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Critical Care Medicine Nov 2023
Topics: Diaphragm; Respiration, Artificial; Lung
PubMed: 37902352
DOI: 10.1097/CCM.0000000000006013 -
Journal of Visualized Experiments : JoVE Nov 2023The diaphragm is the main component of the respiratory muscle pump. Diaphragm dysfunction can cause dyspnea and exercise intolerance, and predisposes affected...
The diaphragm is the main component of the respiratory muscle pump. Diaphragm dysfunction can cause dyspnea and exercise intolerance, and predisposes affected individuals to respiratory failure. In mechanically ventilated patients, the diaphragm is susceptible to atrophy and dysfunction through disuse and other mechanisms. This contributes to failure to wean and poor long-term clinical outcomes. Point-of-care ultrasound provides a valid and reproducible method for evaluating diaphragm thickness and contractile activity (thickening fraction during inspiration) that can be readily employed by clinicians and researchers alike. This article presents best practices for measuring diaphragm thickness and quantifying diaphragm thickening during tidal breathing or maximal inspiration. Once mastered, this technique can be used to diagnose and prognosticate diaphragm dysfunction, and guide and monitor response to treatment over time in both healthy individuals and acute or chronically ill patients.
Topics: Humans; Diaphragm; Point-of-Care Systems; Thorax; Respiratory Muscles; Point-of-Care Testing
PubMed: 37982511
DOI: 10.3791/65431 -
Thoracic Surgery Clinics May 2024An elevated diaphragm may be due to eventration or paralysis. Diaphragm elevation is often asymptomatic and found incidentally on imaging. Fluoroscopic testing can be...
An elevated diaphragm may be due to eventration or paralysis. Diaphragm elevation is often asymptomatic and found incidentally on imaging. Fluoroscopic testing can be used to differentiate eventration (no paradoxic motion) from paralysis (paradoxic motion). Regardless of etiology, a diaphragm plication is indicated in all symptomatic patients with an elevated diaphragm. Plication can be approached either from a thoracic or abdominal approach, though most thoracic surgeons perform minimally invasive thoracoscopic plication. The goal of plication is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm. Diaphragm plication is safe, has excellent outcomes, and is associated with symptom improvement.
Topics: Humans; Diaphragm; Diaphragmatic Eventration; Respiratory Paralysis
PubMed: 38705666
DOI: 10.1016/j.thorsurg.2024.01.006 -
Nutrition (Burbank, Los Angeles County,... Jan 2024The aim of this study was to determine the development of sarcopenia in a COVID-19 intensive care unit population by sequential quadriceps and diaphragm ultrasound and... (Clinical Trial)
Clinical Trial
OBJECTIVE
The aim of this study was to determine the development of sarcopenia in a COVID-19 intensive care unit population by sequential quadriceps and diaphragm ultrasound and its relationship with hospital outcomes.
METHODS
We assessed muscle thickness, cross-sectional area, fascicle length, pennation angle, and echo intensity within 48 h after intubation, at days 5 and 10 and at discharge from the intensive care unit in 30 critically ill patients with confirmed COVID-19.
RESULTS
A different evolution of muscle thickness of the diaphragm and m. rectus femoris was observed; the changes between the two muscles were not correlated (Pearson's χ 3.91, P = 0.419). The difference in muscle thickness was linked to the outcome for both m. rectus femoris and diaphragm, with the best survival seen in the group with stable muscle thickness. The greatest loss of muscle thickness occurred between days 5 and 10. The echo intensity was higher in the patients with increased muscle thickness, who also had a worse prognosis. There was a correlation between cross-sectional area on day 5 and handgrip strength (r = 0.290, P = 0.010). Only 31% of patients were able to return to their preadmission residence without any additional rehabilitation.
CONCLUSIONS
Muscle atrophy and decline in muscle strength appear in the earliest stages after admission to the intensive care unit and are related to functional outcome.
Topics: Humans; COVID-19; Critical Illness; Diaphragm; Hand Strength; Intensive Care Units; Quadriceps Muscle; Sarcopenia; Ultrasonography
PubMed: 37918311
DOI: 10.1016/j.nut.2023.112250 -
Muscle & Nerve Jan 2024Phrenic nerve conduction studies (NCSs) and needle electromyography (EMG) can provide important information on the underlying pathophysiology in patients presenting with... (Review)
Review
Phrenic nerve conduction studies (NCSs) and needle electromyography (EMG) can provide important information on the underlying pathophysiology in patients presenting with unexplained shortness of breath, failure to wean from the ventilator, or consideration of phrenic nerve pacemaker implantation. However, these techniques are often technically challenging, require experience, can lack sensitivity and specificity, and, in the case of diaphragm EMG, involve some degree of risk. Diagnostic high-resolution ultrasound has been introduced in recent years as an adjuvant technique readily available at the bedside that can increase the overall sensitivity and specificity of the neurophysiologic evaluation of respiratory symptoms. Two-dimensional ultrasound in the zone of apposition can identify atrophy and evaluate contractility of the diaphragm, in addition to localizing a safe zone for needle EMG. M-mode ultrasound can identify decreased excursion or paradoxical motion of the diaphragm and can increase the reliability of phrenic NCSs. When used in combination, ultrasound, phrenic NCSs and EMG of the diaphragm can differentiate neuropathic, myopathic, and central disorders, and can offer aid in prognosis that is difficult to arrive at solely from clinical examination. This article will review techniques to successfully perform phrenic NCSs, needle EMG of the diaphragm, and ultrasound of the diaphragm. The discussion will include technical pitfalls and clinical pearls as well as future directions and clinical indications.
