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Respiratory Care Nov 2023Diaphragm inactivity during invasive mechanical ventilation leads to diaphragm atrophy and weakness, hemodynamic instability, and ventilatory heterogeneity. Absent...
Diaphragm inactivity during invasive mechanical ventilation leads to diaphragm atrophy and weakness, hemodynamic instability, and ventilatory heterogeneity. Absent respiratory drive and effort can, therefore, worsen injury to both lung and diaphragm and is a major cause of failure to wean. Phrenic nerve stimulation (PNS) can maintain controlled levels of diaphragm activity independent of intrinsic drive and as such may offer a promising approach to achieving lung and diaphragm protective ventilatory targets. Whereas PNS has an established role in the management of chronic respiratory failure, there is emerging interest in how its multisystem putative benefits may be temporarily harnessed in the management of invasively ventilated patients with acute respiratory failure.
Topics: Humans; Phrenic Nerve; Electric Stimulation Therapy; Respiration, Artificial; Diaphragm; Respiratory Distress Syndrome; Respiratory Insufficiency
PubMed: 37875317
DOI: 10.4187/respcare.11439 -
Current Opinion in Critical Care Feb 2024The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive... (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed.
RECENT FINDINGS
Lung ultrasound can accurately diagnose the cause of acute respiratory failure, including acute respiratory distress syndrome and can identify focal and nonfocal lung morphology in these patients. This is essential in determining optimal ventilator strategy and PEEP level. Assessment of the effect of PEEP on lung recruitment using lung ultrasound is promising, especially in the perioperative setting. Diaphragm ultrasound can monitor the effects of PEEP on the diaphragm, but this needs further validation. In patients with an acute exacerbation of chronic obstructive pulmonary disease, diaphragm ultrasound can be used to predict noninvasive ventilation failure. Lung and diaphragm ultrasound can be used to predict weaning outcome and accurately diagnose the cause of weaning failure.
SUMMARY
Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.
Topics: Humans; Diaphragm; Lung; Positive-Pressure Respiration; Respiratory Insufficiency; Respiratory Distress Syndrome
PubMed: 38085883
DOI: 10.1097/MCC.0000000000001119 -
Thoracic Surgery Clinics May 2024A variety of diaphragmatic and non-diaphragmatic pathologies may require resection, reconstruction, or repair of the diaphragm. Adequate reconstruction is crucial in...
A variety of diaphragmatic and non-diaphragmatic pathologies may require resection, reconstruction, or repair of the diaphragm. Adequate reconstruction is crucial in cases of diaphragmatic resection to prevent the herniation of abdominal organs into the chest and to maintain optimal respiratory function. This article aims to provide a detailed overview of the techniques used for surgical diaphragm reconstruction, taking into account factors such as the size and location of the defect, available options for reconstructive materials, potential challenges and pitfalls, and considerations related to the recurrence or failure of the repair.
Topics: Humans; Diaphragm; Hernia, Diaphragmatic; Plastic Surgery Procedures; Surgical Flaps
PubMed: 38705660
DOI: 10.1016/j.thorsurg.2024.01.001 -
Medicina Intensiva Nov 2023This review addresses the phenomenon of "reverse triggering", an asynchrony that occurs in deeply sedated patients or patients in transition from deep to light sedation.... (Review)
Review
This review addresses the phenomenon of "reverse triggering", an asynchrony that occurs in deeply sedated patients or patients in transition from deep to light sedation. Reverse triggering has been reported to occur in 30-90% of all ventilated patients. The underlying pathophysiological mechanisms remain unclear, but "entrainment" is proposed as one of them. Detecting this asynchrony is crucial, and methods such as visual inspection, esophageal pressure, diaphragmatic ultrasound and automated methods have been used. Reverse triggering may have effects on lung and diaphragm function, probably mediated by the level of breathing effort and eccentric activation of the diaphragm. The optimal management of reverse triggering has not been established, but may include the adjustment of ventilatory parameters as well as of sedation level, and in extreme cases, neuromuscular block. It is important to understand the significance of this condition and its detection, but also to conduct dedicated research to improve its clinical management and potential effects in critically ill patients.
