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Background: Compared to conventional oxygen devices, high-flow oxygen treatment (HFOT) through the nasal cannulae has demonstrated clinical benefits. Limited data exist on whether such effects are also present in HFOT through tracheostomy. Hence, we aimed to examine the short-term effects of HFOT through tracheostomy on diaphragmatic function and respiratory parameters in tracheostomized patients on prolonged mechanical ventilation. Methods: A randomized, crossover, physiological study was conducted in our ICU between December 2020 and April 2021, in patients with tracheostomy and prolonged mechanical ventilation. The patients underwent a 30-min spontaneous breathing trial (SBT) and received oxygen either via T-piece or by HFOT through tracheostomy, followed by a washout period of 15-min breathing through the T-piece and receipt of 30-min oxygen with the other modality in a randomized crossover manner. At the start and end of each session, blood gasses, breathing frequency (f), and tidal volume (VT) via a Wright's spirometer were measured, along with diaphragm ultrasonography including diaphragm excursion and diaphragmatic thickening fraction, which expressed the inspiratory muscle effort. Results: Eleven patients were enrolled in whom 19 sessions were uneventfully completed; eight patients were studied twice on two different days with alternate sessions; and three patients were studied once. Patients were randomly assigned to start the SBT with a T-piece (n=10 sessions) or with HFOT (n=9 sessions). With HFOT, VT and minute ventilation (VE) significantly increased during SBT (from [465±119] mL to [549±134] mL, P

IntroductionAssessing the influence of respiratory assistive devices on the diaphragm mobility is essential for advancing patient care and improving treatment outcomes. Existing respiratory assistive robots have not yet effectively assessed their impact on diaphragm mobility. In this study, we introduce for the first time a non-invasive, real-time clinically feasible ultrasound method to evaluate the impact of soft wearable robots on diaphragm displacement.MethodsWe measured and compared diaphragm displacement and lung volume in eight participants during both spontaneous and robotic-assisted respiration. Building on these measurements, we proposed a human-robot coupled two-compartment respiratory mechanics model that elucidates the underlying mechanism by which our extracorporeal wearable robots augments respiration. Specifically, the soft robot applies external compression to the abdominal wall muscles, inducing their inward movement, which consequently pushes the diaphragm upward and enhances respiratory function. Finally, we investigated the level and shape of various robotic assistive forces on diaphragm motion.ResultsThis robotic intervention leads to a significant increase in average diaphragm displacement by 1.95 times and in lung volume by 2.14 times compared to spontaneous respiration. Furthermore, the accuracy of the proposed respiratory mechanics model is confirmed by the experimental results, with less than 7% error in measurements of both diaphragm displacement and lung volume. Finally, the magnitude of robotic assistive forces positively correlates with diaphragm movement, while the shape of the forces shows no significant relationship with diaphragm activity.ConclusionOur experimental findings validate the effective assistance mechanism of the proposed robot, which enhances diaphragm mobility and assists in ventilation through extracorporeal robotic intervention. This robotic system can assist with ventilation while increasing diaphragm mobility, potentially resolving the issue of diaphragm atrophy. Additionally, this work paves the way for improved robotic designs and personalized assistance, tailored to the dynamics of the diaphragm in respiratory rehabilitation.

BackgroundConventional single indicators have low sensitivity and specificity for predicting weaning from mechanical ventilation in pediatric patients, necessitating the establishment of a combined prediction model for predicting weaning outcomes.ObjectivesTo explore the combined predictive value of PaO2/FiO2 Ratio (P/F ratio), diaphragm excursion-rapid shallow breathing index (DE-RSBI), diaphragm thickening fraction-rapid shallow breathing index (DTF-RSBI), and Pediatric Critical Illness Score (PCIS) in weaning from mechanical ventilation in pediatric patients.MethodsSixty critically ill pneumonia pediatric patients requiring mechanical ventilation treatment from July 2022 to June 2023 at the Second Affiliated Hospital of Jiaxing University were selected. They all underwent a spontaneous breathing trial (SBT) and were divided into the weaning success group (42 cases) and weaning failure group (18 cases) based on the weaning outcome. Parameters including total duration of illness, mechanical ventilation duration, heart rate (HR), P/F ratio, diaphragm excursion (DE), DE-RSBI, diaphragm thickening fraction (DTF), DTF-RSBI, and PCIS were included in univariate and multivariate logistic regression analyses to determine independent factors affecting pediatric weaning success. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of P/F ratio, DE-RSBI, DTF-RSBI, PCIS alone or in combination for weaning success.ResultsComparing P/F ratio, DE, DE-RSBI, DTF, DTF-RSBI and PCIS, there were statistically significant differences (P

