Effect of EPA and HMB on Diaphragm and Limb Muscle Strength in Mechanically Ventilated Patients
Phase: NA
Conditions: Muscle Weakness
Sponsor: Gerald Supinski

Effect of EPA and HMB on Strength in ICU Patients 
 
NCT01270516 
 
3-12-21 
 
Research Description 
 
 

Form B: Research Description 
1.Background.   
Over the past 20 years there has been a dramatic growth in the numbers of patients 
requiring mechanical ventilation to sustain life in the United States. At most large 
medical centers, the number of patients needing more than transient mechanical 
ventilation for respiratory insufficiency has approximately tripled over the past 10 years. 
To deal with this burgeoning number of mechanically ventilated patients, stand-alone 
ventilator units have been created in the United States in most large cities, with literally 
hundreds of mechanically ventilated patients placed in such units in each of the large 
metropolitan areas in this country. In aggregate, we estimate that as many as 50,000 
patients are on sustained mechanical ventilation at any given time in the United States. 
The total cost of caring for these patients now consumes approximately 6% of the yearly 
health care budget, or upwards of 1% of the United States GNP. 
We have recently completed a study at the University of Kentucky that indicates that a 
major process contributing to respiratory failure in critically ill patients is respiratory 
muscle weakness. This work found that the average patient in the UK ICU has a 
diaphragm pressure generation (PDI) in response to phrenic magnetic twitch stimulation 
of only 8 + 3 cm H2O, compared to an accepted normal value of 30 cm H2O for healthy 
adults. Moreover, we found that 70% of patients have twitch PDI measurements that are 
less than a third of normal. These data suggest, moreover, that severe respiratory 
muscle weakness contributes to respiratory failure in mechanically ventilated patients, 
with the weakest patients taking the longest to wean from mechanical ventilation and 
having the highest mortality. 
Unfortunately, there is currently no specific defined treatment to prevent or reverse 
respiratory muscle weakness in mechanically ventilated patients. Theoretically such a 
treatment may improve outcomes in these patients, reducing the time required to wean 
from mechanical ventilation, shortening hospital duration, and potentially improving 
mortality. While no specific treatment is available for patients with respiratory muscle 
weakness, animal studies indicate that there are defined cellular pathways (calpain, 
caspase, free radicals, the proteasomal pathway) that contribute to diaphragm 
weakness in response to the clinical stresses placed on critically ill patients (i.e. 
inactivity due to mechanical ventilation, inflammation secondary to infection, 
hyperglycemia). Moreover, these pathways can be blocked and diaphragm dysfunction 
prevented in these animal models of disease by administration of either 
eicosapentaenoic acid (EPA, a caspase and calpain inhibitor)) or hydroxymethylbutyrate 
HMB (a caspase and PKR inhibitor). Both these agents, EPA and HMB, have been 
safely administered to many patients in previous studies (EPA to prevent vascular 
disease, HMB to improve muscle function in cancer patients). Neither drug has been 
reported to cause significant side effects at the dosages chosen. Both are over the 
counter supplements that can be obtained without prescription in drug stores, health 
food stores and over the internet. 
Based on this information, we postulated that it may be possible to prevent the 
development of diaphragm and limb muscle weakness in critically ill, mechanically 

ventilated patients by early administration of either EPA or HMB. We recently completed 
an IRB approved pilot study examining the effects of EPA and HMB on diaphragm 
strength in a small group of mechanically ventilated MICU patients. This study found 
that both agents induced increases in diaphragm strength and that administration of 
HMB reduced the duration required to wean patients from mechanical ventilation. These 
pilot data were used to submit a grant application to the NIH, entitled “Treatment of 
Skeletal Muscle Dysfunction in ICU Patients”, which was subsequently funded. 
2. Objectives.  
The objective for this study is to determine if administration of either EPA or HMB can 
prevent or reverse the development of respiratory muscle weakness in critically ill, 
mechanically ventilated patients. We plan to randomize patients accepted into this 
protocol to administration of either a control (saline enteral control solution), EPA 
administration, HMB, or the combination of EPA +HMB. Drugs will be administered for 
10 days and measurements of muscle strength (diaphragm and quadriceps), muscle 
size (diaphragm and quadriceps thickness by ultrasound), and muscle signaling protein 
profile (obtained using vastus lateralis muscle biopsy specimens) will be performed 
immediately before and immediately after the period of drug administration (days 1 and 
11). An additional assessment of muscle strength, muscle size and signaling protein 
profile will be made at 10 days after completion of the drug administration regimen (i.e. 
on day 21). As part of the study, patients will be weaned from mechanical ventilation 
using the University of Kentucky ventilator separation protocol, the nutritional regimen 
will be reviewed with the MICU nutritionists to ensure it conforms to study requirements, 
and it is expected that patients will receive standard MICU mobilization therapy by 
physical therapy.    
We will also perform a chart review and assess ventilator mechanics (respiratory 
system static compliance and inspiratory airway resistance) at the time of strength 
assessment. We would expect that mean diaphragm and quadriceps muscle strength 
and size measurements will be similar for four groups immediately before initiation of 
drug administration. Our hypothesis will be supported if post drug administration 
diaphragm and limb muscle strength are higher for patients receiving EPA , HMB and/or 
the combination of EPA+HMB when compared the control group receiving no active 
drug. We will also determine if administration of these agents shortens the time required 
to wean patients from mechanical ventilation. 
3. Study Design.  
The basic study design is to:  
(a) measure magnetic stimulated diaphragm Pdi twitch and quadriceps twitch strength, 
measure diaphragm and quadriceps thickness using ultrasonography, obtain a vastus 
lateralis muscle biopsy, determine lung mechanics (respiratory system compliance, 
determine airway resistance), and perform a chart review,  
(b) randomize patients to treatment with either: 

