Topography and morphology of the Eira barbara diaphragm.

BACKGROUND: The diaphragm, the main muscle involved in respiration and one of those responsible for maintaining life, is still little explored in terms of its morphology in wild animals. There are few studies on the anatomy of Eira barbara, a carnivorous mustelid that is a victim of the urbanization process. In order to contribute to the conservation of the species, we described the topography and morphology of the diaphragm, which may be involved in injuries caused by the impacts of human activities. RESULTS: We studied five specimens of Eira barbara, whose diaphragmatic muscle had a dorsal insertion on the 14th thoracic vertebra, laterally between the 8th and 13th intercostal space (EIC) and ventrally on the 8th EIC, with attachment to the xiphoid process. Consisting of three muscle regions (lumbar, costal and sternal), the diaphragm in Eira barbara showed radially arranged bundles, with the right costal muscle being slimmer than the left; the left pillar wider than the right and between them were the aortic and esophageal hiatuses. The Y-shaped tendinous center housed the foramen of the vena cava bordering the right costal region. In the most dorsal portion of the diaphragm, between the costal regions and the diaphragmatic pillar, we found two triangular-shaped regions devoid of muscle. CONCLUSIONS: Our findings, when compared with the current literature, indicate that the location and positioning of the diaphragm are independent of the physical conformation of the species, and that the right costal region, as well as the triangular areas devoid of musculature, may be fragile points for herniation in cases of Eira barbara being run over.

Assessment of Cheyne-Stokes respiration using diaphragmatic ultrasonography.

This case explores Cheyne-Stokes respiration (CSR), a breathing pattern common in heart failure and brain injury patients. Using diaphragmatic ultrasound, the study assesses a 74-year-old patient with heart failure exhibiting CSR during sleep. Diaphragmatic excursion patterns reveal the characteristic crescendo-decrescendo pattern of CSR.

Exploring diaphragmatic response to high-flow nasal cannula in patients with COVID-19 pneumonia using ultrasound: a proof of concept study.

BACKGROUND: Recent studies have highlighted the recognition of diaphragmatic dysfunction as a significant factor contributing to respiratory disturbances in severely ill COVID-19 patients. In the field of noninvasive respiratory support, high-flow nasal cannula (HFNC) has shown effectiveness in relieving diaphragm dysfunction. This study aims to investigate the diaphragmatic response to HFNC in patients with COVID-19 pneumonia by utilizing ultrasound. METHODS: This retrospective study was conducted in a medical-surgical intensive care unit (ICU) at a tertiary care center in Buenos Aires, Argentina (Sanatorio de Los Arcos) over a 16-month period (January 2021-June 2022). The study included patients admitted to the ICU with a diagnosis of COVID-19 pneumonia who were deemed suitable candidates for HFNC therapy by the attending physician. Diaphragm ultrasound was conducted, measuring diaphragmatic excursion (DE) both before and during the utilization of HFNC for these patients. RESULTS: A total of 10 patients were included in the study. A statistically significant decrease in respiratory rate was observed with the use of HFNC (p = 0.02), accompanied by a significant increase in DE (p = 0.04). CONCLUSION: HFNC leads to a reduction in respiratory rate and an increase in DE as observed by ultrasound in patients with COVID-19 pneumonia, indicating promising enhancements in respiratory mechanics. However, further research is required to validate these findings.

Effect of high-flow nasal cannula at different flow rates on diaphragmatic function in subjects recovering from an acute exacerbation of COPD: a physiological prospective pilot study.

BACKGROUND: Noninvasive ventilation (NIV) is widely employed as the initial treatment for patients with chronic acute exacerbation of obstructive pulmonary disease (AECOPD). Nevertheless, high-flow nasal cannula (HFNC) has been increasingly utilized and investigated to mitigate the issues associated with NIV. Flow rate may play a significant role in diaphragmatic function among subjects recovering from AECOPD. Based on these observations, we conducted a physiological study to assess the impact of HFNC therapy on diaphragmatic function, as measured by US, respiratory rate (RR), gas exchange, and patient comfort at various flow rates. METHODS: A prospective physiological pilot study enrolled subjects with a diagnosis of AECOPD who required NIV for more than 24 h. After stabilization, these subjects underwent a 30-min trial using NIV and HFNC at different sequential flow rates (30-60 L/min). At the end of each trial, diaphragmatic displacement (DD, cm) and diaphragmatic thickness fraction (DTF, %) were measured using ultrasound. Additionally, other physiological variables, such as RR, gas exchange, and patient comfort, were recorded. RESULTS: A total of 20 patients were included in the study. DD was no different among trials (p = 0.753). DTF (%) was significantly lower with HFNC-30 L/min compared to HFNC-50 and 60 L/min (p < 0.001 for all comparisons). No significant differences were found in arterial pH and PaCO2 at discontinuation of NIV and at the end of HFNC trials (p > 0.050). During HFNC trials, RR remained unchanged without statistically significant differences (p = 0.611). However, we observed that HFNC improved comfort compared to NIV (p < 0.001 for all comparisons). Interestingly, HFNC at 30 and 40 L/min showed greater comfort during trials. CONCLUSIONS: In subjects recovering from AECOPD and receiving HFNC, flows above 40 L/min may not offer additional benefits in terms of comfort and decreased respiratory effort. HFNC could be a suitable alternative to COT during breaks off NIV.

