体外膈肌电刺激早期干预机械通气儿童膈肌功能的随机对照试验

A randomized controlled trial of early intervention of external diaphragmatic electrical stimulation on diaphragmatic function in mechanically ventilated children

目的研究体外膈肌电刺激对机械通气儿童膈肌厚度及功能的影响。方法采用随机对照试验方法将2021年6月至2022年4月入住复旦大学附属儿科医院PICU行机械通气的患儿分为干预组和对照组。对照组给予机械通气常规治疗,干预组除常规治疗外,在机械通气早期给予体外膈肌电刺激治疗。在机械通气后1周内每天应用床旁超声连续测量膈肌厚度,观察两组机械通气儿童膈肌厚度变化趋势,同时计算膈肌增厚分数(DTf)及呼吸机相关膈肌功能障碍(VIDD)的发生率。结果共纳入患儿32例,干预组15例(男10例),对照组17例(男11例)。患儿年龄中位数为33(10,77)个月,机械通气天数中位数为12(8,21)d。患儿行机械通气的原因包括呼吸功能不全10例、脑功能障碍10例、心功能衰竭8例、外科术后4例。干预组和对照组呼气末膈肌厚度(DTe)从第1天至第7天均呈逐渐下降趋势。干预组(左侧)第7天与第1天相比,DTe减少了11%,对照组则减少了18%;干预组平均每日DTe减少2%,对照组每日减少3%。右侧与左侧DTe变化趋势相似。干预组DTe均大于对照组,其中左侧第7天干预组DTe均值为(0.1107±0.0237)cm,大于对照组(0.0935±0.0169)cm,差异有统计学意义(t=-2.372,P<0.05);右侧第2天干预组DTe均值为(0.1267±0.0277)cm,大于对照组(0.1047±0.0181)cm,差异有统计学意义(t=-2.688,P<0.05)。第7天两侧DTf干预组均低于对照组,但差异无统计学意义(左DTf:干预组与对照组的调整均数差为-0.117,P=0.088;右DTf:干预组与对照组的调整均数差为-0.065,P=0.277)。干预组VIDD的发生率低于对照组(33.3%比41.2%),但差异无统计学意义(χ^(2)=0.005,P=0.946)。结论体外膈肌电刺激可能对机械通气儿童减缓膈肌萎缩有一定的帮助,但膈肌萎缩的改善是否对临床有益仍需要进一步研究。

Objective To explore the effects of external diaphragm electrical stimulation on the diaphragm thickness and function in mechanically ventilated children.Methods A randomized controlled trial was conducted in children who were admitted to PICU at Children′s Hospital of Fudan University and received mechanical ventilation between June 2021 and April 2022.The control group was given the routine treatment of mechanical ventilation,and the intervention group was given external diaphragm electrical stimulation in the early stage of mechanical ventilation in addition to routine treatment.Diaphragm thickness was continuously measured by bedside ultrasound every day for one week after mechanical ventilation,and the changing trend of diaphragm thickness was observed,and the diaphragmatic thickening fraction(DTf)and the incidence of ventilator-induced diaphragmtic dysfunction(VIDD)were calculated at the same time.Results A total of 32 valid samples were included,including 15 cases in intervention group(10 males)and 17 cases in control group(11 males).The median age of the patients was 33(10,77)months,and the median duration of mechanical ventilation was 12(8,21)days.The reasons for mechanical ventilation in children included respiratory insufficiency in ten cases,brain dysfunction in ten cases,heart failure in eight cases,and postoperative surgery in four cases.The diaphragm end-expiratory thickness(DTe)in intervention group and the control group showed a gradually decreasing trend from the 1st day to the 7th day.The left thickness was reduced by 11%on the 7th day compared to 1st day in intervention group,which was reduced by 18%in control group;the average daily DTe was reduced by 2%per day in intervention group and by 3%per day in control group.The trends on the right and left were similar.The DTe thickness in the intervention group was greater than that in control group,among which,the mean DTe thickness in the left side of the intervention group on the 7th day was(0.1107±0.0237)cm,which was greater than that in control group(0.0935±0.0169)cm,and the difference was statistically significant(t=-2.372,P<0.05);On the second day,the mean DTe thickness on the right side in the intervention group was(0.1267±0.0277)cm,which was greater than that in control group(0.1047±0.0181)cm,and the difference was statistically significant(t=-2.688,P<0.05).DTf in the intervention group was lower than that in control group at 7th day,but the difference was not statistically significant(left DTf:adjusted mean difference was-0.117,P=0.088;right DTf:adjusted mean difference was-0.065,P=0.277).The incidence of VIDD in the intervention group was lower than that in control group(33.3%vs.41.2%),but the difference was not statistically significant(χ^(2)=0.005,P=0.946).Conclusion External diaphragmatic electrical stimulation may be helpful for alleviating diaphragmatic atrophy in mechanically ventilated children.However,whether the improvement of diaphragm atrophy is beneficial to clinical outcome still needs further study.