Placebo this will be given as two tablespoons of salt water solution, 1.5 grams of amino 
acids and 0.2 teaspoons of corn oil every 12 hours,  
Eicosapentaenoic acid (EPA); this will be given as two tablespoons of salt water, 1.5 
grams of amino acids  and 1000 mg EPA every 12 hours, 
Hydroxymethylbutyrate (HMB); this will be given as two tablespoons of salt water 
solution, 1500 mg HMB  and 0.4 teaspoons of corn oil every 12 hours,  
HMB and EPA; two tablespoons of salt water, 1500 mg HMB and 1000 mg EPA every 
12 hours. 
(c) continue drugs for 10 days then 
(d) on day 11, remeasure magnetic stimulated diaphragm Pdi twitch and quadriceps 
twitch strength, measure diaphragm and quadriceps thickness using ultrasonography, 
obtain a vastus lateralis muscle biopsy, and determine lung mechanics (respiratory 
system compliance, determine airway resistance), and 
(e) on day 21, remeasure magnetic stimulated diaphragm Pdi twitch and quadriceps 
twitch strength, measure diaphragm and quadriceps thickness using ultrasonography, 
and determine lung mechanics (respiratory system compliance, determine airway 
resistance) if the patient is still requiring mechanical ventilation.  
In preliminary work we have verified that HMB easily goes into solution when placed in 
saline. In addition, EPA goes into solution easily when placed in a mixture of oil and 
saline (in a 1:3 ratio). We will plan to administer the agents at 7 AM and 7 PM whenever 
possible so that the administration of these agents does not interfere with dosing of 
patient medications. The IDS will perform both blinding and randomization of the agents 
provided. The IDS will perform randomization using an online computer program (www. 
Randomization.com). Note that HMB has no side effects at any dosage. At higher doses 
than the doses to be used in the current study, EPA can interfere with clotting and 
potentiate the effects of aspirin and Coumadin. 
For each chart review we will obtain the following information: age, sex, diagnoses, 
medications, reason for institution of mechanical ventilation, vital signs, bedside 
parameters of mechanical ventilation use (including mode of ventilation, duration of 
ventilation, level of oxygen, breath volume and rate, % triggered breaths), most recent 
arterial blood gas values, chest radiograph readings, recorded assessments of mental 
status. 
4.  Study Population.  
 
Adult patients requiring mechanical ventilation for respiratory failure for more than 24 
hours in one of the University of Kentucky adult ICU’s will be asked to participate. An 
additional inclusion criterion is that the attending physician caring for the patient must 
anticipate that the patient is likely to remain on mechanical ventilation for more than 24 

hours. We will include patients regardless of gender, race, or adult age. It is hoped that 
sufficient minorities and women will be studied so that the subject population is 
representative of the general patient population, but we will be somewhat constrained 
by the numbers of available patients and the day to day makeup of the patient 
population in the UK ICU’s. Inclusion of minorities and women will make the study 
results more generally applicable. 
Patients will be excluded: (a) if the physician caring for the patient determines that the 
patient is too unstable to tolerate these measurements, (b) if the patient requires high 
dose pressors (more than 15 mcg/min of norepinephrine or more than 15 mg/kg/min of 
dopamine), (c) if the patient requires more than 80% FiO2 or more than 15 cm H2O of 
PEEP, (d) if the patient has a cardiac pacemaker or implanted defibrillator, (e) if the 
patient has received neuromuscular blocking agents within the 48 hours preceding 
testing, (f) if the patient has a history of a preexisting neuromuscular disease, (g) if the 
patient has a history of recent variceal bleeding, (h) if the patient has profound and 
uncorrectable hypokalemia (less than 2.5) or hypophosphatemia (less than 1.0), (i) if the 
patient is a pregnant female, (j) if the patient is a prisoner, (k) if the patient is 
institutionalized, (l) if the patient is allergic to fish, (m) if the patient cannot receive 
enteral medications, (n) if it is thought that the patient is terminal and will have care 
withdrawn within days,  (o) in addition, if a given patient has a coagulopathy at the time 
of enrollment into the study (defined as an elevation of the INR above 1.5, an aPTT 
50% or more above the normal range, or a platelet count less than 60,000), we will not 
perform muscle biopsies on the patient but will collect the other data planned. 
 
