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      Real-time shear wave ultrasound elastography: a new tool for the evaluation of diaphragm and limb muscle stiffness in critically ill patients

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          Abstract

          Background

          Muscle weakness following critical illness is the consequence of loss of muscle mass and alteration of muscle quality. It is associated with long-term disability. Ultrasonography is a reliable tool to quantify muscle mass, but studies that evaluate muscle quality at the critically ill bedside are lacking. Shear wave ultrasound elastography (SWE) provides spatial representation of soft tissue stiffness and measures of muscle quality. The reliability and reproducibility of SWE in critically ill patients has never been evaluated.

          Methods

          Two operators tested in healthy controls and in critically ill patients the intra- and inter-operator reliability of the SWE using transversal and longitudinal views of the diaphragm and limb muscles. Reliability was calculated using the intra-class correlation coefficient and a bootstrap sampling method assessed their consistency.

          Results

          We collected 560 images. Longitudinal views of the diaphragm (ICC 0.83 [0.50–0.94]), the biceps brachii (ICC 0.88 [0.67–0.96]) and the rectus femoris (ICC 0.76 [0.34–0.91]) were the most reliable views in a training set of healthy controls. Intra-class correlation coefficient for inter-operator reproducibility and intra-operator reliability was above 0.9 for all muscles in a validation set of healthy controls. In critically ill patients, inter-operator reproducibility and intra-operator 1 and 2 reliability ICCs were respectively 0.92 [0.71–0.98], 0.93 [0.82–0.98] and 0.92 [0.81–0.98] for the diaphragm; 0.96 [0.86–0.99], 0.98 [0.94–0.99] and 0.99 [0.96–1] for the biceps brachii and 0.91 [0.51–0.98], 0.97 [0.93–0.99] and 0.99 [0.97–1] for the rectus femoris. The probability to reach intra-class correlation coefficient greater than 0.8 in a 10,000 bootstrap sampling for inter-operator reproducibility was respectively 81%, 84% and 78% for the diaphragm, the biceps brachii and the rectus femoris respectively.

          Conclusions

          SWE is a reliable technique to evaluate limb muscles and the diaphragm in both healthy controls and in critically ill patients.

          Trial registration

          The study was registered (ClinicalTrial NCT03550222).

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          Most cited references32

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          Supersonic shear imaging: a new technique for soft tissue elasticity mapping

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            EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications.

            The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way. © Georg Thieme Verlag KG Stuttgart · New York.
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              Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans.

              Diaphragmatic function is a major determinant of the ability to successfully wean patients from mechanical ventilation (MV). Paradoxically, MV itself results in a rapid loss of diaphragmatic strength in animals. However, very little is known about the time course or mechanistic basis for such a phenomenon in humans. To determine in a prospective fashion the time course for development of diaphragmatic weakness during MV; and the relationship between MV duration and diaphragmatic injury or atrophy, and the status of candidate cellular pathways implicated in these phenomena. Airway occlusion pressure (TwPtr) generated by the diaphragm during phrenic nerve stimulation was measured in short-term (0.5 h; n = 6) and long-term (>5 d; n = 6) MV groups. Diaphragmatic biopsies obtained during thoracic surgery (MV for 2-3 h; n = 10) and from brain-dead organ donors (MV for 24-249 h; n = 15) were analyzed for ultrastructural injury, atrophy, and expression of proteolysis-related proteins (ubiquitin, nuclear factor-κB, and calpains). TwPtr decreased progressively during MV, with a mean reduction of 32 ± 6% after 6 days. Longer periods of MV were associated with significantly greater ultrastructural fiber injury (26.2 ± 4.8 vs. 4.7 ± 0.6% area), decreased cross-sectional area of muscle fibers (1,904 ± 220 vs. 3,100 ± 329 μm²), an increase of ubiquitinated proteins (+19%), higher expression of p65 nuclear factor-κB (+77%), and greater levels of the calcium-activated proteases calpain-1, -2, and -3 (+104%, +432%, and +266%, respectively) in the diaphragm. Diaphragmatic weakness, injury, and atrophy occur rapidly in critically ill patients during MV, and are significantly correlated with the duration of ventilator support.
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                Author and article information

                Contributors
                aurelien.flattres@gmail.com
                y-aarab@chu-montpellier.fr
                Stephanie.Nougaret@icm.unicancer.fr
                f-garnier@chu-montpellier.fr
                r-larcher@chu-montpellier.fr
                m-amalric@chu-montpellier.fr
                k-klouche@chu-montpellier.fr
                pascal.etienne@umontpellier.fr
                gilles.subra@umontpellier.fr
                s-jaber@chu-montpellier.fr
                n-molinari@chu-montpellier.fr
                s-matecki@chu-montpellier.fr
                b-jung@chu-montpellier.fr
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                3 February 2020
                3 February 2020
                2020
                : 24
                : 34
                Affiliations
                [1 ]ISNI 0000 0001 2097 0141, GRID grid.121334.6, Medical Intensive Care Unit, , Montpellier University and Montpellier Lapeyronie Teaching Hospital, ; Avenue du Doyen Gaston Giraud, 34000 Montpellier, France
                [2 ]ISNI 0000 0001 2097 0141, GRID grid.121334.6, INSERM U1046, CNRS UMR9214, Université de Montpellier, ; Montpellier, France
                [3 ]IRCM, INSERM U1194, and Department of Radiology, Montpellier Cancer Research Institute, 208 Ave des Apothicaires, 34295 Montpellier, France
                [4 ]ISNI 0000 0001 2097 0141, GRID grid.121334.6, Laboratoire Charles Coulomb (L2C), , University of Montpellier, CNRS, ; Montpellier, France
                [5 ]ISNI 0000 0001 2097 0141, GRID grid.121334.6, Institut des Biomolécules Max Mousseron (IBMM), , UMR5247 CNRS, ENSCM, Université de Montpellier, ; 34000 Montpellier, France
                [6 ]ISNI 0000 0001 2097 0141, GRID grid.121334.6, Saint Eloi Anesthesiology and Critical Care Medicine, , Montpellier University and Montpellier Teaching Hospital, ; Montpellier, France
                [7 ]ISNI 0000 0001 2097 0141, GRID grid.121334.6, Biostatistics Department, , Montpellier University and Montpellier Teaching Hospital, ; Montpellier, France
                Article
                2745
                10.1186/s13054-020-2745-6
                6998330
                32014005
                d2a6a66c-4b9a-45c3-b71c-c74911ed0b0b
                © The Author(s). 2020

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 18 July 2019
                : 16 January 2020
                Funding
                Funded by: Université de Montpellier
                Award ID: Not applicable
                Award ID: Not applicable
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2020

                Emergency medicine & Trauma
                sonoelastography,intensive care unit acquired weakness,diaphragmatic dysfunction,cachexia

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