Search Results (30)

Background/Objectives: Deceleration can cause liver ruptures via ligament traction, with a specific, little-known transverse rupture in segment II of the left lobe being a concern. This study aimed to provide a detailed morphological characterization of these segment II ruptures, analyse their formation mechanisms using autopsy material, and propose a systematic intraoperative assessment method to improve their detection. Methods: This study analysed the autopsy cases of 132 victims of sudden, violent deceleration (falls from height, traffic accidents) performed between 2011 and 2014. Liver injuries were meticulously described, focusing on the morphological characteristics of ruptures (course, shape, depth) and their location relative to hepatic ligaments. Cases with prior liver resection due to injuries were excluded. Results: Liver ruptures were found in 61 of the 132 analysed cases (46.2%). A “new location” for ruptures was identified on the diaphragmatic surface of the left lobe’s segment II, near and along the left coronary and triangular ligaments. This specific type of rupture was found in 14 cases. Overall, 40 cadavers had liver ruptures near ligaments, totalling 55 such distinct ruptures, indicating that some had multiple ligament-associated tears. The incidence of liver rupture at this newly described site was statistically significant. Conclusions: Transverse rupture of the left hepatic lobe’s segment II, in its subdiaphragmatic area, results from ligament “pulling” forces during deceleration and is a characteristic injury. Its presence should be considered following blunt abdominal trauma involving deceleration, and the subdiaphragmatic area of the left lateral lobe requires intraoperative inspection, especially if other ligament-associated liver ruptures are found. Full article

Background and Clinical Significance: In recent years, the catheter ablation of cardiac arrhythmias has significantly reduced the incidence of sudden cardiac deaths and the need for chronic antiarrhythmic therapy. Endocardial ablation of ventricular arrhythmias is less common than atrial ablation and is technically more challenging. There are few documented extracardiac complications for ventricular ablation, and there is no report of diaphragmatic laceration. Case Presentation: We report a case of acute diaphragmatic laceration following endovascular ventricular ablation resulting in the strangulation of the gastric fundus in a patient who experienced previous transcutaneous ventricular ablation two years before. The patient underwent exploratory laparoscopy, revealing a diaphragmatic laceration with incarceration of the gastric fundus. Resection of the gastric fundus, showing acute ischemic damage, and closure of the diaphragmatic defect near the right ventricle with sutures were required. No complications were observed in the postoperative course. Conclusions: Although diaphragmatic injury is extremely rare, it should be considered among the complications associated with ventricular ablation. Full article

Neonates with congenital conditions which require surgical management frequently experience respiratory distress. This review discusses the management of pulmonary complications and the respiratory support strategies for four conditions: oesophageal atresia-tracheoesophageal fistula (OA-TOF), congenital diaphragmatic hernia (CDH), congenital lung malformations (CLM), and anterior abdominal wall defects (AWD). Mechanical ventilation techniques which can reduce the risk of ventilator-induced lung injury (VILI) are discussed, as well as the use of non-invasive respiratory support modes. While advances in perioperative respiratory support have improved outcomes in infants with OA-TOF, managing respiratory distress in premature OA-TOF neonates remains a challenge. In CDH infants, a randomised trial has suggested that conventional ventilation may improve outcomes compared to high-frequency ventilation. Echocardiographic assessment is essential in the management of CDH infants with pulmonary hypertension. Lung-protective ventilation settings may lower the rate of postoperative complications in symptomatic CLM infants, but there remains debate regarding the choice of expectant versus surgical management in neonates with asymptomatic CLMs. Infants with AWDs can require ventilation due to pulmonary hypoplasia, but the effects of this on their long-term respiratory health are poorly understood. As surgical techniques continue to evolve and novel ventilation techniques become available, prospective multi-centre studies will be required to define the optimal respiratory support strategies for neonatal surgical conditions that affect lung function. Full article

