Estimation of transpulmonary driving pressure using a lower assist maneuver (LAM) during synchronized ventilation in patients with acute respiratory failure: a physiological study.

BACKGROUND: We previously showed in animals that transpulmonary driving pressure (PL) can be estimated during Neurally Adjusted Ventilatory Assist (NAVA) and Neural Pressure Support (NPS) using a single lower assist maneuver (LAM). The aim of this study was to test the LAM-based estimate of PL (PL_LAM) in patients with acute respiratory failure. METHODS: This was a prospective, physiological, and interventional study in intubated patients with acute respiratory failure. During both NAVA and simulated NPS (high and low levels of assist), a LAM was performed every 3 min by manually reducing the assist to zero for one single breath (by default, ventilator still provides 2 cmH2O). Following NAVA and NPSSIM periods, patients were sedated and passively ventilated in volume control and pressure control ventilation, to obtain PL during controlled mechanical ventilation (PL_CMV). PL using an esophageal balloon (PL_Pes) was also compared to PL_LAM and PL_CMV. We measured diaphragm electrical activity (Edi), ventilator pressure (PVent), esophageal pressure (Pes) and tidal volume. PL_LAM and PL_Pes were compared to themselves, and to PL_CMV for matching flows and volumes. RESULTS: Ten patients were included in the study. For the group, PL_LAM was closely similar to PL_CMV, with a high correlation (R2 = 0.88). Bland-Altman analysis revealed a low Bias of 0.28 cmH2O, and 1.96SD of 5.26 cmH2O. PL_LAM vs PL_Pes were also tightly related (R2 = 0.77). CONCLUSION: This physiological study in patients confirms our previous pre-clinical data that PL_LAM is as good an estimate as PL_Pes to determine PL, in spontaneously breathing patients on assisted mechanical ventilation. Trial registration The study was registered at clinicaltrials.gov (ID NCT05378802) on November 6, 2021.

Hepatic ectopic pregnancy with hemorrhage secondary diaphragmatic adhesion: A case report.

BACKGROUND: Primary abdominal pregnancy is an extremely rare form of ectopic pregnancy. Ectopic pregnancies that occur in the liver and diaphragm are even rarer, limited case reports are available in the literature. CASE SUMMARY: A woman of childbearing age was transferred to the emergency department due to lumbar and abdominal pain radiating to the back toward the lower right. After a series of physical and auxiliary examinations, she was clinically diagnosed with hepatic ectopic pregnancy. Laparoscopic surgery was performed to remove the pregnancy tissue and achieve hemostasis. After a period of follow-up, the patient was successfully cured. CONCLUSION: Paying attention to the patient's signs and utilizing imaging examination methods can help avoid missed diagnoses of liver pregnancy.

Robotic Repair of Acute Traumatic Diaphragmatic Injury From an Abdominal Approach: A Case Report.

Traumatic diaphragmatic injury is a rare condition with a significant mortality risk and may cause a herniation of an intraperitoneal organ into the pleural space. In the acute phase, traumatic diaphragmatic hernia (TDH) may be repaired with laparotomy or thoracotomy and is often associated with multiple concurrent injuries. This case report highlights a rare clinical scenario of blunt traumatic DH in a 62-year-old male with approximately seven centimeters of stomach herniating into the left pleural space, repaired with minimally invasive surgery. This was done via a transabdominal approach with robotic-assisted laparoscopic hernia repair and institution of biologic mesh and represents an important opportunity that potentially reduces the morbidity risk involved with open surgeries.

Diaphragm Disease of the Terminal Ileum: The Great Imitator.

