Intensive Care Med

https://doi.org/10.1007/s00134-024-07472-x

EDITORIAL

Implementing diaphragm protection

© 2024 Springer-Verlag GmbH Germany, part of Springer Nature

Diaphragm function is a critical determinant of suc- the magnitude of diaphragmatic effort can be estimated
cessful liberation from mechanical ventilation. Multiple from the negative deflection in airway pressure (the
factors contribute to the high prevalence of diaphragm occlusion pressure, Pocc) [4]. Diaphragm electrical activ-
dysfunction in mechanically ventilated patients [1]. In ity (Edi) technique is an electromyography-based method
particular, diaphragm dysfunction may develop as a con- for continuously monitoring diaphragm activity; normal-
sequence of insufficient diaphragmatic effort or because izing Edi based on intermittent measurements of neu-
of excessive or dyssynchronous diaphragmatic con- romuscular coupling (Pocc/Edi) provides a simple way
tractions. This mechanistic framework is the basis for a to use Edi to assess diaphragmatic effort [5]. Diaphragm
rational therapeutic approach to protect the diaphragm ultrasound can measure diaphragm muscle thickening
during invasive mechanical ventilation (Fig. 1). Readers during contractions although noise and variability in this
should appreciate that the framework relies on available measurement can be substantial [6].
physiological and observational data; the impact of dia-
phragm-protective ventilation on outcomes has not been Step 2: Minimize the duration of diaphragm
established and clinical trials are awaited. inactivity
Diaphragm inactivity is associated with rapid disuse atro-
Step 1: Monitor diaphragmatic effort phy and acute mitochondrial dysfunction with resulting
Diaphragmatic activity cannot be accurately inferred cellular oxidative stress injury [1]. Mechanical ventilation
from ventilator settings [2]. Diaphragm protection reduces diaphragm activity by augmenting ventilation
therefore requires direct monitoring of diaphragmatic and attenuating respiratory drive [7]. Diaphragm inactiv-
effort. The reference technique is measurement of trans- ity results when the arterial carbon dioxide tension falls
diaphragmatic pressure using a dual balloon catheter below the apnea threshold and the level of consciousness
for esophageal and gastric manometry. However, this is depressed because of sleep, sedation, or neurological
method requires specialized expertise and equipment insult. For this reason, sedation is a critical determinant
and a variety of simpler techniques are now available to of the time to resume diaphragm activity after intuba-
indirectly assess diaphragmatic effort. Respiratory drive tion [8]. Since opioids tend to depress neural respiratory
quantified by the airway occlusion pressure (P0.1) is cor- rate [9], they especially predispose patients to diaphragm
related with diaphragmatic effort; a low P0.1 (< 1 ­cmH2O) inactivity.
is sensitive and specific for low diaphragmatic activity [3]. To minimize the duration of diaphragm inactivity, it
Diaphragmatic effort may also be assessed non-invasively is critical to minimize sedation exposure as much as
using a simple occlusion maneuver: when the patient possible. If continuous sedation is necessary, prefer-
makes an inspiratory effort against the occluded airway, ence may be given to the use of propofol over opioids,
although effective and adequate analgesia remains a
critical independent goal. Sedation should be adjusted
*Correspondence: [email protected] to satisfy established goals for relief of distress as well
4
Toronto General Hospital Research Institute, 585 University Ave., Toronto, as to optimize diaphragmatic effort and patient-venti-
ON M5G 2N2, Canada
Full author information is available at the end of the article lator interaction.
If the set rate on the ventilator exceeds the patient’s
intrinsic neural respiratory rate when the patient is
sedated, the patient will be much less likely to breathe
to trigger the ventilator [7]. Reducing the set rate on
the ventilator during controlled ventilation as much injury [12]. In one study, both insufficient and exces-
as possible to avoid hypocapnia and stimulate respira- sive diaphragm contractile activity were associated with
tory drive will help to avoid needless hyperventilation- prolonged mechanical ventilation [13], suggesting that
induced diaphragm inactivity. Reducing ventilatory excessive effort may be deleterious to outcome.
support (inspiratory pressure or flow) will usually Respiratory drive and effort may be controlled by
increase diaphragmatic effort to avoid overassistance. manipulating the ventilator inspiratory support level
In future, techniques such as diaphragm neurostimu- including inspiratory pressure and flow. Increasing or
lation may permit direct control of diaphragm activity decreasing positive end-expiratory pressure (PEEP) can
to maintain regular diaphragm contractions when res- reduce drive and effort depending on the change in lung
piratory drive is absent [10]. mechanics and diaphragm configuration [11]. Although
To protect the lung from excess lung-distending hypoxemia is a comparatively weak stimulus for res-
pressures and maintain safe and effective ventilation, it piratory drive, increasing the fraction of inspired oxy-
may sometimes be necessary to render the diaphragm gen can attenuate drive in some patients. Sedation may
and other respiratory muscles inactive with neuromus- be employed to attenuate excessive respiratory effort
cular blocking agents. While diaphragm protection if ventilator titration is ineffective; propofol is more
may be important, lung protection remains the pri- effective than opioids to reduce drive and effort [9]. In
mary priority for optimal ventilation. patients on extracorporeal life support, increasing sweep
gas flow is often a highly effective means to reduce res-
Step 3: Avoid excessive respiratory drive and effort piratory drive and effort [11]. Trials are needed to test
As patients transition to spontaneous breathing dur- the benefit of extracorporeal C ­ O2 removal as a tech-
ing ventilation, respiratory effort frequently becomes nique to promote early safe spontaneous breathing and
markedly elevated [11]. This might in theory contrib- diaphragm protection.
ute to acute lung injury and load-induced diaphragm

Fig. 1 Stepwise approach to implementing diaphragm protection during mechanical ventilation. Solid black arrows represent the duration of post-
inspiratory loading of the diaphragm (time from end of mechanical inspiration to end of neural inspiration, defined as 70% of peak Edi). Paw airway
pressure. Figure adapted from Bertoni et al. [16] and Coiffard et al. [15]
Step 4: Maintain patient–ventilator synchrony Desarrollo (ANID), Fondecyt Regular 2022 /Folio 1220853. He reports receiving
personal fees from Stimit AG. BP is supported by a career development award
If the diaphragm is actively contracting as the ventila- from the National Institutes of Health (NIH/NHLBI HL148387).
tor cycles into the mechanical expiratory phase, it may
be forced to lengthen as it contracts. Such ‘lengthen- Publisher’s Note
ing’ (eccentric) contractions may occur during differ- Springer Nature remains neutral with regard to jurisdictional claims in pub-
ent types of patient–ventilator dyssynchronies, resulting lished maps and institutional affiliations.
in acute diaphragm injury and weakness depending on Springer Nature or its licensor (e.g. a society or other partner) holds exclusive
the force of contraction [14]. One recent clinical study rights to this article under a publishing agreement with the author(s) or other
demonstrated that prolonged exposure to these loading rightsholder(s); author self-archiving of the accepted manuscript version of
this article is solely governed by the terms of such publishing agreement and
conditions was associated with progressive diaphragm applicable law.
dysfunction [15].
To protect the diaphragm from eccentric myotrauma, Received: 19 February 2024 Accepted: 2 May 2024
close attention should be paid to ensuring that neural
and mechanical expiratory phases are well synchronized
(Fig. 1). The flow tracing can be inspected to look for
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1
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