Value of combined diaphragm and intercostal muscle ultrasonography in guiding weaning assessment in mechanically ventilated patients with sepsis

doi:10.3969/j.issn.1674-8115.2025.02.007

Abstract

Abstract:

Objective ·To explore the value of combined diaphragm and intercostal muscle ultrasound assessment compared with conventional diaphragm ultrasound in predicting the weaning outcome in mechanically ventilated patients with sepsis. Methods ·Mechanically ventilated patients with sepsis, consecutively admitted to the Department of Critical Care Medicine of Affiliated Hospital of Nantong University from October 2022 to December 2023, were selected. During the peri-weaning period, after the patient's sepsis condition improved and the patient passed the spontaneous breathing trial (SBT), ultrasound evaluation of respiratory muscles was performed by ultrasound qualified personnel with ultrasound qualification and experience in bedside ultrasound examination. Diaphragm excursion (DE), thickening fraction of diaphragm (TFD), and thickening fraction of intercostal muscle (TFic) were measured, respectively. The patients were divided into a successful weaning group (n=114) and a failed weaning group (n=24) according to the weaning results. Receiver operating characteristic (ROC) curves were used to analyze the value of diaphragm ultrasound and intercostal muscle ultrasound, alone and in combination, in predicting ventilator weaning outcome. Results ·TFic and TFic/TFD were significantly higher in the failed weaning group during SBT than in the successful weaning group (all P<0.05). The areas under the ROC curve (AUROC) of DE, TFD, and TFic to predict weaning failure in mechanically ventilated patients with sepsis during the period of SBT were 0.689 (0.591‒0.776), 0.657 (0.557‒0.747), and 0.769 (0.676‒0.846), respectively, whereas the combined indexes TFic/TFD and TFic&TFD_mix had AUROCs of 0.867 (0.786‒0.925) and 0.860 (0.778‒0.920), respectively. TFic/TFD with a cutoff value of >0.95 had a sensitivity of 86.7% and a specificity of 75.3% in predicting weaning failure, and TFic&TFD_mix with a cutoff value of >0.13 had a sensitivity of 86.6% and a specificity of 80.9% in predicting weaning failure. Moreover, the intercostal muscle ultrasonography method had an intra-observer intraclass correlation coefficient (ICC) of 0.890 and an extra-observer ICC of 0.876 for measurement reliability, which were both rated as good (P<0.001). Conclusion ·Combined diaphragm and intercostal muscle ultrasonography provides a more comprehensive picture of the patient's overall respiratory muscles, and has a higher guiding value in predicting the weaning outcomes in mechanically ventilated patients with sepsis than diaphragm ultrasound alone.

Key words: diaphragm ultrasound, intercostal muscle ultrasound, sepsis, mechanical ventilation, weaning assessment

CLC Number:

R445.1

SHEN Haoliang, YUAN Kaihao, YU Lei, YANG Nana, WANG Yiping, ZHAO Hongsheng, GUO Fengmei, SUN Chenliang. Value of combined diaphragm and intercostal muscle ultrasonography in guiding weaning assessment in mechanically ventilated patients with sepsis[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(2): 186-193.

Figures/Tables 7

TrendMD

References 33

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Item	Successful weaning group (n=114)	Failed weaning group (n=24)	χ²/t/Z value	P value
Age/year	73.6±12.7	75.3±6.4	-0.967	0.337
Sex/n(%)			2.421	0.120
Male	61 (53.5)	17 (70.8)
Female	53 (46.5)	7 (29.2)
BMI/(kg·m^-2)	22.6±2.3	23.2±1.4	-1.648	0.105
APACHEⅡ	16.4±4.9	17.3±2.2	-1.517	0.133
SOFA	6.9±2.4	8.0±1.6	-2.039	0.043
Sepsis source/n(%)
Respiratory system	32 (28.1)	5 (20.8)	0.529	0.467
Digestive system	36 (31.6)	10 (41.7)	0.908	0.341
Urinary system	29 (25.4)	7 (29.2)	0.143	0.705
Others	17 (14.9)	2 (8.3)	‒	0.527
Patient source/n(%)			0.164	0.686
Post-operation	71 (62.3)	16 (66.7)
General medicine	43 (37.7)	8 (33.3)
Causes of mechanical ventilation/n(%)			0.095	0.758
Intrapulmonary factors	39 (34.2)	9 (37.5)
Extrapulmonary factors	75 (65.8)	15 (62.5)
Mechanical ventilation time/h	47 (29‒93)	180 (103‒210)	-5.694	<0.001
Length of ICU stay/d	5 (4‒8)	21 (14‒33)	-6.730	<0.001
Total length of stay/d	17 (12‒22)	31 (22‒42)	-4.536	<0.001
28-day mortality/n(%)	15 (13.2)	7 (29.2)	‒	0.066