Topics: Humans; Reproducibility of Results; Electromyography; Dyspnea; Diaphragm; Peripheral Nervous System Diseases; Phrenic Nerve
PubMed: 37975205
DOI: 10.1002/mus.27998 -
Thoracic Surgery Clinics May 2024The diaphragm is a musculoaponeurotic structure separating the thoracic and abdominal cavities. It plays important roles in both respiration and maintaining...
The diaphragm is a musculoaponeurotic structure separating the thoracic and abdominal cavities. It plays important roles in both respiration and maintaining gastrointestinal function. A careful consideration of anatomy should be taken during surgical procedures to minimize injury to this crucial organ.
Topics: Humans; Diaphragm
PubMed: 38705658
DOI: 10.1016/j.thorsurg.2024.01.002 -
Obstetrics and Gynecology Sep 2023The APEX-IUD (Association of Perforation and Expulsion of Intrauterine Devices) study evaluated the association of postpartum timing of intrauterine device (IUD)...
OBJECTIVE
The APEX-IUD (Association of Perforation and Expulsion of Intrauterine Devices) study evaluated the association of postpartum timing of intrauterine device (IUD) insertion, breastfeeding, heavy menstrual bleeding, and IUD type (levonorgestrel-releasing vs copper) with risks of uterine perforation and IUD expulsion in usual clinical practice. We summarize the clinically important findings to inform counseling and shared decision making.
METHODS
APEX-IUD was a real-world (using U.S. health care data) retrospective cohort study of individuals aged 50 years and younger with IUD insertions between 2001 and 2018 and with electronic health record data. Cumulative incidences of uterine perforation and IUD expulsion were calculated. Adjusted hazard ratios (aHRs) and 95% CIs were estimated from proportional hazards models with control of confounding.
RESULTS
Among the study population of 326,658, absolute risk of uterine perforation was low overall (cumulative incidence, 0.21% [95% CI 0.19-0.23%] at 1 year and 0.61% [95% CI 0.56-0.66% at 5 years]) but was elevated for IUDs inserted during time intervals within 1 year postpartum, particularly among those between 4 days and 6 weeks postpartum (aHR 6.71, 95% CI 4.80-9.38), relative to nonpostpartum insertions. Among postpartum insertions, IUD expulsion risk was greatest for insertions in the immediate postpartum period (0-3 days after delivery) compared with nonpostpartum (aHR 5.34, 95% CI 4.47-6.39). Postpartum individuals who were breastfeeding had a slightly elevated risk of perforation and lowered risk of expulsion than those not breastfeeding. Among nonpostpartum individuals, those with a heavy menstrual bleeding diagnosis were at greater risk of expulsion than those without (aHR 2.84, 95% CI 2.66-3.03); heavy menstrual bleeding also was associated with a slightly elevated perforation risk. There was a slightly elevated perforation risk and slightly lower expulsion risk associated with levonorgestrel-releasing IUDs compared with copper IUDs.
CONCLUSION
Absolute risk of adverse outcomes with IUD insertion is low. Clinicians should be aware of the differences in risks of uterine perforation and expulsion associated with IUD insertion during specific postpartum time periods and with a heavy menstrual bleeding diagnosis. This information should be incorporated into counseling and decision making for patients considering IUD insertion.
FUNDING SOURCE
Bayer AG.
CLINICAL TRIAL REGISTRATION
EU PAS register, EUPAS33461.
Topics: Female; Humans; Intrauterine Device Expulsion; Intrauterine Devices; Intrauterine Devices, Copper; Levonorgestrel; Menorrhagia; Retrospective Studies; Uterine Perforation; Middle Aged
PubMed: 37535968
DOI: 10.1097/AOG.0000000000005299 -
Multimedia Manual of Cardiothoracic... Oct 2023Diaphragm paralysis can lead to significant dyspnoea and, in severe cases, the need for invasive ventilation. Surgical repair via diaphragm plication remains the only...