Reliability and reference values for diaphragmatic excursion, thickness, and thickening fraction and quadriceps femoris muscle thickness in full-term newborns evaluated by ultrasound.

To determine the diaphragm thickness, thickening fraction, and excursion and thickness of the quadriceps femoris muscle in full-term newborns and to evaluate the intra- and interrater reliability of these measurements. This was a prospective, observational clinical study including full-term newborns born within the first 48 h after birth. Serial measurements of the thickness, thickening fraction, and mobility of the diaphragm muscles and the thickness of the quadriceps muscle were obtained using ultrasound images. A total of 69 newborns with a mean gestational age of 39 weeks were included. The following measurements were obtained and are expressed as the mean (standard deviation): inspiratory diaphragm thickness, 0.19 cm (0.04); expiratory diaphragm thickness, 0.16 cm (0.04); diaphragm thickness fraction, 16.70 cm (10.27); diaphragmatic excursion, 0.68 cm (0.22); and quadriceps thickness, 0.99 cm (0.14). Intrarater reliability was assessed using intraclass correlation coefficients (ICCs). Excellent intrarater agreement was observed for the two groups of operators (ICC > 0.86, p < 0.001) for all measurements except for the diaphragm thickening fraction, which showed good agreement for both operator groups (ICC = 0.70, p < 0.001). Regarding interrater reliability, moderate agreement between the raters was observed in the means of all measures (ICC > 0.49, p < 0.001), except for the diaphragm thickening fraction, which showed poor agreement.    Conclusion: Good intrarater and moderate interrater reliability were achieved in ultrasound evaluations of the thickness and mobility of the diaphragm and quadriceps femoris muscles in full-term newborns, demonstrating the feasibility of this technique for clinical use. This pioneering study offers reference values for these muscles in a single study, allowing comparisons between different clinical conditions. What is Known: • Ultrasound is a highly reliable tool for muscle assessment that can be used to assess muscular atrophy in critically ill patients. • Muscle atrophy worsens the patient's condition and has been associated with worse outcomes. What is New: • To our knowledge, this is the first study to jointly evaluate the diaphragm and quadriceps muscle thickness and evaluate the reliability of all measurements. • Our study presents reference values for both muscles, enabling comparisons between different clinical conditions.

Application of Computed Tomography Angiography in Preoperative Diagnosis of Coarctation of Aorta and Evaluation of Aortic Dilatation in Infants.

OBJECTIVE: To evaluate the occurrence of aortic dilatation and its associated predictors with coarctation of the aorta (CoA) in infants using multi-slice computed tomography (MSCT). METHODS: The clinical data of 47 infantile patients with CoA diagnosed by MSCT and 28 infantile patients with simple ventricular septal defect were analyzed retrospectively. Aortic diameters were measured at six different levels, and aortic sizes were compared by z score. The coarctation site-diaphragm ratio was used to describe the degree of narrowing. Relevant clinical data were collated and analyzed. RESULTS: The dilation rate and z score of the ascending aorta in the severe CoA group were significantly higher than those in the mild CoA group (11 [52.38%] vs. 21 [80.77%], P=0.038 and 2.00 ± 0.48 vs. 2.36 ± 0.43, P=0.010). Pearson's correlation analysis found that the z score of the ascending aorta was negatively correlated with the coarctation site-diaphragm ratio value (r=-0.410, P=0.004). A logistic retrospective analysis found that an increased degree of coarctation was an independent predictor of aortic dilatation (adjusted odds ratio 0.002; 95% confidence interval 0.00-0.819; P=0.043). The z score of the ascending aorta in the severe CoA group was significantly higher than that in the ventricular septal defect group (P<0.05). CONCLUSION: Most infants with CoA can also have significant dilatation of the ascending aorta, and the degree of this dilatation is related to the degree of coarctation. Assessment of aortic diameter and related malformations by MSCT can predict the risk of aortic dilatation in infants with CoA.