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	χ²/t/Z value	P value
Age/year	73.6±12.7	75.3±6.4	-0.967	0.337
Sex/n(%)			2.421	0.120
Male	61 (53.5)	17 (70.8)
Female	53 (46.5)	7 (29.2)
BMI/(kg·m^-2)	22.6±2.3	23.2±1.4	-1.648	0.105
APACHEⅡ	16.4±4.9	17.3±2.2	-1.517	0.133
SOFA	6.9±2.4	8.0±1.6	-2.039	0.043
Sepsis source/n(%)
Respiratory system	32 (28.1)	5 (20.8)	0.529	0.467
Digestive system	36 (31.6)	10 (41.7)	0.908	0.341
Urinary system	29 (25.4)	7 (29.2)	0.143	0.705
Others	17 (14.9)	2 (8.3)	‒	0.527
Patient source/n(%)			0.164	0.686
Post-operation	71 (62.3)	16 (66.7)
General medicine	43 (37.7)	8 (33.3)
Causes of mechanical ventilation/n(%)			0.095	0.758
Intrapulmonary factors	39 (34.2)	9 (37.5)
Extrapulmonary factors	75 (65.8)	15 (62.5)
Mechanical ventilation time/h	47 (29‒93)	180 (103‒210)	-5.694	<0.001
Length of ICU stay/d	5 (4‒8)	21 (14‒33)	-6.730	<0.001
Total length of stay/d	17 (12‒22)	31 (22‒42)	-4.536	<0.001
28-day mortality/n(%)	15 (13.2)	7 (29.2)	‒	0.066

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	t/Z value	P value
Body temperature/℃	37.0±0.7	36.8±0.6	1.025	0.311
Heart rate/(beat·min^-1)	90.8±15.0	94.5±13.6	-1.129	0.261
Mean arterial pressure/mmHg	86.3±11.5	91.2±11.9	-1.904	0.059
Respiratory rate/(times·min^-1)	16.2±4.6	17.2±3.6	-0.965	0.336
Voluntary tidal volume/mL	440 (377‒474)	398 (341‒457)	-1.697	0.090
Rapid shallow breathing index/(times·L^-1·min^-1)	37.0 (28‒45)	40.0 (32‒54)	-1.706	0.088
Albumin/(g·L^-1)	27.3 (23.8‒31.0)	28.1 (23.3‒32.6)	-0.360	0.719
Pre-albumin/(mg·L^-1)	289.3±47.9	275.7±50.3	1.249	0.214
White blood cell/(×10⁹·L^-1)	16.0 (13.8‒18.1)	16.7 (13.9‒18.4)	-0.677	0.498
C-reactive protein/(mg·L^-1)	75.2 (61.0‒90.5)	81.2 (62.2‒89.9)	-0.768	0.443
Procalcitonin/(μg·L^-1)	71.9 (63.7‒83.5)	74.3 (62.9‒85.4)	-0.003	0.998
Artery blood gas
pH value	7.42±0.05	7.45±0.04	-2.623	0.010
PaO₂/mmHg	97.4±19.5	92.9±14.8	1.053	0.294
PaCO₂/mmHg	39.6±6.2	42.3±6.1	-1.917	0.057
PaO₂/FiO₂	316.9±64.9	309.8±49.3	0.506	0.613
Base excess/(mmol·L^-1)	1.95±3.73	3.10±2.81	-1.723	0.092
Lactate/(mmol·L^-1)	1.32±0.64	1.48±0.73	-1.109	0.269

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	t/Z value	P value
Body temperature/℃	37.0±0.7	36.8±0.6	1.025	0.311
Heart rate/(beat·min^-1)	90.8±15.0	94.5±13.6	-1.129	0.261
Mean arterial pressure/mmHg	86.3±11.5	91.2±11.9	-1.904	0.059
Respiratory rate/(times·min^-1)	16.2±4.6	17.2±3.6	-0.965	0.336
Voluntary tidal volume/mL	440 (377‒474)	398 (341‒457)	-1.697	0.090
Rapid shallow breathing index/(times·L^-1·min^-1)	37.0 (28‒45)	40.0 (32‒54)	-1.706	0.088
Albumin/(g·L^-1)	27.3 (23.8‒31.0)	28.1 (23.3‒32.6)	-0.360	0.719
Pre-albumin/(mg·L^-1)	289.3±47.9	275.7±50.3	1.249	0.214
White blood cell/(×10⁹·L^-1)	16.0 (13.8‒18.1)	16.7 (13.9‒18.4)	-0.677	0.498
C-reactive protein/(mg·L^-1)	75.2 (61.0‒90.5)	81.2 (62.2‒89.9)	-0.768	0.443
Procalcitonin/(μg·L^-1)	71.9 (63.7‒83.5)	74.3 (62.9‒85.4)	-0.003	0.998
Artery blood gas
pH value	7.42±0.05	7.45±0.04	-2.623	0.010
PaO₂/mmHg	97.4±19.5	92.9±14.8	1.053	0.294
PaCO₂/mmHg	39.6±6.2	42.3±6.1	-1.917	0.057
PaO₂/FiO₂	316.9±64.9	309.8±49.3	0.506	0.613
Base excess/(mmol·L^-1)	1.95±3.73	3.10±2.81	-1.723	0.092
Lactate/(mmol·L^-1)	1.32±0.64	1.48±0.73	-1.109	0.269

Peri-weaning period	Successful weaning group (n=114)	Failed weaning group (n=24)	χ²/t value	P value
Before extubation (during SBT)
DE/cm	1.13±0.35	0.88±0.15	4.558	<0.001
TFD/%	19.1±3.2	17.4±3.0	1.855	0.066
TFic/%	16.3±3.5	19.5±2.9	-3.343	0.001
TFic/TFD	0.87±0.19	1.14±0.16	-5.265	<0.001
After extubation (within 2 h)
DE/cm	1.14±0.34	0.96±0.20	1.928	0.057
TFD/%	18.3±4.8	15.4±3.4	2.277	0.025
TFic/%	15.6±5.7	19.8±4.8	-2.738	0.007
TFic/TFD	0.86±0.25	1.36±0.47	-4.073	0.001