Topics: Humans; Respiration, Artificial; Diaphragm; Deep Sedation; Respiratory Mechanics
PubMed: 37867118
DOI: 10.1016/j.medine.2023.10.009 -
International Journal of Gynaecology... Jan 2024The postpartum period is the perfect time to access family planning services. WHO guidelines contraindicate combined hormonal contraceptives postpartum in breastfeeding... (Review)
Review
The postpartum period is the perfect time to access family planning services. WHO guidelines contraindicate combined hormonal contraceptives postpartum in breastfeeding patients between 6 weeks and 6 months after delivery (Medical Eligibility Criteria category 3). On the contrary, the Faculty of Sexual and Reproductive Healthcare and the Centers for Disease Control and Prevention guidelines do not contraindicate their use in women who breastfeed from 6 weeks to 6 months postpartum. New combined hormonal contraceptives with natural estrogens have never been studied in this setting. Guidelines agree on the prescription of the progestin-only pill postpartum in non-breastfeeding women (category 1). Differences are found in women who breastfeed. In non-breastfeeding women, an implant is considered safe (category 1) by all guidelines, without any distinction in time. Regarding postpartum breastfeeding women, the guidelines for implants give quite different indications but are still permissive. Intrauterine devices are viable options for postpartum contraception but guidelines give different indications about the timing of insertion. Postplacental intrauterine device placement can reduce the subsequent unintended pregnancy rate, particularly in settings at greatest risk of not having recommended postpartum controls. However, it has yet to be understood whether this approach can really have an advantage in high-income countries. Postpartum contraception is not a 'matter of guidelines': it is the best customization for each woman, as early as possible but at the ideal timing.
Topics: Pregnancy; Humans; Female; Contraception; Postpartum Period; Reproduction; Family Planning Services; Intrauterine Devices; Contraceptive Agents
PubMed: 37334892
DOI: 10.1002/ijgo.14928 -
Skeletal Muscle Jul 2023As a result of aging, skeletal muscle undergoes atrophy and a decrease in function. This age-related skeletal muscle weakness is known as "sarcopenia". Sarcopenia is...
BACKGROUND
As a result of aging, skeletal muscle undergoes atrophy and a decrease in function. This age-related skeletal muscle weakness is known as "sarcopenia". Sarcopenia is part of the frailty observed in humans. In order to discover treatments for sarcopenia, it is necessary to determine appropriate preclinical models and the genes and signaling pathways that change with age in these models.
METHODS AND RESULTS
To understand the changes in gene expression that occur as a result of aging in skeletal muscles, we generated a multi-time-point gene expression signature throughout the lifespan of mice and rats, as these are the most commonly used species in preclinical research and intervention testing. Gastrocnemius, tibialis anterior, soleus, and diaphragm muscles from male and female C57Bl/6J mice and male Sprague Dawley rats were analyzed at ages 6, 12, 18, 21, 24, and 27 months, plus an additional 9-month group was used for rats. More age-related genes were identified in rat skeletal muscles compared with mice; this was consistent with the finding that rat muscles undergo more robust age-related decline in mass. In both species, pathways associated with innate immunity and inflammation linearly increased with age. Pathways linked with extracellular matrix remodeling were also universally downregulated. Interestingly, late downregulated pathways were exclusively found in the rat limb muscles and these were linked to metabolism and mitochondrial respiration; this was not seen in the mouse.
CONCLUSIONS
This extensive, side-by-side transcriptomic profiling shows that the skeletal muscle in rats is impacted more by aging compared with mice, and the pattern of decline in the rat may be more representative of the human. The observed changes point to potential therapeutic interventions to avoid age-related decline in skeletal muscle function.
Topics: Humans; Mice; Female; Male; Rats; Animals; Diaphragm; Transcriptome; Rats, Sprague-Dawley; Muscle, Skeletal; Sarcopenia; Mice, Inbred C57BL
PubMed: 37438807
DOI: 10.1186/s13395-023-00321-3 -
BMJ Sexual & Reproductive Health Jul 2023
Topics: Humans; Female; Contraception; Intrauterine Devices
PubMed: 37197913
DOI: 10.1136/bmjsrh-2023-201841 -
Muscle & Nerve Feb 2024Easy fatigability, the clinical hallmark of generalized myasthenia gravis (GMG), cannot be detected in a dynamic way. The aim of this study was to assess respiratory...
INTRODUCTION/AIMS
Easy fatigability, the clinical hallmark of generalized myasthenia gravis (GMG), cannot be detected in a dynamic way. The aim of this study was to assess respiratory function dynamically through diaphragmatic ultrasonography (DUS) in GMG patients.
