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Observational Study
. 2021 Feb:284:103585.
doi: 10.1016/j.resp.2020.103585. Epub 2020 Nov 13.

Diaphragmatic thickening fraction as a potential predictor of response to continuous positive airway pressure ventilation in Covid-19 pneumonia: A single-center pilot study

Francesco Corradi  1 , Luigi Vetrugno  2 , Daniele Orso  2 , Tiziana Bove  2 , Annia Schreiber  3 , Enrico Boero  4 , Gregorio Santori  5 , Alessandro Isirdi  6 , Greta Barbieri  7 , Francesco Forfori  6
Affiliations
Observational Study

Diaphragmatic thickening fraction as a potential predictor of response to continuous positive airway pressure ventilation in Covid-19 pneumonia: A single-center pilot study

Francesco Corradi et al. Respir Physiol Neurobiol. 2021 Feb.

Abstract

Background: In a variable number of Covid-19 patients with acute respiratory failure, non-invasive breathing support strategies cannot provide adequate oxygenation, thus making invasive mechanical ventilation necessary. Factors predicting this unfavorable outcome are unknown, but we hypothesized that diaphragmatic weakness may contribute.

Methods: We prospectively analyzed the data of 27 consecutive patients admitted to the general Intensive Care Unit (ICU) from March 19, 2020, to April 20, 2020 and submitted to continuous positive airway pressure (CPAP) before considering invasive ventilation. Diaphragmatic thickening fraction (DTF) inferred by ultrasound was determined before applying CPAP.

Results: Eighteen patients recovered with CPAP, whereas nine required invasive mechanical ventilation with longer stay in ICU (p < 0.001) and hospital (p = 0.003). At univariate logistic regression analysis, CPAP failure was significantly associated with low DTF [β: -0.396; OR: 0.673; p < 0.001] and high respiratory rate [β: 0.452; OR: 1.572; p < 0.001] but only DTF reached statistical significance at multivariate analysis [β: -0.384; OR: 0.681; p < 0.001]. The DTF best threshold predicting CPAP failure was 21.4 % (AUC: 0.944; sensitivity: 94.4 %, specificity: 88.9 %).

Conclusions: In critically ill patients with Covid-19 respiratory failure admitted to ICU, a reduced DTF could be a potential predictor of CPAP failure and requirement of invasive ventilation.

Keywords: Covid-19; Diaphragmatic thickening fraction; ICU; Non-invasive ventilation; Prediction; Respiratory failure.

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Conflict of interest statement

The authors report no declarations of interest.

Figures

Fig. 1
Fig. 1
Study design: All critically ill patients with Covid-19 respiratory failure from the ED and admitted to ICU were treated for at least 24 h with non-invasive ventilation. At the end of this period they were re-evaluated, and a weaning trial was carried out. Based on the clinical decision of the doctors, the patient was intubated and subjected to invasive ventilation or continued with CPAP. At the same time, another operator not involved in the clinical management of the patient performed ultrasound measurements of the diaphragmatic functionality.
Fig. 2
Fig. 2
A: Global performance of the multivariate logistic regression model for non-invasive ventilation failure (independent variables: diaphragmatic thickening fraction and respiratory rate). B: ROC curve of the same multivariate logistic regression model.
Fig. 3
Fig. 3
Receiver operator characteristic (ROC) curve for diaphragm thickening fraction (DTF) related to continuous positive airway pressure success/failure (AUC: area under the curve with the 95 % confidence interval). The best DTF value (0.214) that maximize sensibility (0.944) and specificity (0.889) is reported.
Fig. 4
Fig. 4
A: Comparison of the Kaplan–Meier curves for cumulative probability of survival in patients with a diaphragmatic thickening fraction (DTF) higher or lower than 21.4 %, by censoring patients at hospital discharge (p = 0.270). B: Comparison of the Kaplan–Meier curves for cumulative probability of adverse outcomes (IMV) in patients with DTF higher or lower than 21.4 %, by censoring patients at intensive care unit (ICU) discharge (p = 0.003).
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