Diaphragm ultrasound, transthyretin and phosphorus serum levels as a method to predict treatment outcomes in children requiring mechanical ventilation: a prospective, observational, cohort study
Keywords:diaphragm ultrasonography, transthyretin, phosphorus, weaning from mechanical ventilation
AbstractBackground. 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.
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