Introduction: Detection of blunt traumatic diaphragm injury (TDI) can be challenging in the absence of surgical exploration. Our objective is to study the mechanisms of injury and detection modes for patients with blunt TDI. Methods: This is a single-center, retrospective review conducted in a level 1 trauma center from 2016 to 2023, inclusive. We identified seven patients with blunt TDI using the primary mechanisms and trauma type. Results: Out of seven patients, two were associated with motor vehicle collisions, four were pedestrians struck, and one fell down the stairs. The mean ISS was 48.4 (29–75). Of the seven patients with blunt TDI, four died in the trauma bay–two from traumatic arrest and two died spontaneously. Multiple rib fractures were one of the common injury patterns in six cases, whereas in the remaining case, blunt TDI was confirmed at laparotomy and repaired. One patient died two days after admission. Of the two patients who survived, one had a TDI identified during video-assisted thoracic surgery (VATS) for retained hemothorax, and one patient had a TDI repaired during emergent exploratory laparotomy for other injuries. In the remaining four patients, blunt TDI was confirmed based on their autopsy reports. Conclusions: Injuries in all seven cases were sustained with a high-energy injury mechanism. Multiple rib fractures were reported in six cases. Based on our findings, we recommend that clinicians maintain a high level of suspicion for blunt TDI in patients with thoracoabdominal trauma, especially in cases with rib fractures or high-impact trauma. Full article

This study analyzed the effects of an 8-week diaphragmatic core training program on postural stability during high-intensity squats and examined its efficacy in injury prevention and performance enhancement. Thirty-seven male participants were randomly assigned to three groups: diaphragmatic core training group (DCTG, n = 12), core training group (CTG, n = 13), and control group (CG, n = 12). Outcome measurements included diaphragm thickness, respiratory function (mean and maximal respiratory pressures), and squat postural stability (distance between the sacral and upper body center points, peak trunk extension moment, peak knee flexion moment, and dynamic postural stability index). Compared to both CTG and CG, DCTG demonstrated significantly greater improvements in diaphragm thickness (DCTG: 34.62% increase vs. CTG: 1.36% and CG: 3.62%, p < 0.001), mean respiratory pressure (DCTG: 18.88% vs. CTG: 1.31% and CG: 0.02%, p < 0.001), and maximal respiratory pressure (DCTG: 18.62% vs. CTG: 0.72% and CG: 1.90%, p < 0.001). DCTG also showed superior improvements in postural stability measures, including reductions in the distance between sacral and upper body center points (DCTG: −6.19% vs. CTG: −3.26% and CG: +4.55%, p < 0.05), peak trunk extension moment (DCTG: −15.22% vs. CTG: −5.29% and CG: +19.31%, p < 0.001), and dynamic postural stability index (DCTG: −28.13% vs. CTG: −21.43% and CG: no change, p < 0.001). No significant between-group differences were observed in peak knee flexion moment. Core training incorporating diaphragmatic strengthening was more effective than conventional training in improving postural stability during high-intensity squats. Core training programs, including diaphragmatic strengthening exercises, may contribute to injury prevention and performance enhancement in exercises requiring lumbar stability, such as squats. Full article

Acute respiratory distress syndrome (ARDS) presents significant challenges in critical care, primarily due to its inflammatory nature, which leads to impaired gas exchange and respiratory mechanics. While mechanical ventilation (MV) is essential for patient support, the transition from controlled to assisted ventilation is complex and may be associated with intensive care unit-acquired weakness, ventilator-induced diaphragmatic dysfunction and patient self-inflicted lung injury. This paper explores the multifaceted challenges encountered during this transition, with a focus on respiratory effort, sedation management, and monitoring techniques, and investigates innovative approaches to enhance patient outcomes. The key strategies include optimizing sedation protocols, employing advanced monitoring methods like esophageal pressure measurements, and implementing partial neuromuscular blockade to prevent excessive respiratory effort. We also emphasize the importance of personalized treatment plans and the integration of artificial intelligence to facilitate timely transitions. By highlighting early rehabilitation techniques, continuously assessing the respiratory drive, and fostering collaboration among multidisciplinary teams, clinicians can improve the transition from controlled to assisted MV, ultimately enhancing recovery and long-term respiratory health in patients with ARDS. Full article

Hepatocellular carcinoma (HCC) stands as a significant contributor to cancer-related mortality globally. While the acute and often fatal manifestations of locally advanced HCC primarily present within the abdomen, it is crucial to recognize that the respiratory and circulatory systems can also fall victim due to the liver’s unique anatomical position within the body. Here, we present the case of a 63-year-old male recently diagnosed with locally advanced HCC with vascular invasion. Shortly after receiving target therapy and focal radiotherapy, the patient developed repeated secondary infections and a persistent diaphragmatic defect. As the necrotic tissue invaded the pleural space, subsequent tumor-to-bronchial and tumor-to-cardiac fistulas emerged, resulting in an abnormal connection between the respiratory and cardiovascular systems, leading to massive air emboli in circulation. This report highlights the risk of supradiaphragmatic complications in HCC patients with post-treatment secondary infections, particularly in patients predisposed to developing diaphragmatic defects. Full article

