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Assessment of Diaphragm Dysfunction in Mechanically Ventilated Patients
Published in Massimo Zambon, Ultrasound of the Diaphragm and the Respiratory Muscles, 2022
Patients presenting with respiratory distress exhibit important inspiratory efforts. The latter may be responsible for respiratory muscles over-activity which may result in diaphragm injury.16 Orozco-Levi et al. observed that diaphragm overactivity induced by intense inspiratory efforts can lead to histological signs of diaphragm injury in healthy patients.18 In addition, higher risk of non-invasive ventilation failure has been documented in patients with diaphragm dysfunction.26 These studies suggest that monitoring the diaphragm function of patients with respiratory distress may be of interest to evaluate the risk of diaphragm overactivity. Whether it may lead to a clinical decision (intubation) remains to be established.
Pediatric abdominal trauma
Published in David E. Wesson, Bindi Naik-Mathuria, Pediatric Trauma, 2017
Lauren Gillory, Bindi Naik-Mathuria
Diaphragm rupture or injury in pediatric trauma is uncommon and easily missed on initial evaluation. According to a retrospective series extracted from the National Pediatric Trauma Registry, 4% of patients with proven thoracic or abdominal trauma had a diaphragm injury [1]. Diaphragmatic injury is often associated with penetrating mechanism [108]. There is a high incidence of accompanying injuries, most commonly of the musculoskeletal system and abdomen [108–110]. Complaints that may indicate this injury include chest pain radiating to the shoulder, shortness of breath, and abdominal pain. Children have a higher propensity for swallowing air and causing gastric distention, which may lead to respiratory distress with a left-sided diaphragmatic rupture [108]. Other physical findings to suggest the injury are bowel sounds in the chest, absence of breath sounds, and scaphoid abdomen. The most classic radiographic finding is loops of bowel in the chest on plain film, but CT scan of the abdomen may be useful to confirm the diagnosis and evaluate for accompanying injuries. Early diagnosis of traumatic diaphragmatic injury requires a high index of suspicion, as it may not be obvious on clinical exam or imaging.
Diaphragmatic Injuries
Published in Stephen M. Cohn, Matthew O. Dolich, Kenji Inaba, Acute Care Surgery and Trauma, 2016
The optimal approach to the evaluation and management of these TDI remains poorly defined and is particularly challenging. Several factors are responsible for this. First, the diaphragm is a thin musculoaponeurotic layer at the junction of the thoracic and peritoneal cavities. As a result, it may be involved in traumatic injuries involving either or both of these cavities. Second, associated injuries are frequent. These may dominate the clinical pictures and dictate the course of management making the issue of diaphragm injury secondary. Third, when isolated, these injuries usually have no pathognomic features; hence, they require a high index of suspicion if the diagnosis is to be made in a timely manner. This is becoming increasingly important as nonoperative strategies are being more commonly employed in select cases of thoracoabdominal trauma. Also, key differences exist in injuries due to blunt and penetrating trauma and in injuries to the left and right sides of the diaphragm. This effectively precludes a universal algorithm for the management of all diaphragmatic injuries. Finally, while some of these missed injuries may never manifest, the potential for an adverse outcome with its attendant increase in morbidity and mortality makes prompt diagnosis and management desirable.
Advantages and drawbacks of helmet noninvasive support in acute respiratory failure
Published in Expert Review of Respiratory Medicine, 2023
Filippo Bongiovanni, Teresa Michi, Daniele Natalini, Domenico L. Grieco, Massimo Antonelli
The consistent application of higher PEEP levels may be particularly relevant in the AHRF setting. Indeed, as will be discussed in the following sections, non-invasive management of this group of patients poses significant challenges due to the risk of patient self-inflicted lung injury (P-SILI) [15]. In AHRF patients with preserved spontaneous breathing, dysregulated espiratory drive [16] and intense inspiratory effort result in high tidal volumes, tachypnea, and large swings in transpulmonary pressure, which expose the lungs to the risks of volo- and baro-trauma [17,18]. Functional residual capacity (FRC) is reduced due to consolidations and atelectasis (the ‘baby lung’ concept of acute respiratory distress syndrome, ARDS [19]), and the delivery of high tidal volumes to a small FRC increases dynamic strain, an engineering-derived concept, which represents the deformation of a structure due to an applied external load [20]. Lung parenchyma becomes inhomogeneous, making the transmission of inflation forces not uniform: an alveolar pressure gradient develops between different lung zones, leading to gas displacement from non-dependent anterior to dependent posterior lung regions, the so-called pendelluft phenomenon [21,22]. Moreover, the large pleural pressure swings produced by intense inspiratory effort lead to high transmural vascular pulmonary pressure, enhancing alveolar edema and exacerbating lung damage [23,24]. Finally, uncontrolled inspiratory effort may cause diaphragm myotrauma and atrophy, resulting in diaphragm injury [25,26].