Impacto da fisioterapia aquática em UTIN sobre a mobilidade diafragmática avaliada por ultrassonografia cinesiológica: ensaio clínico / Impact of Aquatic Therapy in the NICU on diaphragmatic mobility assessed by ultrasound: clinical trial

INTRODUÇÃO: A fisioterapia aquática é uma modalidade de hidroterapia realizada em recém-nascidos (RN) nas Unidades de Terapia Intensiva Neonatal (UTIN). Os efeitos sobre nível de dor, estado comportamental e função respiratória já são conhecidos, porém pouco se refere aos efeitos sobre a função diafragmática na população recém-nascida a termo prematura. OBJETIVO: Avaliar o efeito da fisioterapia aquática sobre a amplitude diafragmática por meio da ultrassonografia cinesiológica diafragmática (USCD) em RNs internados em UTIN, bem como a segurança de sua realização quanto a estabilidade clínica dos RNs, estado comportamental, dor e desconforto respiratório. MÉTODOS: Ensaio clínico tipo antes e depois, de caráter transversal. Os RNs participantes do estudo receberam uma única intervenção com fisioterapia aquática durante 10 minutos. Foi realizada a avaliação utilizando a USCD antes e depois da sessão, e anotado as frequências cardíaca e respiratória, estado comportamental, dor e desconforto respiratório. RESULTADOS: Participaram 26 RNs. Observou-se aumento significativo da amplitude diafragmática (p= 0,02) e da saturação periférica de oxigênio (p= 0,05); os parâmetros fisiológicos permaneceram nos limites da normalidade e a intervenção não provocou desorganização comportamental, dor ou desconforto respiratório aos RNs. CONCLUSÃO: A fisioterapia aquática promoveu aumento da amplitude diafragmática, sugerindo que esta técnica pode ser utilizada como forma de estimular a contração da musculatura respiratória em RN, além de se mostrar uma técnica segura, pois não gerou instabilidade clínica, desorganização comportamental, dor ou desconforto respiratório aos participantes.

INTRODUCTION: Aquatic physiotherapy is a modality of hydrotherapy performed on newborn babies (NB) in the Neonatal Intensive Care Unit (NICU). The effects on pain levels, behavior, and respiratory function are already known; however, little has been said about the effects on diaphragmatic function in the preterm newborn population. OBJECTIVE: To evaluate the effect of aquatic physiotherapy on diaphragmatic amplitude using diaphragmatic kinesiologic ultrasound (DKUS) in NBs admitted to a NICU, as well as the safety regarding the clinical stability of the NBs, behavioral state, pain, and respiratory distress. METHODS: Crosssectional before-and-after clinical trial. The NBs participating in the study received a single intervention with aquatic physiotherapy for 10 minutes. An assessment was performed using the USCD before and after the session, and heart and respiratory rates, behavioral state, pain, and respiratory discomfort were recorded. RESULTS: Twenty-six NBs participated. There was a significant increase in diaphragmatic amplitude (p= 0.02) and peripheral oxygen saturation (p= 0.05); physiological parameters remained within normal limits, and the intervention did not cause behavioral disorganization, pain, or respiratory discomfort in NBs. CONCLUSION: Aquatic physiotherapy promoted an increase in diaphragmatic amplitude, suggesting that this technique can be used as a way to stimulate the contraction of the respiratory muscles in NB, in addition to being a safe technique, as it did not generate clinical instability, behavioral disorganization, pain, or respiratory discomfort to the participants.

Respiratory activity during seizures induced by pentylenetetrazole.