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with an array of intestinal injuries: erosions, ulcers, enteropathy, strictures and diaphragm disease. The diagnosis of diaphragm disease is challenging. Diaphragm disease can cause thin, concentric and stenosing strictures, which can induce intermittent or complete bowel obstruction. NSAID-induced lesions are reversible following discontinuation of the offending agent. Treatment of diaphragm disease can be conservative, endoscopic or surgical through stricturoplasty and/or segmental resection. We report a case of a 59-year-old female presenting with intermittent right lower quadrant pain diagnosed with diaphragm disease upon combined ileo-colonoscopy and histopathological analysis. Her diaphragm disease was successfully treated conservatively through drug cessation, avoiding more invasive procedures like endoscopic and surgical interventions. LEARNING POINTS: The incidence of diaphragm disease has been soaring due to the widespread use of non-steroidal anti-inflammatory drugs (NSAIDs).Diaphragm disease is characterized by diaphragm-like mucosal projections and annular constrictions that induce luminal narrowing and result in bowel obstruction.Physicians should get acquainted with diaphragm disease and include it in their differential diagnosis when approaching a patient with obstruction-like symptoms or non-specific and vague abdominal pain in the setting of chronic NSAIDs usage.

Predictive Value of Diaphragm Muscle Ultrasound for Ventilator Weaning Outcomes After Cervical Spinal Cord Injury: A Retrospective Case Series.

OBJECTIVES: Neuromuscular respiratory failure after cervical spinal cord injury (cSCI) can lead to dependence on an invasive mechanical ventilator. Ventilator-free breathing after cSCI is associated with improved morbidity, mortality, and quality of life. We investigated the use of diaphragm muscle ultrasound to predict ventilator weaning outcomes after cSCI. METHODS: This is a retrospective case series conducted at a university-affiliated freestanding inpatient rehabilitation facility. We identified patients with cSCI who had a tracheostomy and were dependent on an invasive mechanical ventilator at the time of admission to inpatient rehabilitation. A diaphragm muscle ultrasound was performed, which included measurements of the thickness of the diaphragm and a calculation of the thickening ratio (TR), which reflects diaphragm muscle contraction. The primary outcome measure was the need for mechanical ventilation at time of discharge from the inpatient rehabilitation facility. Successful ventilator weaning was defined as either daytime or full 24-hour ventilator-free breathing. RESULTS: Of the 21 patients enrolled, 11 (52%) were able to wean successfully (partially or fully) from the ventilator. Of the ultrasound measurements that were taken, the TR was the optimal predictor for ventilator weaning outcomes. A threshold of TR ≥ 1.2 as the maximum hemidiaphragm measurement had a sensitivity of 1.0 and specificity of 0.90 for predicting ventilator weaning. CONCLUSION: Normal diaphragm contractility (TR ≥ 1.2) as determined by diaphragm muscle ultrasound is a strong positive predictor for successful ventilator weaning in patients with cSCI. Utilizing diaphragm ultrasound, rehabilitation physicians can set precision rehabilitation goals regarding ventilator weaning for inpatients with respiratory failure after cSCI, potentially improving both outcomes and quality of life.

Diaphragm Tracking System That Superimposes Planned Diaphragm Contours on Kilovolt Cine Images During Multiple Breath-Hold Volumetric Modulated Arc Therapy for Abdominal Tumors.

We recently published a phantom validation of our diaphragm tracking system, DiaTrak, on an Elekta linear accelerator with an integrated cone-beam computed tomography (CBCT) unit for multiple breath-hold volumetric modulated arc therapy of abdominal tumors, where the diaphragm position was compared between digitally reconstructed radiography (DRR) and kilovolt (kV) projection streaming images by template matching. In the present report, the visual feedback of the diaphragm position was added to the reported system. DICOM-RT diaphragm contour data were additionally exported from a treatment planning system to the DiaTrak PC. Following phantom localization by registering the CBCT to the planning CT images, a projected diaphragm contour was overlaid on each DRR image, whereas another two projected diaphragm contours were superimposed on each kV projection cine image every 180 ms after shifting ±5 mm (set as breath-hold tolerance) in the craniocaudal direction during gantry rotation. It was visually confirmed that the projected diaphragm surface was observed within the two contour lines on the kV cine window. The diaphragm registration errors of the localized phantom were also calculated based on image cross-correlation between the DRR and the projection cine images every 180 ms. It was found that the mean diaphragm registration error was -0.29 mm with a standard deviation of 0.32 mm during the gantry rotation. In conclusion, a new interface for the 5 mm tolerance check was proposed to provide direct visual feedback, thereby giving a sense of assurance to the attending radiotherapy technologists. The calculated diaphragm registration errors were relatively small compared to the tolerance of 5 mm, and therefore it is considered clinically acceptable.