BackgroundAlthough diaphragm ultrasound can be used for detecting residual neuromuscular blockade post-surgery, there exists notable dearth in contemporary research exploring the correlation between preoperative Child-Pugh classification and the effectiveness of sugammadex in reversing rocuronium-induced blockade as evaluated by diaphragmatic ultrasonography.MethodsThis was a prospective, double-blind, non-randomized controlled clinical trial conducted on patients scheduled for laparoscopic liver resection surgery. The participants were categorized into two groups, A and B, based on their preoperative Child-Pugh classification. Prior to anesthesia induction, baseline diaphragm thickness was evaluated using ultrasonography. Throughout the surgical procedure, a deep neuromuscular blockade was maintained with rocuronium. Post-surgery, sugammadex (2 mg/kg) was intravenously administered to patients in both groups upon reaching a train-of-four ratio of 0.2. Diaphragm thickness was assessed at 0, 10, and 30 min, as well as 2 h after extubation, to analyze thickening fractioning (TF) and thickness recovery fractioning (TRF).ResultsNo significant differences in TF or TRF were observed between the two groups at 0, 10, and 30 min, as well as 2 h after extubation. Furthermore, there were no significant variances in hemodynamic stability following sugammadex administration. However, patients in the Child-Pugh B group experienced a significantly prolonged time from sugammadex administration to tracheal extubation (19 ± 8.0 min vs. 11 ± 6.1 min) and an extended post-anesthesia care unit stay (123 ± 28.3 min vs. 103 ± 26.0 min) compared to those in the Child-Pugh A group.ConclusionThe preoperative Child-Pugh grades may not exhibit a significant association with the reversal effect of sugammadex on rocuronium, as evaluated through diaphragmatic ultrasonography.Clinical trial registrationRegistered in the ClinicalTrials.gov (NCT05028088) on July 18, 2021.

Background Upper abdominal surgical treatment may reduce respiratory muscle function and mucociliary clearance, which might be a cause of postoperative pulmonary complications (PPCs). Threshold inspiratory muscle training (IMT) may serve as an effective modality to improve respiratory muscle strength and endurance in patients. However, whether this training could help patients with upper abdominal surgery remains to be determined. The aim of the present investigation was to determine the effect of a fully engaged IMT on PPCs and respiratory function in patients undergoing upper abdominal surgery. We hypothesized that the fully engaged IMT could reduce PPCs and improve respiratory muscle function in patients with upper abdominal surgery.Methods This is a randomized controlled trial (RCT) with 28 patients who underwent upper abdominal surgery. Patients were randomly assigned to the control (CLT) group or the IMT group. The CTL group received regular health care. The IMT group received 3 weeks of IMT with 50% of MIP as the initial intensity before the operation. The intensity of MIP increased by 5–10% per week. The IMT was continued for 4 weeks after the operation. The study investigated the outcomes including PPCs, respiratory muscle strength, diaphragmatic function, cardiopulmonary function, and quality of life (QoL).Results We found that IMT improved respiratory muscle strength and diaphragmatic excursion. IMT also had a beneficial effect on the incidence of postoperative pulmonary complications (PPCs) compared to CLT care.Conclusion The results from this study revealed that IMT provided positive effects on parameters associated with the respiratory muscle function and reduced the incidence of PPCs. We propose that fully engaged IMT should be a part of clinical management in patients with upper abdominal surgery.KEY MESSAGESThe fully engaged inspiratory muscle training reduces postoperative pulmonary complications rate in patients with upper abdominal surgery.The fully engaged inspiratory muscle training increases maximal inspiratory pressure in patients with upper abdominal surgery.The fully engaged inspiratory muscle training increases diaphragm function in patients with upper abdominal surgery.The fully engaged inspiratory muscle training increases the quality of life in patients with upper abdominal surgery.