This study investigated the respiratory activity in adult Wistar rats across different behavioral seizure severity induced by pentylenetetrazole (PTZ). Animals underwent surgery for electrodes implantation, allowing simultaneous EEG and diaphragm EMG (DIAEMG) recordings and the respiratory frequency and DIAEMG amplitude were measured. Seizures were acutely induced through PTZ injection and classified based on a pre-established score, with absence-like seizures (spike wave discharge (SWD) events on EEG) representing the lowest score. The respiratory activity was grouped into the different seizure severities. During absence-like and myoclonic jerk seizures, the breathing frequency decreased significantly (∼50% decrease) compared to pre- and post-ictal periods. Pronounced changes occurred with more severe seizures (clonic and tonic) with periods of apnea, especially during tonic seizures. Apnea duration was significantly higher in tonic compared to clonic seizures. Notably, during PTZ-induced tonic seizures the apnea events were marked by tonic DIAEMG contraction (tonic-phase apnea). In the majority of animals (5 out of 7) this was a fatal event in which the seizure-induced respiratory arrest preceded the asystole. In conclusion, we provide an assessment of the respiratory activity in the PTZ-induced acute seizures and showed that breathing dysfunction is more pronounced in seizures with higher severity.

Pressure dynamics of the esophagogastric junction at rest and during inspiratory maneuvers after Nissen fundoplication.

Low sphincter pressure and inability of the crural diaphragm to elevate it at the esophagogastric junction are important pathophysiological mechanisms of gastroesophageal reflux disease (GERD). The object of this study was to depict how Nissen fundoplication changed the resting and inspiratory pressures of the anti-reflux barrier. We selected 14 patients (eight males; mean age 42.7 years; mean body mass index 27.8) for surgery. They answered symptoms questionnaires and underwent high-resolution manometry (HRM) before and 6 months after Nissen fundoplication. We used a standard manometric protocol (resting and liquid swallows) and assessment of esophagogastric junction (EGJ) pressure metrics during standardized forced inspiratory maneuvers against increasing loads (Threshold Maneuvers). We used the Wilcoxon test for comparison of pre and postoperative data. After fundoplication, heartburn and regurgitation scores diminished remarkably (from 4.5 and 2, respectively, to zero; P = 0.002 and P = 0.0005, respective medians). Also, the median expiratory EGJ pressure had a significant increase from 8.1 to 18.1 mmHg (P = 0.002), while mean respiratory pressure and EGJ contractility integral (EGJ-CI) increased without statistical significance (P = 0.064 and P = 0.06, respectively). Axial EGJ displacement was lower after fundoplication. The EGJ relaxation pressure (P = 0.001), the mean distal esophageal intrabolus pressure (P = 0.01) and the distal latency (P = 0.017) increased after fundoplication. There was a reduction in the contraction front velocity (P = 0.043). During evaluation with standardized inspiratory maneuvers, the inspiratory EGJ pressures (under loads of 12, 24, 36 and 48 cmH2O) were lower after surgery for all loads (median for load 12 cmH2O: 145.6 vs. 102.7 mmHg; P = 0.004). Fundoplication and hiatal closure increased the expiratory EGJ pressure and promoted a great GERD symptom relief. The surgery seemed to overcompensate a reduced EGJ mobility and inspiratory pressure.

Efficacy of educational instructions on pelvic floor muscle training in the treatment of urinary incontinence: Systematic review and meta-analysis.

OBJECTIVE: The present study aimed to investigate the efficacy of educational interventions on pelvic floor (PF) muscle training in the treatment of urinary incontinence (UI). METHODS: This is a systematic review of literature with meta-analysis, performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). To do so, randomized clinical trials that performed educational interventions of PF, UI, and developed the training of PF muscles (TPFM) for incontinent women, performing group or individual comparisons, with control and experimental groups or with two or more experimental groups were selected. The search for papers was performed in the following databases: PubMed, Scopus, Embase, Web of Science, and SciELO, no specific publication date was chosen. The risk of bias was performed using the PEDro scale and the quality of the evidence was performed using GRADE. RESULTS: The review included six studies with 1003 participants. Most studies presented 5-8 points regarding risk of bias. Most of the studies were performed in the last 5 years, with women of various ages, high educational level and prevalence of UI of effort. The present study showed that offering educational instructions and guiding women on TPFM was capable of reducing urinary symptoms. When compared to control, significant between-group differences were found in the studies, in which the control group did not receive any kind of instructions or treatment (p < 0.05). The use of technologies through mobile apps was efficient in the treatment of incontinent women (p < 0.05). Performing TPFM individually or in groups did not present differences in the results, with both improving urinary symptoms. The meta-analysis presented a mean effect and a clinically important difference in three studies. CONCLUSION: The interventions involving instructions to TPFM associated to health education brought improvements to urinary symptoms.

