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VOLUME 25 , ISSUE 9 ( September, 2021 ) > List of Articles

Original Article

Ultrasonographic Assessment of Diaphragmatic Inspiratory Amplitude and Its Association with Postoperative Pulmonary Complications in Upper Abdominal Surgery: A Prospective, Longitudinal, Observational Study

Prasanna V Vanamail, Kalpana Balakrishnan, Sarojini Prahlad, Punitha Chockalingam, Radhika Dash, Dinesh K Soundararajan

Keywords : Diaphragm excursion, Diaphragmatic dysfunction, Diaphragmatic inspiratory amplitude, Gastrectomy, Pancreaticoduodenectomy, Pneumonia, Postoperative, Pulmonary complications, Ultrasound, Upper abdominal surgery

Citation Information : Vanamail PV, Balakrishnan K, Prahlad S, Chockalingam P, Dash R, Soundararajan DK. Ultrasonographic Assessment of Diaphragmatic Inspiratory Amplitude and Its Association with Postoperative Pulmonary Complications in Upper Abdominal Surgery: A Prospective, Longitudinal, Observational Study. Indian J Crit Care Med 2021; 25 (9):1031-1039.

DOI: 10.5005/jp-journals-10071-23962

License: CC BY-NC 4.0

Published Online: 08-09-2021

Copyright Statement:  Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Background: Diaphragmatic dysfunction following upper abdominal surgery is less recognized due to a lack of diagnostic modality for bedside evaluation. We used point-of-care ultrasound to evaluate the diaphragmatic inspiratory amplitude (DIA) in upper abdominal surgery for cancer. Our primary hypothesis was DIA would be reduced in the immediate postoperative period in patients with postoperative pulmonary complications (PPCs). Our aim was to identify an optimal cutoff of DIA for the diagnosis of PPCs. Methods: We conducted a prospective, observational study in patients aged 18–75 years undergoing elective, upper abdominal oncological surgeries under combined general and epidural anesthesia. Ultrasound evaluation of the diaphragm was done by measuring the DIA in the right and left hemidiaphragms during quiet and deep breathing on the day before surgery and postoperative days (PODs) 1, 2, and 3. Patients were followed up for PPCs until POD 7. The linear mixed-effects model examined the association between DIA and PPCs and other perioperative factors. Receiver-operating characteristics analysis was done to determine the optimal cutoff of DIA in diagnosing PPCs. Results: DIA measured in the 162 patients showed a significant decrease in their absolute values postoperatively from its preoperative baseline measurement. This decrease in DIA was significantly associated with PPC [right hemidiaphragm, β = −0.17, 95% confidence interval (CI) −0.31 to −0.02, p = 0.001 during quiet breathing; left hemidiaphragm, β = −0.24, 95% CI = −0.44 to −0.04, p = 0.018 and β = −0.40, 95% CI = −0.71 to −0.09, p = 0.012 during quiet and deep breathing, respectively]. A cutoff value of DIA of left hemidiaphragm at 1.3 cm during quiet breathing and 1.6 cm during deep breathing had a sensitivity of 77 and 75%, respectively, in their ability to diagnose PPCs [left hemidiaphragm quiet breathing, area under the curve (AUC): 0.653, 95% CI 0.539–0.768, p = 0.015; left hemidiaphragm deep breathing, AUC: 0.675, 95% CI 0.577–0.773, p = 0.007]. Conclusion: Following upper abdominal surgery, the DIA is decreased and associated with PPCs. DIA of left hemidiaphragm less than 1.3 cm during quiet breathing and 1.6 cm during deep breathing has a sensitivity of 77 and 75%, respectively, in diagnosing PPCs following upper abdominal surgery.

