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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 605-611

Role of assessment of the diaphragm by ultrasound during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease


1 Department of Chest Diseases, Faculty of Medicine, AL-Azhar University, Cairo, Egypt
2 Chest Diseases Department, Al Azhar Faculty of Medicine, Cairo, Egypt

Date of Submission28-Jun-2019
Date of Decision28-Jun-2019
Date of Acceptance09-Jul-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
MD Ibrahim H.E Ibrahim
Lecturar of Chest Diseases. Faculty of Medicine, Al-Azhar University, Egypt
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_61_19

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  Abstract 


Background Diaphragmatic rapid shallow breathing index (D-RSBI) is a new promising tool to predict weaning outcome. The D-RSBI is the ratio between respiratory rate (RR) and the ultrasonographic evaluation of diaphragmatic displacement (DD). Its accuracy in predicting weaning failure, in ready-to-wean mechanically ventilated (MV) patients with chronic obstructive pulmonary disease (COPD), needs to be evaluated.
Aim To assess diaphragm using ultrasound during weaning from MV in patients with COPD and to compare the new D-RSBI with traditional RSBI.
Patients and methods A prospective observational study was carried out on MV patients with COPD who were ready to wean. During spontaneous breathing trial, evaluation of the right hemi-DD and diaphragmatic thickness by using M-mode ultrasonography was done. Then calculation of D-RSBI (RR/DD), and RSBI (RR/tidal volume) was carried out simultaneously. Outcomes of the weaning trials were recorded. Receiver operating characteristic curves were used to evaluate the diagnostic accuracy of D-RSBI and RSBI.
Results A total of 104 patients with acute exacerbation COPD who were ready to perform an spontaneous breathing trial from MV were included. Overall, 86 (82.7%) were successfully liberated from MV, and 18 (17.3%) patients had failure of weaning. The sensitivity and specificity of DD were 72.2 and 93.0%, respectively. The sensitivity and specificity of RSBI were 77.8 and 70.9%, respectively. However, the sensitivity and specificity of D-RSBI were 83.3 and 90.7%, respectively.
Conclusion D-RSBI (RR/DD) is superior than the traditional RSBI (RR/tidal volume) in predicting weaning outcome in patients with acute exacerbation COPD.

Keywords: diaphragmatic displacement, diaphragmatic rapid shallow breathing, spontaneous breathing trial, ultrasonography, weaning


How to cite this article:
Yousif WG, Ibrahim IH, Abo-Alyzeid HA. Role of assessment of the diaphragm by ultrasound during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. Sci J Al-Azhar Med Fac Girls 2019;3:605-11

How to cite this URL:
Yousif WG, Ibrahim IH, Abo-Alyzeid HA. Role of assessment of the diaphragm by ultrasound during weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Aug 10];3:605-11. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/605/278037




  Introduction Top


Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality throughout the world, and many people experience this disease for years and die prematurely owing to it or its complications [1],[2].

The diaphragm is the major respiratory muscle and contributes to 75% of resting lung ventilation, with an excursion of 1–2 cm. During forced breathing, its excursion reaches 7–11 cm, which is variable with individual characteristics and methods [3]. The evaluation of diaphragmatic mobility has been traditionally performed using fluoroscopy. In recent years, ultrasound has also been used to evaluate diaphragmatic mobility. It offers some advantages over fluoroscopy including the lack of ionizing radiation and the possibility of using at the bedside of the patient. So ultrasonography has been shown to be a promising tool in the evaluation of the diaphragm function [4].

Mechanical ventilation (MV) is a life-support measure for patients who cannot maintain adequate alveolar ventilation, including patients with COPD [5]. Discontinuing MV is a rapid and uneventful process for most patients, but for one of every four or five patients, the transition to spontaneous breathing is a prolonged process that can consume almost half of the total time on a ventilator [5]. Predicting extubation outcome and preventing extubation failure is therefore an important task. Various weaning parameters have been suggested to be useful, for example, minute ventilation (VE), respiratory rate (RR), tidal volume (VT), rapid shallow breathing index (RR divided by VT, f/VT), maximum inspiratory pressure (PI max), and trans-diaphragmatic pressure (Pdi). However, the prediction rate of these parameters may not be satisfactory. Evaluating the strength of the respiratory muscles becomes important, as the imbalance between respiratory demand and supply will lead to weaning failure through the development of respiratory muscle fatigue [6].

