Diaphragm ultrasound: A novel approach to assessing pulmonary function in patients with traumatic rib fractures.
Journal
The journal of trauma and acute care surgery
ISSN: 2163-0763
Titre abrégé: J Trauma Acute Care Surg
Pays: United States
ID NLM: 101570622
Informations de publication
Date de publication:
07 2020
07 2020
Historique:
pubmed:
14
4
2020
medline:
10
9
2020
entrez:
14
4
2020
Statut:
ppublish
Résumé
Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature. We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed. A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC. To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles. Diagnostic tests or criteria, Level III.
Sections du résumé
BACKGROUND
Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature.
METHODS
We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed.
RESULTS
A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC.
CONCLUSION
To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles.
LEVEL OF EVIDENCE
Diagnostic tests or criteria, Level III.
Identifiants
pubmed: 32282755
doi: 10.1097/TA.0000000000002723
pii: 01586154-202007000-00016
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
96-102Références
Kasotakis G, Hasenboehler EA, Streib EW, et al. Operative fixation of rib fractures after blunt trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82(3):618–626.
Chapman BC, Herbert B, Rodil M, et al. RibScore: a novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. J Trauma Acute Care Surg. 2016;80(1):95–101.
Brasel KJ, Moore EE, Albrecht RA, et al. Western Trauma Association Critical Decisions in Trauma: management of rib fractures. J Trauma Acute Care Surg. 2017;82(1):200–203.
May L, Hillermann C, Patil S. Rib fracture management. BJA Education. 2015;16(1):26–32.
Pyke OJ Jr., Rubano JA, Vosswinkel JA, McCormack JE, Huang EC, Jawa RS. Admission of elderly blunt thoracic trauma patients directly to the intensive care unit improves outcomes. J Surg Res. 2017;219:334–340.
Vivier E, Roche-Campo F, Brochard L, Mekontso Dessap A. Determinants of diaphragm thickening fraction during mechanical ventilation: an ancillary study of a randomised trial. Eur Respir J. 2017;50(3):1700783.
Moury PH, Cuisinier A, Durand M, et al. Diaphragm thickening in cardiac surgery: a perioperative prospective ultrasound study. Ann Intensive Care. 2019;9(1):50.
Cohn D, Benditt JO, Eveloff S, McCool FD. Diaphragm thickening during inspiration. J Appl Physiol (1985). 1997;83(1):291–296.
McCool FD, Benditt JO, Conomos P, Anderson L, Sherman CB, Hoppin FG Jr. Variability of diaphragm structure among healthy individuals. Am J Respir Crit Care Med. 1997;155(4):1323–1328.
McCool FD, Conomos P, Benditt JO, Cohn D, Sherman CB, Hoppin FG Jr. Maximal inspiratory pressures and dimensions of the diaphragm. Am J Respir Crit Care Med. 1997;155(4):1329–1334.
McCool FD, Tzelepis GE. Dysfunction of the diaphragm. N Engl J Med. 2012;366(10):932–942.
Wait JL, Nahormek PA, Yost WT, Rochester DP. Diaphragmatic thickness-lung volume relationship in vivo. J Appl Physiol (1985). 1989;67(4):1560–1568.
Cardenas LZ, Santana PV, Caruso P, Ribeiro de Carvalho CR, Pereira de Albuquerque AL. Diaphragmatic ultrasound correlates with inspiratory muscle strength and pulmonary function in healthy subjects. Ultrasound Med Biol. 2018;44(4):786–793.
Sartucci F, Pelagatti A, Santin M, Bocci T, Dolciotti C, Bongioanni P. Diaphragm ultrasonography in amyotrophic lateral sclerosis: a diagnostic tool to assess ventilatory dysfunction and disease severity. Neurol Sci. 2019;40(10):2065–2071.
Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM. Diaphragm muscle thinning in patients who are mechanically ventilated. Chest. 2012;142(6):1455–1460.