Diaphragmatic and excursion thickness in newborns using diaphragmatic kinesiology ultrasound: an observational study / Espessura e excursão diafragmática em recém-nascidos usando ultrassonografia cinesiológica do diafragma: um estudo observacional

Abstract Introduction The study of the diaphragm muscle has aroused the interest of physiotherapists who work with kinesiological ultrasonography, but still little explored; however, its findings can contribute to the clinical practice of hospitalized patients in neonatal intensive care units. Objective To measure the excursion and thickening of the diaphragm and describe measurements among neonates, preterm, and full-term. Methods Diaphragmatic kinesiological ultrasonography was performed on hospitalized newborns, in Neonatal Unit Care Unit, placed in supine position in their own bed, on the sixth day of life. Three repeated measurements of the same respiratory cycle were made, both for excursion and for diaphragmatic thickening. Results 37 newborns participated in the study and 25 were premature. The mean weight at the time of collection was 2,307.0 ± 672.76 grams and the gestational age was 35.7 ± 3.3 weeks. Diaphragmatic excursion increased with increasing gestational age (p = 0.01, df = 0.21) in term infants (p = 0.17, df = 0.35). Conclusion There was a positive correlation between diaphragmatic excursion and gestational age. There was no statistically significant difference in the measurements of excursion and inspiratory diaphragm thickening between preterm and term newborns, although pointing to higher measurements in the latter group.

Resumo Introdução O estudo do músculo diafragma tem des-pertado o interesse dos fisioterapeutas que trabalham com ultrassonografia cinesiológica. Ainda pouco explo-rado, contudo, seus achados podem contribuir para a prática clínica dos pacientes internados em unidades de terapia intensiva neonatal (UTIN). Objetivo Mensurar a excursão e o espessamento diafragmático e descrever as medidas entre recém-nascidos prematuros e a termo. Métodos Realizou-se ultrassonografia cinesiológica diafragmática em recém-nascidos internados em UTIN, posicionados em supino em seu próprio leito, no sexto dia de vida. Foram realizadas três medidas repetidas do mesmo ciclo respiratório, tanto da excursão quanto do espessamento diafragmático. Resultados Participaram do estudo 37 recém-nascidos, dos quais 25 eram pre-maturos. O peso no momento da coleta foi de 2.307,0 ± 672,76 gramas e a idade gestacional foi de 35,7 ± 3,3 semanas. A excursão diafragmática aumentou de acordo com o aumento da idade gestacional (p = 0,01; df = 0,21). A espessura variou entre 0,10 e 0,16 cm durante a inspiração nos prematuros e entre 0,11 e 0,19 cm nos nascidos a termo (p = 0,17; df = 0,35). Conclusão Houve correlação positiva entre a excursão diafragmá-tica e a idade gestacional. Não observou-se diferença estatisticamente significativa das medidas de excursão e de espessamento diafragmático inspiratório entre recém-nascidos prematuros e recém-nascidos a termo, embora apontando para maiores medidas neste último grupo.

Application of Computed Tomography Angiography in Preoperative Diagnosis of Coarctation of Aorta and Evaluation of Aortic Dilatation in Infants

ABSTRACT Objective: To evaluate the occurrence of aortic dilatation and its associated predictors with coarctation of the aorta (CoA) in infants using multi-slice computed tomography (MSCT). Methods: The clinical data of 47 infantile patients with CoA diagnosed by MSCT and 28 infantile patients with simple ventricular septal defect were analyzed retrospectively. Aortic diameters were measured at six different levels, and aortic sizes were compared by z score. The coarctation site-diaphragm ratio was used to describe the degree of narrowing. Relevant clinical data were collated and analyzed. Results: The dilation rate and z score of the ascending aorta in the severe CoA group were significantly higher than those in the mild CoA group (11 [52.38%] vs. 21 [80.77%], P=0.038 and 2.00 ± 0.48 vs. 2.36 ± 0.43, P=0.010). Pearson's correlation analysis found that the z score of the ascending aorta was negatively correlated with the coarctation site-diaphragm ratio value (r=-0.410, P=0.004). A logistic retrospective analysis found that an increased degree of coarctation was an independent predictor of aortic dilatation (adjusted odds ratio 0.002; 95% confidence interval 0.00-0.819; P=0.043). The z score of the ascending aorta in the severe CoA group was significantly higher than that in the ventricular septal defect group (P<0.05). Conclusion: Most infants with CoA can also have significant dilatation of the ascending aorta, and the degree of this dilatation is related to the degree of coarctation. Assessment of aortic diameter and related malformations by MSCT can predict the risk of aortic dilatation in infants with CoA.