Abstract Background Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively. Methods/design In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I–III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively. Discussion Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting. Trial registration ClinicalTrials.gov NCT05040490 . Registered on 3 September 2021

Introduction: We aimed to clarify the differences in static and dynamic diaphragm parameters between the expiratory and inspiratory phases in amyotrophic lateral sclerosis (ALS).Methods: Twenty patients with early-stage ALS and 16 healthy controls were enrolled in the study. We measured the amplitudes of compound muscle action potential (phCMAP) by electrical stimulation of the phrenic nerve and the zone of apposition wall thickness of the diaphragm (DT) using ultrasonography. We analyzed the differences in phCMAP (∆phCMAP) and DT (∆DT) between the end-inspiratory and end-expiratory phases and their correlation with forced vital capacity (FVC).Results: The ΔphCMAP (mean 129.7 ± SD 204.7 µV) and ∆DT (0.80 ± 0.88 cm) in patients were significantly smaller than those in controls (348.6 ± 247.7 µV, p = 0.0003 and 1.89 ± 1.10 cm, p = 0.0002, respectively). Although ∆DT was significantly correlated with FVC, we found no correlation between ∆phCMAP and FVC. The phCMAP was paradoxically smaller during inspiration than during expiration in 35% of patients but in none of the controls.Conclusion: Dynamic parameters of the diaphragm were abnormal in early-stage ALS. The paradoxical reduction in phCMAP during inspiration may reflect early respiratory dysfunction. Assessment of dynamic abnormalities of the diaphragm may provide helpful information for respiratory management in patients with ALS. [ABSTRACT FROM AUTHOR]

Upper abdominal surgical treatment may reduce respiratory muscle function and mucociliary clearance, which might be a cause of postoperative pulmonary complications (PPCs). Threshold inspiratory muscle training (IMT) may serve as an effective modality to improve respiratory muscle strength and endurance in patients. However, whether this training could help patients with upper abdominal surgery remains to be determined. The aim of the present investigation was to determine the effect of a fully engaged IMT on PPCs and respiratory function in patients undergoing upper abdominal surgery. We hypothesized that the fully engaged IMT could reduce PPCs and improve respiratory muscle function in patients with upper abdominal surgery. This is a randomized controlled trial (RCT) with 28 patients who underwent upper abdominal surgery. Patients were randomly assigned to the control (CLT) group or the IMT group. The CTL group received regular health care. The IMT group received 3 weeks of IMT with 50% of MIP as the initial intensity before the operation. The intensity of MIP increased by 5–10% per week. The IMT was continued for 4 weeks after the operation. The study investigated the outcomes including PPCs, respiratory muscle strength, diaphragmatic function, cardiopulmonary function, and quality of life (QoL). We found that IMT improved respiratory muscle strength and diaphragmatic excursion. IMT also had a beneficial effect on the incidence of postoperative pulmonary complications (PPCs) compared to CLT care. The results from this study revealed that IMT provided positive effects on parameters associated with the respiratory muscle function and reduced the incidence of PPCs. We propose that fully engaged IMT should be a part of clinical management in patients with upper abdominal surgery. The fully engaged inspiratory muscle training reduces postoperative pulmonary complications rate in patients with upper abdominal surgery. The fully engaged inspiratory muscle training increases maximal inspiratory pressure in patients with upper abdominal surgery. The fully engaged inspiratory muscle training increases diaphragm function in patients with upper abdominal surgery. The fully engaged inspiratory muscle training increases the quality of life in patients with upper abdominal surgery. [ABSTRACT FROM AUTHOR]

Abstract Background We aim to assess the role of diaphragm ultrasonography in evaluating the outcome of surgical diaphragmatic plication in adults with symptomatic unilateral diaphragmatic eventration. Results Forty patients with symptomatic unilateral diaphragmatic eventration underwent surgical diaphragmatic plication between 2015 and 2020. The etiology was idiopathic in 34 (85%) cases, and 37 (92.5%) of them were suffering from dyspnea. Diaphragm ultrasonography showed no diaphragmatic movement on the affected side in 10 (25%) patients and a paradoxical movement in 30 (75%) patients. Surgical diaphragmatic plication was done successfully in all cases. Postoperative complications were reported in 3 (7.5%) cases, with no mortality. There was a highly significant improvement in dyspnea at 1 week and 6 months follow-up. CXR showed a highly significant decrease in the mean height of eventration at 1 week 3.7 ± 1.2 cm (P

