ObjectiveTo evaluate clinical outcomes of diaphragm plication for the treatment of diaphragmatic paralysis (DP) in infants after surgical correction for congenital heart diseases. MethodsClinical data of 13 infants who had DP after surgical correction for congenital heart diseases from December 2009 to December 2012 were retrospectively analyzed. There were 5 male and 8 female patients with their age of 35 days-11 months (6.6±3.2 months) and body weight of 3.5-9.6 (6.2±1.8) kg. Diaphragm plication was performed 19.08±4.29 days after open heart surgery. All the patients were not able to wean from mechanical ventilation,or were repeatedly reintubated because of severe respiratory failure after extubation. All the 13 patients received diaphragm plication for singleor double-sided DP. ResultsTwo patients had ventilator associated pneumonia (15.4%) including 1 patient with positive sputum cultures for Acinetobacter baumannii but negative blood culture. Another patient who had double-sided DP after surgical correction for tetralogy of Fallot with pulmonary atresia underwent double-sided diaphragm plication and later died of multiple organ dysfunction syndrome,whose sputum and blood cultures were both positive for Pseudomonas aeruginosa on the 11th day after double-sided diaphragm plication. Chest X-ray of all the patients showed plicated diaphragm in normal position after diaphragm plication. The average time from diaphragm plication to extubation was 5.38±3.09 days. After diaphragm plication,arterial partial pressures of oxygen (PaO2) significantly increased (90.22±8.47 mm Hg vs. 80.69±6.72 mm Hg,P<0.05) and arterial partial pressures of carbon dioxide (PaCO2) significantly decreased (39.87±6.31 mm Hg vs. 56.38±7.19 mm Hg,P<0.05). Twelve patients were followed up for 24 months after discharge. During follow-up,1 patient who received double-sided diaphragm plication had 2 episodes of pneumonia within 6 months after discharge. Respiratory function of all the other patients was normal. All the patients were in NYHA class Ⅰ-Ⅱ. ConclusionDiaphragm plication is a safe,easy and effective treatment to increase survival rate and decrease the incidence of hospital-acquired infection for infants who have DP and are unable to wean from mechanical ventilation after surgical correction for congenital heart diseases.
Objective To investigate the changes of respiratory mechanics in response to elevated respiratory central drive and their impacts on the inspiratory signals detection.Methods 10 normal volunteers were recruited for the study from the colleagues of the State Key Laboratory of Respiratory Disease. Rebreathing method was used to increase the end expiratory PCO2 ( PCO2 -ET) to the subject’s maximal tolerance in order to stimulate the increase of respiratory central drive. The changes of respiratory mechanics in response to elevated respiratory central drive and their impacts on the initiation signals of inspiration were observed.Results After re-breathing, the average maximal tolerated PCO2 -ET was ( 81. 2 ±6. 6) mm Hg. As the PCO2 -ET rising, electromyogram of diaphragmatic muscle ( RMSdi ) ,transdiaphragmatic pressure ( Pdi ) and tidal volume ( VT ) increased progressively while the time of respiratory cycle ( Ttot ) shorten gradually. As the PCO2 -ETlevel increased frombaseline [ PCO2 -ET( level-0) ] to the maximal level [ PCO2 -ET( level-4) ] , RMSdi increased from( 17. 17 ±12. 41) μV to ( 147. 99 ±161. 64) μV,Pdi and VT increased from ( 7. 5 ±1. 7) cmH2O and ( 0. 68 ±0. 27) L to ( 26. 13 ±11. 51) cm H2O and ( 2. 21 ±0. 37) L respectively, while Ttot shorten from ( 2. 91 ±0. 85) s to ( 1. 92 ±0. 39) s. These four parameters of respiratory mechanics, RMSdi, Pdi, VT and Ttot, were highly correlated linearly with PCO2 -ET ( r value was 0. 956, 0. 973,0. 956 and 0. 89 respectively, all P lt;0. 001) . At the start of inspiration, the first detectable signal was electromyogramof diaphragmatic muscle ( RMSdi) , followed by mouth pressure ( Pm)and inspiratory flow ( Flow) on time sequence. As the rising of PCO2 -ET, the time lag of Pmand Flow from RMSdi after the initiation of inspiration increased gradually. However, the time lag between Flow and Pm remained constant. Conclusions At the start of inspiration, the signal of RMSdi appears first as compared with Pm and Flow. As the rising of PCO2 -ET, the time lag of Pmand Flow fromRMSdi after the initiation of inspiration increased gradually, suggesting RMSdi is more sensitive inspiratory signal, which might be used for triggering of ventilator in order to improve the synchronization, especially in the situation of elevated respiratory central drive.
