Am J Respir Crit Care Med 2017;195(1):57–66. DOI: 10.1164/rccm.201602-0367OC
  23. Jung B, Moury PH, Mahul M, et al. Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med 2015;42(5):853–861. DOI: 10.1007/s00134-015-4125-2
  24. Amoateng-Adjepong Y, Jacob BK, Ahmad M, et al. The effect of sepsis on breathing pattern and weaning outcomes in patients recovering from respiratory failure. Chest 1997;112(2):472–477. DOI: 10.1378/chest.112.2.472
  25. Demoule A, Molinari N, Jung B, et al. Patterns of diaphragm function in critically ill patients receiving prolonged mechanical ventilation: a prospective longitudinal study. Ann Intensive Care 2016;6(1):75–82. DOI: 10.1186/s13613-016-0179-8
  26. Cappellini I, Picciafuochi F, Ostento D, et al. Recovery of muscle function after deep neuromuscular block by means of diaphragm ultrasonography and adductor of pollicis acceleromyography with comparison of neostigmine vs. sugammadex as reversal drugs: study protocol for a randomized controlled trial. Trials 2018;19(1):135–141. DOI: 10.1186/s13063-018-2525-7
  27. Schepens T, Verbrugghe W, Dams K, et al. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. Crit Care 2015;19:422–429. DOI: 10.1186/s13054-015-1141-0
  28. Vassilakopoulos T, Petrof BJ. Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 2004;169(3):336–341. DOI: 10.1164/rccm.200304-489CP
  29. Supinski GS, Westgate P, Callahan LA. Correlation of maximal inspiratory pressure to transdiaphragmatic twitch pressure in intensive care unit patients. Crit Care 2016;20:77–91. DOI: 10.1186/s13054-016-1247-z
  30. Laghi F, Cattapan SE, Jubran A, et al. Is weaning failure caused by low-frequency fatigue of the diaphragm? Am J Respir Crit Care Med 2003;167(2):120–127. DOI: 10.1164/rccm.200210-1246OC
  31. Dres M, Goligher EC, Dubé BP, et al. Diaphragm function and weaning from mechanical ventilation: an ultrasound and phrenic nerve stimulation clinical study. Ann Intensive Care 2018;8(1):53–59. DOI: 10.1186/s13613-018-0401-y
  32. Capdevila X, Perrigault PF, Ramonatxo M, et al. Changes in breathing pattern and respiratory muscle performance parameters during difficult weaning. Crit Care Med 1998;26(1):79–87. DOI: 10.1097/00003246-199801000-00020
  33. Medrinal C, Prieur G, Frenoy É, et al. Respiratory weakness after mechanical ventilation is associated with one-year mortality - a prospective study. Crit Care 2016;20(1):231–237. DOI: 10.1186/s13054-016-1418-y
  34. Manders E, Bonta PI, Kloek JJ, et al. Reduced force of diaphragm muscle fibers in patients with chronic thromboembolic pulmonary hypertension. Am J Physiol Lung Cell Mol Physiol 2016;311(1):L20–L28. DOI: 10.1152/ajplung.00113.2016
  35. Kelley RC, Ferreira LF. Diaphragm abnormalities in heart failure and aging: mechanisms and integration of cardiovascular and respiratory pathophysiology. Heart Fail Rev 2017;22(2):191–207. DOI: 10.1007/s10741-016-9549-4
  36. Ferrari G, De Filippi G, Elia F, et al. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J 2014;6(1):8–13. DOI: 10.1186/2036-7902-6-8
  37. Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med 2003;168(1):10–48. DOI: 10.1164/rccm.2206020
  38. Spadaro S, Grasso S, Mauri T, et al. Can diaphragmatic ultrasonography performed during the T-tube trial predict weaning failure? The role of diaphragmatic rapid shallow breathing index. Crit Care 2016;20(1):305–315. DOI: 10.1186/s13054-016-1479-y
  39. Supinski GS, Callahan LA. Diaphragm weakness in mechanically ventilated critically ill patients. Crit Care 2013;17(3):R120–R136. DOI: 10.1186/cc12792
  40. Shamil PK, Gupta NK, Ish P, et al. Prediction of weaning outcome from mechanical ventilation using diaphragmatic rapid shallow breathing index. Indian J Crit Care Med 2022;26(9):1000–1005. DOI: 10.5005/jp-journals-10071-24316
  41. Ramaswamy A, Kumar R, Arul M, et al. Prediction of weaning outcome from mechanical ventilation using ultrasound assessment of parasternal intercostal muscle thickness. Indian J Crit Care Med 2023;27(10): 704–708. DOI: 10.5005/jp-journals-10071-24548
  42. Amara V, Vishwas P, Maddani SS, et al. Evaluation of abdominal expiratory muscle thickness pattern, diaphragmatic excursion, and lung ultrasound score in critically Ill patients and their association with weaning patterns: a prospective observational study. Indian J Crit Care Med 2022;26(3):307–313. DOI: 10.5005/jp-journals-10071-24125.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.