5. Subject Recruitment.   
Our goals are to recruit and randomize 80 patients into the study (2 patients/month).  If 
patients drop out of the study during initial measurements (because of unwillingness to 
complete the protocol or for technical issues, e.g. inability to attain supramaximal 
conditions during magnetic stimulation) we will recruit additional replacement subjects 
so that the desired randomized numbers (80 total) are achieved. We believe this is a 
realistic timetable. Our institution has three MICU attending services and currently has 
40-50 patients/day on these services, with the great majority (i.e. 30-40 at any given 
time) on mechanical ventilators. When performing our pilot studies we found that is 
possible to recruit as many as 3 patients/week from our MICU population. As a result 
the recruitment requirements of the current study are a fraction of the number of 
patients available from the MICU population at the University of Kentucky. It should also 
be noted that, the families that we approached to obtain pilot data for this proposal 
agreed enthusiastically to participate in the study. As a result, based on our recent track 
record, we believe we can easily recruit the patients required to complete these 
protocols. 
The PI of this study will meet 3-5 times a week with the MICU attendings at the 
University of Kentucky to identify patients who would be suitable candidates for this 
study based on the study inclusion and exclusion criteria. The MICU attending will then 
approach the patient and the patient’s LAR (the legally appointed person that can 
provide consent) to determine if the patient agrees to allow the PI to discuss the study 

with them. The PI will then approach the family and review the study with them and ask 
if they wish to participate. The consent form will be reviewed with the patient and their 
LAR detailing the risks associated with the planned measurements. If the patient and 
LAR agree, the consent form will be signed and the investigator will obtain the required 
equipment to assess quadriceps and diaphragm twitch measurements. Measurements 
will be made at the bedside, in the patient’s room. No form of advertisement will be used 
for this study. 
6.  Informed Consent.   
After identification of a potential study subject during the interaction between the PI and 
the MICU attending, the subject and their LAR will be approached in the MICU within 
the next 1-3 hours. If they decide to be included in the study, the consent form will be 
reviewed with them immediately. The PIs (Dr. Gerald Supinski and Dr. Leigh Ann 
Callahan) will obtain all informed consents for the study. To eliminate coercion, all LARs 
and study participants will be told that refusal to participate will in no way influence their 
care while at the University of Kentucky. Consent will be documented by having both 
the patient and the LAR sign the consent form. Because most ICU patients receive 
some form of sedation, it is the intent of the PI to always inform the LAR as well as the 
patient and always have the LAR sign the consent form. Under certain circumstances 
the patient may be so disabled that signage of the consent form is not possible (e.g. 
both hands are instrumented with IV’s and pressure transducers) or may be very 
sedated. In the event of physical inability of the patient to sign the consent form, the 
LAR alone will sign the form. 
7. Research Procedures.  
It will first be verified that the patient does not meet any exclusion criteria and that 
informed consent has been obtained.  
Diaphragm Strength: The PI will then place gastric and esophageal balloon tipped 
catheters to allow measurement of transdiaphragmatic pressure (Pdi). We will employ 
sterile single use commercially available balloon tipped catheters (from Ackred Medical, 
NJ) which have been manufactured specifically for this use and are in widespread 
usage in the US and other countries for this application.  Each catheter will be inserted 
via the nose after topical lidocaine application (1 cc of 1% Lidocaine gel applied to the 
outside of each catheter) and directed via the esophagus. One catheter so placed will 
be inserted until the tip lies in the stomach while the other will be left in the esophagus. 
Correct placement will be verified by connecting the catheters to Validyne pressure 
transducers and assessing pressure waveforms during various maneuvers. The 
correctly placed gastric catheter will generate a positive pressure during spontaneous 
breathing efforts, mechanical breaths, and with gentle pressure over the stomach. The 
esophageal catheter should generate negative pressures during spontaneous breathing 
efforts, positive pressures during mechanical breaths, and little or no pressure during 
gentle pressure over the stomach. The pressure signals from the two catheters will 
“added” (i.e. the absolute swings in gastric and esophageal pressure during stimulation 
will be summed) to obtain transdiaphragmatic pressure (Pdi). Pressure signals will be 
recorded continuously using a flat bed strip recorder. Once pressure signals are being 
recorded, a sterile pneumatic occlusion valve will be placed in the ventilator circuit 