ObjectiveTo evaluate the predictive value of diaphragmatic rapid shallow breathing index (D-RSBI) for weaning outcome prediction.MethodsThis was a prospective observation study. Respiratory rate (RR) and tidal volume (Vt) were recorded at the end of spontaneous breathing trial, and both M-Mode and B-Mode ultrasonography were used to assess the right diaphragmatic displacement (DD). In parallel, outcome of the weaning attempt, length of mechanical ventilation, length of stay in intensive care unit (ICU) and mortality of ICU were recorded. According to the weaning outcome, the patients were grouped into the successful group and the failed group. The receiver operator characteristic (ROC) curve was used to assess the value of rapid shallow breathing index (RSBI, RR/Vt) and D-RSBI (RR/DD) in predicting weaning failure for ICU patients with mechanical ventilation.ResultsA total of 110 patients recruited in this study. Of them, 73 (66.4%) patients were successfully liberated from mechanical ventilation, and 37 patients failed (33.6%) weaning procedure. The RSBI and D-RSBI of the patients in the failed group were higher than those in the success weaning group (P<0.01). The area under the ROC curves of RSBI and D-RSBI for predicting weaning failure was 0.78 (95% confidence interval 0.69 - 0.87), 0.91 (95% confidence interval 0.85 - 0.97), respectively, a cutoff of RSBI>69 breaths/(L·min) yielded sensitivity of 55% and specificity of 89%, and a cutoff of D-RSBI>1.5 breaths/(min·mm) yielded sensitivity of 87% and specificity of 80%.ConclusionD-RSBI is more accurate than traditional RSBI in predicting the weaning outcome.
ObjectiveTo explore the effects of volume mechanical ventilation with different tidal on the diaphragm discharge in rats. MethodsTwenty-four SD rats were randomly divided into three groups, namely a high tidal volume group, a low tidal volume group, and a control group. The rats in the high tidal volume group and the low tidal volume group underwent volume controlled ventilation with tidal volume of 10 mL/kg and 5 mL/kg, respectively. The rats in the control group breath spontaneously after anesthetization. The EMGdi frequency, diaphragm discharge area, product of diaphragm discharge amplitude and diaphragm discharge rate (A×R) were measured every 2 hours to analyze the characteristics of diaphragm of rats under different duration of ventilation. ResultsCompared with the control group, there was no statistical difference of A×R in the high tidal volume group, but the frequency of the diaphragm discharge reduced and the discharge diaphragm area increased. When compared the low tidal volume group with the control group, only the A×R increased significantly. The transcutaneous oxygen saturation (SpO2) and end-tidal CO2 pressure (PetCO2) in the high tidal volume group decreased significantly compared to the control group while the other indexes had no difference. ConclusionsThe effects of mechanical ventilation with different tidal volume on the rat diaphragm discharge are different. The low tidal volume mechanical ventilation can excite the respiratory center and strengthen the diaphragm discharge with the stabilization of physiological index while the high tide volume inhibits diaphragm function and damages the oxygenation.
ObjectiveTo investigate the clinical features,treatment and pathogenesis of shrinking lung syndrome (SLS). MethodsA patient of systemic lupus erythematosus(SLE)with SLS as initial manifestation was reported.Literatures about SLS were comprehensively reviewed for its clinical characteristics and pathogenesis. ResultsA 27-year-old man was admitted with chief complaint of intermittent dyspnea and chest pain in 2009.Chest X-ray showed small lung volume and elevated diaphragms.Chest CT revealed bilateral pleural thickness and multiple atelectasis,without significant sign of interstitial fibrosis.Lung function showed restrictive pattern.Routine blood test revealed declined white blood cell and platelet count.C3 and C4 were declined.The autoantibody test revealed positive ANA,dsDNA,AHA,and RNP antibody.A diagnosis of SLE with SLS was made.The patient received corticosteroids and immunosuppressive therapy and was followed up for 5 years.His symptoms had relieved,but there was no obvious improvement in chest radiology and lung function.A total of 118 SLS cases were recorded in literature review,among which 100 were females and 18 were males.The average age was 32.98±14.66 years.Common clinical features of SLS included dyspnea,chest pain,orthopnea,breathlessness,and decreased breath sound.Radiology revealed small lung volume,elevated diaphragm,and dysfunction of diaphragm.Lung function showed restrictive pattern.The primary treatment of the disease was corticosteroid and immunosuppressive agents.The use of theophylline,β-agonist and rituximab was also reported. ConclusionWe should be aware of SLS in patients with SLE or other autoimmune diseases when they present with unexplained dyspnea.