Multi targets of cannabidiol (CBD) on skeletal mammalian and avian neuromuscular preparations.

Cannabidiol (CBD) has been used in diseases that affect the central nervous system. Its effects on the peripheral synapses are of great interest, since endocannabinoid receptors are expressed in muscles. CBD (0.3 mM) was analysed using mammalian and avian neuromuscular preparations, through myographic techniques in complementary protocols. Mammalian cells were examined by light microscopy while exogenous acetylcholine (40 µM) and potassium chloride (100 mM) were added into avian preparations, before and at the end of experiments. Pharmacological tools such as atropine (2 µM), polyethylene glycol (PEG 400, 20 µM), Ca2+ (1.8 mM), F55-6 (20 µg/mL), and nifedipine (1.3 mM) were assessed with CBD. In mice, CBD causes a facilitatory effect and paralysis, whereas in avian, paralysis. Concluding, CBD is responsible for activated or inhibited channels, for ACh release via muscarinic receptor modulation, and by the inhibition of nicotinic receptors leading to neuromuscular blockade, with no damage to striated muscle cells.

UDC- COVID 19: herramienta digital para predecir el retiro de la ventilación mecánica invasiva de pacientes con COVID-19

En diciembre de 2019 las Autoridades de la República Popular China, comunicaron a la OMS varios casos de neumonía de etiología desconocida en Wuhan, una ciudad situada en la provincia china de Hubei. Una semana más tarde confirmaron que se trataba de un nuevo coronavirus que fue denominado SARS-CoV-2, este virus causa diversas manifestaciones clínicas englobadas bajo el término COVID-19. El presente trabajo presenta un prototipo de aplicación con el nombre UDC-COVID19 que propone una herramienta digital sobre la base de una revisión actualizada de la evaluación ultrasonográfica del diafragma como elemento predictivo para retirar la ventilación mecánica invasiva en pacientes con COVID-19, proporcionando una excelente herramienta digital para la evaluación de la estructura y función dinámica diafragmática, es precisa, reproducible, sin radiación ionizante, fácil de realizar a la cabecera del paciente y costo efectiva en pacientes críticamente enfermos.

In December 2019, the Authorities of the People's Republic of China reported to the WHO several cases of pneumonia of unknown etiology in Wuhan, a city located in the Chinese province of Hubei. A week later, they confirmed that it was a new coronavirus called SARS-CoV-2, which causes various clinical manifestations encompassed under the term COVID-19. The present work presents an application prototype with the name UDC-COVID19 that proposes a digital tool based on an updated review of the ultrasonographic evaluation of the diaphragm as a predictive element to withdraw invasive mechanical ventilation in patients with COVID-19, providing an excellent digital tool for the evaluation of the diaphragmatic structure and dynamic function since it is precise, reproducible, without ionizing radiation, easy to perform at the patient's bedside and cost effective in critically ill patients; mechanical ventilation.

Medición de la fuerza muscular en adultos como predictor de extubación en Unidades de Cuidados Intensivos. Revisión narrativa / Measurement of muscular strength in adults as a predicator of extubation in intensive care units. Narrative review

Resumen: Introducción: uno de los principales efectos de la ventilación mecánica invasiva es la lesión de los músculos respiratorios, específicamente, sobre el diafragma en el que pueden ocurrir alteraciones estructurales y funcionales que modifican parcial o totalmente su función. Durante la ventilación mecánica se produce un proceso de atrofia por desuso de dicho músculo. Por ello la utilidad clínica de la medición de la fuerza muscular diafragmática es importante para conocer si el paciente tiene la capacidad de activar los mecanismos protectores de la vía aérea para lograr la extubación exitosa y el retiro del ventilador mecánico en el menor tiempo posible. Objetivos: describir la medición de la fuerza muscular como predictor de la extubación en las unidades de cuidados intensivos. Material y métodos: se realizó una revisión de la literatura, entre 2011 y 2022. Resultados: los pacientes que son sometidos a ventilación mecánica invasiva prolongada generalmente desarrollan una afección muscular diafragmática, lo que se convierte en una problemática para el proceso de extubación temprana, por lo cual es vital conocer los métodos de medición de fuerza muscular como predictor de extubación.

