Destete guiado por ecografía / Ultrasound-Guided Extubation

Introducción: La observación del diafragma con el ultrasonido ha sido posible desde hace más de cuatro décadas; recientemente se le ha dado importancia a la valoración ultrasonográfica del diafragma en el proceso de destete del paciente ventilado. Objetivo: Describir la utilización de la ecografía diafragmática en la evaluación del proceso de destete en dos pacientes. Presentación de caso: Se presentan dos casos, el primer caso paciente femenino de 79 años con diagnóstico de infarto cerebral, coma y bronconeumonía; que precisó ventilación mecánica invasiva y previa prueba de ventilación espontánea. Se le realizó ultrasonido de diafragma donde se comprobó alta probabilidad de falla en la extubación, por lo que se modificó el esquema de destete para corregir las causas. El segundo paciente masculino de 68 años con diagnóstico de neumonitis aspirativa por queroseno que necesitó soporte ventilatorio invasivo; cuando presentó mejoría del cuadro inicial y parámetros de oxigenación, se le evaluó la función diafragmática mediante ultrasonografía se comprobó alta probabilidad de éxito en la extubación, se logró sin complicaciones. Conclusiones: Se utilizó la ultrasonografía diafragmática, emerge como una herramienta de fácil acceso y bajo costo, en la evaluación del proceso de destete en los pacientes ventilados, permitió la exploración de la función del diafragma en directo y en pie de cama. La valoración de la excursión diafragmática y la fracción de engrosamiento diafragmático proporcionó una escala predictiva valiosa, para prever que pacientes tendrán una extubación exitosa o no(AU)

Introduction: The observation of the diaphragm with ultrasound has been possible for more than four decades; but only recently has importance been given to the ultra-sonographic assessment of the diaphragm in the weaning process of the ventilated patient. Objective: To describe the use of diaphragmatic ultrasound in the evaluation of the weaning process in two patients. Case presentation: Two cases are presented, the first case is a 79-year-old female patient with a diagnosis of cerebral infarction, coma and bronchopneumonia; that she required invasive mechanical ventilation and after a spontaneous ventilation test, an ultrasound of the diaphragm was performed, where a high probability of failure in extubation was verified, for which the weaning scheme was modified to correct the causes. The second 68-year-old male patient diagnosed with kerosene aspiration pneumonitis that required invasive ventilator support; that when he presented improvement of the initial symptoms and oxygenation parameters, his diaphragmatic function was evaluated by ultrasonography, verifying a high probability of success in extubation, achieved without complications. Conclusions: Diaphragmatic ultrasonography emerges as a tool of easy access and low cost, in the evaluation of the weaning process in ventilated patients, allowing the exploration of the function of the diaphragm in direct and at the foot of the bed. The evaluation of the diaphragmatic excursion and the fraction of diaphragmatic thickening provide us with a valuable predictive scale, to anticipate which patients will have a successful extubation or not(AU)

Índice de respiración rápida superficial diafragmática como predictor weaning de la ventilación mecánica / Rate of rapid superficial diaphragmatic breathing as a weaning predictor of mechanical ventilation

El destete de la ventilación mecánica (VM) es un paso clave para los pacientes sometidos a VM invasiva en la unidad de cuidados intensivos (UCI). Entre las diversas herramientas destinadas a ayudar a predecir el fracaso sucesor del destete, encontramos el índice rápido de respiración superficial (RSBI por sus siglas en inglés), es decir, la relación entre la frecuencia respiratoria y el volumen corriente (Fr/Vt) medido durante una prueba de respiración espontánea (SBT por sus siglas en inglés). Objetivo: Describir el índice de respiración superficial diagramática como predictor Weaning de la ventilación mecánica. Materiales y métodos: Estudio de revisión, de tipo monográfico. Apoyado en artículos científicos, publicados en diferentes revistas indexzada en índices reconocidos. Resultado: Durante un SBT, el valor de RSBI parece ser paralelo a la evolución de la fatiga de los músculos respiratorios. Por lo tanto, se considera que el RSBI refleja la carga inspiratoria, siendo la disminución del volumen tidal junto con el aumento de frecuencia respiratoria indicativo de posible debilidad o fatiga de los músculos inspiratorios, u otros efectos fisiológicos. Conclusión: Entre los pacientes ventilados en la UCI, una alteración multifactorial del diafragma es común y puede resultar en falla del destete y prolongación de la VM invasiva; por lo tanto, evaluar la función del diafragma es un medio útil para evaluar la capacidad del paciente para tolerar la respiración espontánea(AU)