Objective To study the role of ubiquitin-proteasome pathway in diaphragm of COPD rats. Mathods Thirty rats were divided into a normal control group and a COPD group. COPD model was established by exposure to cigarette smoke for three months. The protein levels of E2-14k and proteasome subunit C8 in diaphragms were measured by Western blot. The mRNA levels of ubiquitin and proteasome subunit C2 in diaphragms were measured bymeans of realtime polymerase chain reaction( RT-PCR) . Results Compared with the control group, the protein expression of E2-14k increased significantly in the COPD group ( 0. 81 ±0. 28 vs 0. 50 ±0. 25, P lt;0. 05) , but C8 protein level was not significantly different between the two groups( P gt;0. 05) . The mRNA expression of ubiquitin increased significantly in the COPD group( 0. 89 ±0. 20 vs 0. 50 ±0. 15, P lt;0. 05) , but C2 mRNA level was not significantly different between the two groups ( P gt; 0. 05 ) . Conclusions The mRNA and protein expressions of ubiquitin-proteasome pathway in diaphragmincreased significantly in COPD rats, suggesting that the activity of ubiquitin-proteasome pathwayincreased, which lead to an increase of protein degradation.
Objective To investigate the protective effects of recombinant human insulin-like growth factor-1 ( rhIGF-1) on apoptosis of diaphragm in rats with COPD and its impact on pulmonary function. Methods Forty-five male Wistar rats were randomly divided into three groups, ie. a normal control group, a model group, and an IGF-1 intervention group, with 15 rats in each group. The rats in the model group and IGF-1 group were exposed to 5% smoke ( 30 min perday, lasting 28 days) in a sealed box, and 200 μg lipopolysaccharide was injected intratracheally on the 1st and 14th day. The rats in the IGF-1 group were given rhIGF-1 ( 60 μg /100 g) additionally by subcutaneous injection once a day, lasting 28 days. On the 1st, 14th, 28th day, 5 rats from each group were sacrificed. The weight, rate of apoptosis, Fas gene and Fas protein expression of isolated diaphragms were detected. The pulmonary function was measured on the 28th day before sacrificed. Results The mass of diaphragms, minute ventilation ( VE) , peak expiratory flow ( PEF) , inspiratory capacity ( IC) , forced expiratory volume in 0. 3 second ( FEV0. 3) of themodel groupand IGF-1 group were all decreased compared with the control group ( P lt; 0. 05) . The mass of diaphragms, VE, IC of the IGF-1 group were higher than those of the model group ( P lt;0. 05) , and the differences of PEF and FEV0. 3 were not significant ( P gt; 0. 05) . On the 14th, 28th day, rate of apoptosis, Fas gene and protein expressions in the IGF-1 group were lower than those in the model group, and still higher than those in the control group ( P lt; 0. 05) . Conclusions Fas/FasL mediated apoptosis way is involved in the diaphragm apoptosis. rhIGF-1 may reduce the apoptosis of the diaphragmand improve the VE and IC of rats with COPD by intervening Fas/FasL pathway.