between the endotracheal tube and the ventilator tubing y connector. Subsequently, 
bilateral magnetic coils will be placed over the phrenic nerves on the anterior neck. The 
occlusion valve will be activated between spontaneous breaths for approximately half a 
second and, during the occlusion, bilateral magnetic pulses will be applied to the 
phrenic nerves to generate a diaphragmatic twitch. Twitches will be repeated to obtain 
three reproducible maximal twitches. This assessment will take approximately 5 
minutes. Once these measurements are completed, the esophageal and gastric 
balloons will be withdrawn. 
Quadriceps Strength: For this assessment, we will place a quadriceps board (Bailey 
Manufacturing) under the left leg, positioned so that the knee lies immediately over the 
apex of the apparatus. We will then strap a force transducer (Interface, Model SSM-AJ) 
over the lower leg, positioned at one-fourth the distance between the lateral malleolus of 
the ankle and the knee. We will first assess twitch force with the apparatus set at the 
fourth “peg” position, corresponding to a 90o angle between the thigh and lower leg (we 
have found this corresponds to the optimal angle for quadriceps force generation in the 
majority of subjects). We will then adjust magnetic field strength during femoral nerve 
stimulation to ensure optimization of twitch force (i.e. usually at 85% of the maximum 
Magstim magnetic field strength). Five consecutive twitches will be performed at this 
setting. Subsequently, to verify the 90o knee angulation setting represents the optimal 
preload, twitches will be repeated at knee angle settings above and below 90o (i.e. at 
“peg” settings of 2 and 6). The average of the three best twitch forces generated at the 
optimal knee angle with supramaximal field strength will be averaged and this measure 
will be reported as the quadriceps twitch force. 
Muscle Size: Diaphragm thickness will be assessed using a 2D ultrasound unit 
(Sonosound). For this determination an abdominal ultrasound transducer will be placed 
over the right eighth-ninth intercostal space in the mid axillary line. The probe will be 
angled to identify the diaphragm which appears as a three layered structure just above 
the liver (see figure 8); the echogenic outer lines of this structure represent the 
peritoneal and diaphragmatic pleural layers with the inner layer representing muscle. 
With spontaneous inspiration, this portion of the diaphragm thickens, and then thins at 
end expiration. Images will be taken at end expiration and diaphragm thickness 
measured with the sonoprobe caliper utility. In our experience it is easier to identify the 
diaphragm and measure its thickness on the right side than on the left, and it is because 
of this that we have chosen to assess right diaphragm thickness. Our normal controls 
have had end expiratory diaphragm thicknesses between 0.40 and 0.55 cm. We will 
employ a recently described approach to assess quadriceps size using ultrasound. The 
quadriceps is composed of four muscles, so this technique measures the thickness of 
each of these components of the quadriceps (vastus lateralis (VL), vastus medialis 
(VM), vastus intermedius (VIM), rectus femoris (RF), determined as the distance from 
the adipose tissue-muscle interface to the intermuscular interface for each muscle. The 
measurements for the VM will be taken at 30% and those for the VL, VIM, and RF at 
50% of the distance between the lateral condyle of the femur and the greater trochanter.  
Muscle Biopsy: We plan to biopsy the vastus lateralis leg muscle to obtain tissue for 
assessment of signaling pathways and single fiber force-pCa assessments. Biopsy of 
the vastus lateralis is a widely used, conventionally accepted approach to obtaining 

skeletal muscle for analysis in patients, this procedure is very safe, and one of the 
investigators (Dr. Callahan) has significant experience in obtaining tissue by this means. 
For all these reasons, we plan to obtain vastus lateralis biopsies whenever possible in 
recruited patients (if a clotting disorder is present but a patient otherwise qualifies for 
study, we will include the patient but omit the muscle biopsy). Patients will be on 
continuous tube feedings (we believe it would be incompatible for ethical ICU care to 
fast these critically ill patients before obtaining biopsies). Patients will be at bed rest 
over night prior to performance of all biopsies and, more specifically, no patient will be 
exercised over night in the morning before biopsies are obtained. For the biopsy 
procedure, the skin will be sterilely prepped over the muscle, the skin infiltrated with 
lidocaine, a small skin incision made, and a Bergstrom needle advanced into the 
muscle. Suction will be applied to the Bergstrom needle and two-three biopsies taken 
(total anticipated muscle yield of 200 mg). The needle will be withdrawn, a portion of the 
biopsy will be dissected free of adipose tissue and frozen in liquid nitrogen for latter 
assessment of signaling pathway protein levels. The remaining tissue will be processed 
for single fiber force-pCa determinations and fiber type determination using 
histochemistry.following the biopsy, pressure will be applied at the biopsy site and an 
occlusive dressing placed. The investigators will return to examine the biopsy site for 
seven days to confirm adequate site healing.  
Ventilator Mechanics: The mechanical ventilator will then be viewed and ventilator 
settings (tidal volume, mode of ventilation, oxygen concentration, minute ventilation, 
breathing frequency, PEEP level) recorded. Respiratory system static compliance, 
airway resistance, and autoPEEP levels will also be determined and recorded used the 
Siemens ventilator built in diagnostic module. 
Clinical Parameters: These parameters (age, gender, diagnoses, diagnosis of infection 
[positive cultures or clinical diagnosis of sepsis], antibiotic usage, glucose levels, 
albumin levels, BUN, SOFA scores, time on mechanical ventilation before testing, use 
of corticosteroids, vital signs, reason for institution of mechanical ventilation, mode of 
mechanical ventilation, duration of ventilation, FiO2 level, breath volume and rate, % 
triggered breaths, most recent arterial blood gas values, chest radiograph readings) will 
be obtained from the medical record using values collected as closely as possible to the 
time at which physiological data measurements are made. To provide an assessment of 
pre-hospital function, family members will be asked four questions: (a) how far could the 
patient ambulate, (b) how many flights of steps could the patient go up, (c) which 
activities of daily living (dressing, carrying objects, performing daily grooming tasks), if 
any, were impaired, and (d) did the patient have difficulty standing from a sitting position 
or lifting objects over their head. 
Hospital Outcomes: After recruitment into studies, electronic hospital records will be 
reviewed at weekly intervals to determine the time from the point of initial study 
measurements to successful weaning from mechanical ventilation (defined as remaining 
off all mechanical ventilation for more than 4 days). Alternative outcomes that will be 
recorded, for patients that are not weaned from mechanical ventilation, include transfer 
to a chronic facility for long term weaning from mechanical ventilation (i.e. an LTAC) or 
death. Deaths will be further subclassified as death due to withdrawal of care and death 
due to progression of disease. We will also record total ICU stay, total days of hospital 