Diaphragm paralysis can lead to significant dyspnoea and, in severe cases, the need for invasive ventilation. Surgical repair via diaphragm plication remains the only surgical option for these patients. Nerve transplantation and pacing have not proven to be effective alternatives. Nevertheless, diaphragm plication, whether through a thoracotomy or via minimally invasive techniques, has proven to yield high recurrence rates during the years following plication surgery. Re-exploration of recurrent cases has identified that plication relapse may be caused secondary to the elasticity of the non-plicated stretched muscle fibres. In contrast, a tendon does not possess elastic properties like those of muscle fibres and thus is not liable to expand gradually over time. We present a novel, minimally invasive technique for diaphragm plication that involves plication of a non-elastic central tendon to a fixed chest wall (central tendon fixation). Utilizing a robotic-assisted approach, our goal was to describe the techniques involved in achieving successful diaphragm plication with mid-term results (2-year follow-up).
Topics: Humans; Diaphragm; Robotic Surgical Procedures; Treatment Outcome; Retrospective Studies; Neoplasm Recurrence, Local
PubMed: 37818761
DOI: 10.1510/mmcts.2023.041 -
Muscle & Nerve Nov 2023Amyotrophic lateral sclerosis (ALS) leads to diaphragmatic weakness at some point during its course, which is a major cause of respiratory insufficiency. The aim of this...
INTRODUCTION/AIMS
Amyotrophic lateral sclerosis (ALS) leads to diaphragmatic weakness at some point during its course, which is a major cause of respiratory insufficiency. The aim of this study was to evaluate ultrasound-based measures for assessing the diaphragmatic competency and the need for ventilatory support.
METHODS
Twenty-six subjects with ALS and 12 healthy controls were enrolled. All participants underwent B-mode diaphragm ultrasound (DUS). Diaphragm thickness and thickening indices were recorded. In the subjects with ALS, further assessments included functional scales and spirometry. We investigated the diagnostic accuracy of DUS thickening indices in predicting diaphragmatic dysfunction and the correlation between clinical, spirometric, and DUS data.
RESULTS
Significant relationships were found between forced vital capacity and all diaphragmatic thickening indices. Similarly, all diaphragmatic thickening indices correlated with both Milano Torino staging and disease progression rate. Only thickening fraction (TFdi) correlated with score on the revised ALS Functional Rating Scale (r = 0.459, P = .024). TFdi had better accuracy in predicting diaphragmatic dysfunction (area under the curve [AUC] = 0.839, 95% confidence interval [CI] 0.643 to 0.953) and the need for initiation of noninvasive ventilation (NIV) (AUC = 0.989, 95% CI 0.847 to 1.000) compared with the other indices. A TFdi cut-off point of 0.50 was a sensitive threshold to consider NIV.
DISCUSSION
DUS successfully identifies diaphragmatic dysfunction in ALS, being a valuable accessory modality for investigating respiratory symptoms. TFdi was found to be the most useful DUS index, which encourages further investigation.
Topics: Humans; Diaphragm; Amyotrophic Lateral Sclerosis; Noninvasive Ventilation; Respiratory Insufficiency; Ultrasonography
PubMed: 37814924
DOI: 10.1002/mus.27980 -
Biomolecules Nov 2023mice with a spontaneous mutation in exon 23 of the gene represent the most common model to investigate the pathophysiology of Duchenne muscular dystrophy (DMD). The...
mice with a spontaneous mutation in exon 23 of the gene represent the most common model to investigate the pathophysiology of Duchenne muscular dystrophy (DMD). The disease, caused by the lack of functional dystrophin, is characterized by irreversible impairment of muscle functions, with the diaphragm affected earlier and more severely than other skeletal muscles. We applied a label-free (LF) method and the more thorough tandem mass tag (TMT)-based method to analyze differentially expressed proteins in the diaphragm of 6-week-old mice. The comparison of both methods revealed 88 commonly changed proteins. A more in-depth analysis of the TMT-based method showed 953 significantly changed proteins, with 867 increased and 86 decreased in dystrophic animals (-value < 0.05, fold-change threshold: 1.5). Consequently, several dysregulated processes were demonstrated, including the immune response, fibrosis, translation, and programmed cell death. Interestingly, in the dystrophic diaphragm, we found a significant decrease in the expression of enzymes generating hydrogen sulfide (HS), suggesting that alterations in the metabolism of this gaseous mediator could modulate DMD progression, which could be a potential target for pharmacological intervention.
Topics: Animals; Mice; Mice, Inbred mdx; Diaphragm; Proteome; Muscular Dystrophy, Duchenne; Muscle, Skeletal; Mice, Inbred C57BL
PubMed: 38002330
DOI: 10.3390/biom13111648