Nicolas Lerolle1, Emmanuel Guérot2, Saoussen Dimassi2, Rachid Zegdi3, Christophe Faisy2, Jean-Yves Fagon2, Jean-Luc Diehl2. 1. Service de Réanimation Médicale, Hôopital Européen Georges Pompidou, Assistance Publique-Hôopitaux de Paris, Université Paris Descartes, Faculté de Médecine, Paris, France. Electronic address: nicolas.lerolle@egp.aphp.fr. 2. Service de Réanimation Médicale, Hôopital Européen Georges Pompidou, Assistance Publique-Hôopitaux de Paris, Université Paris Descartes, Faculté de Médecine, Paris, France. 3. Département de Chirurgie Cardiovasculaire, Hôopital Européen Georges Pompidou, Assistance Publique-Hôopitaux de Paris, Université Paris Descartes, Faculté de Médecine, Paris, France.
Abstract
BACKGROUND: Severe diaphragmatic dysfunction can prolong mechanical ventilation after cardiac surgery. An ultrasonographic criterion for diagnosing severe diaphragmatic dysfunction defined by a reference technique such as transdiaphragmatic pressure measurements has never been determined. METHODS: Twenty-eight patients requiring mechanical ventilation > 7 days postoperatively were studied. Esophageal and gastric pressures were measured to calculate transdiaphragmatic pressure during maximal inspiratory effort and the Gilbert index, which evaluates the diaphragm contribution to respiratory pressure swings during quiet ventilation. Ultrasonography allowed measuring right and left hemidiaphragmatic excursions during maximal inspiratory effort. Best E is the greatest positive value from either hemidiaphragm. Twenty cardiac surgery patients with uncomplicated postoperative course were also evaluated with ultrasonography preoperatively and postoperatively. Measurements were performed in semirecumbent position. RESULTS: Transdiaphragmatic pressure during maximal inspiratory effort was below normal value in 27 of the 28 patients receiving prolonged mechanical ventilation (median, 39 cm H(2)O; interquartile range [IQR] 28 cm H(2)O). Eight patients had Gilbert indexes <or= 0 indicating severe diaphragmatic dysfunction. Best E was lower in patients with Gilbert index <or= 0 than > 0 (30 mm; IQR, 10 mm; vs 19 mm; IQR, 7 mm, respectively; p = 0.001). Best E < 25 mm had a positive likelihood ratio of 6.7 (95% confidence interval [CI], 2.4 to 19) and a negative likelihood ratio of 0 (95% CI, 0 to 1.1) for having a Gilbert index <or= 0. None of the patients with uncomplicated course had Best E < 25 mm either preoperatively or postoperatively. CONCLUSIONS: Ultrasonographic-based determination of hemidiaphragm excursions in patients requiring prolonged mechanical ventilation after cardiac surgery may help identify those with and without severe diaphragmatic dysfunction as defined by the Gilbert index.
BACKGROUND: Severe diaphragmatic dysfunction can prolong mechanical ventilation after cardiac surgery. An ultrasonographic criterion for diagnosing severe diaphragmatic dysfunction defined by a reference technique such as transdiaphragmatic pressure measurements has never been determined. METHODS: Twenty-eight patients requiring mechanical ventilation > 7 days postoperatively were studied. Esophageal and gastric pressures were measured to calculate transdiaphragmatic pressure during maximal inspiratory effort and the Gilbert index, which evaluates the diaphragm contribution to respiratory pressure swings during quiet ventilation. Ultrasonography allowed measuring right and left hemidiaphragmatic excursions during maximal inspiratory effort. Best E is the greatest positive value from either hemidiaphragm. Twenty cardiac surgery patients with uncomplicated postoperative course were also evaluated with ultrasonography preoperatively and postoperatively. Measurements were performed in semirecumbent position. RESULTS: Transdiaphragmatic pressure during maximal inspiratory effort was below normal value in 27 of the 28 patients receiving prolonged mechanical ventilation (median, 39 cm H(2)O; interquartile range [IQR] 28 cm H(2)O). Eight patients had Gilbert indexes <or= 0 indicating severe diaphragmatic dysfunction. Best E was lower in patients with Gilbert index <or= 0 than > 0 (30 mm; IQR, 10 mm; vs 19 mm; IQR, 7 mm, respectively; p = 0.001). Best E < 25 mm had a positive likelihood ratio of 6.7 (95% confidence interval [CI], 2.4 to 19) and a negative likelihood ratio of 0 (95% CI, 0 to 1.1) for having a Gilbert index <or= 0. None of the patients with uncomplicated course had Best E < 25 mm either preoperatively or postoperatively. CONCLUSIONS: Ultrasonographic-based determination of hemidiaphragm excursions in patients requiring prolonged mechanical ventilation after cardiac surgery may help identify those with and without severe diaphragmatic dysfunction as defined by the Gilbert index.
Authors: Xavier Valette; Amélie Seguin; Cédric Daubin; Jennifer Brunet; Bertrand Sauneuf; Nicolas Terzi; Damien du Cheyron Journal: Intensive Care Med Date: 2015-01-20 Impact factor: 17.440
Authors: Biagio Liccardo; Francesca Martone; Paolo Trambaiolo; Sergio Severino; Gian Alfonso Cibinel; Antonello D'Andrea Journal: World J Radiol Date: 2016-05-28