stay, and incidence of recurrent respiratory failure, defined as a requirement for 
reintubation either during the initial hospitalization or at any time out to day 60 after 
entry into the study.  
Ventilator Separation Protocol: All patients will be weaned using the University of 
Kentucky Ventilator Separation Protocol. This protocol is currently employed in all 
University of Kentucky adult intensive care units and provides a standardized approach 
to weaning patients from mechanical ventilation. Every morning mechanically ventilated 
patients are evaluated for potential weaning trial employment. Inclusion criteria for a 
spontaneous breathing trial (SBT) includes evidence that the patient is: (a) awake, (b) 
has a gag reflex, (c) has a cough reflex, (d) has a RASS scale of -1 to 0, (e) has a FiO2 
≤50% and PEEP applied ≤ 6 H2O, (f) has a pH ≥7.35, (g) has a MAP of ≥ 65 mm Hg, 
(h) is off pressor drips (e.g. epinephrine) save for doses of dopamine ≤ 5 mcg/kg/min or 
dobutamine ≤ 5 mcg/kg/min, and (i) is not on an intra-aortic balloon pump. Exclusion 
criteria include increased intracranial pressure, use of paralytics, active seizures, 
excessive agitation and active myocardial ischemia. If the patient meets all inclusion 
criteria and has no exclusion criteria, sedation will be reduced and the patient will 
receive a spontaneous breathing trial (SBT) for 1 hour, with an ABG drawn at the end of 
the trial. During the trial patients will be monitored serially for evidence of weaning 
success or failure (i.e. observed at the 5, 15, 30, 45 and 60 minute time points into the 
trial).Trials will be stopped if any of the following events occur: (a) oxygen saturation 
falls below 90% for more than three minutes, (b) the heart rate increases above 130 or 
falls below 60, (c) systolic blood pressure falls below 90 or increases above 180, (d) the 
mixed venous oxygen saturation falls below 60 mm Hg (if monitored), (e) the respiratory 
rate increases above 35 or the RSBI increases above 100, (f) the patient develops 
chest pain or a new dysrhythmia, (g) the patient’s mentation worsens, or (h) the patient 
develops diaphoresis, distress or excessive anxiety. Blood gases will be examined at 
the end of trials and trials will be judged a success if, in addition to passing the criteria in 
the preceding sentence, the final paO2 is greater than 60 mm Hg and there is no 
respiratory acidosis. If the patient achieves a successful SBT, the attending will be 
asked for an extubation order. If the trial fails, the patient will be placed on their previous 
ventilator mode and settings. If trial failure is associated with evidence of excessive 
sedation, sedation levels will be reduced in preparation for the next day trial. 
Nutrition Protocol: At study entry the nutritional plan developed by the MICU nutrition 
support service will be reviewed with the nutritional consultant for the patient. In general, 
the following protocol will be used by this service to provide tube feeds to our patients 
(prepared with input from Barbara Magnuson, head of the MICU nutritional team at the 
University of Kentucky): 
(1) First, basal energy expenditure (i.e. caloric requirements) will be estimated based on 
the Harris- Benedict equations:  
BEE Men = 66 + (13.7 x Wt kg) + (5.0 x Ht cm) – (6.8 x Age yrs) 
BEE Women = 665 + (9.6 x Wt kg) + (1.7 x Ht cm) – (4.7 x Age yrs) 
(2) Second, adjustment will be made for obesity if >125% ideal body weight by adding 
25% of the difference between BEE for actual and ideal body weight to the BEE for 
ideal body weight. 

(3) Third, a multiplier will be used to adjust caloric requirements to adjust for severity of 
illness; 1.2 for stroke, 1.3 for pneumonia or ARDS 
(4) Fourth, we will estimate protein needs for unstressed patients as 0.8-1.0 gm/kg, for 
mild stress as 1.0-1,2 gm/kg, for moderate stress as 1.2-1.5 gm/kg, for infection or 
severe stress as 1.3-1.6 gm/kg; actual body weight will be used unless >125% of ideal 
body weight in which case adjusted body weight will be used, as calculated in (2) 
(5) Fifth, additional adjustments in nutrition will be made for patients with renal or liver 
failure based on the University of Kentucky Adult Nutrition Support Handbook 
(6) Sixth, an enteral feeding product is chosen; for the present study a good formulation 
is Jevity 1.2 which is composed of 18.5% protein calories, 29% fat calories, and 52.5% 
carbohydrate calories. For Jevity 1.2, the total calories required per day as calculated in 
(3) will be divided by 1.2 cal/ml to derive the volume of Jevity 1.2 to be provided over 24 
hours. Of note, patients receiving Juven will not be enrolled in the study as this product 
contains HMB (It is not the current practice of MICU physicians at UK to use this 
formula). We will also not study any patients fed any other tube feed formulations 
containing eiter EPA or HMB. 
(7) Once the Jevity 1.2 volume is determined, the protein provided by this delivery will 
be calculated; additional protein to reach the daily protein needs of the patient will be 
provided by adding Beneprotein supplement to bring the total protein delivery to that 
calculated in (4). 
(8) Enteral access will be established, if not already present, as per UK Enteral Access 
Guidelines 
(9) The volume of enteral feeding will be administered as a continuous feed delivered by 
a pump over 24 hours. 
8. Resources. The PI has studied various aspects of respiratory muscle function and 
dysfunction over a 25 year period. During this time, the PI has published approximately 
100 peer reviewed papers on original research related to respiratory muscle and other 
critical care topics, as well as 150 abstract presentations at national meetings. The PI 
has given state-of-the art presentations on assessment of Pimax at the national 
American Thoracic Society meeting and is a co-author of the ATS-ERS International 
statement on measurement of respiratory muscle function. The PI has published several 
papers employing assessment of both Pimax and transdiaphragmatic pressure 
measurements. In addition, the PI has practiced critical care medicine for 25 years, 
measuring Pimax in approximately 2000 patients over that time span. In addition, in 
both northern Ohio and Western New York the PI was the regional resource providing 
measurement of transdiaphragmatic pressure when this was required clinically.  
The PI is currently funded by an NIH grants as PI and also receives support as a co-
investigator from another NIH grant held by Dr. Callahan. The PI’s laboratory is 
equipped with a cart containing all the apparati required to obtain transdiaphragmatic 
pressure readings, including Ackrad balloon tipped catheters, Validyne differential 
pressure transducers, Validyne preamplifier racks (3 preamps/rack, two racks), a 
pressure manometer for calibration, and a two channel recorder. This cart is mobile and 
can be moved to the ICU rooms when needed to assess Pdi-twitch. The cart is 

