Diaphragm Dysfunction, Respiratory Failure, ICU, Weaning Invasive Mechanical Ventilation
Conditions
Keywords
Diaphragm, Weaning, Invasive Mechanical Ventilation, Diaphragm Hibernation
Brief summary
Rationale: Patients with invasive mechanical ventilation (IMV) frequently develop diaphragm dysfunction and experience difficult weaning. Recent ex vivo work suggests that a subset of mechanically ventilated ICU patients may exhibit diaphragm hibernation, an energy conserving myosin state that reduces force generation and may lead to a reversible increase in diaphragm strength over time. However, it is unknown whether diaphragm hibernation can be demonstrated in vivo during IMV and which clinical and biological factors are associated with this phenotype. Objective: Primary objective is to determine the driving factors (biomarkers) of diaphragm hibernation during IMV. Secondary objectives are to determine the proportion of ventilated critically ill patients who exhibit diaphragm hibernation during IMV, to investigate inflammatory and metabolic factors and other clinical exposures associated with diaphragm hibernation, and to explore associations between diaphragm hibernation and weaning related and survival outcomes. Study design: Prospective, observational, longitudinal cohort study. Study population: Adult ICU patients receiving IMV, expected to remain mechanically ventilated for at least 72 hours. Intervention (if applicable): Not applicable. This is an observational study. Study specific procedures consist of repeated phrenic nerve magnetic stimulation and additional blood sampling. Main study parameters/endpoints: The primary study parameter is the proportion of participants exhibiting diaphragm hibernation during IMV. Diaphragm hibernation is defined as an increase in stimulated twitch tracheal pressure (Ptr,stim), a measure of diaphragm strength, of at least 10% relative to baseline (Day 0-1) at any follow up assessment (Day 2, 3, 5, or 7) obtained before extubation or death. Ptr,stim will be assessed repeatedly on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Participant burden is limited and mainly consists of repeated phrenic nerve magnetic stimulation during a ventilator delivered end expiratory occlusion and additional blood sampling of 9.5 mL per time point, up to a total of 47.5 mL across the study period. Magnetic stimulation is non-invasive and expected discomfort is transient. Rare transient physiological changes may occur and measurements are performed under continuous ICU monitoring and will be postponed or omitted if considered unsafe or interfering with clinical care. Direct benefit for participants is limited, but the study may provide clinically relevant knowledge on diaphragm hibernation and its driving factors. The research questions are specific to diaphragm physiology during IMV in critically ill patients, therefore the study is group related and cannot be performed in a different population.
Interventions
None listed
Sponsors
Radboud University Medical Center
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Age ≥ 18 years. * Receiving invasive mechanical ventilation at screening. * Expected to remain mechanically ventilated for ≥ 72 hours from enrolment. * The first study assessment can be performed within 36 hours after initiation of invasive mechanical ventilation.
Exclusion criteria
* Pre-existing neuromuscular disease affecting the diaphragm (e.g. motor neuron disease, myasthenia gravis, advanced muscular dystrophy, high cervical spinal cord injury) or use of neuromuscular blocker. * Known phrenic nerve palsy or prior diaphragmatic paralysis. * Long-term home mechanical ventilation (invasive or non-invasive) prior to ICU admission. * Post-operative patients after planned diaphragm or phrenic nerve surgery. * Contraindications to phrenic nerve magnetic stimulation (e.g., unstable cervical spine injury, uncontrolled intracranial hypertension, metallic implants in stimulation area as per manufacturer guidance). * Pregnancy. * Participation in another interventional trial that explicitly prohibits co-enrolment or is expected to substantially influence diaphragm function (e.g. experimental neuromuscular blocking strategies), as decided by the principal investigator.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Blood C reactive protein level | C reactive protein will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | C reactive protein will be assessed by blood sample. |
| Blood procalcitonin level | Procalcitonin will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | Procalcitonin will be assessed by blood sample. |
| Blood metabolic biomarkers level | Metabolic biomarkers will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | Metabolic biomarkers will be assessed by blood sample using OLINK Target 96 panel. |
| Blood TNF-α level | TNF-α will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | TNF-α will be assessed by blood sample. |
| Blood IL-10 level | IL-10 will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | IL-10 will be assessed by blood sample. |
| Blood IL-8 level | IL-8 will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | IL-8 will be assessed by blood sample. |
| Blood IL-6 level | IL-6 will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | IL-6 will be assessed by blood sample. |
| Blood ferritin level | Ferritin will be assessed on Day 0-1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | Ferritin will be assessed by blood sample. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of participants exhibiting diaphragm hibernation during invasive mechanical ventilation | Ptr,stim will be assessed repeatedly on Day 0 to 1, Day 2, Day 3, Day 5, and Day 7, or until extubation or death, whichever occurs first. | Diaphragm hibernation is defined as an increase in stimulated twitch tracheal pressure (Ptr,stim), a measure of diaphragm strength, of at least 10% relative to baseline (Day 0 to 1) at any follow up assessment (Day 2, 3, 5, or 7) obtained before extubation or death. |
| Number of days from intubation to successful extubation | Collected from study inclusion until Day 28, or ICU/hospital discharge or death, whichever occurs first | Data about number of days from intubation to successful extubation will be retrieved from electronic medical records. |
| Number of days from first SBT to successful extubation | Collected from study inclusion until Day 28, or ICU/hospital discharge or death, whichever occurs first | Data about number of days from first SBT to successful extubation will be retrieved from electronic medical records. |
| Incidence of weaning failure | Collected from study inclusion until Day 28, or ICU/hospital discharge or death, whichever occurs first | Weaning failure is defined as SBT failure or reintubation within 48 hours. Data will be retrieved from electronic medical records. |
| ICU length of stay | Collected from study inclusion until Day 28, or ICU discharge or death, whichever occurs first | Data about ICU length of stay will be retrieved from electronic medical records. |
| Hospital length of stay | Collected from study inclusion until Day 28, or hospital discharge or death, whichever occurs first | Data about hospital length of stay will be retrieved from electronic medical records. |
| ICU mortality | Collected from study inclusion until Day 28, or ICU discharge or death, whichever occurs first | Data about ICU mortality will be retrieved from electronic medical records. |
| Hospital mortality | Collected from study inclusion until Day 28, or hospital discharge or death, whichever occurs first | Data about hospital mortality will be retrieved from electronic medical records. |
| Day 28 all-cause mortality | Collected from study inclusion until Day 28 or death, whichever occurs first | Data about day 28 all-cause mortality will be retrieved from electronic medical records. |
| ICU-free days through day 28 | Collected from ICU discharge until Day 28 or death, whichever occurs first | Data about ICU-free days through day 28 will be retrieved from electronic medical records. |
| Hospital-free days through day 28 | Collected from hospital discharge until Day 28 or death, whichever occurs first | Data about hospital-free days through day 28 will be retrieved from electronic medical records. |
| Time to ICU discharge alive through day 28 | Collected from study inclusion until Day 28, or ICU discharge or death, whichever occurs first | Data about time to ICU discharge alive through day 28 will be retrieved from electronic medical records. |
| Time to hospital discharge alive through day 28 | Collected from study inclusion until Day 28, or hospital discharge or death, whichever occurs first | Data about time to hospital discharge alive through day 28 will be retrieved from electronic medical records. |
Countries
Netherlands
Contacts
CONTACTJinyu Zhou, M.sc.
PRINCIPAL_INVESTIGATORJonne Doorduin, PhD
Radboud University Medical Centre (Radboudumc)
STUDY_CHAIRLeo Heunks, M.D., PhD
Radboud University Medical Centre (Radboudumc)
Outcome results
None listed