Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes
Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes
复制标题
DOI：
10.1164/rccm.201703-0536oc
复制
发表时间：
2018-01-15
影响因子：
24.7
通讯作者：
Ferguson, Niall D.
中科院分区：
文献类型：
--
作者：
Goligher, Ewan C.;Dres, Martin;Ferguson, Niall D.
基本原理：膈肌功能障碍是机械通气患者的结局，但机械通气引起的膈肌结构和功能的潜在可预防变化的临床影响尚不清楚。通过增厚分数评估吸气努力。主要结局是从通气中解放的时间。次要结局包括并发症（重新插管、气管造口术、延长通气或死亡）。协会进行了调整，年龄，疾病的严重程度，败血症，镇静，神经肌肉阻滞，和comorbidity. Measures和主要结果：211例患者参加，191有两个或两个以上的隔膜厚度测量。到中位第4天，78例患者（41%）的厚度下降超过10%（四分位距，3-5）。厚度降低的发展与较低的每日通气释放概率相关（校正的风险比，0.69; 95%置信区间[CI]，0.54-0.87;每降低10%），延长ICU住院时间（校正的持续时间比，1.71; 95%CI，1.29-2.27），和更高的并发症风险（校正的比值比，3.00; 95%CI，1.34-6.72）。厚度增加（n = 47; 24%）的发展也预测了通气时间延长（调整后的持续时间比，1.38; 95% CI，1.00-1.90）。厚度减小与吸气努力异常低有关;厚度增加与过度努力有关。前3天增厚分数在15%至30%之间（类似于休息时的呼吸）的患者的通气时间最短。结论：机械通气期间发生的横膈膜萎缩强烈影响临床结果。目标吸气努力水平类似于健康受试者在休息时可能会加速从通气中解放出来。
Rationale: Diaphragm dysfunction worsens outcomes in mechanically ventilated patients, but the clinical impact of potentially preventable changes in diaphragm structure and function caused by mechanical ventilation is unknown.Objectives: To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation.Methods: Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity.Measurements and Main Results: Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median Day 4 (interquartile range, 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted hazard ratio, 0.69; 95% confidence interval [CI], 0.54-0.87; per 10% decrease), prolonged ICU admission (adjusted duration ratio, 1.71; 95% CI, 1.29-2.27), and a higher risk of complications (adjusted odds ratio, 3.00; 95% CI, 1.34-6.72). Development of increased thickness (n = 47; 24%) also predicted prolonged ventilation (adjusted duration ratio, 1.38; 95% CI, 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15% and 30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation.Conclusions: Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation.