Progressive Diaphragm Atrophy in Pediatric Acute Respiratory Failure

Objectives : Diaphragm atrophy is associated with delayed weaning from mechanical ventilation and increased mortality in critically ill adults. We sought to test for the presence of diaphragm atrophy in children with acute respiratory failure. Design: Prospective, observational study. Setting: Single-center tertiary noncardiac PICU in a children’s hospital. Patients: Invasively ventilated children with acute respiratory failure. Measurements and Main Results: Diaphragm thickness at end-expiration and end-inspiration were serially measured by ultrasound in 56 patients (median age, 17 mo; interquartile range, 5.5–52), first within 36 hours of intubation and last preceding extubation. The median duration of mechanical ventilation was 140 hours (interquartile range, 83–201). At initial measurement, thickness at end-expiration was 2.0 mm (interquartile range, 1.8–2.5) and thickness at end-inspiration was 2.5 mm (interquartile range, 2–2.8). The change in thickness at end-expiration during mechanical ventilation between first and last measurement was –13.8% (interquartile range, –27.4% to 0%), with a –3.4% daily atrophy rate (interquartile range, –5.6 to 0%). Thickening fraction = ([thickness at end-inspiration – thickness at end-expiration]/thickness at end-inspiration) throughout the course of mechanical ventilation was linearly correlated with spontaneous breathing fraction (beta coefficient, 9.4; 95% CI, 4.2–14.7; p = 0.001). For children with a period of spontaneous breathing fraction less than 0.5 during mechanical ventilation, those with exposure to a continuous neuromuscular blockade infusion (n = 15) had a significantly larger decrease in thickness at end-expiration compared with children with low spontaneous breathing fraction who were not exposed to a neuromuscular blockade infusion (n = 18) (–16.4%, [interquartile range, –28.4% to –7.0%] vs –7.3%; [interquartile range, –10.9% to –0%]; p = 0.036). Conclusions: Diaphragm atrophy is present in children on mechanical ventilation for acute respiratory failure. Diaphragm contractility, measured as thickening fraction, is strongly correlated with spontaneous breathing fraction. The combination of exposure to neuromuscular blockade infusion with low overall spontaneous breathing fraction is associated with a greater degree of atrophy. This work was performed at the Children’s Hospital of Philadelphia, Philadelphia, PA. Supported, in part, by Endowed Chair, Critical Care Medicine, Children’s Hospital of Philadelphia. Drs. Glau, Conlon, and Himebauch received honoraria and travel reimbursement from Society of Critical Care Medicine (SCCM). Dr. Yehya’s institution received funding from National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute, and he received support for article research from the NIH. Dr. Weiss’s institution received funding from National Institute of General Medical Sciences K23GM110496, and he received funding from ThermoFisher Scientific (honorarium for lecture), Medscape (honorarium via unrestricted grant from Roche), and Bristol-Meyers Squibb Company (advisory board member). Dr. Nishisaki received funding from SCCM Critical Care Ultrasound Course-Pediatric and Neonatal (honorarium and travel expense). Dr. Berg has disclosed that he does not have any potential conflicts of interest. For information regarding this article, E-mail: glauc@email.chop.edu ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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