Yoğun bakım hastalarında diyafram ve rektus abdominis kas kalınlıklarının mortalitenin, morbiditenin ve mekanik ventilatörden ayırma başarısının belirlenmesindeki rolü

Abstract

Amaç: Bu çalışmada, yoğun bakım ünitesine kabul edilen hastalarda diyafram ve rektus abdominis (RA) kas kalınlıklarının mortalite, morbidite ve mekanik ventilatörden ayırma (weaning) başarısı ile ilişkisi değerlendirilmiştir. Gereç ve yöntem: Çalışmaya 87 erişkin yoğun bakım hastası dahil edildi. Hastaların diyafram ve RA kas kalınlıkları, yatışın 1., 3., 7. ve çıkış günlerinde ultrasonografi ile ölçüldü. Klinik veriler, mekanik ventilatör ihtiyacı, weaning durumu, enfeksiyon gelişimi, sedasyon, inotrop ve steroid kullanımı ile birlikte kaydedildi. Bulgular: Çalışmaya dahil edilen hastaların %82,7’sinde invaziv mekanik ventilasyon (İMV) uygulandı. Weaning başarısı yalnızca %15,2 oranında sağlandı. Çıkış gününde İMV uygulanan hastalarda diyafram ve RA kalınlıkları, uygulanmayanlara göre anlamlı derecede daha düşüktü (sırasıyla p=0,029, p=0,004). RA kalınlığı ile weaning başarısı arasında anlamlı ilişki saptandı (p=0,03). Diyafram kalınlığı ile BKİ arasında pozitif yönde zayıf korelasyon mevcuttu. NUTRIC skoru ile RA kalınlığı arasında zayıf negatif korelasyon bulundu. Kas kalınlıkları ile yaş, APACHE-II ve SOFA skorları arasında korelasyon izlenmedi. Sonuç: Diyafram ve RA kas kalınlıklarının takibi, yoğun bakım hastalarında ventilatörden ayırma süreci ve mortalite riski açısından yol gösterici olabilir. Özellikle RA kalınlığı, weaning başarısının öngörülmesinde potansiyel bir biyobelirteç olarak değerlendirilebilir.

Keywords

• Diyafram
• rektus abdominis
• kas ultrasonografisi

The role of diaphragm and rectus abdominis muscle thickness in predicting mortality, morbidity, and weaning success from mechanical ventilation in ICU patients

Abstract

Purpose: This study aimed to evaluate the relationship between diaphragm and rectus abdominis (RA) muscle thickness and mortality, morbidity, and weaning success from mechanical ventilation in intensive care unit (ICU) patients. Materials and methods: A total of 87 adult ICU patients were included. Diaphragm and RA muscle thicknesses were measured via ultrasound on the 1st, 3rd, 7th, and discharge days of ICU stay. Clinical data, including mechanical ventilation status, weaning outcome, infections, and the use of sedation, inotropes, and steroids, were recorded. Results: Invasive mechanical ventilation (IMV) was applied in 82.7% of patients. Weaning was successful in only 15.2% of IMV patients. On the discharge day, diaphragm and RA thicknesses were significantly lower in the IMV group than in the non-IMV group (p=0.029, p=0.004, respectively). RA thickness was significantly higher on day 1 in the successfully weaned group (p=0.03). Diaphragm thickness showed a weak positive correlation with BMI. A weak negative correlation was found between RA thickness and NUTRIC score. No correlation was observed between muscle thicknesses and age, APACHE-II or SOFA scores. Conclusion: Monitoring diaphragm and RA muscle thickness may guide the assessment of weaning and mortality risk in ICU patients. Particularly, RA thickness may serve as a potential biomarker for predicting weaning success.

Keywords

• Diaphragm
• rectus abdominis
• muscle ultrasound

References

1. Dres M, Goligher EC, Heunks LMA, Brochard LJ. Critical illness-associated diaphragm weakness. Intensive Care Med. 2017;43(10):1441-1452. doi:10.1007/s00134-017-4928-4
2. Petrof BJ, Hussain SN. Ventilator-induced diaphragmatic dysfunction: what have we learned? Curr Opin Crit Care. 2016;22(1):67-72. doi:10.1097/MCC.0000000000000272
3. De Jonghe B, Bastuji-Garin S, Durand MC, et al. Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med. 2007;35(9):2007-2015. doi:10.1097/01.ccm.0000281450.01881.d8
4. Goligher EC, Dres M, Fan E, et al. Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes. Am J Respir Crit Care Med. 2018;197(2):204-213. doi:10.1164/rccm.201703-0536OC
5. Supinski GS, Morris PE, Dhar S, Callahan LA. Diaphragm Dysfunction in Critical Illness. Chest. 2018;153(4):1040-1051. doi:10.1016/j.chest.2017.08.1157
6. Yang T, Li Z, Jiang L, Xi X. Corticosteroid use and intensive care unit-acquired weakness: a systematic review and meta-analysis. Crit Care. 2018;22(1):187. doi:10.1186/s13054-018-2111-0
7. Jung B, Nougaret S, Conseil M, et al. Sepsis is associated with a preferential diaphragmatic atrophy: a critically ill patient study using tridimensional computed tomography. Anesthesiology. 2014;120(5):1182-1191. doi:10.1097/ALN.0000000000000201
8. Shi ZH, Jonkman A, de Vries H, et al. Expiratory muscle dysfunction in critically ill patients: towards improved understanding. Intensive Care Med. 2019;45(8):1061-1071. doi:10.1007/s00134-019-05664-4

9. Schepens T, Verbrugghe W, Dams K, Corthouts B, Parizel PM, Jorens PG. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. Crit Care. 2015;19:422. doi:10.1186/s13054-015-1141-0
10. Demoule A, Jung B, Prodanovic H, et al. Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact-a prospective study. Am J Respir Crit Care Med. 2013;188(2):213-219. doi:10.1164/rccm.201209-1668OC
11. Zambon M, Beccaria P, Matsuno J, et al. Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study. Crit Care Med. 2016;44(7):1347-1352. doi:10.1097/CCM.0000000000001657
12. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107-1116. doi:10.1056/NEJMoa1005372
13. De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288(22):2859-2867. doi:10.1001/jama.288.22.2859
14. Friedrich O, Reid MB, Van den Berghe G, et al. The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill. Physiol Rev. 2015;95(3):1025-1109. doi:10.1152/physrev.00028.2014
15. Lerolle N, Guérot E, Dimassi S, et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest. 2009;135(2):401-407. doi:10.1378/chest.08-1531
16. Umbrello M, Formenti P, Longhi D, et al. Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study. Crit Care. 2015;19(1):161. doi:10.1186/s13054-015-0894-9
17. Batt J, Herridge M, Dos Santos C. Mechanism of ICU-acquired weakness: skeletal muscle loss in critical illness. Intensive Care Med. 2017;43(12):1844-1846. doi:10.1007/s00134-017-4758-4