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Characteristics and flow chart of each sub-study. PSV, pressure support ventilation; SBT, spontaneous breathing trial.
Source publication
Background:
The assessment of diaphragm function with diaphragm ultrasound seems to bring important clinical information to describe diaphragm work and weakness. When the diaphragm is weak, extradiaphragmatic muscles may play an important role, but whether ultrasound can also assess their activity and function is unknown. This study aimed to (1) e...
Contexts in source publication
Context 1
... main study was divided into three substudies, all conducted between January 2015 and December 2016 at two sites: the outpatient clinic at the Toronto Western Hospital (Toronto, Canada) and the Respiratory and Medical Critical Care Department at Hôpital Pitié-Salpêtrière (Paris, France; see fig. 1 which displays characteristics of each substudy). Across three studies, parasternal intercostal ultrasound was performed in different conditions. All subjects, or their next of kin in the case of the critically ill patients, provided written informed consent. The study was approved by the Institutional Review Boards at both ...
Context 2
... the 294 patients admitted during the study period, 54 were enrolled in Study C ( fig. 1 shows the flow chart of the study). Patient characteristics are displayed in table 2. Among them, 33 (61%) had diaphragm dysfunction and 21 (39%) did not. Pressure support and PEEP level were similar in the two groups, but tidal volume was lower in patients with diaphragm dysfunction (table 3). had higher parasternal intercostal muscle ...
Similar publications
Objectives
Neuromuscular respiratory failure after spinal cord injury (SCI) can lead to dependence on a ventilator. Ventilator-free breathing after SCI is associated with improved morbidity, mortality, and quality of life. We investigated the use of diaphragm muscle ultrasound to predict ventilator weaning outcomes after spinal cord injury.
Method...
Citations
... When the diaphragmatic workload increases, these accessory muscles are recruited [41]. With higher levels of diaphragmatic inspiratory support, parasternal muscle activation decreases (in terms of thickening), while in patients with diaphragmatic dysfunction, the parasternal muscle thickening value increases [42]. The IM-TF is a good predictor of weaning outcome in mechanically ventilated critically ill patients. ...
Background:
Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity.
Methods:
This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score.
Results:
Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs.
Conclusion:
This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.
... Among these accessory muscles, the intercostal muscles are one of the most crucial for managing chest expansion. 12,13 A few studies on subjects receiving invasive mechanical ventilation found that increased parasternal intercostal muscle TF, a reproducible technique with a high intraclass correlation coefficient, might indicate diaphragm dysfunction and increased respiratory load. 13 However, data on patients receiving NIV support are yet to be determined. ...
... 12,13 A few studies on subjects receiving invasive mechanical ventilation found that increased parasternal intercostal muscle TF, a reproducible technique with a high intraclass correlation coefficient, might indicate diaphragm dysfunction and increased respiratory load. 13 However, data on patients receiving NIV support are yet to be determined. This study aimed to establish whether a relationship exists between intercostal muscle TF, measured by ultrasound, and NIV failure. ...
... The sample size calculation utilized data from a study by Dres et al, 13 considering an expected ratio of 20% in NIV failure/NIV success. A sample of 150 subjects (with at least 30 NIV failures) was deemed necessary to achieve 80% power with an alpha level of 5% as calculated using the G*Power 3.1.9.6 (Heinrich-Heine-Universität Düsseldorf, Germany). ...
... Patients who have weakness of the diaphragm may compensate for diaphragmatic dysfunction with parasternal muscle activity. The use of ultrasound to measure parasternal intercostal muscle thickening (Tic) and intercostal muscle thickening fraction (TFic), and the combination of these measurements with diaphragmatic ultrasound, has been used to predict the ability of patients to wean from MV [70]. ...
... The probe should be oriented transversally in the sagittal plane, precisely between the 2nd and 3rd ribs. For example, in a patient positioned supine with a 20 • head-up angle, the linear probe is placed at a right angle to the front surface of the thorax in the longitudinal scan [70,71]. Ultrasound assessment of the parasternal intercostal muscles is performed mostly on the right side, as it is more feasible [72]. ...
... Slightly above the pleural line, the parasternal intercostal muscle can be recognized as a biconcave structure with three layers. These layers consist of two linear hyperechoic membranes extending from the anterior and posterior aspects of the adjacent ribs, along with a central portion displaying muscle echotexture [70,73]. With this mode, intercostal muscle thickness (Tic) can be measured between the inner and outermost hyperechogenic layers of the muscle fascial borders. ...
Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.
... Anyway, long ICU stay and prolonged invasive mechanical ventilation, can cause dysfunction and atrophy to respiratory muscles, which, during the extubation or SBT phase, are not able to cope with the increased oxygen cost of breathing. In this respect, no activation or, on the other hand, early and elevated activation of the SCM during the SBT have been associated to weaning failures, reflecting the inability of primary respiratory muscles to resume autonomous respiration (Parthasarathy et al. 2007, Dres et al. 2017, Dres & Demoule 2018, Dres et al. 2020, Van Hollebeke et al. 2022. ...