METHODS
GMG patients and controls were recruited in a 1:1 ratio. DUS was performed during one quiet breath and 15 consecutive deep breaths. The diaphragm thicknesses were measured at different positions. Diaphragm thickening fraction (TFdi) and the maximal change in diaphragm thickness (Tmax) during 15 consecutive deep breaths were calculated and transformed to normality, named N-TFdi and N-Tmax, respectively. The percentages of changes in TFdi and Tmax compared with baseline were named ΔTFdi and ΔTmax, respectively. The diagnostic parameter for respiratory muscle fatigue was chosen from ΔTFdi and ΔTmax at different deep breath times according to their ability to distinguish GMG patients from controls and the interrater reliability of TFdi and Tmax.
RESULTS
Thirty-four GMG patients and 30 healthy controls were enrolled. N-TFdi and N-Tmax significantly changed as the number of deep breaths increased (p < .001) in GMG patients, but not in controls. ΔTmax of the 15th deep breath (ΔTmax15) was selected as the diagnostic parameter for respiratory muscle fatigue. There were no significant differences in percentage of predicted values of forced vital capacity and arterial partial pressure of carbon dioxide between patients with normal and abnormal ΔTmax15.
DISCUSSION
DUS could identify diaphragm fatiguability in GMG patients, which may be more reliable and sensitive in assessment of diaphragm fatigue than conventional methods.
Topics: Humans; Diaphragm; Reproducibility of Results; Myasthenia Gravis; Vital Capacity; Ultrasonography
PubMed: 38124677
DOI: 10.1002/mus.28020 -
World Journal of Emergency Surgery :... Jul 2023Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. (Review)
Review
BACKGROUND
Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.
METHODS
A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.
RESULTS
CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.
CONCLUSIONS
Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.
Topics: Humans; Diaphragm; Hernias, Diaphragmatic, Congenital; Tomography, X-Ray Computed; Thorax; Hernia, Hiatal; Thoracic Injuries
PubMed: 37496073
DOI: 10.1186/s13017-023-00510-x -
Clinical Rheumatology Jan 2024Muscle dysfunction may cause disability and reduce the quality of life of patients with systemic sclerosis (SSc) when compared to healthy individuals. However, the...
Ultrasound assessment of diaphragm and quadriceps muscles and its relationship with handgrip and respiratory muscle strength in patients with systemic sclerosis: a cross-sectional study.
BACKGROUND
Muscle dysfunction may cause disability and reduce the quality of life of patients with systemic sclerosis (SSc) when compared to healthy individuals. However, the literature on the topic is scarce and uses several criteria for assessing muscle dysfunction in this population.
OBJECTIVES
To compare diaphragm and quadriceps muscle thickness, diaphragm mobility, and handgrip strength between patients with SSc and healthy individuals.
METHOD
This cross-sectional study included 16 patients with SSc and 16 self-reported healthy individuals matched for age. We assessed quadriceps and diaphragm thickness and diaphragmatic mobility (ultrasound), handgrip strength (hand-held dynamometer), and respiratory muscle strength (manovacuometer). Patients also responded to the Health Assessment Questionnaire Disability Index and the International Physical Activity Questionnaire.
RESULTS
Patients with SSc presented lower quadriceps thickness (p < 0.0001), diaphragmatic mobility (p = 0.01), handgrip (p < 0.0001), and respiratory muscle strength (p < 0.0001) than healthy individuals. A moderate positive correlation was observed between handgrip strength and quadriceps thickness in patients with SSc (rho = 0.576; p = 0.02).
CONCLUSIONS
Patients with SSc presented reduced quadriceps thickness, diaphragmatic mobility, handgrip, and respiratory muscle strength when compared to healthy individuals Also, handgrip strength was correlated with quadriceps thickness in patients with SSc, suggesting that loss of muscle mass accompanies loss of peripheral muscle strength group of patients. Key Points • SSc patients presented reduced quadriceps thickness and diaphragmatic mobility • SSc patients have reduced handgrip and respiratory muscle strength • Lower handgrip muscle strength correlated with lower quadriceps thickness.
Topics: Humans; Diaphragm; Quadriceps Muscle; Cross-Sectional Studies; Hand Strength; Quality of Life; Muscle Strength; Respiratory Muscles; Scleroderma, Systemic
PubMed: 38015305
DOI: 10.1007/s10067-023-06812-4