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Observational Study
. 2018 May;19(5):406-411.
doi: 10.1097/PCC.0000000000001485.

Progressive Diaphragm Atrophy in Pediatric Acute Respiratory Failure

Christie L Glau  1 , Thomas W Conlon  1   2 , Adam S Himebauch  1   2 , Nadir Yehya  1   2 , Scott L Weiss  1   2 , Robert A Berg  1   2 , Akira Nishisaki  1   2
Affiliations
Observational Study

Progressive Diaphragm Atrophy in Pediatric Acute Respiratory Failure

Christie L Glau et al. Pediatr Crit Care Med. 2018 May.

Abstract

Objectives: Diaphragm atrophy is associated with delayed weaning from mechanical ventilation and increased mortality in critically ill adults. We sought to test for the presence of diaphragm atrophy in children with acute respiratory failure.

Design: Prospective, observational study.

Setting: Single-center tertiary noncardiac PICU in a children's hospital.

Patients: Invasively ventilated children with acute respiratory failure.

Measurements and main results: Diaphragm thickness at end-expiration and end-inspiration were serially measured by ultrasound in 56 patients (median age, 17 mo; interquartile range, 5.5-52), first within 36 hours of intubation and last preceding extubation. The median duration of mechanical ventilation was 140 hours (interquartile range, 83-201). At initial measurement, thickness at end-expiration was 2.0 mm (interquartile range, 1.8-2.5) and thickness at end-inspiration was 2.5 mm (interquartile range, 2-2.8). The change in thickness at end-expiration during mechanical ventilation between first and last measurement was -13.8% (interquartile range, -27.4% to 0%), with a -3.4% daily atrophy rate (interquartile range, -5.6 to 0%). Thickening fraction = ([thickness at end-inspiration - thickness at end-expiration]/thickness at end-inspiration) throughout the course of mechanical ventilation was linearly correlated with spontaneous breathing fraction (beta coefficient, 9.4; 95% CI, 4.2-14.7; p = 0.001). For children with a period of spontaneous breathing fraction less than 0.5 during mechanical ventilation, those with exposure to a continuous neuromuscular blockade infusion (n = 15) had a significantly larger decrease in thickness at end-expiration compared with children with low spontaneous breathing fraction who were not exposed to a neuromuscular blockade infusion (n = 18) (-16.4%, [interquartile range, -28.4% to -7.0%] vs -7.3%; [interquartile range, -10.9% to -0%]; p = 0.036).

Conclusions: Diaphragm atrophy is present in children on mechanical ventilation for acute respiratory failure. Diaphragm contractility, measured as thickening fraction, is strongly correlated with spontaneous breathing fraction. The combination of exposure to neuromuscular blockade infusion with low overall spontaneous breathing fraction is associated with a greater degree of atrophy.

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Conflict of interest statement

Conflicts of Interest

The authors have no conflicts of interest to report related to the content of this manuscript. Christie Glau, Thomas Conlon, Adam Himebauch and Akira Nishisaki have received honoraria and travel reimbursement from the Society of Critical Care Medicine.

Figures

Figure 1
Figure 1
B-Mode Ultrasound Measurement of Diaphragm Thickness at the Zone of Apposition at End-expiration.
Figure 2
Figure 2
M-mode Ultrasound Measurement of Diaphragm Thickening Fraction at the Zone of Apposition.
Figure 3
Figure 3
Percentage Change in Diaphragm Thickness by Subject, n=52.
Figure 4
Figure 4
Correlation of Diaphragm Thickening Fraction and Spontaneous Breathing Fraction. *P-value was adjusted for clustering by subject.
Figure 5
Figure 5
Change in Diaphragm Thickness during Period of Mechanical Ventilation with Spontaneous Breathing Fraction < 0.5.
See this image and copyright information in PMC

Comment in

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