The rapid shallow breathing index (RSBI) (defined as the ratio of RR/VT) is one of the most widely used predictors of weaning outcome. Unfortunately, it has variable sensitivity and specificity. So recently, Yamaguti et al. [7] introduced the diaphragmatic rapid shallow breathing index (D-RSBI) by substituting VT with diaphragmatic displacement (DD) in the RSBI (i.e. D-RSBI=RR/DD). This avoids masking the underlying diaphragmatic dysfunction caused by the contribution of the accessory muscles in generating VT that could impair the diagnostic accuracy of the RSBI [7],[8].


  Patients and methods Top


Study design and patients

A prospective observational study was carried out in the respiratory ICU of the Abbasia Chest Hospitals, Alhussin University Hospital, and Elsayed Galal Hospital during the period from November 2017 to October 2018. It included 104 patients with AECOPD who required MV. Patients with AECOPD were divided into two groups:
  • Group A: 86 MV patients with COPD with weaning success.
  • Group B: 18 MV patients with COPD with weaning failure.


The study was approved by the Faculty of Medicine, Azhar University Ethics Committee. Written informed consent was obtained from all patients.

Inclusion criteria

Patients with COPD with acute exacerbation were included.

Exclusion criteria

The following were the exclusion criteria:
  1. Neuromuscular disease.
  2. Use of muscle-paralyzing agents within 48 h before the study.
  3. History or new detection of paralysis or paradoxical movement of a single hemidiaphragm on diaphragmatic ultrasonographic.



  Methods Top


All studied patients were subjected to the following:
  1. Complete history taking and general and local chest clinical examination.
  2. Routine laboratory investigation examination, including complete blood count (CBC), arterial blood gases, chest radiograph, and computerised tomography (CT) chest if needed.
    • Patients intubated and MV for more than 48 h were considered to be ready for spontaneous breathing trial (SBT) (i.e. spontaneous ventilation through a pressure support) and met all of the following criteria:
    1. Clinical improvement of the underlying cause for MV.
    2. Improvement of respiratory failure.
    3. Hemodynamic stability: absence of active myocardial ischemia and absence of clinically important hypotension (no vasopressor/low-dose vasopressors such as dopamine or dobutamine 5 µ/kg/min).
    4. Intact ventilatory drive, and the patient has spontaneous breathing effort.
    5. Afebrile (temperature<38°C).
    6. No significant respiratory acidosis.
    7. Adequate nutritional status (not hypo/hyper).
    8. Stable metabolic status (electrolytes: Ca, P, and Mg).
    9. Adequate hemoglobin (Hb) level (8–10 g/dl)/SVO2 more than 65%.
    10. Adequate mentality (arousable, GCS>13, and no continuous sedation).
    11. Adequate oxygenation [i.e. arterial oxygen saturation (SaO2) 92% with inspiratory oxygen fraction (FiO2) 0.5 with positive end expiratory pressure below 8 cmH2O].
    12. Adequate pulmonary function [i.e. RR below 30 breaths/min with VT above 5 ml/kg ideal body weight, and no significant respiratory acidosis].
  3. Ultrasonographic scanning of the right hemidiaphragm after 30 min from the beginning of the SBT. The patients were lying in the semirecumbent position, with the head of the bed elevated at an angle between 30° and 45°.
  4. Diaphragmatic movement was measured using superficial and deep US probe placed over one of the lower intercostal spaces in the right anterior axillary line with ultrasound. With the probe fixed on the chest wall during respiration, the ultrasound beam was directed to the hemidiaphragmatic dome at an angle of not less than 70°. During inspiration, the normal diaphragm contracts and moves caudally toward the transducer; this is recorded as an upward motion of the M-mode tracing. The amplitude of excursion was measured on the vertical axis of the tracing from the baseline to the point of maximum height of inspiration on the graph. Four or three measurements were recorded and averaged. All measurements were performed during tidal breathing at 6–12 ml/kg, excluding smaller or deeper breaths. The whole US examination was accomplished in 5 min. Negative excursion was an indicator of paradoxical diaphragmatic movement. 12 M-mode ultrasonography of the diaphragm of a patient with a conserved right hemidiaphragm function (DD=16 mm) is shown in [Figure 1]. Diaphragmatic ultrasonography was performed for all patients by two independent operators to measure the DD. All patients’ recordings were analyzed twice by both operators. All measurements were tested for intraobserver and interobserver reproducibility.
    Figure 1 Receiver operating characteristic (ROC) curve for diaphragmatic displacement (DD), diaphragmatic rapid shallow breathing index (D-RSBI), respiratory rate (RR) and traditional rapid shallow breathing index (RSBI).