Introduction: Assessing the influence of respiratory assistive devices on the diaphragm mobility is essential for advancing patient care and improving treatment outcomes. Existing respiratory assistive robots have not yet effectively assessed their impact on diaphragm mobility. In this study, we introduce for the first time a non-invasive, real-time clinically feasible ultrasound method to evaluate the impact of soft wearable robots on diaphragm displacement., Methods: We measured and compared diaphragm displacement and lung volume in eight participants during both spontaneous and robotic-assisted respiration. Building on these measurements, we proposed a human-robot coupled two-compartment respiratory mechanics model that elucidates the underlying mechanism by which our extracorporeal wearable robots augments respiration. Specifically, the soft robot applies external compression to the abdominal wall muscles, inducing their inward movement, which consequently pushes the diaphragm upward and enhances respiratory function. Finally, we investigated the level and shape of various robotic assistive forces on diaphragm motion., Results: This robotic intervention leads to a significant increase in average diaphragm displacement by 1.95 times and in lung volume by 2.14 times compared to spontaneous respiration. Furthermore, the accuracy of the proposed respiratory mechanics model is confirmed by the experimental results, with less than 7% error in measurements of both diaphragm displacement and lung volume. Finally, the magnitude of robotic assistive forces positively correlates with diaphragm movement, while the shape of the forces shows no significant relationship with diaphragm activity., Conclusion: Our experimental findings validate the effective assistance mechanism of the proposed robot, which enhances diaphragm mobility and assists in ventilation through extracorporeal robotic intervention. This robotic system can assist with ventilation while increasing diaphragm mobility, potentially resolving the issue of diaphragm atrophy. Additionally, this work paves the way for improved robotic designs and personalized assistance, tailored to the dynamics of the diaphragm in respiratory rehabilitation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Li, Zhang, Wang, Xue, Nan, Li, Tan, Guo, Zhang, Zhao, Ge and Wang.)

Background: Conventional single indicators have low sensitivity and specificity for predicting weaning from mechanical ventilation in pediatric patients, necessitating the establishment of a combined prediction model for predicting weaning outcomes., Objectives: To explore the combined predictive value of PaO 2 /FiO 2 Ratio (P/F ratio), diaphragm excursion-rapid shallow breathing index (DE-RSBI), diaphragm thickening fraction-rapid shallow breathing index (DTF-RSBI), and Pediatric Critical Illness Score (PCIS) in weaning from mechanical ventilation in pediatric patients., Methods: Sixty critically ill pneumonia pediatric patients requiring mechanical ventilation treatment from July 2022 to June 2023 at the Second Affiliated Hospital of Jiaxing University were selected. They all underwent a spontaneous breathing trial (SBT) and were divided into the weaning success group (42 cases) and weaning failure group (18 cases) based on the weaning outcome. Parameters including total duration of illness, mechanical ventilation duration, heart rate (HR), P/F ratio, diaphragm excursion (DE), DE-RSBI, diaphragm thickening fraction (DTF), DTF-RSBI, and PCIS were included in univariate and multivariate logistic regression analyses to determine independent factors affecting pediatric weaning success. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of P/F ratio, DE-RSBI, DTF-RSBI, PCIS alone or in combination for weaning success., Results: Comparing P/F ratio, DE, DE-RSBI, DTF, DTF-RSBI and PCIS, there were statistically significant differences ( P  < 0.05). Through collinearity analysis and binary logistic regression analysis,P/F ratio [OR   =   0.777, 95% CI (0.641,0.941)], DE-RSBI [OR   =   1.694, 95% CI (1.172, 2.447)], DTF-RSBI [OR   =   1.057, 95% CI (1.002, 1.114)], and PCIS [OR   =   0.661, 95% CI (0.445, 0.982)] were identified as independent factors affecting successful weaning( P  < 0.05).The regression equation was: Logit P  = 73.299-0.253 P/F ratio + 0.525DE-RSBI + 0.055DTF-RSBI-0.43PCIS.The sensitivity of the combined indicator Logit( P ) in predicting successful weaning from mechanical ventilation in pediatric patients was 88.9%, with a specificity of 95.2% (optimal cutoff value of 0.511), and the area under the ROC curve (AUC) was 0.960 [95% CI (0.915, 1.000)]. The AUC of the combined prediction model for predicting pediatric weaning was greater than that of P/F ratio, DE-RSBI, DTF-RSBI and PCIS alone ( Z values   =   9.129, 2.061, 2.075, 8.326, P  < 0.05)., Conclusions: In mechanically ventilated pediatric patients, the combined prediction model has better predictive value for weaning success compared to using P/F ratio, DE-RSBI, DTF-RSBI, or PCIS alone., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Ge, Zhang, Teng and Hu.)