Weaning from mechanical ventilation (MV) is a key step for patients undergoing invasive MV in the intensive care unit (ICU). Among the various tools intended to help predict successor failure weaning, we found the rapid shallow breathing index (RSBI for its acronym in English), that is, the relationship between the respiratory rate and the volume current (Fr/Vt) measured during a spontaneous breathing test (SBT by its acronym in English). Objective: To describe the rate of shallow breathing Diagrammatic as a Weaning predictor of mechanical ventilation. Materials and methods: Review study, monographic type. supported by articles scientific, published in different magazines indexed in recognized indices. Result: During an SBT, the RSBI value appears to be parallel to the evolution of respiratory muscle fatigue. Therefore, it is considered that the RSBI reflects the inspiratory load, being the decrease in tidal volume together with the increased respiratory rate indicative of possible weakness or fatigue of the inspiratory muscles, or other physiological effects. Conclusion: Among the patients ventilated in the ICU, a multifactorial alteration of the diaphragm is common and can result in weaning failure and prolongation of invasive MV; by Therefore, assessing diaphragm function is a useful means of assessing the patient's ability to tolerate spontaneous breathing(AU)

Excursión diafragmática como predictor de éxito para el retiro de la ventilación mecánica en el paciente obeso / Diaphragmatic excursion as a predictor of success in the removal of mechanical ventilation in obese patient / Mobilidade diafragmática como preditor de sucesso na remoção da ventilação mecânica no paciente obeso

Resumen: Introducción: El soporte respiratorio es una de las principales indicaciones para los pacientes que ingresan a la Unidad de Cuidados Intensivos (UCI). La liberación de la ventilación mecánica invasiva (VMI) representa hasta 40% del tiempo en la VMI; comorbilidades como obesidad son más frecuentes en la UCI; existen recomendaciones en la liberación de la VMI en este grupo de pacientes, sin embargo, no existen predictores de éxito que esté ajustado para la población mexicana. Objetivo: Evaluar la excursión diafragmática (ED) como predictor de éxito para el retiro de la VMI en pacientes obesos. Material y métodos: Se realizó un estudio transversal, prospectivo, comparativo y analítico, en pacientes obesos ingresados a las UCI con VMI por más de 48 horas. Se analizaron variables demográficas, índice de ventilación de respiración superficial (IVRS) y ED. El punto de desenlace fue el éxito en la liberación de la VMI. Resultados: La distribución por género fue 42% de mujeres y 58% de hombres; la edad fue de 41.3 ± 12.8 años; estancia hospitalaria de 9.6 ± 4.6 días; el tiempo de VMI: 8.8 ± 4.8 días, e índice de masa corporal (IMC): 33.3 ± 2.7 kg/cm2; representados en grado I: 76%, grado II: 2%, grado III: 22%, IVRS: 59 ± 9.4; ED: 1.55 ± 0.11. El área bajo la curva (ABC) para IRS fue 0.60 y ED de 0.77. Adicionalmente, el mejor punto de corte para éxito fue IVRS < 44 con sensibilidad y especificidad de 100%, y la ED > 1.9 cm con sensibilidad y especificidad de 100%. Conclusión: El mejor predictor de éxito fue la ED con respecto al IVRS. Se proponen nuevos puntos de corte para IVRS y ED.

Abstract: Introduction: Respiratory support is an indication of admission to Intensive Care Units (ICU). The release of invasive mechanical ventilation (VMI), represents up to 40% of the time in VMI; comorbidities such as obesity are more frequent in the ICU; there are recommendations on the release of the VMI (LVMI) in this group of patients, however, there are no adjusted predictors of success for the Mexican population. Objective: To evaluate the diaphragmatic excursion (ED) as a predictor of success in the removal of IMV in obese patients (PO). Material and methods: A cross-sectional, prospective, comparative and analytical study was conducted in POs admitted to ICUs with IMV for more than 48 hours, demographic variables, surface respiration index (RSBI), ED were analyzed, the outcome was the success in LVMI. Results: The distribution by gender was women 42% and men 58%; age: 41.3 ± 12.8 years; hospital stay: 9.6 ± 4.6 days; VMI time: 8.8 ± 4.8 days, l body mass index (BMI): 33.3 ± 2.7; represented in grade I: 76%, grade II: 2%, grade III: 22%, RSBI: 59 ± 9.4; ED: 1.55 ± 0.11. The area under the curve (ABC) for RSBI was 0.60 and ED 0.77. Additionally, the best cut-off point for success was: RSBI < 44 with 100% sensitivity and specificity, and ED > 1.9 cm with 100% sensitivity and specificity. Conclusion: The best predictor of success was the ED with respect to the RSBI, new cut-off points for RSBI and ED are proposed.

