Mechanical Ventilation–induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes

Abstract

Rationale Diaphragm dysfunction worsens outcomes in mechanically ventilated patients but the clinical impact of potentially preventable changes in diaphragm structure and function due to mechanical ventilation is unknown. Objectives To determine whether diaphragm atrophy developing during mechanical ventilation leads to prolonged ventilation. Methods Diaphragm thickness was measured daily by ultrasound in adults requiring invasive mechanical ventilation; inspiratory effort was assessed by thickening fraction. The primary outcome was time to liberation from ventilation. Secondary outcomes included complications (reintubation, tracheostomy, prolonged ventilation, or death). Associations were adjusted for age, severity of illness, sepsis, sedation, neuromuscular blockade, and comorbidity. Measurements and Main Results Of 211 patients enrolled, 191 had two or more diaphragm thickness measurements. Thickness decreased more than 10% in 78 patients (41%) by median day 4 (IQR 3-5). Development of decreased thickness was associated with a lower daily probability of liberation from ventilation (adjusted HR 0.69, 95%CI 0.54-0.87, per 10% decrease), prolonged ICU admission (duration ratio 1.71, 95%CI 1.29-2.27), and a higher risk of complications (OR 3.00, 95%CI 1.34-6.72). Development of increased thickness (n=47, 24%) also predicted prolonged ventilation (duration ratio 1.38, 95%CI 1.00-1.90). Decreasing thickness was related to abnormally low inspiratory effort; increasing thickness was related to excessive effort. Patients with thickening fraction between 15-30% (similar to breathing at rest) during the first 3 days had the shortest duration of ventilation. Conclusions Diaphragm atrophy developing during mechanical ventilation strongly impacts clinical outcomes. Targeting an inspiratory effort level similar to that of healthy subjects at rest might accelerate liberation from ventilation.