Composite mesh a novel innovative bridge approach for refractory pancreatic effusion - sequelae of porous diaphragm syndrome: Case series.

INTRODUCTION AND IMPORTANCE: Managing refractory pancreatic effusion due to porous diaphragm syndrome (PDS) is a challenge. Various surgical interventions such as repairing the defect, sealing with fibrin glue, performing parietal pleurectomy, and talc pleurodesis have been reported however, the use of composite mesh placement in treating PDS has not been described in the literature. CASE PRESENTATION: All three male patients with a low body mass index were diagnosed with pancreatic disease as described in cases 1-3 and associated pancreatic effusion. These patients required medical treatment as an initial approach and surgical intervention in the form of decortication, sterilization of the thoracic cavity with 20 % betadine and normal saline in the ratio 1:4, followed by warm normal saline washes and composite mesh placement for PDS followed by endoscopic retrograde cholangiopancreatography (ERCP) as a pancreatic intervention after 3 weeks. Only one patient underwent sphincterotomy, while the other two patients had no abnormality on ERCP. Post-operative follow-ups at 3, 6, and 12 months were uneventful with no recurrence. CLINICAL DISCUSSION: The mechanism for pancreatic effusion is explained by pancreatic duct disruption followed by enzyme leak leading to pancreatic-pleural communication mediated by PDS. Various studies have described their role in treating PDS, even thoracoscopic pleurodesis requiring prolong chest tube and repeated talc slurry for better outcome. However, to address this, we performed the above procedure as a bridge approach followed by a pancreatic intervention. CONCLUSION: Thoracic intervention with composite mesh can serve as a bridge procedure before future pancreatic intervention or surgery.

[Laparoscopic repair of hiatal hernia after minimally invasive esophagectomy]. / Laparoskopicheskoe ustranenie parastebel'chatoi gryzhi posle mini-invazivnoi ezofagektomii.

Postoperative hiatal hernia is a rare and specific complication after esophagectomy. This complication leads to emergency and affects mortality. Incidence of this complication has increased due to the great number of minimally invasive procedures over the past decades. In addition, chronic cough, preoperative hiatal hernia and transhiatal approach also increase the risk of recurrent hernias. Most post-esophagectomy hiatal hernias do not require emergency surgery. About 70% of patients have symptoms reducing the quality of life. About 25% of cases are asymptomatic and discovered incidentally during follow-up examinations. The role of surgery for asymptomatic post-esophagectomy hernias is a matter of debate because the risk of symptoms or complications is poorly predictable. Surgical treatment is the only radical method for symptomatic or complicated hernias. However, there is still no consensus regarding surgical approach and technique. Most surgeons prefer open surgery fearing severe adhesive process and other technical difficulties. Laparoscopic approach is widely accepted as the "gold standard" for primary hiatal hernia. However, minimally invasive access for post-esophagectomy hiatal hernias is not sufficiently studied and described in several case reports. Currently, it is very important to study the risk factors of hiatal hernias after esophagectomy. We present successful laparoscopic repair of hiatal hernia after hybrid McKeown esophagectomy.

Evaluation and modeling of diaphragm displacement using ultrasound imaging for wearable respiratory assistive robot.

Introduction: Assessing the influence of respiratory assistive devices on the diaphragm mobility is essential for advancing patient care and improving treatment outcomes. Existing respiratory assistive robots have not yet effectively assessed their impact on diaphragm mobility. In this study, we introduce for the first time a non-invasive, real-time clinically feasible ultrasound method to evaluate the impact of soft wearable robots on diaphragm displacement. Methods: We measured and compared diaphragm displacement and lung volume in eight participants during both spontaneous and robotic-assisted respiration. Building on these measurements, we proposed a human-robot coupled two-compartment respiratory mechanics model that elucidates the underlying mechanism by which our extracorporeal wearable robots augments respiration. Specifically, the soft robot applies external compression to the abdominal wall muscles, inducing their inward movement, which consequently pushes the diaphragm upward and enhances respiratory function. Finally, we investigated the level and shape of various robotic assistive forces on diaphragm motion. Results: This robotic intervention leads to a significant increase in average diaphragm displacement by 1.95 times and in lung volume by 2.14 times compared to spontaneous respiration. Furthermore, the accuracy of the proposed respiratory mechanics model is confirmed by the experimental results, with less than 7% error in measurements of both diaphragm displacement and lung volume. Finally, the magnitude of robotic assistive forces positively correlates with diaphragm movement, while the shape of the forces shows no significant relationship with diaphragm activity. Conclusion: Our experimental findings validate the effective assistance mechanism of the proposed robot, which enhances diaphragm mobility and assists in ventilation through extracorporeal robotic intervention. This robotic system can assist with ventilation while increasing diaphragm mobility, potentially resolving the issue of diaphragm atrophy. Additionally, this work paves the way for improved robotic designs and personalized assistance, tailored to the dynamics of the diaphragm in respiratory rehabilitation.