Background: Postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs), and both of them will lead to adverse consequences on surgical patient recovery. The train-of-four ratio (TOFr) which is detected by acceleromyography of the adductor pollicis is thought as the gold standard for the measurement of PORC. However, diaphragm function recovery may differ from that of the peripheral muscles. Recent studies suggested that diaphragm ultrasonography may be useful to reveal the diaphragm function recovery, and similarly, lung ultrasound was reported for the assessment of PPCs in recent years as well. Sugammadex reversal of neuromuscular blockade is rapid and complete, and there appear to be fewer postoperative complications than with neostigmine. This study aims to compare the effects of neostigmine and sugammadex, on PORC and PPCs employing diaphragm and lung ultrasonography, respectively.Methods/design: In this prospective, double-blind, randomized controlled trial, patients of the American Society of Anesthesiologists Physical Status I-III, aged over 60, will be enrolled. They will be scheduled to undergo arthroplasty under general anesthesia. All patients will be allocated randomly into two groups, group NEO (neostigmine) and group SUG (sugammadex), using these two drugs for reversing rocuronium. The primary outcome of the study is the incidence of PPCs in the NEO and SUG groups. The secondary outcomes are the evaluation of diaphragm ultrasonography and lung ultrasound, performed by an independent sonographer before anesthesia, and at 10 min and 30 min after extubation in the post-anesthesia care unit, respectively.Discussion: Elimination of PORC is a priority at the emergence of anesthesia, and it may be associated with reducing postoperative complications like PPCs. Sugammadex was reported to be superior to reverse neuromuscular blockade than neostigmine. Theoretically, complete recovery of neuromuscular function should be indicated by TOFr > 0.9. However, the diaphragm function recovery may not be the same matter, which probably harms pulmonary function. The hypothesis will be proposed that sugammadex is more beneficial than neostigmine to reduce the incidence of PPCs and strongly favorable for the recovery of diaphragm function in our study setting.Trial Registration: ClinicalTrials.gov NCT05040490 . Registered on 3 September 2021. [ABSTRACT FROM AUTHOR]

Purpose: We have focused on the two-dimensional (B-mode) and the time-motion (M-mode) analysis of the zone of apposition to determine the reliability of diaphragm ultrasonography in the clinical environment. Methods: Ten healthy volunteers were enrolled and studied by three operators with different skills in ultrasonography. For every volunteer, each operator acquired three images of the diaphragm for each side, both in B-mode and in M-mode. Then a fourth operator calculated the thickening fraction (TF), by means of the formula TF = (TEI − TEE)/TEE (TEI is the thickness at end inspiration and TEE the thickness at end expiration). Afterwards, intraclass correlation coefficients (ICCs) were computed on TF to establish reproducibility and repeatability both in the B- and M-modes. A Coefficient of Repeatability or repeatability (CR) ≤ 0.3 was considered acceptable. Results: Both B-mode (CRs 0.16–0.26) and M-mode (CRs 0.10–0.15) were sufficiently repeatable to assess TF, except for the less experienced operator (CRs B-Mode 0.20–0.32). Reproducibility was moderate to good between operators with CRs much narrower for the M-Mode (0.13–0.14). Conclusions: The results of our study have shown that diaphragm ultrasound is repeatable and reproducible when carried out by a radiologist or an intensivist with a basic curriculum in ultrasonography. The method is more accurate when using the M-mode for less experienced operators, and in this case, repeatability and reproducibility are not sufficient to make clinical decisions. No TF value lower than 36% was obtained using both techniques. This suggests the existence of a cut-off value that could be used as an initial tool to discriminate healthy subjects from those affected by diaphragmatic dysfunction. Clinical trial registration: EUDRACT 2015-004635-12. [ABSTRACT FROM AUTHOR]

