Diaphragm dysfunction induced by mechanical ventilation – pathophysiology and treatment options

Autori:

Iva Pažur, Josipa Kovačić, Ognjen Ožegić

Sažetak
Disfunkcija ošita se javlja kod 60 – 80% bolesnika koji su podvrgnuti mehaničkoj respiracijskoj potpori u jedinicama intenzivnog liječenja. Patofiziološki procesi koji dovode do disfunkcije toga najvažnijeg respiracijskog mišića započinju već nakon 24 sata mehaničke ventilacije. Disfunkcija ošita značajno doprinosi otežanom odvajanju bolesnika od ventilatora, produljenju mehaničke ventilacije, povećanju morbiditeta i mortaliteta bolesnika. Etiologija disfunkcije ošita uzrokovane mehaničkom ventilacijom (engl. ventilator induced diaphragm dysfunction – VIDD) složena je i ovisna o više čimbenika, uključuje neusklađenost disanja između bolesnika i ventilatora, višednevnu vazopresornu potporu, ali i metaboličke i upalne promjene u mišićnom tkivu kod kritično oboljelih. Uz liječenje osnovnog uzroka zatajenja disanja, temelj uspješne prevencije i liječenja VIDD-a predstavlja pravilno titriranje sedativa i mišićnih relaksansa, praćenje udjela spontane respiracijske aktivnosti, odabir proporcionalnih modaliteta ventilacije čija potpora spontanom disanju u odnosu na konvencionalne modalitete nije konstantna, već je propocionalna spontanoj respiracijskoj aktivnosti. S ciljem prikaza najnovijih spoznaja iz područja patofiziologije i liječenja VIDD-a stručnoj javnosti, elektronički su pretraživane baze podataka PubMed, Medline i Google Scholar. Naše pretraživanje je bilo ograničeno na randomizirana klinička istraživanja i na pregledne radove na engleskom jeziku koji su uključivali bolesnike starije od 18 godina, a koji su bili publicirani u razdoblju od 2016. do 2021., korištenjem rječnika MeSH (engl. medical subject headings). Zaključak: Pandemija virusa SARS-CoV2 posebno je aktualizirala tematiku mehaničke ventilacije kao „life saving“ metode liječenja koja može uzrokovati i značajne nuspojave poput disfunkcije ošita. Neprestano se razvijaju i usavršavaju nove strategije i modaliteti mehaničke ventilacije s ciljem zaštite pluća, ali i ošita. Provođenjem mehaničke ventilacije s ciljem zaštite ošita smanjuju se vrijeme trajanja mehaničke ventilacije, incidencija komplikacija poput višestrukoga organskog zatajenja te posljedično i mortalitet.
Summary

Majority of mechanically ventilated patients in intensive care units (ICU) suffer from diaphragm dysfunction. It occurs in approximately 60 to 80 % of such patients. Early after the initiation of mechanical ventilation pathophysiological processes leading to diaphragm dysfunction are triggered. Inadequate diaphragm function significantly contributes to difficult weaning, prolonged mechanical ventilation as well as increased morbidity and mortality. Etiology of ventilation induced diaphragm dysfunction (VIDD) is complex and multifactorial. Metabolic and inflammatory changes in muscular tissue are one of the hallmarks of critical illness and together with patient-ventilator asynchrony and prolonged vasopressor support play a key role in VIDD pathophysiology. Treatment of primary cause of respiratory insufficiency is of utmost importance, but besides this, adequate titration of sedatives and muscle relaxants, monitoring of respiratory mechanics and deployment of proportional modes of ventilation are of great significance in prevention and treatment of VIDD. Proportional modes offer support to spontaneous breathing. However, unlike the conventional modes, this support is not constant, it changes with every breath, offering assistance that is proportional to activity of respiratory muscles. The aim of this article was to offer an insight into latest data from scientific literature to healthcare providers. The electronic search of Pubmed, Medline and Google Scholar was conducted by using MeSH (Medical Subject Headings) terms. Our search was limited to randomized controlled trials and review articles written in English, which were published from 2016 to 2021 and conducted on adult patients. Conclusion: During the pandemic of SARS-CoV-2, the importance of mechanical ventilation with all its aspects came into the focus of medical community. Mechanical ventilation is considered as a life saving method of treatment, but serious adverse effects such as dysfunction of diaphragm can be encountered. There are ongoing developments of new strategies and modes of mechanical ventilation aiming at protection of lungs and diaphragm. Diaphragm protective mechanical ventilation reduces the duration of mechanical ventilator support, decreases the incidence of severe complications such as multiple organ failure and consequntely mortality.

Volumen: 1-2, 2022

Liječ Vjesn 2022;144:59–65

Preuzmi PDF