Functional state of the diaphragm in patients with cervical spinal cord injury at the stages of respiratory support

Objective. To analyze the role of the functional state of the diaphragm in patients with cervical spinal cord injury at the stages of respiratory support and to substantiate additional criteria for their readiness to transfer to spontaneous breathing.

Material and Methods. The state of the diaphragm was assessed by ultrasound in 24 patients with spinal cord injury. The excursion of the diaphragm during quiet breathing, the excursion and thickness of the diaphragm during forced breathing, and the change in forced expiratory volume from the moment of admission till the end of mechanical ventilation were analyzed.

Results. On the first day, on the background of mechanical ventilation, there was a significant decrease in the excursion and thickness of the diaphragm during forced breathing (p = 0.002; p = 0.008) which persisted up to 3 days (p < 0.001; p < 0.001); by the fifth day of mechanical ventilation, the indicators increased to the initial levels (p = 0.112; p = 0.433); and by the 10th day they exceeded the initial values (p < 0.001). When comparing the excursion and thickness of the diaphragm during the transfer of patients to spontaneous breathing with the data on their admission, a significant difference was obtained (p < 0.001; p < 0.001). The dynamics of forced expiratory volume indicators was similar to those of diaphragm excursion during forced breathing.

Conclusion. A peculiarity of the functional state of the diaphragm in patients with cervical spinal cord injury in the acute period was a significant decrease in diaphragm excursion and the development of ventilator-induced diaphragm dysfunction (VIDD) associated with mechanical ventilation in replacement modes. The tactics of early tracheostomy and the use of auxiliary ventilation modes determined the absence of progression of VIDD during prolonged mechanical ventilation. The presence of a strong correlation between the diaphragm excursion during forced breathing and the forced expiratory volume allows concluding that these indicators can be additional objective criteria for the  readiness of patients with cervical SC injury to transfer to spontaneous breathing, since they reflect not only the functional state of the diaphragm, but also the state of the lung tissue.

1. Berney S, Bragge P, Granger C, Opdam H, Denehy L. The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury: a systematic review. Spinal Cord. 2011;49:17–29. DOI: 10.1038/sc.2010.39.

2. Schreiber AF, Garlasco J, Vieira F, Lau YH, Stavi D, Lightfoot D, Rigamonti A, Burns K, Friedrich JO, Singh JM, Brochard LJ. Separation from mechanical ventilation and survival after spinal cord injury: a systematic review and meta-analysis. Ann Intensive Care. 2021;11:149. DOI: 10.1186/s13613-021-00938-x.

3. Berlowitz DJ, Wadsworth B, Ross J. Respiratory problems and management in people with spinal cord injury. Breathe (Sheff). 2016;12:328–340. DOI: 10.1183/20734735.012616.

4. Стаценко И.А., Лебедева М.Н., Первухин С.А., Пальмаш А.В., Рерих В.В., Самохин А.Г., Волков С.Г. Особенности течения осложненной травмы шейного отдела позвоночника в зависимости от срочности выполнения декомпрессии спинного мозга // Современные проблемы науки и образования. 2018. № 6. URL: https://science-education.ru/ru/article/view?id=28193. [Statsenko IA, Lebedeva MN, Pervukhin SA, Palmash AV, Rerikh VV, Samokhin AG, Volkov SG. The peculiarities of clinical course of complicated cervical spine injury depending on the urgency of spinal cord decompression. Modern problems of science and education. 2018;(6). URL: https://science-education.ru/ru/article/view?id=28193].

5. Wilson M, Nickels M, Wadsworth B, Kruger P, Semciw A. Acute cervical spinal cord injury and extubation failure: A systematic review and meta-analysis. Aust Crit Care. 2020;33:97–105. DOI: 10.1016/j.aucc.2019.01.007.

6. Esteban A, Anzueto A, Frutos F, Alia I, Brochard L, Stewart TE, Benito S, Epstein SK, Apezteguia C, Nightingale P, Arroliga AC, Tobin MJ. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002;287:345–355. DOI: 10.1001/jama.287.3.345.

7. Неклюдова Г.В., Авдеев С.Н. Возможности ультразвукового исследования диафрагмы // Терапевтический архив. 2019. Т. 91. № 3. C. 86–92. [Neklyudova GV, Avdeev SN. Possibilities of ultrasound research of the diaphragm. Therapeutic Archive. 2019;91(3):86–92]. DOI: 10.26442/00403660.2019.03.000129.

8. Li C, Li X, Han H, Cui H, Wang G, Wang Z. Diaphragmatic ultrasonography for predicting ventilator weaning: A meta-analysis. Medicine (Baltimore). 2018;97:e10968. DOI: 10.1097/MD.0000000000010968.

9. Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34:535–546. DOI: 10.1179/204577211X13207446293695.

10. Chang JE, Park SH, Do SH, Song IA. Successful weaning from mechanical ventilation in the quadriplegia patient with C2 spinal cord injury undergoing C2-4 spine laminoplasty – A case report. Korean J Anesthesiol. 2013;64:545–549. DOI: 10.4097/kjae.2013.64.6.545.

11. Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM. Diaphragm muscle thinning in patients who are mechanically ventilated. Chest. 2012;142:1455–1460. DOI: 10.1378/chest.11-1638.

12. Schepens T, Verbrugghe W, Dams K, Corthouts B, Parizel PM, Jorens PG. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. Crit Care. 2015;19:422. DOI: 10.1186/s13054-015-1141-0.

13. Zambon M, Beccaria P, Matsuno J, Gemma M, Frati E, Colombo S, Cabrini L, Landoni G, Zangrillo A. Mechanical ventilation and diaphragmatic atrophy in critically ill patients: an ultrasound study. Crit Care Med. 2016;44:1347–1352. DOI: 10.1097/CCM.0000000000001657.

14. Бабаев М.А., Быков Д.Б., Бирг Т.М., Выжигина М.А., Еременко А.А. ИВЛ-индуцированная дисфункция диафрагмы (обзор) // Общая реаниматология. 2018;14(3):82–103. [Babaev MA, Bykov DB, Birg ТM, Vyzhigina MА, Eremenko AA. Ventilator-induced diaphragm dysfunction (review). General Reanimatology.2018;14(3):82–103]. DOI: 10.15360/1813-9779-2018-3-82-103.

15. Boussuges A, Rives S, Finance J, Bregeon F. Assessment of diaphragmatic function by ultrasonography: Current approach and perspectives. World J Clin Cases. 2020;8:2408–2424. DOI: 10.12998/wjcc.v8.i12.2408.

16. Malas FU, Koseoglu F, Kara M, Ece H, Aytekin M, Ozturk GT, Ozcakar L, Ulasll AM. Diaphragm ultrasonography and pulmonary function tests in patients with spinal cord injury. Spinal Cord. 2019;57:679–683. DOI: 10.1038/s41393-019-0275-3.

17. Zhu Z, Li J, Yang D, Gao F, Du L, Yang M. Ultrasonographic evaluation of diaphragm thickness and excursion in patients with cervical spinal cord injury. J Spinal Cord Med. 2021;44:742–747. DOI: 10.1080/10790268.2019.1669955.