Resumo: Introdução: O suporte respiratório é uma indicação de admissão em Unidades de Terapia Intensiva (UTI), a liberação de ventilação mecânica invasiva (VMI) representa até 40% do tempo na VMI; comorbidades como obesidade são mais frequentes na UTI; existem recomendações sobre a liberação do VMI (LVMI) nesse grupo de pacientes, no entanto, não há preditores ajustados de sucesso para a população mexicana. Objetivo: Avaliar a mobilidade diafragmática (MD) como preditor de sucesso na remoção de VMI em pacientes obesos (PO). Material e métodos: Foi realizado um estudo transversal, prospectivo, comparativo e analítico em PO admitidos em UTI com VMI por mais de 48 horas, foram analisadas variáveis demográficas, índice de ventilação da respiração superficial (IVRS), MD. O resultado foi bem-sucedido em LVMI. Resultados: A distribuição por gênero foi de mulheres 42%, homens 58%; idade 41.3 ± 12.8 anos internação 9.6 ± 4.6 dias, tempo de VMI: 8.8 ± 4.8 dias, índice de massa corporal (IMC) 33.3 ± 2.7; representado em Grau I 76%, Grau II 2%, Grau III 22%, IRS 59 ± 9.4; MD 1.55 ± 0.11. A área sob a curva (ABC) para IRS foi de 0.60 e MD 0.77. Além disso, o melhor ponto de corte para o sucesso foi: IVRS < 44 com 100% de sensibilidade e especificidade e ED > 1.9 cm com sensibilidade e especificidade de 100%. Conclusão: O melhor preditor de sucesso foi o MD em relação ao IVRS, novos pontos de corte para IVRS e MD são propostos.

The value of the excursion of diaphragm tested by ultrosonography to predict weaning from mechanical ventilation in ICU patients / 中华内科杂志

Objective To evaluate the excursion of the diaphragm and analyze the value in predicting weaning from mechanical ventilation in intensive care unit patients.Methods The patients with mechanical ventilation (＞48 hours) in ICU at Hebei Forth Medical University Hospital from June 2014 to December were classified into a success group or a failure group according to the weaning outcome.T-piece spontaneous breathing (SBT),airway occlusion pressure at 0.1 sec (P0.1) and maximal inspiratory pressure (MIP),rapid shallow breathing index (RSBI) and P0.1/MIP were measured or calculated.During the period of the 1 st hour SBT,the excursion of diaphragm was measured with ultrasonography.The predictive value of each parameter to weaning was evaluated with ROC curve.Results A total of 98 patients were enrolled in this study,including 74 successfully weaning and 24 failed.There were significant differences between two groups (success group and failure group) in P0.1 [(2.00 ± 2.00) cmH2O (1 cmH2O =0.098 kPa) vs (3.00 ±2.75)cmH2O,P ＜0.05],RSBI (39.14 ± 16.81 vs 52.00 ± 19.18,P ＜0.05),left diaphragmatic excursion [(1.12 ± 0.97) cm vs (0.69 ± 1.00) cm,P ＜ 0.001],right diaphragmatic excursion(1.87 ± 0.75) cm vs (1.17 ± 0.76) cm,P ＜ 0.001] and mean value of left and right diaphragmatic excursion [(1.57 ± 0.52) cm vs (0.83 ± 0.53) cm,and P ＜ 0.001].The ventilation time [2.00 (2.00-4.00) d vs 4.00 (2.00-5.00) d],ICU hospital lengths of stay [4.50 (3.00-7.25) d vs 8.50 (6.25-15.25) d] and total hospital lengths of stay [20.00 (15.00-25.25) d vs 25.00 (20.25-37.25)d] were also statistically significant in success group and failure group respectively (all P ＜ 0.05).The cutoff value of diaphragmatic excursion for predicting successful extubation was determined to be 1.14 cm by ROC curve analysis.The sensitivity of diaphragmatic excursion to predict successful weaning was 89.2％ and the specificity was 75.0％,the AUCROC was 0.849.Conclusion As an early predictor of diaphragmatic dysfunction,diaphragmatic excursion is probably superior to the traditional parameters in predicting weaning from ventilator in ICU patients.