Abstract: Introduction: one of the main effects of invasive mechanical ventilation is injury to the respiratory muscles, specifically the diaphragm. In which structural and functional alterations can occur that partially or totally modify its function. During mechanical ventilation, a process of disuse atrophy of said muscle occurs. Therefore, the clinical utility of measuring diaphragmatic muscle strength is important to know if the patient has the ability to activate the protective mechanisms of the airway to achieve successful extubation and removal of the mechanical ventilator in the shortest time possible. Objective: describe the measurement of muscle strength as a predictor of extubation in intensive care units. Material and methods: a literature review was carried out, carried out between 2011 and 2022. Results: patients who are subjected to prolonged mechanical ventilation generally develop a diaphragmatic muscle disorder, becoming a problem for the weaning, for it is important know the methods of measuring muscle strength.

Utilization of spontaneous breathing trial, objective cough test, and diaphragmatic ultrasound results to predict extubation success: COBRE-US trial.

BACKGROUND: The results of clinical and weaning readiness tests and the spontaneous breathing trial (SBT) are used to predict the success of the weaning process and extubation. METHODS: We evaluated the capacity of the cuff leak test, rate of rapid and shallow breathing, cough intensity, and diaphragmatic contraction velocity (DCV) to predict the success of the SBT and extubation in a prospective, multicenter observational study with consecutive adult patients admitted to four intensive care units. We used receiver operating characteristic (ROC) curves to assess the tests' predictive capacity and built predictive models using logistic regression. RESULTS: We recruited 367 subjects who were receiving invasive mechanical ventilation and on whom 456 SBTs were performed, with a success rate of 76.5%. To predict the success of the SBT, we derived the following equation: (0.56 × Cough) - (0.13 × DCV) + 0.25. When the cutoff point was ≥ 0.83, the sensitivity was 91.5%, the specificity was 22.1%, and the overall accuracy was 76.2%. The area under the ROC curve (AUC-ROC) was 0.63. To predict extubation success, we derived the following equation: (5.7 × SBT) + (0.75 × Cough) - (0.25 × DCV) - 4.5. When the cutoff point was ≥ 1.25, the sensitivity was 96.8%, the specificity was 78.4%, and the overall accuracy was 91.5%. The AUC-ROC of this model was 0.91. CONCLUSION: Objective measurement of cough and diaphragmatic contraction velocity could be used to predict SBT success. The equation for predicting successful extubation, which includes SBT, cough, and diaphragmatic contraction velocity values, showed excellent discriminative capacity.

Fate of the Patent False Lumen of the Descending Aorta After Surgical Treatment for Acute Type 1 Aortic Dissection.

INTRODUCTION: This study aimed to investigate the factors affecting false lumen patency in the descending thoracic aorta among patients who underwent surgery for acute type 1 aortic dissection. METHODS: A total of 112 patients with acute type 1 aortic dissection, with the flap below the diaphragm level, underwent surgery between January 2010 and September 2019. Of these, 60 patients who were followed up for ≥ 12 months and whose computed tomography scans were available were included in this study. The patients were divided into two groups: group I, consists of patent false lumen (n=36), and group II, consists of thrombosed false lumen (n=24). Demographic data, operative techniques, postoperative descending aortic diameters, reintervention, and late mortality were compared between the two groups. RESULTS: The mean follow-up period of all patients was 37.6±26.1 months (range: 12-104). The diameter increase in the proximal and distal descending aorta was significantly higher in the patent false lumen group (5.3±3.7 mm vs. 3.25±2.34 mm; P=0.015; 3.1±2.52 mm vs. 1.9±1.55 mm; P=0.038, respectively). No significant difference in terms of hypertension was found between the two groups during the follow-up period (21 patients, 58.3% vs. 8 patients, 33.3%; P=0.058). A total of 29 patients (48.3%) were found to be hypertensive in the postoperative period. CONCLUSION: After surgical treatment for acute type 1 aortic dissection, patients should be monitored closely, regardless of whether the false lumen is patent or thrombosed. Mortality and reintervention can be seen in patients with patent false lumen during follow-up.

Assessment of diaphragmatic function through surface electromyography in healthy individuais. A cross-section observational study

Introduction: Diaphragmatic surface electromyography is a procedure designed to assess the diaphragm. The physiological values of the electrical activity may have potential use in rehabilitation, sports training, ventilatory support withdrawal in critical care units and follow-up of respiratory disease. Objective: To assess and describe the diaphragmatic function through surface electromyography in a population of individuals during spontaneous and forced breathing. Methods: Observational, exploratory cross-sectional study including subjects with no comorbidities. Diaphragmatic surface EMG was performed measuring the mean quadratic root during tidal volume and vital capacity breathing. The body composition of the participants was also assessed. Results: 28 males and 22 females were included in the study. The mean quadratic root of the tidal volume for two minutes was 13.94 nV for females and 13.31 nV for males. The vital capacity was 23.24 nV for males and 22.4 nV for females. A correlation was identified between the mean quadratic root, weight, and body surface. Conclusions: Mean quadratic root values of tidal volume in two minutes in healthy females and males have been documented. The mean quadratic root values are correlated with the physiological and functional characteristics of the participants.