Diaphragmatic rupture due to massive gastric volvulus after robotic-assisted diaphragm plication.

Gastric volvulus has been rarely associated with diaphragmatic paralysis or eventration. In this article, we present the case of a patient with idiopathic paralysis of the left hemidiaphragm that underwent treatment with a robotic thoracoscopic diaphragm plication, which was complicated by massive gastric volvulus resulting in such significant intra-abdominal hypertension that the ipsilateral diaphragm ruptured anterior to the plication suture line.

Sex-based differences in the blood pressure responses to muscle metaboreflex activation are consistent between limb and respiratory muscle.

The purpose of this study was to compare sex-based differences in the mean arterial blood pressure (MAP) response to limb and inspiratory metaboreflex activation, during relative and absolute workloads. Healthy males (M; n=9) and females (F; n=8) completed pulmonary function testing, forearm volume and circumference measurements, and bouts of limb and inspiratory muscle exercise. The exercises performed included bouts of rhythmic handgrip exercise (RHG) and inspiratory pressure threshold loading (PTL) to task failure, performed in a randomized order, and separated by 30 minutes of rest. Participants performed both RHG and PTL at predetermined relative (R) and absolute (A) workloads while cardiopulmonary measurements were recorded continuously. A time-dependent rise in MAP was observed in all participants, regardless of sex, muscle, or workload (p<0.001). MAP was greater in males than females during all exercise bouts regardless of muscle group or workload (p<0.001). The change in MAP from baseline was also greater in males (R-RHG: ∆31±12 mmHg; R-PTL: ∆31±9; A-RHG: ∆35±6; A-PTL: ∆30±7) than females (R-RHG: ∆21±7 mmHg; R-PTL: ∆13±7; A-RHG: ∆21±7; A-PTL: ∆14±3) (p<0.001). Results from this study show that when the forearm and diaphragm perform the same relative or absolute work, the blood pressure response is statistically similar, and both responses are greater in males than females. The findings from the present study suggest that the sex-based difference in the response to metaboreflex activation is similar between the limb and respiratory musculature.

Transvenous Phrenic Nerve Stimulation Reduces Diaphragm Injury During Controlled Mechanical Ventilation In A Preclinical Model of ARDS.

Patients with acute respiratory distress syndrome (ARDS) require periods of deep sedation and mechanical ventilation, leading to diaphragm dysfunction. Our study seeks to determine whether the combination of temporary transvenous diaphragm neurostimulation (TTDN) and mechanical ventilation changes the degree of diaphragm injury and cytokines concentration in a preclinical ARDS model. Moderate ARDS was induced in pigs using oleic acid, followed by ventilation for 12 hours post-injury with volume-control at 8 ml/kg, PEEP 5 cmH2O, respiratory rate and FiO2 set to achieve normal arterial blood gases. Two groups received TTDN: every second breath (MV+TTDN50%, n=6) or every breath (MV+TTDN100%, n=6). One group received ventilation only (MV, n=6). Full thickness diaphragm and quadricep muscle biopsies were taken at study end. Samples were fixed and stained with Hematoxylin and Eosin and a point counting technique was applied to calculate abnormal muscle area fraction. Cytokine concentrations were measured in homogenized tissue using porcine-specific ELISA and compared to serum samples. Percentage of abnormal diaphragm tissue was different between MV (8.1% (6.0-8.8)) vs. MV+TTDN50% (3.4% (2.1-4.8)), p=0.010 and MV vs. MV+TTDN100% (3.1% (2.5-4.0)), p=0.005. Percentage of abnormal quadriceps tissue was not different between groups. Cytokine concentration patterns in diaphragm samples were different between all groups (p<0.001) and the interaction between TTDN application and resultant cytokine concentration pattern was significant (p=0.025). TTDN, delivered in synchrony with mechanical ventilation, mitigated diaphragm injury, as evidenced by less abnormal tissue in the diaphragm samples, in pigs with oleic acid-induced ARDS and is an exciting tool for lung and diaphragm-protective ventilation.