Ultrasonido: una alternativa en la evaluación del diafragma en niños con distrofia muscular de Duchenne / Ultrasound, an alternative in the evaluation of the diaphragm in children with Duchenne muscular dystrophy

The outcome of children with Duchenne muscular dystrophy (DMD) depends on respiratory involvement, so a timely assessment of the diaphragm is required. We propose ultrasound (US) imaging as an alternative in the evaluation of the diaphragm in children with DMD, correlating diaphragmatic thickness and excursion values yielded by the US study with pulmonary function tests. We conducted a case-control study including 27 children, 15 controls and 12 patients. Excursion and thickness of both hemidiaphragms were measured by U.S., and spirometry was performed. The DMD group showed less excursion and a significantly higher thickness of the right hemidiaphragm; 60 percent of patients showed spirometric restrictive pattern and FEV1, FVC, PEF and PIM values were significantly lower. We found a negative trend when correlating diaphragmatic excursion with pulmonary function tests. We conclude that the US technique is suitable for screening alterations in diaphragmatic excursion and thickness in children with DMD, since it provides supporting data to pulmonary function tests.

El pronóstico de los niños con distrofia muscular de Duchenne (DMD) depende del compromiso respiratorio, siendo necesaria la evaluación oportuna del diafragma. Proponemos el ultrasonido (US) como alternativa en la evaluación del diafragma en niños con DMD, correlacionando los valores de excursión y grosor del diafragma obtenido con US, con las pruebas de función pulmonar. Realizamos un estudio de casos y controles, incluyendo 27 niños, 15 controles y 12 pacientes. Se midió excursión y grosor de ambos hemidiafragmas con US; se realizó espirometría y pimometría. El grupo DMD presentó menor excursión y grosor significativamente mayor del hemidiafragma derecho; el 60 por ciento mostró patrón restrictivo en la espirometría y los valores de VEF1, CVF, FEP y PIM fueron significativamente menores. Encontramos una tendencia negativa al correlacionar la excursión diafragmática con las pruebas de función pulmonar. Concluimos que el US es apto para pesquisar alteraciones en la excursión y grosor del diafragma en niños con DMD, apoyando las pruebas de función pulmonar.

M-mode Ultrasound Assessment of Diaphagmatic Excursions in Chronic Obstructive Pulmonary Disease: Relation to Pulmonary Function Test and Mouth Pressure / 결핵

BACKGROUND: Respiratory muscle interaction is further profoundly affected by a number of pathologic conditions. Hyperinflation may be particularly severe in chronic obstructive pulmonary disease(COPD) patients, in whom the functional residual capacity(FRC) often exceeds predicted total lung capacity(TLC). Hyperinflation reduces the diaphragmatic effectiveness as a pressure generator and reduces diaphragmatio contribution to chest wall motion Ultrasonography has recently been shown to be a sensitive and reproducible method of assessing diaphragmatic excursion. This study was performed to evaluate how differences of diaphragmatic excursion measured by ultrasonography associate with normal subjects and COPD patients. METHODS: We measured diaphragmatic excursions with ultrasonography on 28 healthy subjects(16 medical studentz 12 age-matched control) and 17 COPD patientc Ultrasonographic measurements were performed during tidal breathing and maxima] respiratory efforts approximating vital capacity breathing using Aloka KEC-620 with 3.5 MHz transducen Measurements were taken in the supine posture. The ultrasonograpbic probe was positioned transversely in the midclavicular line below the right subcostal margin After detecting the right hetnidiaphragm in the B-mode the ultrasound beam was then positioned so that it was approximately parallel to the movement of middle or posterior third of right diaphragm. Recordings in the M-inodc at this position were made throughout the test Measurements of diaphragmatio excursion on M-mode tmcing were calculated by the average gap in 3 times-respiration cycle. Pulmonary functicn test(SensorMedics 2800), maximal inspiratory(Plmax) and expiratory mouth pressure(PEmax, Vitalopower KH-101, Chest) were measured in the seated posture. RESULTS: During the tidal breathing, diaphragmatic excursions were recorded 1.5 +/-0.5cm, 1.7+/-0.5cm and 1.5 +/- 0.6cm in medical students, age-matched control group and COPD patients, respectively. Diaphragm excursions during maximal respiratory efforts were significantly decreased in COPD patients (3.7+/-1.3cm) when compared with medical students, age-matched control group(6.7+/-1.3cm, 5.8+/-1.2cm, p<0.05). During maximal respiratory efforts in control subjects, diaphragm excursions were cowelatal with FEV1, FEV1/FVC, PEF, PIF, and height. In COPD patients, diaphragm excursions during maximal respiratory efforts were correlated with PEmax(maxinIal expiratory pressure), age, and %FVC. In multiple regression analysis, The combination of PEmax and age was an independent marker of diaplngnt excursions during maximal respiratory efforts with COPD patients. CONCLUISON: COPD subjects had smaller diaplragmatic excursions during maximal respintoty efforts than control subjects. During maximal respiratory efforts in COPD patients, diaphragm excursions were well correlated with PEmax. Those results suggest that diaphragm excursions during rnaximel respiratory efforts with COPD patients may be valuable at predicting the pulnionmy function.