equipped with sterile wipes that will be used to disinfect all exposed surfaces before and 
after entrance and exit from patient rooms. The cart is also equipped with two MagStim 
200 magnetic stimulators equipped with dual figure of eight coils for phrenic nerve 
stimulation. This device is FDA approved and is used regularly for the purpose of 
performing Pdi-twitch assessment in the USA and around the world.  
Ackrod balloon tipped catheters and t-pieces will be disposed of after use and new 
catheters/tpieces employed for every set of measurements. The ventilator circuit 
pneumatic occlusion valves will be sterilized by autoclaving prior to use.  
9. Potential Risks 
The magnetic twitch assessment procedures described in the protocol have been used 
extensively in both the US and England. We have performed this assessment many 
times in our ICU population over the past year both to recruit patients into other studies 
and to perform diagnostic studies on ICU patients for routine management issues (i.e. to 
detect diaphragm paralysis, to assess the response to treatment for myasthenia and 
other neuromuscular diseases, to assess patients with respiratory failure of unclear 
etiology). We have not had a single complication from our use of magnetic stimulation 
per se or from placement of esophageal and gastric balloon tipped catheters for 
pressure assessment. In addition, the PI recently visited Dr. Polkey and Dr. Moxham’s 
laboratories in England and spoke directly with them regarding their experience with the 
magnetic twitch-Pdi technique. They have not observed a serious complication from this 
procedure and reported only minor temporary discomfort from the delivery of the 
magnetic stimulus or from placement of the esophageal and gastric balloons. There is 
no reported long term risk reported in response to single stimulus excitation of 
peripheral nerves (such as the phrenic nerve) using a magnetic stimulating device. The 
magnetic stimulator to be employed (Magstim 200) is commonly used for the application 
proposed and is FDA approved for stimulation of peripheral nerves. 
We extensively searched the Internet and other sources and, to our knowledge, 
hydroxymethylbutyrate (HMB) has no known side effects at any dosage. This agent is a 
biopharmaceutical, a normal breakdown product of leucine, and is present in small 
quantities in all human beings. The other agent to be employed in the present study, 
eicosapentaenoic acid (EPA) has only been reported to produce minor side effects 
(occasional nausea, diarrhea, heartburn, skin rash, itching) at the dosage to be 
employed in the current study. At high doses this agent may potentiate the effects of 
Coumadin or interfere with platelet function; for this reason we will not use doses higher 
than the one included in the study protocol. Both drugs are available as over the counter 
medicines and are not subject to FDA regulation. 
Risks associated with biopsy of the vastus lateralis muscle include bleeding into the 
biopsy site and potential infection at the site. There should be no risks associated with 
measurement of muscle size via ultrasound or chart review to assess clinical 
parameters. As indicated in the above paragraphs most of procedures included in this 
study are extremely safe, with no possibility of patient injury due to ultrasound 
measurement, magnetic stimulation or HMB administration. In addition, it is difficult to 
imagine that the low dose of EPA to be used will produce significant injury. The only 
component of the experimental plan that could potentially cause patient injury is the 