NO EFFECT OF AEROBIC FITNESS ON EXERCISE-INDUCED DIAPHRAGM FATIGUE IN FEMALES.

We tested the hypothesis that the incidence and magnitude of diaphragm fatigue following high-intensity exercise would be lower in females with a high aerobic capacity (Hi-Fit) compared to healthy females with an average aerobic fitness (Avg-Fit). Participants were assigned to groups based on their peak O2 uptake (V̇O2peak) obtained during cycle exercise: Hi-Fit n=9, V̇O2peak > 56.1±3.4 mL·kg-1·min-1 vs. Avg-Fit n=9, V̇O2peak < 35.7±4.9 mL·kg-1·min-1. On a second day, diaphragm fatigue was assessed before and after constant load exercise test to exhaustion. Magnetic stimulation of the phrenic nerve roots was used to non-volitionally assess diaphragm fatigue by measurement of transdiaphragmatic twitch pressure (Pdi,tw). Both groups exercised at > 90% of V̇O2peak for a similar duration (Hi-Fit: 546.1 ± 177.8 vs Avg-Fit: 559.3 ± 175.0 seconds, p = 0.9). Diaphragm fatigue was defined as a > 15% reduction in Pdi,tw, approximately 2 times greater than the coefficient of variation. The mean group average reduction in Pdi,tw following exercise in the Hi-Fit (17.5%) and Avg-Fit groups (12.2%) was not different between groups (p = 0.2). The Hi-Fit group performed exercise at a higher absolute work rate that elicited significantly greater ventilatory work and inspiratory muscle force output. The Hi-Fit group did not experience greater fatigue compared to the Avg-Fit group, which we attribute to a greater reliance on accessory respiratory muscle recruitment, to training-induced increases in the aerobic capacity of the diaphragm, or a combination of the two. In summary, aerobic fitness is not predictive of exercise-induced diaphragm fatigue in healthy females.

Predictive value of diaphragm ultrasound for mechanical ventilation outcome in patients with acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is often combined with respiratory failure, which increases the patient's morbidity and mortality. Diaphragm ultrasound (DUS) has developed rapidly in the field of critical care in recent years. Studies with DUS monitoring diaphragm-related rapid shallow breathing index have demonstrated important results in guiding intensive care unit patients out of the ventilator. Early prediction of the indications for withdrawal of non-invasive ventilator and early evaluation of patients to avoid or reduce disease progression are very important. AIM: To explore the predictive value of DUS indexes for non-invasive ventilation outcome in patients with AECOPD. METHODS: Ninety-four patients with AECOPD who received mechanical ventilation in our hospital from January 2022 to December 2023 were retrospectively analyzed, and they were divided into a successful ventilation group (68 cases) and a failed ventilation group (26 cases) according to the outcome of ventilation. The clinical data of patients with successful and failed noninvasive ventilation were compared, and the independent predictors of noninvasive ventilation outcomes in AECOPD patients were identified by multivariate logistic regression analysis. RESULTS: There were no significant differences in gender, age, body mass index, complications, systolic pressure, heart rate, mean arterial pressure, respiratory rate, oxygen saturation, partial pressure of oxygen, oxygenation index, or time of inspiration between patients with successful and failed mechanical ventilation (P > 0.05). The patients with successful noninvasive ventilation had shorter hospital stays and lower partial pressure of carbon dioxide (PaCO2) than those with failed treatment, while potential of hydrogen (pH), diaphragm thickening fraction (DTF), diaphragm activity, and diaphragm movement time were significantly higher than those with failed treatment (P < 0.05). pH [odds ratio (OR) = 0.005, P < 0.05], PaCO2 (OR = 0.430, P < 0.05), and DTF (OR = 0.570, P < 0.05) were identified to be independent factors influencing the outcome of mechanical ventilation in AECOPD patients. CONCLUSION: The DUS index DTF can better predict the outcome of non-invasive ventilation in AECOPD patients.

