Journal
INTENSIVE CARE MEDICINE
Volume 45, Issue 4, Pages 488-500Publisher
SPRINGER
DOI: 10.1007/s00134-019-05566-5
Keywords
Ventilator-induced diaphragm dysfunction or damage (VIDD); Atrophy; Mechanical ventilation; Brain death; Maastricht III; Muscle dysfunction
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Funding
- Instituto de Salud Carlos III-Fondo Europeo de Desarrollo Regional (FEDER) [PI18/00025]
- Spanish Critical Patient Foundation (FEEC 2017)
- Catalan Society of Critical Care (SOCMIC 2018)
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PurposeVentilator-induced diaphragm dysfunction or damage (VIDD) is highly prevalent in patients under mechanical ventilation (MV), but its analysis is limited by the difficulty of obtaining histological samples. In this study we compared diaphragm histological characteristics in Maastricht III (MSIII) and brain-dead (BD) organ donors and in control subjects undergoing thoracic surgery (CTL) after a period of either controlled or spontaneous MV (CMV or SMV).MethodsIn this prospective study, biopsies were obtained from diaphragm and quadriceps. Demographic variables, comorbidities, severity on admission, treatment, and ventilatory variables were evaluated. Immunohistochemical analysis (fiber size and type percentages) and quantification of abnormal fibers (a surrogate of muscle damage) were performed.ResultsMuscle samples were obtained from 35 patients. MSIII (n=16) had more hours on MV (either CMV or SMV) than BD (n=14) and also spent more hours and a greater percentage of time with diaphragm stimuli (time in assisted and spontaneous modalities). Cross-sectional area (CSA) was significantly reduced in the diaphragm and quadriceps in both groups in comparison with CTL (n=5). Quadriceps CSA was significantly decreased in MSIII compared to BD but there were no differences in the diaphragm CSA between the two groups. Those MSIII who spent 100h or more without diaphragm stimuli presented reduced diaphragm CSA without changes in their quadriceps CSA. The proportion of internal nuclei in MSIII diaphragms tended to be higher than in BD diaphragms, and their proportion of lipofuscin deposits tended to be lower, though there were no differences in the quadriceps fiber evaluation.ConclusionsThis study provides the first evidence in humans regarding the effects of different modes of MV (controlled, assisted, and spontaneous) on diaphragm myofiber damage, and shows that diaphragm inactivity during mechanical ventilation is associated with the development of VIDD.
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