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  1. Nason LK, Walker CM, Mcneeley MF, Burivong W, Fligner CL, David Godwin J. Imaging of the diaphragm: anatomy and function. Radiographics 2012;32(2):E51–E70. DOI: 10.1148/rg.322115127.
  2. Lomauro A. Should the diaphragm be evaluated after abdominoplasty? J Bras Pneumol 2019;45(3):e20190146. DOI: 10.1590/1806-3713/e20190146.
  3. Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med 2003;168(1):10–48. DOI: 10.1164/rccm.2206020.
  4. Kim SH, Na S, Choi J-S, Na SH, Shin S, Koh SO. An evaluation of diaphragmatic movement by M-Mode sonography as a predictor of pulmonary dysfunction after upper abdominal surgery. Anesth Analg 2010;110(5):1349–1354. DOI: 10.1213/ANE.0b013e3181d5e4d8.
  5. Kim K, Jang DM, Park JY, Yoo H, Kim HS, Choi WJ. Changes of diaphragmatic excursion and lung compliance during major laparoscopic pelvic surgery: a prospective observational study. PLoS One 2018;13(11):1–9. DOI: 10.1371/journal.pone.0207841.
  6. Gropper MA. Postoperative respiratory muscle dysfunction: only the strong survive. Anesthesiology 2013;118(4):783–784. DOI: 10.1097/ALN.0b013e318288823b.
  7. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004;199(4):531–537. DOI: 10.1016/j.jamcollsurg.2004.05.276.
  8. Suzuki S, Kanaji S, Matsuda Y, Yamamoto M, Hasegawa H, Yamashita K, et al. Long-term impact of postoperative pneumonia after curative gastrectomy for elderly gastric cancer patients. Ann Gastroenterol Surg 2018;2(1):72–78. DOI: 10.1002/ags3.12037.
  9. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370(9596):1453–1457. DOI: 10.1016/S0140-6736(07)61602-X.
  10. Sarwal A, Walker FO, Cartwright MS. Neuromuscular ultrasound for evaluation of the diaphragm. Muscle and Nerve 2013;47(3):319–329. DOI: 10.1002/mus.23671.
  11. Jammer I, Wickboldt N, Sander M, Smith A, Schultz MJ, Pelosi P, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Artic Eur J Anaesthesiol 2015;32(2):88–105. DOI: 10.1097/EJA.0000000000000118.
  12. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications. Ann Surg 2004;240(2):205–213. DOI: 10.1097/01.sla.0000133083.54934.ae.
  13. Lerolle N, Guérot E, Dimassi S, Zegdi R, Faisy C, Fagon JY, et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest 2009;135(2):401–407. DOI: 10.1378/chest.08-1531.
  14. The LAS VEGAS investigators. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS – an observational study in 29 countries. Eur J Anaesthesiol 2017;34(8):492–507. DOI: 10.1097/EJA.0000000000000646.
  15. Spadaro S, Grasso S, Dres M, Fogagnolo A, Dalla Corte F, Tamburini N, et al. Point of care ultrasound to identify diaphragmatic dysfunction after thoracic surgery. Anesthesiology 2019;131(2):266–278. DOI: 10.1097/ALN.0000000000002774.
  16. Ayoub J, Cohendy R, Prioux J, Ahmaidi S, Bourgeois JM, Dauzat M, et al. Diaphragm movement before and after cholecystectomy: a sonographic study. Anesth Analg 2001;92(3):755–761. DOI: 10.1097/00000539-200103000-00038.
  17. Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010;113(6):1338–1350. DOI: 10.1097/ALN.0b013e3181fc6e0a.
  18. de Cleva R, de Assumpção MS, Sasaya F, Chaves NZ, Santo MA, Fló C, et al. Correlation between intra-abdominal pressure and pulmonary volumes after superior and inferior abdominal surgery. Clinics 2014;69(7):483–486. DOI: 10.6061/clinics/2014(07)07.
  19. Treschan TA, Kaisers W, Schaefer MS, Bastin B, Schmalz U, Wania V, et al. Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function. Br J Anaesth 2012;109(2):263–271. DOI: 10.1093/bja/aes140.
  20. Bauer M, Opitz A, Filser J, Jansen H, Meffert RH, Germer CT, et al. Perioperative redistribution of regional ventilation and pulmonary function: a prospective observational study in two cohorts of patients at risk for postoperative pulmonary complications. BMC Anesthesiol 2019;19(1):132. DOI: 10.1186/s12871-019-0805-8.
  21. Ferreyra GP, Baussano I, Squadrone V, Richiardi L, Marchiaro G, Del Sorbo L, et al. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg 2008;247(4):617–626. DOI: 10.1097/SLA.0b013e3181675829.
  22. Nair J, Streeter KA, Turner SMF, Sunshine MD, Bolser DC, Fox EJ, et al. Anatomy and physiology of phrenic afferent neurons. J Neurophysiol 2017;118(6):2975–2990. DOI: 10.1152/jn.00484.2017.
  23. Chae WS, Choi S, Sugiyama D, Richerson GB, Brennan TJ, Kang S. Effect of thoracic epidural anesthesia in a rat model of phrenic motor inhibition after upper abdominal surgery. Anesthesiology 2018;129(4):791–807. DOI: 10.1097/ALN.0000000000002331.
  24. Clemente A, Carli F. The physiological effects of thoracic epidural anesthesia and analgesia on the cardiovascular, respiratory and gastrointestinal systems. Minerva Anestesiol 2008;74(10): 549–563. PMID: 18854796.
  25. Moraca RJ, Sheldon DG, Thirlby RC. The role of epidural anesthesia and analgesia in surgical practice. Ann Surg 2003;238(5):663–673. DOI: 10.1097/01.sla.0000094300.36689.ad.
  26. Schober P, Vetter TR. Repeated measures designs and analysis of longitudinal data: if at first you do not succeed-try, try again. Anesth Analg 2018;127(2):569–575. DOI: 10.1213/ANE.0000000 000003511.
  27. Martinez BP, Silva JR, Silva VS, Neto MG, Forgiarini Júnior LA. Influence of different body positions in vital capacity in patients on postoperative upper abdominal. Brazilian J Anesthesiol 2015;65(3):217–221. DOI: 10.1016/j.bjane.2014.06.002.
  28. Gea J, Gáldiz JB, Comtois N, Zhu E, Salazkin I, Fiz JA, et al. Changes in diaphragm activity induced by median laparotomy and changes in abdominal wall rigidity. Arch Bronconeumol 2009;45(1):30–35. DOI: 10.1016/j.arbres.2008.02.005.
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