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  5. Calculation of RSBI (RR/VT) and D-RSBI (RR/DD) was done.
  6. Assessment of weaning outcome was as follows: a successful weaning trial was reported when patients were extubated and breathed spontaneously for more than 48 h.
  7. The reinstitution of MV during or at the end of the SBT, re-intubation within 48 h, or the use of noninvasive ventilation within 48 h of extubation was reported as a failed weaning trial.


Statistical analysis

Data were analyzed using a statistical program, statistical package for the social sciences (SPSS), version 23.0 for Windows (SPSS Inc., Chicago, Illinois, USA), NCSS 12 for Windows (NCSS LCC., Kaysville, Utah, USA), and MedCalc 15.4 for Windows (MedCalc Software bvba, Ostend, Belgium). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage.


  Results Top


Patients’ demography

[Table 1] shows no statistically significant difference between groups A and B regarding sex, age, and smoking, whereas regarding patients’ comorbidities, a significant statistical difference was present, as of the 86 patients in group A with successful weaning, 32 (37.2%) had comorbidities, whereas of the 18 patients in group B with weaning failure, 16 (88.9%) patients had comorbidities.
Table 1 Patient characteristics

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Weaning parameters

[Table 2] shows a highly statistically significant difference between both groups regarding the parameters of weaning. FiO2 in weaning success group was 42.1±4.1 and in weaning failure group was 50.0±6.9, O2 saturation in patient with successful weaning was 93.5±1.4 in comparison with 91.7±1.1 in the failure group, and finally, VT in patient with successful weaning was 385±29 in comparison with 338±37 in the failure group.
Table 2 Parameters of weaning

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Predictors of failed weaning and its accuracy

[Table 3] shows highly statistically significant difference between both groups regarding the SBT parameters (D-RSBI, RSBI, DD, and diaphragmatic thickening). In group A, D-RSBI was 1.11±0.34 compared with 2.24±0.69 in group B, with a statistically highly significant difference between both groups. Moreover, group A had lower RSBI (67.4±11.7) compared with group B (85.6±16.7), with statistically highly significant difference between both groups. DD was higher in group A (23.1±4.2) compared with group B (16.0±5.4), with statistically highly significant difference between both groups. Finally, group A had higher diaphragmatic thickening (%) (23.2±3.9) compared with group B (17.4±6.4), with statistically highly significant difference between both groups.
Table 3 Patients’ diaphragmatic rapid shallow breathing index, rapid shallow breathing index, diaphragmatic displacement, and diaphragmatic thickening, as weaning predictors among the studied patients

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[Table 4] and [Figure 1] show highly statistically significant accuracy of D-RSBI, RSBI, DD, and RR after SBT in predicting weaning failure by using receiver operating characteristic curve. D-RSBI is more highly sensitive and specific than others indices such as RSBI, DD, and RR after SBT in predicting weaning failure.
Table 4 Sensitivity, specificity, negative predictive value, and positive predictive value according to weaning predictors

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The area under receiver operating characteristic curve for D-RSBI was significantly different from the one for RSBI (0.89 vs. 0.72; P=0.001).


