ObjectiveTo investigate the timing and clinical efficacy of diaphragmatic plication in the treatment of diaphragmatic paralysis after congenital heart disease (CHD) operation.MethodsFrom January 2013 to February 2019, 30 children with CHD who were treated in Fuwai Hospital were collected, including 17 males and 13 females with a median age of 19.5 (3, 72) months. There were 6 patients with bilateral diaphragmatic paralysis (bilateral group) and 24 patients with unilateral diaphragmatic paralysis (unilateral group). The clinical data of the two groups were compared.ResultsAmong the 6 bilateral diaphragmatic paralysis patients, 2 underwent bilateral diaphragmatic plication, and the other 4 patients continued their off-line exercise after unilateral diaphragmatic plication. Patients in the unilateral group had shorter ventilator use time (266.77±338.34 h vs. 995.33±622.29 h, P=0.001) and total ICU stay time (33.21±23.97 d vs. 67.33±28.54 d, P=0.008) than those in the bilateral group. One patient died in the bilateral group, and there was no statistical difference between the two groups (P=0.363). There was no statistical difference in the ICU stay time after diaphragm plication between the two groups (11.68±10.28 d vs. 29.83±27.73 d, P>0.05).ConclusionDiaphragmatic plication is an effective treatment for diaphragmatic paralysis after CHD operation once the conservative treatment failed. The prognosis of bilateral diaphragmatic paralysis is worse than that of unilateral diaphragmatic paralysis. Strict control of indications for surgery is beneficial to the early recovery of patients.
ObjectiveTo observe the curative effect of pulmonary rehabilitation in patients with stable moderate to severe chronic obstructive pulmonary disease (COPD).MethodsSixty-four patients with stable moderate to severe COPD who visited during January 2016 and December 2017 were recruited in the study. They were randomly divided into an observation group and a control group, with 32 cases in each group. The spirometry was conducted in all patients. The right deep inspiratory end diaphragm thickness and the quiet end expiratory diaphragm thickness were measured by ultrasound, and the diaphragm thickness fraction (DTF) was calculated. The routine drug treatment was given in both groups. The comprehensive pulmonary rehabilitation treatment was given in the observation group (include breath training, exercise training, health education and nutrition guide). The pulmonary function, diaphragm function, severity and quality of life were evaluated before and 6 months later after the treatment.ResultsIn the observation group, the predicted value of forced expiratory volume in one second (FEV1%pred), FEV1/FVC ratio and DTF were all significantly improved compare with before treatment and the control group (all P<0.05). While the BODE index was significantly declined compare with before treatment and the control group (all P<0.05).ConclusionPulmonary rehabilitation treatment can help improve pulmonary function, diaphragm function, condition of the disease and quality of life.
ObjectiveTo explore the effect of early graded respiratory severe rehabilitation training for patients with mechanical ventilation under a multidisciplinary model.MethodsTwo hundred and thirty-six patients were surveyed, who were hospitalized in the intensive care unit of the First Affiliated Hospital of Anhui Medical University from June 3, 2019 to March 31, 2020. They were randomly divided into an observation group and a control group, with 118 patients in each group. The observation group received rehabilitation training using early graded rehabilitation training under the mode of multidisciplinary cooperation, while the control group received routine respiratory rehabilitation training. Diaphragmatic excursion (DE) and diaphragmatic thickening fraction (DTF) of the patients before ventilator weaning were measured by ultrasound. The differences of DE, DTF, peak expiratory flow (PEF), maximal inspiratory pressure (MIP), success rate of withdrawal, duration of mechanical ventilation and intensive care unit (ICU) stay between the two groups were recorded and compared.ResultsAll evaluation indexes were statistically significant between the observation group and the control group (all P<0.05). There were interaction between oxygenation index, PEF, MIP, Acute Physiology and Chronic Health Score, Clinical Pulmonary Infection Score and recovery time.ConclusionRehabilitation training on early graded severe respiratory diseases under a multidisciplinary model can improve the respiratory function of patients on mechanical ventilation and shorten the duration of mechanical ventilation and ICU stay.