Lung and diaphragm protective ventilation: a synthesis of recent data
Published in Expert Review of Respiratory Medicine, 2022
Vlasios Karageorgos, Athanasia Proklou, Katerina Vaporidi
Research has advanced our understanding of the mechanisms; mechanical ventilation can induce lung and diaphragm injury. Lung inhomogeneity is shown to play a cardinal role in the development of VILI, particularly when it is combined with high ventilatory demands from the underlying disease. Reduced diaphragm activity, as a result of passive ventilation or high assist, is the main cause of VIDD. Therefore, to implement lung and diaphragm protective ventilation we need to target these mechanisms, for example by combining spontaneous breathing with low distending pressures, titrating inspiratory effort and assuring patient comfort. Novel technology, such as electrical impedance tomography, continuous esophageal pressure monitoring, proportional modes of assist, transvenous diaphragmatic pacing, and extracorporeal oxygenation or CO2 removal, can help achieve the targets of lung and diaphragm protective ventilation. Clinical trials are needed to optimize patient selection for each intervention, and education of caretakers to enable personalization of ventilator settings.
How to recognize patients at risk of self-inflicted lung injury
Published in Expert Review of Respiratory Medicine, 2022
Tommaso Pettenuzzo, Nicolò Sella, Francesco Zarantonello, Alessandro De Cassai, Federico Geraldini, Paolo Persona, Elisa Pistollato, Annalisa Boscolo, Paolo Navalesi
Future research should focus on better investigating the mechanisms of P-SILI in critically ill patients. Indeed, other components of injury associated with spontaneous breathing, e.g. excessive expiratory muscle effort and diaphragm injury, have been identified and may be included in a broader pathological entity of patient self-inflicted injury. On the one hand, the role of the expiratory muscles cannot be overlooked. Expiration is generally a passive phenomenon regulated by the elastic recoil pressure of the lungs and chest wall. In passive patients, expiratory flow only depends on the time constant, i.e. the product of compliance and resistance, of the respiratory system. However, in case of high metabolic demands, inadequate inspiratory muscle capacity, increased end-expiratory lung volume, and/or increased expiratory resistance, the expiratory muscles are actively recruited. On the other hand, it is well known that mechanical ventilation per se may be responsible for ventilator-induced diaphragmatic dysfunction, which is associated with poor patient outcomes. Increasing data suggest that titrating ventilatory support to maintain adequate, i.e. not excessively low or high, levels of inspiratory effort might prevent this complication. Moreover, the prevention of patient-ventilator asynchronies is important. Under-assistance during partial ventilation modes may favor the occurrence of double triggering, i.e. two ventilator insufflations delivered within one patient inspiratory effort. This type of asynchrony may result, on the one hand, in the provision of unintendedly high tidal volumes because of breath stacking and, on the other hand, in injurious eccentric diaphragmatic contractions. In addition, an excessively low respiratory drive can lead to other forms of patient-ventilator dyssynchronies, such as ineffective efforts, auto-triggering, and reverse triggering, which in turn may promote diaphragmatic disuse atrophy. The diaphragm injury component of P-SILI underscores the concept that, although mechanisms of P-SILI usually involve excessively high respiratory drive and effort, excessively low respiratory drive and effort may be detrimental as well.