  Discussion Top


In this study, [Table 1] shows 90 patients were males and 14 patients were female, with a mean age of 63.0±6.0 years in group A and 60.7±4.9 years in group B. There was no significant statistical difference between the patients with successful and failed weaning regarding the age, sex, and smoking. This was in agreement with many studies, such as Abbas et al. [9], Makhlouf and colleagues, El Hoffy and Khamis [10], and Spadaro et al. [5].

In this study, regarding the number of comorbid disease in each patient, 48 patients had comorbid diseases, in which 32 (22 patients had successful weaning and 10 patients had weaning failure) patients had hypertension, 24 (14 patient had successful weaning and 10 patients had weaning failure) patients had diabetes mellitus, 18 (12 patients had successful weaning and six patients had weaning failure) patients had ischemic heart disease, and eight (two patients had successful weaning and six patients had weaning failure) patients had chronic atrial fibrillation. This revealed that patients with multiple comorbid diseases were associated with a high rate of weaning failure. There was a significant statistical difference between the patient groups regarding the comorbidities [hypertension (HTN), ischemic heart disease (IHD), atrial fibrillation (AF), and diabetes mellitus (DM)]. This was in agreement with Khamiees et al. [14], El Hoffy and Khamis [10], Spadaro et al. [5], Ongel et al. [16] and Mabrouk et al. [12].

Ongel et al. [16] studied the effect of COPD comorbidities in the ICU outcome in 1013 patients in the period from January 2008 to December 2012. The study reported that patients with multiple comorbidities especially cardiac comorbidities had a higher risk of MV and failure of weaning, with higher rates of mortality. Moreover, in accordance with El Hoffy and Khamis [10], in their study, 10 (seven of them had successful weaning and three patients had weaning failure) patients had diabetes mellitus, 20 patients had hypertension (three of them had successful weaning and seven had weaning failure), 12(nine of them had successful weaning and three patients had weaning failure) patients had coronary artery diseases, and six (four of them had successful weaning and two patients had weaning failure) patients had congestive heart failure, with higher failure rates among patients with multiple comorbid diseases. The high prevalence of COPD among male patients was attributed to the high rate of smoking and the occupational exposure.

In this study, the mean value of RSBI (the ratio of RR/VT) was 67.4±11.7 in the group of patients of successful weaning and 85.6±16.7 in the group of patients of failed weaning, with sensitivity 77.8%, specificity 70.9% and accuracy 72.1% using cutoff value less than 105, with statistically significant difference between both groups. RSBI was high in the group of failed weaning as the patients had rapid RR and low VT, in contrast to the patients in the group of successful weaning. There was an agreement with the study carried out by Abbas et al. [9]. A total of 50 patients with AECOPD requiring MV for more than 48 h who were ready to perform a SBT were included. Of these, 37 (74%) were successfully liberated from MV. Among the 13 patients who failed the weaning trial, eight (62%) failed the SBT and were reconnected to the ventilator; two (15%) were reintubated within 48 h of extubation, and three (23%) required noninvasive ventilation support within 48 h of extubation. The areas under the receiver operating characteristic curves for D-RSBI and RSBI were 0.97 (P<0.001) and 0.67 (P<0.06), respectively.

Regarding the assessment of the DD, the mean value in the group B (failure of weaning) was 16.0±5.4 mm, which is higher than the mean value in group A (success of weaning), which was 23.1±4.2 mm, with statistically significant difference between both groups, which could be explained by the respiratory muscle dysfunction in the MV patients, with sensitivity of 72.2%, specificity of 93.0%, and accuracy of 89.4%, using cutoff value of 16.6 mm.

In this study, the mean value of RR in the group of successful weaning was 14.7±0.9, which is lower than the mean value in the group of failed weaning, which was 15.1±1.1, with statistically significant difference between both groups, with sensitivity of 77.8%, specificity of 27.9%, and accuracy of 36.5%, using cutoff value of at least 24. There was agreement with the study by Spadaro et al. [5], where the mean value of RR in the patients with successful weaning was 18±5, which was lower than the mean value in the patients with failed weaning, which was 24±7, with statistically significant difference between both groups, with sensitivity 64.7% and specificity 76.5%, with accuracy of 76% using cutoff value more than 20. Moreover, this was in agreement with the study of Abbas et al. [9], where the mean value of RR in the patients with successful weaning was 23.64±6.48, which was lower than the mean value in the patients with failed weaning which was 29.38±11.27, with statistically significant difference between both groups, with sensitivity of 100%, specificity 29.7%, and accuracy of 48% using cutoff value more than 19.

