Effects of COVID-19 Infection and Critical Illness on Diaphragm Tissue Characteristics and Movement, Visualized With MRI

Study Overview
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Brief Summary
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COVID-19-infection has a large impact on the respiratory system and possibly on the diaphragm, the main respiratory muscle. In ICU-patients, diaphragm weakness is associated with prolonged ICU-stay, difficult weaning and increased mortality. Our research group recently found evidence for fibrosis and expression of genes involved in fibrosis as well as viral infiltration of the SARS-CoV-2 virus in diaphragm biopsies from COVID-19 ICU patients. This finding suggests a unique manifestation of diaphragm injury in COVID-19 patients after mechanical ventilation. However, it remains unclear what the exact nature and location of diaphragm injury is. Additionally, it is largely unknown whether this injury affects the movement of the diaphragm, but this might have important clinical implications. Therefore, we aim at visualizing the tissue characteristics and movement of the diaphragm in COVID-19 patients who recently received long-term mechanical ventilation, other ICU patients and healthy controls, using magnetic resonance imaging (MRI). MRI of the diaphragm was already shown feasible in previous research from our group (article currently under review). New insights in the characteristics of diaphragm weakness and injury in COVID-19 patients and control ICU-patients will contribute to strategies to prevent it and monitor the diaphragm of patients under mechanical ventilation, which can contribute to better patient outcomes.

Official Title
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Effects of COVID-19-infection and Mechanical Ventilation on Movement and Tissue Characteristics of the Diaphragm, Visualized by Magnetic Resonance Imaging: a Proof-of-concept Study

Conditions
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Diaphragm Disease, Covid19

Intervention / Treatment
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* Other: Contrast-enhanced MRI
* Other: Measurement of respiratory muscle force


Participation Criteria
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Eligibility Criteria
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Inclusion criteria In order to be eligible to participate in this study, a subject in the case group must meet all of the following criteria: Invasive mechanical ventilation > 72 hours during current hospital admission Admitted for COVID-19-infection (n = 10) Currently negative COVID-19 PCR test Discharged from the ICU ≤ 7 days ago Signed informed consent Age ≥ 18 years In order to be eligible to participate in this study, a subject in the control group must meet all of the following criteria: Signed informed consent Age ≥ 18 years Similar age (max 5 years difference) and gender of one of the subjects in case group Exclusion criteria A potential subject for the case group who meets any of the following criteria will be excluded from participation in this study: Known history of: Diaphragmatic injury or weakness prior to ICU stay COPD (GOLD IV) Neuromuscular disease (including pathology of the n. phrenicus) Connective tissue disease Chronic use of corticosteroids (>7.5 mg/day for at least 3 months before hospital admission) >10% weight loss within last 6 months prior to ICU admission Obesity (BMI > 30 kg/m2 at hospital admission) Known pregnancy Contraindications for MRI Electrical/metallic implants Claustrophobia Unable to hold breath for 10 seconds Hierarchical relation with one of the collaborating investigators Incapacitation Contraindications for the use of a Gadolinium based contrast agent for MRI Known eGFR < 30 ml/min/1.73m2 Known history of allergic reactions to an MRI contrast medium Known history of allergic reactions requiring immediate treatment Known history of atopy Asthma These exclusion criteria are based on the guidelines for contrast agents from the European Society for Urogenital Radiology (http://www.esur.org/guidelines/). Additional exclusion criteria for the case group, subset non-infected patients are: • History of COVID-19-infection (confirmed with positive test) Additional exclusion criteria for the control group are: History of mechanical ventilation > 24 hours History of COVID-19-infection (confirmed with positive test)

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Healthy volunteers<br>Healthy volunteers, matched by age and gender to patient groups. | Other: Contrast-enhanced MRI<br>* Contrast-enhanced MRI<br>Other: Measurement of respiratory muscle force<br>* Measurement of the maximum inspiratory and expiratory pressure.<br>|
| COVID-19 patients<br>Patients discharged from the ICU after invasive ventilation for COVID-19. | Other: Contrast-enhanced MRI<br>* Contrast-enhanced MRI<br>Other: Measurement of respiratory muscle force<br>* Measurement of the maximum inspiratory and expiratory pressure.<br>|
| ICU patients<br>Patients discharged from the ICU after invasive ventilation for ARDS. | Other: Contrast-enhanced MRI<br>* Contrast-enhanced MRI<br>Other: Measurement of respiratory muscle force<br>* Measurement of the maximum inspiratory and expiratory pressure.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Tissue characteristics of the diaphragm | Extracted from contrast enhanced imaging | 1 hour | 
| Movement of the diaphragm | Description of the movement of the diaphragm in 4D fashion. | 1 hour | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Quantitative dynamic contrast enhanced imaging of the diaphragm | Application of modelling to describe tissue characteristics of the diaphragm using contrast inflow. | 1 hour | 
| Correlation of movement and tissue characteristics of the diaphragm with measurements of maximum inspiratory and expiratory pressure |  | 1 hour | 
| Correlation of movement and tissue characteristics of the diaphragm with clinical parameters | Clinical parameters include ventilator settings, biomarkers for inflammation (CRP, white blood cell count) during ICU admission, daily dosage of drugs known with adverse effects on respiratory muscles, fluid balance, protein intake, primary reason for ICU admission and weaning duration. | 1 hour | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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MRI, Mechanical ventilation, Diaphragm