Diaphragm Assessment by Multimodal Ultrasound Imaging in Healthy Subjects.

Background: In recent years, diaphragm ultrasound (DUS) has been used to identify diaphragm dysfunction in the intensive care unit (ICU). However, there are few studies on DUS parameters to evaluate function, normal ranges, and influencing factors in population. The aim of this study is to provide a methodological reference for clinical evaluation of diaphragm function by measuring different DUS parameters in a healthy population. Methods: A descriptive study was conducted 212 (105 males, 107 females) subjects with normal spirometry underwent ultrasound imaging in this study. The diaphragm contraction and motion related parameters and shear wave velocity (SWV) were measured in the supine position. The effects of gender, age, body mass index (BMI) and lifestyle on diaphragm ultrasound parameters were analyzed. Results: The diaphragm thickness at end-expiration (DT-exp) was 0.14 ±0.05 cm, the diaphragm thickness at end- inspiration (DT-insp) was 0.29±0.10 cm, with thickening fraction (TF) was 1.11±0.54. The diaphragm excursion (DE) was 1.68±0.37cm and diaphragm velocity was 1.45±0.41 cm/s during calm breathing. During deep breathing, the DE was 5.06±1.40cm and diaphragm velocity was 3.20±1.18 cm/s. The Diaphragm shear modulus-longitudinal view were Mean16.72±4.07kPa, Max25.04±5.58kPa, Min11.06±3.88kPa, SD2.56±0.98. The results of diaphragmatic measurement showed that the DT of males was significantly greater than that of females (P< 0.05), but there was no significant difference in TF. The DT-insp (r=0.155, P= 0.024) and the DT-exp (r=0.252, P=0.000) were positively correlated with age, and the DE during calm breathing was negatively correlated with age (r=-0.218, P= 0.001) and BMI (r=-00.280, P= 0.000). The DE (R=0.371, P=0.000) and velocity (R=0.368, P=0.000) during deep breathing were correlated with lifestyle. Conclusion: Our study provides normal reference values of the diaphragm and evaluates the influence of gender, age, body mass index and lifestyle on diaphragmatic morphology.

Post-insufflation diaphragm contractions in patients receiving various modes of mechanical ventilation.

BACKGROUND: During mechanical ventilation, post-insufflation diaphragm contractions (PIDCs) are non-physiologic and could be injurious. PIDCs could be frequent during reverse-triggering, where diaphragm contractions follow the ventilator rhythm. Whether PIDCs happens with different modes of assisted ventilation is unknown. In mechanically ventilated patients with hypoxemic respiratory failure, we aimed to examine whether PIDCs are associated with ventilator settings, patients' characteristics or both. METHODS: One-hour recordings of diaphragm electromyography (EAdi), airway pressure and flow were collected once per day for up to five days from intubation until full recovery of diaphragm activity or death. Each breath was classified as mandatory (without-reverse-triggering), reverse-triggering, or patient triggered. Reverse triggering was further subclassified according to EAdi timing relative to ventilator cycle or reverse triggering leading to breath-stacking. EAdi timing (onset, offset), peak and neural inspiratory time (Tineuro) were measured breath-by-breath and compared to the ventilator expiratory time. A multivariable logistic regression model was used to investigate factors independently associated with PIDCs, including EAdi timing, amplitude, Tineuro, ventilator settings and APACHE II. RESULTS: Forty-seven patients (median[25%-75%IQR] age: 63[52-77] years, BMI: 24.9[22.9-33.7] kg/m2, 49% male, APACHE II: 21[19-28]) contributed 2 ± 1 recordings each, totaling 183,962 breaths. PIDCs occurred in 74% of reverse-triggering, 27% of pressure support breaths, 21% of assist-control breaths, 5% of Neurally Adjusted Ventilatory Assist (NAVA) breaths. PIDCs were associated with higher EAdi peak (odds ratio [OR][95%CI] 1.01[1.01;1.01], longer Tineuro (OR 37.59[34.50;40.98]), shorter ventilator inspiratory time (OR 0.27[0.24;0.30]), high peak inspiratory flow (OR 0.22[0.20;0.26]), and small tidal volumes (OR 0.31[0.25;0.37]) (all P ≤ 0.008). NAVA was associated with absence of PIDCs (OR 0.03[0.02;0.03]; P < 0.001). Reverse triggering was characterized by lower EAdi peak than breaths triggered under pressure support and associated with small tidal volume and shorter set inspiratory time than breaths triggered under assist-control (all P < 0.05). Reverse triggering leading to breath stacking was characterized by higher peak EAdi and longer Tineuro and associated with small tidal volumes compared to all other reverse-triggering phenotypes (all P < 0.05). CONCLUSIONS: In critically ill mechanically ventilated patients, PIDCs and reverse triggering phenotypes were associated with potentially modifiable factors, including ventilator settings. Proportional modes like NAVA represent a solution abolishing PIDCs.