Objective To study the role of ubiquitin-proteasome pathway in diaphragm of COPD rats. Mathods Thirty rats were divided into a normal control group and a COPD group. COPD model was established by exposure to cigarette smoke for three months. The protein levels of E2-14k and proteasome subunit C8 in diaphragms were measured by Western blot. The mRNA levels of ubiquitin and proteasome subunit C2 in diaphragms were measured bymeans of realtime polymerase chain reaction( RT-PCR) . Results Compared with the control group, the protein expression of E2-14k increased significantly in the COPD group ( 0. 81 ±0. 28 vs 0. 50 ±0. 25, P lt;0. 05) , but C8 protein level was not significantly different between the two groups( P gt;0. 05) . The mRNA expression of ubiquitin increased significantly in the COPD group( 0. 89 ±0. 20 vs 0. 50 ±0. 15, P lt;0. 05) , but C2 mRNA level was not significantly different between the two groups ( P gt; 0. 05 ) . Conclusions The mRNA and protein expressions of ubiquitin-proteasome pathway in diaphragmincreased significantly in COPD rats, suggesting that the activity of ubiquitin-proteasome pathwayincreased, which lead to an increase of protein degradation.
膈神经是维持呼吸功能的主要神经, 由颈3 ～5 神经组成, 在维持正常通气功能中占有重要的地位。膈肌位于胸腔和腹腔之间, 为向上膨隆呈穹窿形的扁薄阔肌, 是主要的呼吸肌, 在呼吸运动中起着非常重要的作用。膈肌起搏即通过电刺激膈神经或膈肌使膈肌收缩, 维持患有膈肌功能障碍患者的自然负压呼吸。自发现电刺激能引起膈肌收缩至今已有200 多年历史, 该技术应用于临床也已有60 余年历史[1] 。
ObjectiveTo evaluate clinical outcomes of diaphragm plication for the treatment of diaphragmatic paralysis (DP) in infants after surgical correction for congenital heart diseases. MethodsClinical data of 13 infants who had DP after surgical correction for congenital heart diseases from December 2009 to December 2012 were retrospectively analyzed. There were 5 male and 8 female patients with their age of 35 days-11 months (6.6±3.2 months) and body weight of 3.5-9.6 (6.2±1.8) kg. Diaphragm plication was performed 19.08±4.29 days after open heart surgery. All the patients were not able to wean from mechanical ventilation,or were repeatedly reintubated because of severe respiratory failure after extubation. All the 13 patients received diaphragm plication for singleor double-sided DP. ResultsTwo patients had ventilator associated pneumonia (15.4%) including 1 patient with positive sputum cultures for Acinetobacter baumannii but negative blood culture. Another patient who had double-sided DP after surgical correction for tetralogy of Fallot with pulmonary atresia underwent double-sided diaphragm plication and later died of multiple organ dysfunction syndrome,whose sputum and blood cultures were both positive for Pseudomonas aeruginosa on the 11th day after double-sided diaphragm plication. Chest X-ray of all the patients showed plicated diaphragm in normal position after diaphragm plication. The average time from diaphragm plication to extubation was 5.38±3.09 days. After diaphragm plication,arterial partial pressures of oxygen (PaO2) significantly increased (90.22±8.47 mm Hg vs. 80.69±6.72 mm Hg,P<0.05) and arterial partial pressures of carbon dioxide (PaCO2) significantly decreased (39.87±6.31 mm Hg vs. 56.38±7.19 mm Hg,P<0.05). Twelve patients were followed up for 24 months after discharge. During follow-up,1 patient who received double-sided diaphragm plication had 2 episodes of pneumonia within 6 months after discharge. Respiratory function of all the other patients was normal. All the patients were in NYHA class Ⅰ-Ⅱ. ConclusionDiaphragm plication is a safe,easy and effective treatment to increase survival rate and decrease the incidence of hospital-acquired infection for infants who have DP and are unable to wean from mechanical ventilation after surgical correction for congenital heart diseases.