Objective.In this paper, we present a detailedin vivocharacterization of the optical and hemodynamic properties of the human sternocleidomastoid muscle (SCM), obtained through ultrasound-guided near-infrared time-domain and diffuse correlation spectroscopies.Approach.A total of sixty-five subjects (forty-nine females, sixteen males) among healthy volunteers and thyroid nodule patients have been recruited for the study. Their SCM hemodynamic (oxy-, deoxy- and total hemoglobin concentrations, blood flow, blood oxygen saturation and metabolic rate of oxygen extraction) and optical properties (wavelength dependent absorption and reduced scattering coefficients) have been measured by the use of a novel hybrid device combining in a single unit time-domain near-infrared spectroscopy, diffuse correlation spectroscopy and simultaneous ultrasound imaging.Main results.We provide detailed tables of the results related to SCM baseline (i.e. muscle at rest) properties, and reveal significant differences on the measured parameters due to variables such as side of the neck, sex, age, body mass index, depth and thickness of the muscle, allowing future clinical studies to take into account such dependencies.Significance.The non-invasive monitoring of the hemodynamics and metabolism of the sternocleidomastoid muscle during respiration became a topic of increased interest partially due to the increased use of mechanical ventilation during the COVID-19 pandemic. Near-infrared diffuse optical spectroscopies were proposed as potential practical monitors of increased recruitment of SCM during respiratory distress. They can provide clinically relevant information on the degree of the patient's respiratory effort that is needed to maintain an optimal minute ventilation, with potential clinical application ranging from evaluating chronic pulmonary diseases to more acute settings, such as acute respiratory failure, or to determine the readiness to wean from invasive mechanical ventilation.
... Although previous systematic reviews have supported the reliability and validity of B-mode USG in assessing the morphometry of diaphragm in ventilated patients [18,19], their findings cannot be generalized to nonhospitalized individuals given the diverse functions of diaphragm in different conditions. Additionally, although some studies have used B-mode and M-mode USG to investigate the morphometry and mobility of intercostals and abdominal muscles in different populations [20][21][22], no systematic review has summarized the reliability or validity of such USG in these respiration-related muscles in non-hospitalized individuals. ...
... Intercostal muscle thickness and stiffness: within-day inter-rater reliability One included study measured intercostal muscle thickness [22] and one measured intercostal muscle stiffness [25]. Both studies reported sufficient within-day inter-rater reliability (ICC = 0.92; ICC = 0.80). ...
Objective
To summarize the reliability and validity of ultrasonography in evaluating the stiffness, excursion, stiffness, or strain rate of diaphragm, intercostals and abdominal muscles in healthy or non-hospitalized individuals.
Literature search
PubMed, Embase, SPORTDiscus, CINAHL and Cochrane Library were searched from inception to May 30, 2022.
Study selection criteria
Case–control, cross-sectional, and longitudinal studies were included if they investigated the reliability or validity of various ultrasonography technologies (e.g., brightness-mode, motion-mode, shear wave elastography) in measuring the thickness, excursion, stiffness, or strain rate of any respiratory muscles.
Data synthesis
Relevant data were summarized based on healthy and different patient populations. The methodological quality by different checklist depending on study design. The quality of evidence of each psychometric property was graded by the Grading of Recommendations, Assessment, Development and Evaluations, respectively.
Results
This review included 24 studies with 787 healthy or non-hospitalized individuals (e.g., lower back pain (LBP), adolescent idiopathic scoliosis (AIS), and chronic obstructive pulmonary disease (COPD)). Both inspiratory (diaphragm and intercostal muscles) and expiratory muscles (abdominal muscles) were investigated. Moderate-quality evidence supported sufficient (intra-class correlation coefficient > 0.7) within-day intra-rater reliability of B-mode ultrasonography in measuring right diaphragmatic thickness among people with LBP, sufficient between-day intra-rater reliability of M-mode ultrasonography in measuring right diaphragmatic excursion in non-hospitalized individuals. The quality of evidence for all other measurement properties in various populations was low or very low. High-quality evidence supported sufficient positive correlations between diaphragm excursion and forced expiratory volume in the first second or forced vital capacity (r > = 0.3) in healthy individuals.
Conclusions
Despite the reported sufficient reliability and validity of using ultrasonography to assess the thickness, excursion, stiffness, and strain rate of respiratory muscles in non-hospitalized individuals, further large-scale studies are warranted to improve the quality of evidence regarding using ultrasonography for these measurements in clinical practice. Researchers should establish their own reliability before using various types of ultrasonography to evaluate respiratory muscle functions.
Trial registration
PROSPERO NO. CRD42022322945.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-023-03558-y.
... The parasternal intercostal muscle's thickness at end-expiration is 3.3 mm in healthy males and 2.2 mm in healthy females, with a typical TFic of 3% [84]. In Dres et al.'s study [84], which examined the relationship between TFic and respiratory stress, diaphragm function, and spontaneous breathing trial (SBT) outcomes, patients with lower levels of pressure support, diaphragm dysfunction, or SBT failure exhibited greater TFic than healthy individuals. ...