ObjectiveTo monitor the diaphragm function of mechanical ventilated patients in the intensive care unit. MethodsA prospective study was conducted on mechanical ventilation patients who had been evaluated by ventilation weaning screening test and planning to underwent spontaneous breathing trial between May 2013 and November 2013. A newly designed multi-function esophageal electrode was used to record the phrenic nerve conduction time (PNCT),diaphragm compound muscle action potential (CMAP) and twitch transdiaphragmatic pressure (TwPdi) elicited by bilateral anterolateral magnetic phrenic nerve stimulation. Results14 patients were recruited in this study. 1 case exited because of intolerance of repetitive magnetic stimulation,2 cases had no diaphragmatic electromyographic signals nor twitch signals,1 case had diaphragmatic electromyographic signal but could not be elicited by magnetic stimulation,1 case had no available TwPdi value with PNCT of 7.2 ms and CMAP of 1.26 mV. In the rest 9 cases,the PNCT,CMAP and TwPdi were (8.5±1.5)ms,(1.01±0.35)mV,(11.2±4.7)cm H2O,respectively. ConclusionNewly designed multi-function esophageal electrode catheter combined with bilateral anterolateral magnetic phrenic nerve stimulation can be used for non-volitional comprehensive assessment of diaphragm in critically ill patients,but not suitable for all subjects.
ObjectiveTo explore the technical feasibility, safety, and short- and long-term efficacy of totally portal minimally invasive thoracoscopic diaphragmatic folding assisted by a stapler for the treatment of symptomatic diaphragmatic eventration in adults. MethodsAretrospective study was conducted on patients with symptomatic diaphragmatic eventration who underwent totally portal minimally invasive thoracoscopic stapler-assisted diaphragmatic folding from August 2021 to February 2025. Surgical time, intraoperative blood loss, postoperative drainage volume, length of hospital stay, and complications were recorded. One month postoperatively, diaphragmatic position, lung function [forced expiratory volume in one second (FEV1), forced vital capacity (FVC) ], and symptom relief were assessed, with extended follow-up to 36 months to monitor long-term efficacy. ResultsA total of 7 patients were included, comprising 3 (42.9%) males and 4 (57.1%) females, with an age range of 34 to 66 years and a mean age of (56.4±12.5) years. All surgeries were successfully completed without conversion to open thoracotomy or intraoperative complications. The average surgical time was (44.29±11.47) minutes, intraoperative blood loss was (25.71±33.09) mL, and the postoperative length of stay was (2.00±0.58) days. One-month follow-up showed that the diaphragmatic position returned to normal anatomical levels, FEV1 improved from preoperative (1.93±0.33) L to (2.36±0.47) L, and the effective rate of clinical symptom relief reached 100.0%. Long-term follow-up (36 months) showed: (1) Pain scores decreased from (1.14±0.38) points at one month postoperatively to (0.14±0.38) points at three months postoperatively, remaining at 0 points at six months and thereafter; (2) All patients had stable diaphragmatic positions with no recurrence; (3) FEV1/FVC was ≥80% at three months postoperatively, with three assessable patients at six months maintaining ≥80%; (4) SpO2 remained ≥95% throughout, with no hypoxic events. ConclusionTotally portal minimally invasive thoracoscopic stapler-assisted diaphragmatic folding is a minimally invasive procedure with rapid recovery, significantly improving lung function and stabilizing diaphragmatic anatomical position. Follow-up at 36 months showed complete pain relief, no recurrence, and long-term stability of lung function, making it a safe and effective surgical option for treating symptomatic diaphragmatic eventration in adults. Long-term efficacy still requires validation with a larger sample size.
ObjectiveTo investigate the relationship of diaphragmatic mobility (ΔM) evaluated by ultrasonography with quality of life and athletic ability in patients with chronic obstructive pulmonary disease (COPD) , and analyze the factors those affect the diaphragmatic mobility.MethodsA total of 48 male patients with stable COPD were recruited in the study. The body height, body weight, diaphragmatic mobility, airflow obstruction (FEV1%pred), and exercise capacity (6MWD) were measured. The quality of life was assessed using the St. George’s Respiratory Questionnaire (SGRQ).ResultsThe minimum value of ΔM was 1.89 cm and the maximal value was 8.11 cm in the COPD patients. There were significant correlationship between ΔM and the SGRQ score of the total score, symptom score, impact points, activity points and 6MWD, with correlation coefficients of –0.474, –0.416, –0.432, –0.502 and 0.536, respectively. Multivariate stepwise regression analysis showed that the factors influencing ΔM were height (β=0.407, P=0.021) and FEV1%pred (β=–0.391, P=0.035).ConclusionsDiaphragmatic mobility and quality of life are closely related in COPD patients. The height and FEV1%pred have the greatest effect on diaphragmatic activity. The smaller diaphragm mobility is relevant to the worse quality of life and the smaller activity capacity.