Background: Although diaphragm ultrasound can be used for detecting residual neuromuscular blockade post-surgery, there exists notable dearth in contemporary research exploring the correlation between preoperative Child-Pugh classification and the effectiveness of sugammadex in reversing rocuronium-induced blockade as evaluated by diaphragmatic ultrasonography., Methods: This was a prospective, double-blind, non-randomized controlled clinical trial conducted on patients scheduled for laparoscopic liver resection surgery. The participants were categorized into two groups, A and B, based on their preoperative Child-Pugh classification. Prior to anesthesia induction, baseline diaphragm thickness was evaluated using ultrasonography. Throughout the surgical procedure, a deep neuromuscular blockade was maintained with rocuronium. Post-surgery, sugammadex (2 mg/kg) was intravenously administered to patients in both groups upon reaching a train-of-four ratio of 0.2. Diaphragm thickness was assessed at 0, 10, and 30 min, as well as 2 h after extubation, to analyze thickening fractioning (TF) and thickness recovery fractioning (TRF)., Results: No significant differences in TF or TRF were observed between the two groups at 0, 10, and 30 min, as well as 2 h after extubation. Furthermore, there were no significant variances in hemodynamic stability following sugammadex administration. However, patients in the Child-Pugh B group experienced a significantly prolonged time from sugammadex administration to tracheal extubation (19 ± 8.0 min vs. 11 ± 6.1 min) and an extended post-anesthesia care unit stay (123 ± 28.3 min vs. 103 ± 26.0 min) compared to those in the Child-Pugh A group., Conclusion: The preoperative Child-Pugh grades may not exhibit a significant association with the reversal effect of sugammadex on rocuronium, as evaluated through diaphragmatic ultrasonography., Clinical Trial Registration: Registered in the ClinicalTrials.gov (NCT05028088) on July 18, 2021., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Sun, Sun, Chen, Shen, Chen, Lin and Yao.)

Background: Compared to conventional oxygen devices, high-flow oxygen treatment (HFOT) through the nasal cannulae has demonstrated clinical benefits. Limited data exist on whether such effects are also present in HFOT through tracheostomy. Hence, we aimed to examine the short-term effects of HFOT through tracheostomy on diaphragmatic function and respiratory parameters in tracheostomized patients on prolonged mechanical ventilation., Methods: A randomized, crossover, physiological study was conducted in our ICU between December 2020 and April 2021, in patients with tracheostomy and prolonged mechanical ventilation. The patients underwent a 30-min spontaneous breathing trial (SBT) and received oxygen either via T-piece or by HFOT through tracheostomy, followed by a washout period of 15-min breathing through the T-piece and receipt of 30-min oxygen with the other modality in a randomized crossover manner. At the start and end of each session, blood gasses, breathing frequency (f), and tidal volume (V T ) via a Wright's spirometer were measured, along with diaphragm ultrasonography including diaphragm excursion and diaphragmatic thickening fraction, which expressed the inspiratory muscle effort., Results: Eleven patients were enrolled in whom 19 sessions were uneventfully completed; eight patients were studied twice on two different days with alternate sessions; and three patients were studied once. Patients were randomly assigned to start the SBT with a T-piece ( n =10 sessions) or with HFOT ( n =9 sessions). With HFOT, V T and minute ventilation (V E ) significantly increased during SBT (from [465±119] mL to [549±134] mL, P <0.001 and from [12.4±4.3] L/min to [13.1±4.2] L/min, P <0.05, respectively), but they did not change significantly during SBT with T-piece (from [495±132] mL to [461±123] mL and from [12.8±4.4] mL to [12.0±4.4] mL, respectively); f/V T decreased during HFOT (from [64±31] breaths/(min∙L) to [49±24] breaths/(min∙L), P <0.001), but it did not change significantly during SBT with T-piece (from [59±28] breaths/(min∙L) to [64±33] breaths/(min∙L)); partial pressure of arterial oxygen increased during HFOT (from [99±39] mmHg to [132±48] mmHg, P <0.001), but it decreased during SBT with T-piece (from [124±50] mmHg to [83±22] mmHg, P <0.01). In addition, with HFOT, diaphragmatic excursion increased (from [12.9±3.3] mm to [15.7±4.4] mm, P <0.001), but it did not change significantly during SBT with T-piece (from [13.4±3.3] mm to [13.6±3.3] mm). The diaphragmatic thickening fraction did not change during SBT either with T-piece or with HFOT., Conclusion: In patients with prolonged mechanical ventilation, HFOT through tracheostomy compared with T-piece improves ventilation, pattern of breathing, and oxygenation without increasing the inspiratory muscle effort., Trial Registration: Clinicaltrials.gov ldentifer: NCT04758910., (© 2023 The Authors.)