Mechanical ventilation (MV), used in patients with acute lung injury (ALI), induces diaphragmatic myofiber atrophy and contractile inactivity, termed ventilator-induced diaphragm dysfunction. Phosphoinositide 3-kinase-γ (PI3K-γ) is crucial in modulating fibrogenesis during the reparative phase of ALI; however, the mechanisms regulating the interactions among MV, myofiber fibrosis, and PI3K-γ remain unclear. We hypothesized that MV with or without bleomycin treatment would increase diaphragm muscle fibrosis through the PI3K-γ pathway. Five days after receiving a single bolus of 0.075 units of bleomycin intratracheally, C57BL/6 mice were exposed to 6 or 10 mL/kg of MV for 8 h after receiving 5 mg/kg of AS605240 intraperitoneally. In wild-type mice, bleomycin exposure followed by MV 10 mL/kg prompted significant increases in disruptions of diaphragmatic myofibrillar organization, transforming growth factor-β1, oxidative loads, Masson’s trichrome staining, extracellular collagen levels, positive staining of α-smooth muscle actin, PI3K-γ expression, and myonuclear apoptosis (p < 0.05). Decreased diaphragm contractility and peroxisome proliferator-activated receptor-γ coactivator-1α levels were also observed (p < 0.05). MV-augmented bleomycin-induced diaphragm fibrosis and myonuclear apoptosis were attenuated in PI3K-γ-deficient mice and through AS605240-induced inhibition of PI3K-γ activity (p < 0.05). MV-augmented diaphragm fibrosis after bleomycin-induced ALI is partially mediated by PI3K-γ. Therapy targeting PI3K-γ may ameliorate MV-associated diaphragm fibrosis. Full article

An 18-month-old neutered male domestic shorthair cat was presented for an emergency consultation after falling from the second floor. The cat sustained minor traumatic injuries but did not exhibit dyspnea. Routine radiographic examination raised suspicion of a diaphragmatic hernia, but the circumscribed nature of the soft tissues visible in the thorax was atypical for a classic traumatic diaphragmatic hernia. A positive contrast peritoneography highlighted the likely presence of a hernial sac, which strongly suggested a “true diaphragmatic hernia”, also known as “pleuroperitoneal hernia”. This diagnosis was confirmed during laparotomy, which allowed for the visualization of a 3 cm radial diaphragmatic defect in the right ventral quadrant of the pars sternalis. The diaphragm’s edges were rounded. A portion of the falciform ligament and a part of the omentum were protruding through the defect and were contained within a hernial sac. Herniorrhaphy was performed. The cat recovered without complications. Given its presentation and location, ventrally and to the right, this anomaly is analogous to what is described in humans as “Morgagni hernia”. Six other cases of Morgagni hernias have probably been reported in cats but were not identified as such. This case underscores the utility of peritoneography, a straightforward technique useful for diagnosing diaphragmatic hernias, which enables differentiation between acquired traumatic forms and congenital forms, particularly peritoneopericardial hernias and pleuroperitoneal hernias. True diaphragmatic hernias are almost always serendipitous discoveries. Full article

Background: Mechanical ventilation in preterm neonates aims for synchrony, preventing complications such as lung injury. Neurally Adjusted Ventilatory Assist (NAVA) is a unique mode relying on diaphragmatic electrical signals for synchronization. We conducted a review focusing on the long-term consequences of using invasive NAVA in neonates with a focus on bronchopulmonary dysplasia (BPD). Methods: A systematic review following PRISMA explored invasive NAVA in preterm neonates. Primary objectives compared NAVA to conventional ventilation, assessing BPD incidence, ventilation duration, length of stay, and adverse events. Secondary objectives analyzed ventilator parameters. Results: After screening 282 records, the review incorporated two randomized controlled trials for primary outcomes and seven trials for secondary outcomes, including two randomized crossovers, four prospective crossovers, and one retrospective study. NAVA showed reduced oxygen requirement at 28 days but no significant differences in oxygen need at 36 weeks postmenstrual age, total length of stay, or ventilator days. Substantial variations were not observed in adverse events. Ventilator variables favored NAVA, indicating decreased peak inspiratory pressure, tidal volume, work of breathing, and respiratory severity score. Conclusion: Our study found no significant reduction in BPD with NAVA despite short-term benefits. Future large-scale trials are essential to assess NAVA’s impact on long-term outcomes comprehensively. Full article

