Diaphragm ultrasound, transthyretin and phosphorus serum levels as a method to predict treatment outcomes in children requiring mechanical ventilation: a prospective, observational, cohort study

O.V. Filyk


Background. Diaphragm dysfunction, malnutrition and hypophosphatemia worsen outcomes in patients requiring mechanical ventilation. The aim of this study was to find out whether diaphragm atrophy, severe hypophosphatemia, and low transthyretin level lead to prolonged ventilation. The study hypothesis was that the duration of mechanical ventilation, stay in the intensive care unit, and the frequency of complications in children depend on the diaphragm thickness, transthyretin, and phosphorus levels in the blood serum. Materials and methods. We examined data of 27 patients aged 1 month to 1 year, who needed invasive mechanical ventilation. In 3 children, ultrasound investigation of the diaphragm was impossible. Twenty-four patients were included in the study results analysis. Diaphragm thickness at the end of inspiration, serum levels of phosphorus and transthyretin were obtained on days 1, 3, 5 and then every five days during mechanical ventilation. The primary outcome was the duration of weaning from mechanical ventilation. Secondary outcomes were complications: reintubation, tracheostomy, prolonged ventilation, or death (we evaluated the presence of these adverse events every day from baseline, then on day 28 of hospitalization and until the patient was discharged from the hospital). For data processing, Statistical Package for the Social Sciences was applied, and the results were presented using median (interquartile range (IQR)), adjusted hazard ratio (HR), duration ratio and odds ratio (OR). Results. On day 1, 100 % of patients had severe hypophosphatemia (0.11 (0.18 to 0.06) mmol/l) and low level of transthyretin (104.7 (126.85 to 48.5) ng/ml). Serum level of phosphorus increased up to 0.68 (0.57 to 0.92) by day 5 (IQR 5–10), and the level of transthyretin was 234.75 (626.76 to 213.06) ng/ml by day 10 (IQR 5–15). Presence of hypophosphatemia was associated with prolonged patient’s stay in the intensive care unit (duration ratio 1.45, 95% confidence interval (CI) 1.15–2.25) (IQR 5–10), and a higher risk of complications (OR 1.72, 95% CI 1.15–2.52). Low level of transthyretin was associated with a lower daily probability of weaning from mechanical ventilation (adjusted HR 0.68, 95% CI 0.45–0.82, per 10% decrease). Decreased diaphragm thickness at the end of inspiration was associated with a lower daily probability of weaning from mechanical ventilation (adjusted HR 0.57, 95% CI 0.42–0.65, per 10% decrease). Conclusions. Low level of transthyretin and decreased diaphragm thickness at the end of inspiration during mechanical ventilation may affect clinical outcomes in children with acute respiratory failure.


diaphragm ultrasonography; transthyretin; phosphorus; weaning from mechanical ventilation


Moury P.H., Cuisinier A., Durand M., Bosson J.L., Chavanon O., Payen J.F. et al. Diaphragm thickening in cardiac surgery: a perioperative prospective ultrasound study. Ann. Intensive Care. 2019. 9(1). 50. doi: 10.1186/s13613-019-0521-z.

Schepens T., Dianti J. Diaphragm protection: what should we target? Curr. Opin. Crit. Care. 2019. 25:000-000. DOI: 10.1097/MCC.0000000000000683.

Tsegaye B., Mekasha A., Genet S. Serum Transthyretin Level as a Plausible Marker for Diagnosis of Child Acute Malnutrition. Biochemistry Research International. 2017. Article ID 9196538, 6 pages.

Verhulst S., Haan J., Toussaint M. Influence of Body Mass Index and Prealbumin Levels on Lung Function in Patients with Spinal Muscular Atrophy: A Pilot Study. J. Clin. Neuromuscul. Dis. 2019. 20(3). 137-138. doi: 10.1097/CND.0000000000000225.

Ahmed Nabih El Shazly, Doaa Refaey Soliman, Effat Hussien Assar, Eman Gamal Behiry, Ibrahim Abd El Naby Gad Ahmed. Phosphate disturbance in critically ill children: Incidence, associated risk factors and clinical outcomes. Annals of Medicine and Surgery. 2017. 21: 118e123.

Yuliang Zhao, Zhihai Li, Yinjun Shi, Gungke Cao, Fanying Meng, Wang Zhu, et al. Effect of hypophosphatemia on the withdra­wal of mechanical ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease. Biomedical Reports. 2016. 4. 413-416. DOI: 10.3892/br.2016.605.

Suzuki S. Hypophosphatemia in critically ill patients. J. Crit. Care. 2013. 28(4). 536.e9-19. doi: 10.1016/j.jcrc.2012.10.011.

Dres M., Jung B., Molinari N. et al. Respective contribution of intensive care unit-acquired limb muscle and severe diaphragm weakness on weaning outcome and mortality: a post hoc analysis of two cohorts. Crit. Care. 2019. 23. 370.

Ewan C. Goligher, Laurent J. Brochard, W. Darlene Reid, Eddy Fan, Olli Saarela, Arthur S. Slutsky. et al. Diaphragmatic myo­trauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. Lancet Respir. Med. 2019. 7(1). 90-98.

Robinder G. Khemani, Justin C. Hotz, Margaret J. Klein, Jeni Kwok, Caron Park, Christianne Lane, Erin Smith. et al. A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management). Contemporary Clinical Trials. Contemporary Clinical Trials. 2020. 88. 105893;

Clément Saccheri, Elise Morawiec, Julie Delemazure, Julien Mayaux, Bruno-Pierre Dubé, Thomas Similowski et al. ICU-acquired weakness, diaphragm dysfunction and long-term outcomes of critically ill patients. Ann. Intensive Care. 2020. 10. 1.

Goligher E.C., Brochard L.J., Reid W.D. et al. Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. Lancet Respir. Med. 2019. 7. 90-8. doi: 10.1016/S2213-2600(18)30366-7.

Knisely A.S., Leal S.M., Singer D.B. Abnormalities of diaphragmatic muscle in neonates with ventilated lungs. J. Pediatr. 1988. 113. 1074-7.

Філик О.В. Рівень транстиретину сироватки крові та динаміка співвідношення транстиретину до С-реактивного протеїну у дітей з гострою гіпоксемічною дихальною недостатністю: поширеність порушень та вплив на результати лікування. Медицина невідкладних станів. 2020. 1(104). 36-41.

Brotfain E., Schwartz A., Boniel A., Koyfman L., Boyko M., Kutz R. et al. Clinical outcome of critically ill patients with thrombocytopenia and hypophosphatemia in the early stage of sepsis. Anaesthesiology Intensive Therapy. 2016. 48(5). 294-299. ISSN 0209-1712 10.5603/AIT.a2016.0053.

Keller U. Nutritional Laboratory Markers in Malnutrition. J. Clin. Med. 2019. 8(6). 775. doi:10.3390/jcm8060775.

Copyright (c) 2020 EMERGENCY MEDICINE

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.


© Publishing House Zaslavsky, 1997-2020


   Seo анализ сайта