Acute Crit Care.  2023 May;38(2):200-208. 10.4266/acc.2022.01060.

Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India

• Patel NB
• Jain G
• Chauhan U
• Bhadoria AS
• Chandrakar S
• Indulekha H

• KMID: 2543639
• DOI: http://doi.org/10.4266/acc.2022.01060

Abstract

Background
Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. Methods: In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI) <20% (predefined criteria [PC]) or its cut-off that predicts NIV failure (calculated criteria [CC]) at both timepoints. A predictive-regression analysis was reported. Results: In total, 32 patients developed NIV failure, nine within 2 hours of NIV and remaining in next 6 days. The ∆TDI cut-off that predicted NIV failure (DD-CC) at T1 was ≤19.04% (area under the curve [AUC], 0.73; sensitivity, 50%; specificity, 85.71%; accuracy; 66.67%), while that at T2 was ≤35.3% (AUC, 0.75; sensitivity, 95.65%; specificity, 57.14%; accuracy, 74.51%; hazard ratio, 19.55). The NIV failure rate was 35.1% in those with normal diaphragmatic function by PC (T2) versus 5.9% by CC (T2). The odds ratio for NIV failure with DD criteria ≤35.3 and <20 at T2 was 29.33 and 4.61, while that for ≤19.04 and <20 at T1 was 6, respectively. Conclusions: The DD criterion of ≤35.3 (T2) had a better diagnostic profile compared to baseline and PC in prediction of NIV failure.

Keyword

chronic obstructive pulmonary disease; diaphragmatic dysfunction; diaphragmatic thickness; intubation; non-invasive ventilation

Figure

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  Figure 1. Strengthening the reporting of observational studies in epidemiology (STROBE) flow diagram of patients studied. ICU: intensive care unit; ∆TDI: change in diaphragmatic thickness; NIV: non-invasive ventilation.

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  Figure 2. Receiver operating characteristic (ROC) curve showing the utility of diaphragmatic dysfunction in predicting non-invasive ventilation (NIV) failure at (A) T1 and (B) T2 timepoints. ∆TDI: change in diaphragmatic thickness; T1: at NIV initiation; T2: at 2 hours into NIV; AUC: area under the curve; CI: confidence interval.

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  Figure 3. Cox-proportional hazards plot showing the cumulative hazard for intubation as predicted by diaphragmatic dysfunction (DD) at 2 hours of non-invasive ventilation using (A) calculated criterion (CC) and (B) predefined criterion (PC).

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