Radiofrequency thermal ablation (RFA) is widely used and has been accepted for the treatment of unresectable tumors. The leading technique that is used is percutaneous RFA under CT or US guidance. Multicenter surveys report acceptable morbidity and mortality rates for RFA. The mortality rate ranges from 0.1% to 0.5%, the major complication rate ranges from 2% to 3%. Diaphragmatic injury is a rare complication and it is described after RFA of subdiaphragmatic tumors. Most of them are without clinical importance. There are some case reports about diaphragmatic herniation of the intestine into the pleural cavity. We present a case of diaphragmatic perforation resulting in the herniation of the liver into the pleural cavity. A thoracotomy was performed, the liver was lowered back into the peritoneal cavity and the perforation was closed with mesh. Full article

Hiccups-like contractions, including hiccups, respiratory myoclonus, and diaphragmatic tremor, refer to involuntary, spasmodic, and inspiratory muscle contractions. They have been repeatedly described in mechanically ventilated patients, especially those with central nervous damage. Nevertheless, their effects on patient-ventilator interaction are largely unknown, and even more overlooked is their contribution to lung and diaphragm injury. We describe, for the first time, how the management of hiccup-like contractions was individualized based on esophageal and transpulmonary pressure measurements in three mechanically ventilated patients. The necessity or not of intervention was determined by the effects of these contractions on arterial blood gases, patient-ventilator synchrony, and lung stress. In addition, esophageal pressure permitted the titration of ventilator settings in a patient with hypoxemia and atelectasis secondary to hiccups and in whom sedatives failed to eliminate the contractions and muscle relaxants were contraindicated. This report highlights the importance of esophageal pressure monitoring in the clinical decision making of hiccup-like contractions in mechanically ventilated patients. Full article

Considering the prioritization of life-threatening injuries in trauma care, secondary dysfunctions such as ventilator-induced diaphragmatic dysfunction (VIDD) are often overlooked. VIDD is an entity induced by muscle inactivity during invasive mechanical ventilation, associated with a profound loss of diaphragm muscle mass. In order to assess the incidence of VIDD in polytrauma patients, we performed an observational, retrospective, longitudinal study that included 24 polytraumatized patients. All included patients were mechanically ventilated for at least 48 h and underwent two chest CT scans during their ICU stay. Diaphragmatic thickness was measured by two independent radiologists on coronal and axial images at the level of celiac plexus. The thickness of the diaphragm was significantly decreased on both the left and right sides (left side: −0.82 mm axial p = 0.034; −0.79 mm coronal p = 0.05; right side: −0.94 mm axial p = 0.016; −0.91 coronal p = 0.013). In addition, we obtained a positive correlation between the number of days of mechanical ventilation and the difference between the two measurements of the diaphragm thickness on both sides (r =0.5; p = 0.02). There was no statistically significant correlation between the body mass indexes on admission, the use of vitamin C or N-acetyl cysteine, and the differences in diaphragmatic thickness. Full article

Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function. Full article

Background: Acute respiratory distress syndrome (ARDS) in COVID-19 patients often necessitates mechanical ventilation. Although much has been written regarding intensive care admission and treatment for COVID-19, evidence on specific ventilation strategies for ARDS is limited. Support mode during invasive mechanical ventilation offers potential benefits such as conserving diaphragmatic motility, sidestepping the negative consequences of the longer usage of neuromuscular blockers, and limiting the occurrence of ventilator-induced lung injury (VILI). Methods: In this retrospective cohort study of mechanically ventilated and confirmed non-hyperdynamic SARS-CoV-2 patients, we studied the relation between the occurrence of kidney injury and the decreased ratio of support to controlled ventilation. Results: Total AKI incidence in this cohort was low (5/41). In total, 16 of 41 patients underwent patient-triggered pressure support breathing at least 80% of the time. In this group we observed a lower percentage of AKI (0/16 vs. 5/25), determined as a creatinine level above 177 µmol/L in the first 200 h. There was a negative correlation between time spent on support ventilation and peak creatinine levels (r = −0.35 (−0.6–0.1)). The group predominantly on control ventilation showed significantly higher disease severity scores. Conclusions: Early patient-triggered ventilation in patients with COVID-19 may be associated with lower rates of acute kidney injury. Full article