In this study, the mean value of VT in the group of successful weaning was 385±29 ml, which is higher than the mean value in the group of failed weaning, which was 338±37 ml, with statistically significant difference between both groups.

In the study by Makhlouf et al. [18], the mean value of VT in the group of successful weaning was 420 ml, which was also higher than the mean value in the group of failed weaning, which was 343 ml, with statistically significant difference between both groups. This was in agreement with the study by El Hoffy and Khamis [10], the mean value of VT in the group of successful weaning was 375 ml, which is also higher than the mean value in the group of failed weaning, which was 278 ml, with statistically significant difference between both groups. This was also in agreement with Jiang et al. [17], where the mean value of VT in the group of successful weaning was 382 ml, which is also higher than the mean value in the group of failed weaning, which was 286 ml with statistically significant difference between both groups, and with Alvisi et al. [15], where the mean value of VT in the group of successful weaning was 387 ml, which is also higher than the mean value of the group of failed weaning, which was 292 ml with statistically significant difference between both groups. There was not in agreement with, Mabrouk et al. [12], where although the mean value of VT in the group of successful weaning was 427 ml, which is higher than the mean value in the group of failed weaning, which was 385 ml, there was no statistically significant difference between both groups regarding VT. This may be explained as the MV patients with non-respiratory causes were included in the study, and also the weaning methods from MV were different in each group and the number of patients is also different [11].

Regarding assessment of the D-RSBI, the mean value in the group B (failed weaning) was 2.24±0.69, which is higher than the mean value in group A (success of weaning), which was 1.11±0.34, with statistically significant difference between both groups. This could be explained by the respiratory muscle dysfunction in the MV patients. In group A, the mean value of D-RSBI in the patients with successful weaning was 1.11±0.34, which was lower than the mean value in the patients with failed weaning, which was 2.24±0.69, with statistically significant difference between both groups, with sensitivity of 83.3%, specificity of 90.7%, and accuracy of 89.4% using cutoff value of at least 1.42. This was in agreement with the study by Spadaro et al. [5], where the mean value of D-RSBI in the patients with successful weaning was 1.2 (0.8–1.9), which was lower than the mean value in the patients with failed weaning, which was 2.7 (1.7–4.1), with statistically significant difference between both groups, with sensitivity of 94.1%, specificity of 64.7%, and accuracy of 89% using cutoff value more than 1.3. This was in agreement with the study of Abbas et al. [9], where the mean value of D-RSBI in the patients with successful weaning was 1.43±0.32, which was lower than the mean value in the patients with failed weaning, which was 3.27±0.84, with statistically significant difference between both groups, with sensitivity of 84.6%, specificity of 100%, and accuracy of 96% using cutoff value more than 1.9. Regarding assessment of the RSBI, the mean value in the group B (failed weaning) was 85.6±16.7, which is higher than the mean value in group A (success of weaning), which was 67.4±11.7, with statistically significant difference between both groups, which could be explained by the respiratory muscle dysfunction in the MV patients. In group A, the mean value of RSBI in the patients with successful weaning was 67.4±11.7, which was lower than the mean value in the patients with failed weaning, which was 85.6±16.7, with statistically significant difference between both groups, with sensitivity of 77.8%, specificity of 70.9%, and accuracy of 72.1% using cutoff value of at least 69 [13].


  Conclusion Top


DD when combined with RR in an index that we named D-RSBI (RR/DD) is more accurate than the traditional RSBI (RR/VT) in predicting the weaning outcome. A cutoff of 1.3 is associated with the best sensitivity and specificity. Our results confirm the importance of rapid and shallow breathing as a global index of weaning-induced patient distress.

The sensitivity and specificity of RSBI were 77.8 and 70.9%, respectively. However, the sensitivity and specificity of D-RSBI were 83.3 and 90.7%, respectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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