Lessa TB, de Abreu DK, Bertassoli BM, Ambrosio CE. Diaphragm: a vital respiratory muscle in mammals. Ann Anat. 2016;205:122–127.
Schoser B, Fong E, Geberhiwot T, et al. Maximum inspiratory pressure as a clinically meaningful trial endpoint for neuromuscular diseases: a comprehensive review of the literature. Orphanet J Rare Dis. 2017;12(1):52.
Caruso P, Albuquerque AL, Santana PV, et al. Diagnostic methods to assess inspiratory and expiratory muscle strength. J Bras Pneumol. 2015;41(2):110–123.
Koulouris NG, Dimitroulis I. Structure and function of respiratorymuscles. Pneumon. 2001;14(2):91–108.
Dhungana A, Khilnani G, Hadda V, Guleria R. Reproducibility of diaphragm thickness measurements by ultrasonography in patients on mechanical ventilation. World J Crit Care Med. 2017;6(4):185–189.
Bakhos C, O'Connor J, Kyriakides T, Abou-Nukta F, Bonadies J. Vital capacity as a predictor of outcome in elderly patients with rib fractures. J Trauma. 2006;61(1):131–134.
Carver TW, Milia DJ, Somberg C, Brasel K, Paul J. Vital capacity helps predict pulmonary complications after rib fractures. J Trauma Acute Care Surg. 2015;79(3):413–416.
Vivier E, Mekontso Dessap A, Dimassi S, et al. Diaphragm ultrasonography to estimate the work of breathing during non-invasive ventilation. Intensive Care Med. 2012;38(5):796–803.
DiNino E, Gartman EJ, Sethi JM, McCool FD. Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax. 2014;69(5):423–427.
National Trauma Data Standard. Available at: https://www.facs.org/quality-programs/trauma/tqp/center-programs/ntdb/ntds. Accessed July 31, 2019.
Roman MA, Rossiter HB, Casaburi R. Exercise, ageing and the lung. Eur Respir J. 2016;48(5):1471–1486.
Khan SS, Singer BD, Vaughan DE. Molecular and physiological manifestations and measurement of aging in humans. Aging Cell. 2017;16(4):624–633.
Tralhao A, Cavaleiro P, Arrigo M, et al. Early changes in diaphragmatic function evaluated using ultrasound in cardiac surgery patients: a cohort study. J Clin Monit Comput. 2019. doi:10.1007/s10877-019-00350-8.
doi: 10.1007/s10877-019-00350-8
Soliman SB, Ragab F, Soliman RA, Gaber A, Kamal A. Chest ultrasound in predication of weaning failure. Open Access Maced J Med Sci. 2019;7(7):1143–1147.
Vivier E, Muller M, Putegnat JB, et al. Inability of diaphragm ultrasound to predict extubation failure: a multicenter study. Chest. 2019;155(6):1131–1139.
Rittayamai N, Hemvimon S, Chierakul N. The evolution of diaphragm activity and function determined by ultrasound during spontaneous breathing trials. J Crit Care. 2019;51:133–138.
Qian Z, Yang M, Li L, Chen Y. Ultrasound assessment of diaphragmatic dysfunction as a predictor of weaning outcome from mechanical ventilation: a systematic review and meta-analysis. BMJ Open. 2018;8(9):e021189.
De Troyer A, Boriek AM. Mechanics of the respiratory muscles. Compr Physiol. 2011;1(3):1273–1300.
Unal O, Arslan H, Uzun K, Ozbay B, Sakarya ME. Evaluation of diaphragmatic movement with MR fluoroscopy in chronic obstructive pulmonary disease. Clin Imaging. 2000;24(6):347–350.
Santana PV, Prina E, Albuquerque AL, Carvalho CR, Caruso P. Identifying decreased diaphragmatic mobility and diaphragm thickening in interstitial lung disease: the utility of ultrasound imaging. J Bras Pneumol. 2016;42(2):88–94.