Introducción: La electromiografía de superficie diafragmática es un procedimiento para la evaluación diafragmática. Los valores fisiológicos de la actividad eléctrica tendrían aplicaciones potenciales en rehabilitación, entrenamiento deportivo, en el retiro ventilatorio en unidades de cuidado crítico y en el seguimiento a patologías respiratorias. Objetivo: Evaluar y describir la función diafragmática a través de electromiografía de superficie diafragmática en una población de sujetos durante la respiración espontánea y la respiración forzada. Métodos: Estudio observacional exploratorio de corte transversal en el que se incluyeron sujetos sin comorbilidades. Se realizó electromiografía de superficie diafragmática midiendo la raíz cuadrática media durante respiraciones de volumen corriente y capacidad vital. Adicionalmente, se valoró la composición corporal de los participantes. Resultados: Se incluyeron 28 hombres y 22 mujeres. La raíz cuadrática media de volumen corriente por dos minutos fue de 13,94 µV para mujeres y 13,31 µV para hombres, mientras que la capacidad vital fue 23,24 µV para hombres y 22,4 µV para mujeres. Se encontró una correlación entre la raíz cuadrática media, el peso y la superficie corporal. Conclusiones: Se han documentado los valores de la raíz cuadrática media de volumen corriente por dos minutos en mujeres y hombres sanos. Los valores de la raíz cuadrática media se correlacionan con características fisiológicas y funcionales de los participantes.

Smoking Intensity Increases Diaphragm Muscle Injury: A Clinicopathologic Study.

BACKGROUND: Studying the effects of smoking intensity is important to evaluate the risk of tobacco use on a range of illnesses, such as as sarcopenia among the elderly. Thus, this study aimed to analyze the effects of pack-years of cigarette smoking on the diaphragm muscle (DIAm) histopathology of postmortem samples. METHODS: Subjects were divided into three groups: never-smoker (n = 46); less than 30 pack-years of smoking (n = 12); and more than 30 pack-years of smoking (n = 30). Diaphragm samples were stained with Picrosirius red and hematoxylin and eosin stain for general structure. RESULTS: Participants with more than 30 pack-years of cigarette smoking had a significant increase in adipocytes, blood vessels and collagen deposit, as well as an increase in histopathological alterations. CONCLUSIONS: Pack-years of smoking was associated with DIAm injury. However, further clinicopathological studies are needed to confirm our findings.

Diaphragmatic Dynamics and Thickness Parameters Assessed by Ultrasonography Predict Extubation Success in Critically Ill Patients.

INTRODUCTION: A frequent cause of weaning and extubation failure in critically ill mechanically ventilated patients is diaphragm muscle dysfunction. Ultrasound (US) evaluation of the diaphragm yields important data regarding its thickness (diaphragm thickening fraction [TFdi]) and its movement or excursion (diaphragmatic dynamics) that reveal the presence of diaphragmatic dysfunction. METHODS: Cross-sectional study, which included patients older than 18 years with invasive mechanical ventilation with an expected duration of more than 48 h, in a tertiary referral center in Colombia. The excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi were evaluated by US. Prevalence and use of medications were evaluated, and the association with failure in ventilatory weaning and extubation was analyzed. RESULTS: Sixty-one patients were included. The median age and APACHE IV score were 62.42 years and 78.23, respectively. The prevalence of diaphragmatic dysfunction (assessed by excursion and TFdi) was 40.98%. The sensibility, specificity, positive predictive value, and negative predictive value for TFdi < 20% was 86%, 24%, 75%, and 40%, respectively, with an area under the receiver operating characteristic (ROC) curve of 0.6. The ultrasonographic analysis of excursion of the diaphragm, inspiratory and expiratory thickness, and TFdi (>20%) allow in its set and with normal values, predict success or failure for the extubation with an area under the ROC curve of 0.87. CONCLUSION: Diaphragmatic dynamics and thickness parameters together assessed by ultrasonography could predict the success of extubation in critically ill patients in Colombia, based on the finding of diaphragmatic dysfunction.