Robotic left intrapericardial upper lobectomy, pericardial reconstruction and diaphragmatic plication.

Primary mediastinal malignant germ cell tumours are rare, comprising only 1-4% of mediastinal tumours, of which 50-70% are non-seminomatous germ cell tumours. Non-seminomatous germ cell tumours typically demonstrate an excellent response to cisplatin-based chemotherapy. However, in some cases, tumours may persistently enlarge despite normal tumour markers following chemotherapy, leading to a rare condition known as growing teratoma syndrome. This poses a significant challenge for thoracic surgeons, especially when associated with infiltration of neighbouring pulmonary structures. Robot-assisted thoracoscopic surgery is not commonly employed in the resection of large mediastinal tumours. We present a case showcasing the robotic approach to complete resection of a sizeable mediastinal tumour originating from the left/main pulmonary artery, en bloc with a left upper lobectomy, pericardial resection, and reconstruction and diaphragmatic plication.

Respiratory effort in mechanical ventilation weaning Prediction: An observational, case-control study.

BACKGROUND: The diaphragm is crucial for ventilator weaning, but its specific impact on weaning indicators needs further clarification. This study investigated the variability in weaning outcomes across different diaphragm function populations and the value of respiratory drive and inspiratory effort in weaning. METHODS: This observational case-control study enrolled patients on mechanical ventilation for more than 48 h and completed a 30-minute spontaneous breathing trial (SBT) with pressure-support ventilation for the first time. After the SBT, airway pressure at 100 ms during occlusion (P0.1), inspiratory effort, and diaphragmatic ultrasound were evaluated to predict weaning outcomes. Weaning failure was defined as re-intubation within 48 h of weaning, the need for therapeutic non-invasive ventilation, or death. RESULTS: 68 patients with a mean age of 63.21 ± 15.15 years were included. In patients with diaphragm thickness (DT) ≥ 2 mm, P0.1 (P=0.002), pressure-muscle index (PMI) (P=0.012), and occluded expiratory airway pressure swing (ΔPocc) (P=0.030) were significantly higher in those who failed weaning. Conversely, for patients with DT<2 mm, PMI (P=0.003) and ΔPocc (P=0.002) were lower in the weaning failure group. Additionally, within the DT≥2 mm group, P0.1 demonstrated a higher area under the curve (AUC) for weaning prediction (0.889 vs. 0.739) compared to those with DT<2 mm. CONCLUSIONS: PMI and ΔPocc are predictive of weaning outcomes in patients with diaphragm thickness ≥ 2 mm, where the assessment value of P0.1 is notably higher. Diaphragm function significantly influences the accuracy of weaning predictions based on respiratory drive and inspiratory effort. IMPLICATIONS FOR CLINICAL PRACTICE: Our findings indicate that the effectiveness of respiratory drive and inspiratory effort in predicting successful weaning from mechanical ventilation may vary across different patient populations. Diaphragm function plays a crucial role in weaning assessments, particularly when using P0.1, the pressure-muscle index (PMI), and occluded expiratory airway pressure swing (ΔPocc).