vastus lateralis biopsy. If the investigators detect problems as a result of the biopsy, or if 
the family or professionals caring for the patient complain of biopsy complications or 
report other possible complications that result from these studies, we will stop 
experimentation, and the patient will be withdrawn from the study. 
10. Safety Precautions.  
To minimize the risk of bleeding from balloon placement, patients with variceal bleeds 
will be excluded from this study. Because assessment of PdiTw involves transient 
removal from mechanical ventilation, patients requiring high levels of PEEP, high levels 
of oxygen or in severe shock will be excluded from study.  As indicated in above 
paragraphs, these procedures have been extensively employed in London, UK to 
evaluate patients in both outpatient and ICU settings and the investigators there have 
not observed complications with either balloon placement or magnetic stimulation. In 
fact there are no reported adverse effects using magnetic stimulation to assess 
peripheral nerves except for an isolated report of interference with pacemaker function 
in one patient. For this reason, we will also exclude patients with pacemakers from this 
study. As per standard ICU protocols at UK, during all measurements all patients will be 
connected to invasive or non-invasive blood pressure transducers, EKG monitors, and 
pulse oximetry monitors, providing a continuous assessment of patient pulse rate, blood 
pressure, and oxygen saturation during assessments. If desaturation to less than 90%, 
a raise in heart rate by more than 20 beats, a rise in mean blood pressure more than 10 
torr or a fall in mean blood pressure of more than 10 torr is noted, measurements will 
stop. The PI will return at 24 hours after each study to the patient’s bedside to ascertain 
if any untoward events have occurred and to elicit feedback regarding any concerns that 
the patient and/or their family and/or the nursing staff caring for the patient may have If 
problems are encountered they will be reported to the IRB and data monitoring board. 
To minimize the risk that the patient’s privacy would be compromised, all data will be 
placed into a file at the conclusion of the bedside study and this file will be placed into a 
locked file cabinet in the office of the PI. Each file will be assigned a research number, 
and all data abstracted from the file of an individual subject will be referred to in later 
data analysis by this patient file number with no reference to any identifiable patient 
characteristics (e.g. name, SS number, hospital number). The mean data for the study 
will also be placed in a mean data file and this information also kept in the locked file 
drawer in the PI’s office. 
 
11. Benefit vs. Risk.  
Based on our previous experience and the reported experiences of others, we believe 
the major stress that will be felt by subjects will be the discomfort associated with 
balloon-tipped catheter placement into the esophagus as well as the momentary 
sensation associated with magnetic stimulation. The sensation associated with 
magnetic stimulation is not painful but is more like a “jolt” related to the sudden 
involuntary contraction of the muscles being stimulated distal to the nerve. We do not 
believe these techniques pose a significant risk to patients, in that no long term adverse 
consequences should occur providing the exclusion criteria used for this study are 
rigorously followed.  

Neither of the drugs to be used (HMB or EPA) has been reported to cause side effects 
at the dosages chosen. In fact, we did not find report of any side effects from these 
doses of HMB. EPA has been reported to cause minor side effects in occasional 
patients (nausea; diarrhea, heartburn, skin rash, itching, and joint, back, and muscle 
pain). Both agents are over the counter agents that are sold as health food supplements 
and are available without prescription. Neither is an FDA regulated substance. 
Patients randomized to drug treatment (HMB and/or EPA) may well be stronger as a 
result of this treatment and may well have a shortened ICU stay, a lower mortality, and 
less long term morbidity (i.e. better ambulation, less dyspnea).There are, however, 
important potential benefits for the patients taking part in this study. To date, our work in 
the ICU indicates that the average twitch transdiaphragmatic pressure generated by 
ICU patients is only 23% of the value seen in normal healthy adults. In animal studies, 
both HMB and EPA have been shown to preserve diaphragm strength in models of 
critical illness. If these drugs also prove effective in preserving or improving diaphragm 
strength in ICU patients, the patients randomized to receive these agents may be able 
to recover from respiratory failure faster and be weaned from mechanical ventilation 
sooner than control patients receiving control solutions. 
12. Available Alternative Treatments.  
Currently, there is no defined drug treatment to prevent or reverse the development of 
weakness in critically ill patients. As a result, there is no acceptable alternative to the 
clinical trial drugs (HMB, EPA) planned for these studies. While one might think that 
androgens would be an acceptable alternative, a recent study found these agents 
worsen lung function and actually had deleterious effects on outcomes when tested in 
surgical ICU patients. Currently there are no drugs that have been identified that can 
improve respiratory muscle strength in critically ill patients. As a result, there are no 
alternative treatments to replace the agents being studied in the current project. 
13. Research Materials, Records, Privacy.  
All data collected from the study (i.e. tracings of pressure measurements, 
demographic/clinical data obtained from chart review, the survey form filled out by the 
attending physician) will be placed in a folder which will be stored in a locked filing 
cabinet in the office of the principal investigator in MN616. None of this information will 
be shared with other investigators. All folders will be given a study number and further 
analysis of mean data obtained from patient study folders will be carried out with only 
the patient study number as identification. Folders containing mean data will also be 
stored in the locked filing cabinet in MN616. 
14. Confidentiality.   
For publication, no individual identifying features of the patients will be included in 
abstracts and papers generated using the data collected in this study.  As indicated in 
section 13, all records will be kept in a locked file cabinet in the PI’s office. The records 
for this study will be kept until seven years after the data is published, in keeping with 
current NIH recommendations on data archiving. The data will be kept in the locked file 
cabinet in MN616 at least until the data is published and then transferred to a second 
locked archival filing cabinet in the PI’s office. At seven years after publication all data 

