Monitoring and preserving diaphragmatic function in mechanical ventilation.

PURPOSE OF REVIEW: This review summarizes the evidence on clinical outcomes related to diaphragm dysfunction, providing an overview on available monitoring tools and strategies for its prevention and treatment.

RECENT FINDINGS: Long-term adverse functional outcomes in intensive care survivors are well documented, especially in patients with prolonged mechanical ventilation. Because diaphragm weakness is highly prevalent and strongly associated with weaning failure, a link between diaphragm weakness and adverse functional outcomes is probable. Mechanisms of critical illness-associated diaphragm weakness are complex and include ventilator-related myotrauma through various pathways (i.e. over-assistance, under-assistance, eccentric, expiratory). Given this potential clinical impact, research on preventive and therapeutic strategies is growing, including the development of ventilation strategies aiming at protecting both the lung and the diaphragm. Phrenic nerve stimulation and specific rehabilitation strategies also appear promising.

SUMMARY: Diaphragm dysfunction is associated with adverse clinical outcomes in ventilated patients; therefore, their inspiratory effort and function should be monitored. Whenever possible, and without compromising lung protection, moderate inspiratory effort should be targeted. Phrenic nerve stimulation and specific rehabilitation strategies are promising to prevent and treat diaphragm dysfunction, but further evidence is needed before widespread implementation.