... The parasternal intercostal muscle's thickness at end-expiration is 3.3 mm in healthy males and 2.2 mm in healthy females, with a typical TFic of 3% [84]. In Dres et al.'s study [84], which examined the relationship between TFic and respiratory stress, diaphragm function, and spontaneous breathing trial (SBT) outcomes, patients with lower levels of pressure support, diaphragm dysfunction, or SBT failure exhibited greater TFic than healthy individuals. Mechanically ventilated patients' TFic decreased with increasing pressure support, indicating a dose-response relationship between TFic and respiratory load. ...
Intensive care unit-acquired weakness (ICU-AW) is a serious complication in critically ill patients. Therefore, timely and accurate diagnosis and monitoring of ICU-AW are crucial for effectively preventing its associated morbidity and mortality. This article provides a comprehensive review of ICU-AW, focusing on the different methods used for its diagnosis and monitoring. Additionally, it highlights the role of bedside ultrasound in muscle assessment and early detection of ICU-AW. Furthermore, the article explores potential strategies for preventing ICU-AW. Healthcare providers who manage critically ill patients utilize diagnostic approaches such as physical exams, imaging, and assessment tools to identify ICU-AW. However, each method has its own limitations. The diagnosis of ICU-AW needs improvement due to the lack of a consensus on the appropriate approach for its detection. Nevertheless, bedside ultrasound has proven to be the most reliable and cost-effective tool for muscle assessment in the ICU. Combining the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score assessment, and ultrasound can be a convenient approach for the early detection of ICU-AW. This approach can facilitate timely intervention and prevent catastrophic consequences. However, further studies are needed to strengthen the evidence.
... The increase in transdiaphragmatic pressure during maximal inspiratory sniff manoeuvres in the IMT group is almost exclusively explained by an increase in oesophageal pressure, which is an index of global respiratory muscle effort and suggests increased ribcage muscle contribution. Previous studies have demonstrated a compensatory increase in extra-diaphragmatic respiratory muscle activation with diaphragm weakness or dysfunction [28][29][30][31][32]. Additionally, the magnitude of negative (i.e. ...
... A higher thickening fraction was observed in patients with diaphragmatic dysfunction. 12 An article published in the current issue of the IJCCM by Ramaswamy et al., describes the use of parasternal intercostal muscle thickness for predicting weaning success. This was a single-center study of 60 patients. ...
How to cite this article: Havaldar AA, Krishna B. Wean to Win. Indian J Crit Care Med 2023;27(10):695–696.
... We also assessed the thickening of intercostal muscles, which are easily accessible by USS. Normally, the contribution of intercostal muscles to breathing increases with intense respiratory effort [31]. In our control group, the thickening fraction was low (≤ 5% for upper and middle intercostal muscles, 10% for low intercostals). ...
Objective:
This study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries.
Methods:
We included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A-C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°-30°.
Results:
We analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60-100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80-90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80-90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80-100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg.
Conclusions:
After acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80-90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit.
... Parasternal intercostal muscles can be visualized with a linear high frequency (10)(11)(12)(13)(14)(15) transducer placed at the level of the second and third intercostal space and positioned in cranio-caudal direction 3-5 cm laterally from the sternum [14,47,48]. The patient should be in a supine or semi-seated position (. ...
... During normal resting breathing in healthy volunteers, TFic of 3% [interquartile range, 2-5%] have been reported, whereas the TFic was found to be 5% [3-8%] vs. 17% [10-25%] in ICU patients without (n = 21) and with (n = 33) diaphragm dysfunction, respectively [48]. In healthy volunteers, reproducibility of thickness [48][49][50] and TFic [48] measurements have been reported from fair to excellent and good, respectively. ...
... During normal resting breathing in healthy volunteers, TFic of 3% [interquartile range, 2-5%] have been reported, whereas the TFic was found to be 5% [3-8%] vs. 17% [10-25%] in ICU patients without (n = 21) and with (n = 33) diaphragm dysfunction, respectively [48]. In healthy volunteers, reproducibility of thickness [48][49][50] and TFic [48] measurements have been reported from fair to excellent and good, respectively. In the same report [48], in 16 patients undergoing assisted breathing, a progressive a b ...
Monitoring the function of respiratory muscles is important to limit the detrimental consequences of mechanical ventilation on the respiratory muscles. The use of ultrasound for this purpose is relatively new, but it is becoming increasingly popular in the Intensive Care Unit (ICU) due to its non-invasive nature, real-time visualization, fast learning curve, and bedside availability. In this chapter, we provide an overview of the sonographic techniques currently used to assess structure, activity, and function of diaphragm (excursion and thickness/thickening fraction) and extra-diaphragmatic respiratory muscles (parasternal intercostal muscles and expiratory abdominal muscles). We also describe main clinical applications of respiratory muscle ultrasonography, including (1) detection of respiratory muscle dysfunction, either pre-existing or developed during mechanical ventilation; (2) quantification of the degree of muscle activation during patient effort; (3) support for the identification of patients at risks of weaning failure; (4) use in the assessment of patients with neuromuscular disease; and (5) assessment of patient-ventilator asynchronies. Finally, we also describe key pitfalls and limitations and introduce future directions.