will be destroyed by shredding the documents. All data collected from the study (e.g. 
pressure, force, and muscle size measurements, demographic/clinical data obtained 
from chart review) for a given patient will be placed in a folder which will be stored in a 
locked filing cabinet in the office of the principal investigator in MN616. All folders will be 
given a study number and further analysis of mean data obtained from patient study 
folders will be carried out with only the patient study number as identification. Folders 
containing mean data will also be stored in a locked filing cabinet in MN616 of Chandler 
Medical Center, University of Kentucky. For publication, no individual identifying 
features of the patients will be included in abstracts and papers generated using the 
data collected in this study. 
15. Payment.  
No subject will be paid for participation in the study. 
16. Costs to Subjects.  
There will be no cost to subjects for participation in the study. 
17A. Data Monitoring: Data Safety Monitoring Board 
A detailed description of our Data Safety Monitoring Plan is attached. In brief, to monitor 
the long term conduct of the study, including monitoring of adverse effects, we will 
employ the study monitoring board provided by the CCTS at the University of Kentucky. 
This board will include the chair, Lisa Tannock, MD, Linda Rice, RN, and other current 
members of the DSMB. 
Monitoring for adverse events will be conducted in real-time by the study investigators 
and study coordinator. Risks involved with this study are considered greater than 
minimal risk. For this reason, we will utilize the standing independent Data Safety 
Monitoring Board (DSMB) as chartered by the University of Kentucky Center for Clinical 
and Translational Science (CCTS) to monitor the safety of the study. 
The DSMB will meet three times a year and will review subject recruitment, adverse 
effects, side effects, laboratory results, withdrawals, protocol violations, and 
inclusion/exclusion criteria. More frequent meetings will take place if necessary. The 
board will compile a report for each meeting and present their findings to the PI.  
We will also have the DSMB provide the recommendations they send to us to the 
NHLBI. We will also provide the NIHLBI with the meeting dates of the DSMB. The NIH 
will also be notified of all adverse effects and will have our SAE form send to her along 
with the safety officer, the IRB and the DSMB.  
17B. Safety Monitoring    
During the execution of this protocol the nurse assigned to the patient will be asked to 
be present in the room to provide an ongoing assessment of patient vital signs. As per 
standard ICU protocols at UK, during all measurements all patients will be connected to 
invasive or non-invasive blood pressure transducers, EKG monitors, and pulse oximetry 
monitors, providing a continuous assessment of patient pulse rate, blood pressure, and 
oxygen saturation. If desaturation to less than 90%, a raise in heart rate by more than 
20 beats, a rise in mean blood pressure more than 10 torr or a fall in mean blood 
pressure of more than 10 torr is noted, measurements will stop and the patient will be 

returned to mechanical ventilation. As per standard ICU protocols at UK, during all 
measurements all patients will be connected to invasive or non-invasive blood pressure 
transducers, EKG monitors, and pulse oximetry monitors, providing a continuous 
assessment of patient pulse rate, blood pressure, and oxygen saturation during 
assessments. If desaturation to less than 90%, a raise in heart rate by more than 20 
beats, a rise in mean blood pressure more than 10 torr or a fall in mean blood pressure 
of more than 10 torr is noted, measurements will stop. The PI will return at 24 hours 
after each study to the patient’s bedside to ascertain if any untoward events have 
occurred and to elicit feedback regarding any concerns that the patient and/or their 
family and/or the nursing staff caring for the patient may have If problems are 
encountered they will be reported to the IRB and data monitoring board. The PI or Dr. 
Callahan will also return to inspect the muscle biopsy site daily for seven days to 
confirm adequate healing at the site.  
The PI will provide the nurse with his cell phone number at the completion of each data 
collection with instructions to call the PI if any untoward events occur within the 
following 24 hours. In addition, the PI will return at 24 hours after each study to the 
patient’s bedside to ascertain if any untoward events have occurred and to elicit 
feedback regarding any concerns that the patient and/or their family and/or the nursing 
staff caring for the patient may have. If problems are encountered they will be reported 
to both the monitoring board described in the preceding section and to the IRB board by 
the PI. 
18. Subject Complaints.  
After obtaining consent, the patient and his family will be given  a sheet providing the 
office number, paging number, and cell phone for the PI and instructions on how to 
contact the PI. We will provide the patient and his family any information obtained from 
the Pimax and Pdi-twitch measurements, and will provide them with information as to 
whether the measured numbers are normal or reduced. If any complaints are registered 
by a subject these will be recorded and placed in the patient’s study file. This 
information will be handled in a confidential matter (see above). 
19.Research With Non-English Speaking or Foreign Cultures:   
We do not plan to study patients that, because of language barriers, cannot understand 
English. This study is too complicated to be dealt with adequately through interpreters. 
20.HIV Research:  
This is not applicable. 
21. FDA Regulated Research:  
This is not applicable. 
References 
1.Watson AC, Hughes PD, Louise Harris M, Hart N, Ware RJ, Wenon J, Green M, 
Moxham J. Measurement of twitch transdiaphragmatic, esophageal, and endotracheal 
tube pressure with bilateral anterolateral magnetic phrenic nerve stimulation in patients 
in the intensive care unit. Crit Care Med. 2001 Jul;29(7):1325-31. 

2. Laghi F, Cattapan SE, Jubran A, Parthasarathy S, Warshawsky P, Choi YS, Tobin 
MJ. Is weaning failure caused by low-frequency fatigue of the diaphragm? Am J Respir 
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3. Supinski GS, Deal EC, Kelsen SG.  Comparison of aminophylline and caffeine effects 
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5. Gerald Supinski; ATS Statement, 2002. Respiratory Muscle Testing, Editor and 
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