Diaphragm Dysfunction in Children with Acute Respiratory Failure
Introduction. Acute respiratory failure is accompanied by excessive work of breathing muscles. During the decompensation of acute respiratory failure, a patient will have the violation of the delivery of oxygen and elimination of carbon dioxide. The main causes of respiratory failure can be lung damage with worsening transport of gases through the alveolar-capillary membrane and the violations of various parts of the nervous system with impaired regulation of respiration. One of the main respiratory muscles, performing over 50 % work of the respiratory system, is the diaphragm. Therefore, the detection of diaphragm dysfunction is a necessary component of diagnostics that helps modify the treatment of patients with respiratory failure. Materials and methods. In our study we included 8 patients with respiratory failure (study group) and 10 patients, who had no respiratory failure (control group). We performed the ultrasound examination of the diaphragm during mechanical ventilation in the modes PCV, P-SIMV and during spontaneous breathing 2 hours late after weaning from mechanical ventilation in study group patients and during spontaneous breathing in control group. We studied such parameters as the thickness of the right and left hemidiaphragm, a fraction of thickness, range of diaphragm motion during breathing and the presence of desynchronization during mechanical ventilation. Results. Patients of both groups did not differ significantly by the age, but the average weight of patients in the study group was significantly lower than in the control group. In 75 % of patients in the study group, we identified body weight deficit from 10 to 30 %. We found that in patients of the study group thickness of the right hemidiaphragm during inspiration in all modes of mechanical ventilation was significantly less compared to the same parameter in the control group patients and were 4.60 ± 0.15 mm during PCV mode; 4.40 ± 0.11 mm during P-SIMV mode, 4.50 ± 0.06 mm during spontaneous breathing and 5.90 ± 0.21 mm in the control group patients. The thickness of the left hemidiaphragm during inspiration in patients of the study group was greater at all stages of mechanical ventilation compared with the control group of patients and was 5.10 ± 0.17 mm during PCV mode, decreased to 4.00 ± 0.12 mm during P-SIMV mode and was 4.00 ± 0.12 mm during spontaneous breathing and 3.40 ± 0.04 mm in the control group patients. Thickness fraction of right hemidiaphragm in patients of the study group was significantly lower compared with this indicator in the control group of patients and was 0.25 ± 0.04 during the mechanical ventilation in PCV mode, 0.29 ± 0.02 in P-SIMV mode and 0.38 ± 0.05 during spontaneous breathing versus 0.50 ± 0.08 in control group. Thickness fraction of left hemidiaphragm in patients of the study group had no significant differences in comparison to the control group of patients, but this index showed a better contractility of the left hemidiaphragm compared with right hemidiaphragm during the mechanical ventilation in PCV and P-SIMV modes in study group patients. The frequency of desynchronization between the patient and the machine of mechanical ventilation was highest during the mechanical ventilation in PCV mode and in the most cases it can be reduced with the correction of inspiratory time or the ratio between inspiration and expiration under ultrasound control. This method gives us the opportunity to avoid excessive sedation of patients and makes possible daily assessment for the beginning of the weaning from mechanical ventilation. Conclusions. In children with respiratory failure, there are the dysfunction of the right hemidiaphragm and relaxation dysfunction of the left hemidiaphragm without violating its contractile ability. We suggest using techniques that monitor diaphragm muscle function to confirm a physiologically acceptable level of diaphragm contractility and allow the clinician to optimize ventilator settings in order to improve patient-ventilator interaction.
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