Abstract Background The extensive use of neuromuscular blocking agents (NMBAs) during surgical procedures still leads to potential residual paralyzing effects in the postoperative period. Indeed, neuromuscular monitoring in an intra-operative setting is strongly advocated. Acetylcholinesterase inhibitors can reverse muscle block, but their short half-life may lead to residual curarization in the ward, especially when intermediate or long-acting NMBAs have been administered. Sugammadex is the first selective reversal drug for steroidal NMBAs; it has been shown to give full and rapid recovery of muscle strength, thus minimizing the occurrence of residual curarization. Acceleromyography of the adductor pollicis is the gold standard for detecting residual curarization, but it cannot be carried out on conscious patients. Ultrasonography of diaphragm thickness may reveal residual effects of NMBAs in conscious patients. Methods/design This prospective, double-blind, single-center randomized controlled study will enroll patients (of American Society of Anesthesiologists physical status I–II, aged 18–80 years) who will be scheduled to undergo deep neuromuscular block with rocuronium for ear, nose, or throat surgery. The study’s primary objective will be to compare the effects of neostigmine and sugammadex on postoperative residual curarization using two different tools: diaphragm ultrasonography and acceleromyography of the adductor pollicis. Patients will be extubated when the train-of-four ratio is > 0.9. Diaphragm ultrasonography will be used to evaluate the thickening fraction, which is the difference between the end expiratory thickness and the end inspiratory thickness, normalized to the end expiratory thickness. Ultrasonography will be performed before the initiation of general anesthesia, before extubation, and 10 and 30 min after discharging patients from the operating room. The secondary objective will be to compare the incidence of postoperative complications due to residual neuromuscular block between patients who receive neostigmine and those who receive sugammadex. Discussion Postoperative residual curarization is a topic of paramount importance, because its occurrence can cause complications and increase the length of stay in hospital and the related costs. Diaphragm ultrasound assessment may become a bedside integrative tool in the neuromuscular monitoring field to detect concealed residual curarization in surgical patients who have received paralyzing agents. Trial registration EudraCT, 2013-004787-62. Registered on 18 June 2014, as “Evaluation of muscle function recovery after deep neuromuscular blockade by acceleromyography of the adductor pollicis or diaphragmatic echography: comparison between sugammadex and neostigmine.” ClinicalTrials.gov, NCT02698969. Registered on 15 February 2016, as “Recovery of Muscle Function After Deep Neuromuscular Block by Means of Diaphragm Ultrasonography and Adductor Pollicis Acceleromyography: Comparison of Neostigmine vs. Sugammadex as Reversal Drugs.”

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Introduction: Diaphragm excursion and contraction velocity measured using ultrasonography have been used to assess diaphragm function. We aimed to evaluate the performance of diaphragm ultrasonography during weaning from mechanical ventilation (MV).Methods: Diaphragm ultrasonography was performed on 73 mechanically ventilated patients who were being considered for extubation on three separate occasions: (1) on assist control mode (A/C) during consistent patient triggered ventilation, (2) following 30 min during a spontaneous breathing trial (SBT), (3) 4-24 h following extubation. Right hemidiaphragm excursion and contraction velocity were measured on A/C, during SBT, and following extubation. These measurements were correlated with the outcome of extubation.Results: Twenty patients failed extubation: 6 of whom required re-intubation and 14 of whom required non-invasive ventilatory support. During SBT, the mean diaphragm excursions were 1.7 ± 0.82 cm in the group who failed extubation compared to 2.1 ± 0.9 cm in the group who were successfully extubated (p = 0.06). To predict successful extubation, a decrease in diaphragm excursion of < 16.4% between A/C and SBT had a sensitivity of 84.9% and a specificity of 65%. The area under curve (AUC) for receiver operative characteristics for above cut-off was 0.75. Diaphragm contraction velocity performed poorly in predicting weaning outcome.Conclusions: Diaphragm excursion measured during SBT is an imperfect predictor of the outcome of extubation. Maintenance of diaphragm excursion between A/C and SBT has good performance characteristics by AUC analysis. Diaphragm contraction velocity has poor ability to predict outcome of extubation. [ABSTRACT FROM AUTHOR]