Objective To investigate the changes of respiratory mechanics in response to elevated respiratory central drive and their impacts on the inspiratory signals detection.Methods 10 normal volunteers were recruited for the study from the colleagues of the State Key Laboratory of Respiratory Disease. Rebreathing method was used to increase the end expiratory PCO2 ( PCO2 -ET) to the subject’s maximal tolerance in order to stimulate the increase of respiratory central drive. The changes of respiratory mechanics in response to elevated respiratory central drive and their impacts on the initiation signals of inspiration were observed.Results After re-breathing, the average maximal tolerated PCO2 -ET was ( 81. 2 ±6. 6) mm Hg. As the PCO2 -ET rising, electromyogram of diaphragmatic muscle ( RMSdi ) ,transdiaphragmatic pressure ( Pdi ) and tidal volume ( VT ) increased progressively while the time of respiratory cycle ( Ttot ) shorten gradually. As the PCO2 -ETlevel increased frombaseline [ PCO2 -ET( level-0) ] to the maximal level [ PCO2 -ET( level-4) ] , RMSdi increased from( 17. 17 ±12. 41) μV to ( 147. 99 ±161. 64) μV,Pdi and VT increased from ( 7. 5 ±1. 7) cmH2O and ( 0. 68 ±0. 27) L to ( 26. 13 ±11. 51) cm H2O and ( 2. 21 ±0. 37) L respectively, while Ttot shorten from ( 2. 91 ±0. 85) s to ( 1. 92 ±0. 39) s. These four parameters of respiratory mechanics, RMSdi, Pdi, VT and Ttot, were highly correlated linearly with PCO2 -ET ( r value was 0. 956, 0. 973,0. 956 and 0. 89 respectively, all P lt;0. 001) . At the start of inspiration, the first detectable signal was electromyogramof diaphragmatic muscle ( RMSdi) , followed by mouth pressure ( Pm)and inspiratory flow ( Flow) on time sequence. As the rising of PCO2 -ET, the time lag of Pmand Flow from RMSdi after the initiation of inspiration increased gradually. However, the time lag between Flow and Pm remained constant. Conclusions At the start of inspiration, the signal of RMSdi appears first as compared with Pm and Flow. As the rising of PCO2 -ET, the time lag of Pmand Flow fromRMSdi after the initiation of inspiration increased gradually, suggesting RMSdi is more sensitive inspiratory signal, which might be used for triggering of ventilator in order to improve the synchronization, especially in the situation of elevated respiratory central drive.
ObjectiveTo clarify the risk factors of diaphragmatic dysfunction (DD) after cardiac surgery with extracorporeal circulation. MethodsA retrospective analysis was conducted on the data of patients who underwent cardiac surgery with extracorporeal circulation in the Department of Cardiovascular Surgery of Peking University People's Hospital from January 2023 to March 2024. Patients were divided into two groups according to the results of bedside diaphragm ultrasound: a DD group and a control group. The preoperative, intraoperative, and postoperative indicators of the patients were compared and analyzed, and independent risk factors for DD were screened using multivariate logistic regression analysis. ResultsA total of 281 patients were included, with 32 patients in the DD group, including 23 males and 9 females, with an average age of (64.0±13.5) years. There were 249 patients in the control group, including 189 males and 60 females, with an average age of (58.0±11.2) years. The body mass index of the DD group was lower than that of the control group [(18.4±1.5) kg/m2 vs. (21.9±1.8) kg/m2, P=0.004], and the prevalence of hypertension, chronic obstructive pulmonary disease, heart failure, and renal insufficiency was higher in the DD group (P<0.05). There was no statistical difference in intraoperative indicators (operation method, extracorporeal circulation time, aortic clamping time, and intraoperative nasopharyngeal temperature) between the two groups (P>0.05). In terms of postoperative aspects, the peak postoperative blood glucose in the DD group was significantly higher than that in the control group (P=0.001), and the proportion of patients requiring continuous renal replacement therapy was significantly higher than that in the control group (P=0.001). The postoperative reintubation rate, tracheotomy rate, mechanical ventilation time, and intensive care unit stay time in the DD group were higher or longer than those in the control group (P<0.05). Multivariate logistic regression analysis showed that low body mass index [OR=0.72, 95%CI (0.41, 0.88), P=0.011], preoperative dialysis [OR=2.51, 95%CI (1.89, 4.14), P=0.027], low left ventricular ejection fraction [OR=0.88, 95%CI (0.71, 0.93), P=0.046], and postoperative hyperglycemia [OR=3.27, 95%CI (2.58, 5.32), P=0.009] were independent risk factors for DD. ConclusionThe incidence of DD is relatively high after cardiac surgery, and low body mass index, preoperative renal insufficiency requiring dialysis, low left ventricular ejection fraction, and postoperative hyperglycemia are risk factors for DD.