Background: The extensive use of neuromuscular blocking agents (NMBAs) during surgical procedures still leads to potential residual paralyzing effects in the postoperative period. Indeed, neuromuscular monitoring in an intra-operative setting is strongly advocated. Acetylcholinesterase inhibitors can reverse muscle block, but their short half-life may lead to residual curarization in the ward, especially when intermediate or long-acting NMBAs have been administered. Sugammadex is the first selective reversal drug for steroidal NMBAs; it has been shown to give full and rapid recovery of muscle strength, thus minimizing the occurrence of residual curarization. Acceleromyography of the adductor pollicis is the gold standard for detecting residual curarization, but it cannot be carried out on conscious patients. Ultrasonography of diaphragm thickness may reveal residual effects of NMBAs in conscious patients.Methods/design: This prospective, double-blind, single-center randomized controlled study will enroll patients (of American Society of Anesthesiologists physical status I-II, aged 18-80 years) who will be scheduled to undergo deep neuromuscular block with rocuronium for ear, nose, or throat surgery. The study's primary objective will be to compare the effects of neostigmine and sugammadex on postoperative residual curarization using two different tools: diaphragm ultrasonography and acceleromyography of the adductor pollicis. Patients will be extubated when the train-of-four ratio is > 0.9. Diaphragm ultrasonography will be used to evaluate the thickening fraction, which is the difference between the end expiratory thickness and the end inspiratory thickness, normalized to the end expiratory thickness. Ultrasonography will be performed before the initiation of general anesthesia, before extubation, and 10 and 30 min after discharging patients from the operating room. The secondary objective will be to compare the incidence of postoperative complications due to residual neuromuscular block between patients who receive neostigmine and those who receive sugammadex.Discussion: Postoperative residual curarization is a topic of paramount importance, because its occurrence can cause complications and increase the length of stay in hospital and the related costs. Diaphragm ultrasound assessment may become a bedside integrative tool in the neuromuscular monitoring field to detect concealed residual curarization in surgical patients who have received paralyzing agents.Trial Registration: EudraCT, 2013-004787-62. Registered on 18 June 2014, as "Evaluation of muscle function recovery after deep neuromuscular blockade by acceleromyography of the adductor pollicis or diaphragmatic echography: comparison between sugammadex and neostigmine." ClinicalTrials.gov, NCT02698969 . Registered on 15 February 2016, as "Recovery of Muscle Function After Deep Neuromuscular Block by Means of Diaphragm Ultrasonography and Adductor Pollicis Acceleromyography: Comparison of Neostigmine vs. Sugammadex as Reversal Drugs." [ABSTRACT FROM AUTHOR]

Introduction: The objective of this study was to compare respiratory muscle functions and strength evaluated by ultrasonography between patients who successfully weaned and those who failed to wean. Materials and Methods: This study was conducted in the Respiratory Intensive Care Unit (RICU) of a University Hospital. Between September 2021 and December 2022. Demographic data, disease severity scores and respiratory muscle functions and thickness measured by ultrasonography [diaphragm thickness (DT), diaphragm excursion (DE), diaphragm thickening fraction (DTF), expiratory abdominal muscle thickness, peak contraction velocity (PCV) and peak relaxation velocity (PRV) of diaphragm detected by tissue doppler imaging] were recorded. In addition, respiratory muscle strength, peripheral muscle strength and physical functions were evaluated by maximum inspiratory pressure (MIP) measurement, medical research council (MRC) and physical function scale for intensive care (PFIT) scores. Results: The mean age of the study population was 66.73 (min-max: 28- 88) years. Seven female and 19 male were included the study. Twenty patients (77%) were successfully weaned. The MIP (35.0 vs 14.0; p=0.02), MRC (49.4 vs 35.0; p=0.02), PFIT (4.40 vs 2.17; p=0.02), DE (4.11 vs 2.6; p=0.010) and rectus abdominus thickness (0.85 cm vs 0.53 cm; p=0.011) measurements were higher in patients with successful weaning than patients with weaning failure. As expected, duration of stay in ICU (7.45 vs 21.0; p=0.00) and in hospital (12.0 vs 21.0; p=0.01) were shorter in succesfully weaned patients. There was no significant difference between APACHE-II scores (26.9 vs 29.0; p=0.97), DT-inspiration (0.29 cm vs 0.28 cm; p=0.85), DT-expiration (0.23 cm vs 0.21 cm p=0.92), DTF (27.0% vs 30%; p=0.58), PCV (10.07 cm/sn vs 8.80 cm/sn; p=0.30), PRV (11.40 cm/ sn vs 10.11 cm/sn; p=0.60), thickness of the internal oblique (0.53 cm vs 0.43cm; p=0.27), external oblique (0.41 vs 0.37; p=0.52), transversus abdominus (0.36 cm vs 0.38 cm; p=0.33) muscles. Conclusion: Our study results show that lower diaphragm excursion, MIP, rectus abdominus muscle thickness, and physical function scores are associated with poor clinical outcome and weaning failure. We believe that ultrasonographic asessment of respiratory muscles in the RICU can provide a different perspective in the weaning process [ABSTRACT FROM AUTHOR]