Orrey, Samantha Taylor (2014-04)
ENGLISH ABSTRACT: Introduction: In the intensive care unit population, approximately 40% of patients require mechanical ventilation and 20-25% of these patients will encounter difficulties in the discontinuation of mechanical ventilation. As mechanical ventilation affects the diaphragm, a better understanding of the structural and functional changes of the diaphragm is warranted. Method: A scoping review was done to determine whether a relationship between diaphragm thickness, diaphragm strength and diaphragm endurance had been established. Seven databases were searched using a specific search strategy. Papers were identified based on pre-defined inclusion criteria. Data was extracted by the primary investigator (PI) into a self-developed excel spreadsheet. Criteria were developed for a more focused review to inform the planning of a primary study. The primary study investigated the relationship between diaphragm thickness, diaphragm strength and diaphragm endurance in young, healthy individuals. A sample of convenience was used; included healthy individuals (18-24); three activity-levels (sedentary; endurance- and strength related sporting activities); stratified for gender and BMI. Measurements included: Sonographic measurement of diaphragm thickness; mouth pressure manometer measurements for diaphragmatic strength; and fatigue resistance index as a measure of endurance. Participants were instructed to breathe through a pressure threshold device at 60% of PImax until task failure. The fatigue resistance index was calculated as PImax final/PImax initial. Intra-rater reliability was established and testing procedures standardised a priori. Results: 405 full texts were retrieved and assessed for inclusion into the review. Papers identified the evaluation of diaphragm function in a variety of populations. 23 papers were included in the focused review. Six papers were published on diaphragm thickness, six on diaphragm strength and eleven on diaphragm endurance. No papers identified the correlation between diaphragm thickness, diaphragm strength and diaphragm endurance. 55 subjects, males and females, were recruited for the primary study. Groups were similar at baseline with regards to gender, age and BMI. The mean age of the sample was 21.16 years (SD = 1.55), with a mean body mass index (BMI) of 25.43 kg/m2 (SD = 3.70). A moderate positive correlation was established between diaphragm thickness and diaphragm strength measurements (r = 0.52; r2 = 0.27; p < 0.01). Diaphragm thickness was not correlated with diaphragm endurance (r = -0.15; r2 = 0.02; p = 0.29). No relationship was found between the strength of the diaphragm and the endurance of the diaphragm (r= -0.19; r2 = 0.04; p= 0.16). Conclusion: Guidelines for the measurement of diaphragm function do exist, but they are not adhered to by the majority of studies. Study procedures are inconsistently reported and this may affect the reproducibility of techniques in future studies. We further conclude that a correlation exists between diaphragm thickness and diaphragm strength. The use of ultrasound to measure diaphragm thickness proved to be a reliable technology and gave a moderate indication of the strength of the diaphragm. This technology may help clinicians to detect and monitor dysfunction of the diaphragm in the early stages of admission to the acute setting.
AFRIKAANSE OPSOMMING: Inleiding: Ongeveer 40% van pasiente wat in intensiewe sorgeenheid behandel word, benodig intubasie en meganiese ventilasie. Tot 25% van hierdie pasiënte sal probleme ondervind in die staking van meganiese ventilasie. Meganiese ventilasie beïnvloed die diafragma, daarom word n beter begrip van die strukturele en funksionele veranderinge van die diafragma benodig. Metode: 'n Literatuur oorsig is gedoen om te bepaal of daar 'n verhouding bestaan tussen die dikte, krag en uithouvermoë van die diafragma. Sewe databasisse is deurgesoek aan die hand van spesifieke databasis gedefinieerde soektog strategie. Relevante artikels is geïdentifiseer aan die hand van pre-gedefinieerde insluiting kriteria. Data is onttrek en in ‘n self-ontwikkelde datablad opgesom deur die primêre ondersoeker (PI). Hierdie inligting is gebruik in die beplanning van ‘n primêre studie. Die doel van die primêre studie was om die verhouding tussen die diafragma dikte, krag en uithouvermoë in jong, gesonde individue te ondersoek. ‘n Gerieflikheids steekproef is gebruik; insluitend gesonde individue (18-24); drie aktiwiteits vlakke (passief; uithouvermoë- en krag verwante sportaktiwiteite) en breë spektrum vir geslag en ligaamsbou (BMI). Metings ingesluit: sonografiese meting van die diafragma se dikte; monddruk manometer metings vir diafragmatiese krag en ‘n moegheid/weerstand indeks as maatstaf van diafragmatiese uithouvermoë. Deelnemers is opdrag gegee om asem te haal deur toestel met druk maksimum gestel 60% van PImax, tot mislukking. Die moegheid/weerstand indeks is bereken as PImax finale / PImax oorspronlik. Intra-meter betroubaarheid is bepaal en toets prosedures is gestandaardiseer voordat data ingesamel is. Resultate: 405 vol teks artikels is uitgelig vir insluiting in die literatuur oorsig. Diafragmatiese funksie is ge-evalueer in 'n verskeidenheid bevolkings. Drie en twintig artikels is in die finale oorsig ingesluit. Ses artikels wat diafragma dikte evalueer, ses wat diafragmatiese krag evalueer en elf wat die diafragma se uithouvermoë evalueer is ingesluit in die oorsig. Geen van die artikels uitgelig het ‘n ooreenkoms tussen diafragma dikte, diafragma krag en diafragma uithouvermoë geïdentifiseer nie. 55 deelnemers is gewerf vir die primêre studie. Groepe was soortgelyk by basislyn met betrekking tot geslag, ouderdom en BMI. Die gemiddelde ouderdom van die toetsgroep was 21.16 jaar (SD=1.55), met 'n gemiddelde BMI van 25.43 kg/m2 (SD = 3.70). ‘n Middelmatige positiewe verhouding is waargeneem tussen diafragma dikte en krag (r = 0.52; r2 = 0.27; p < 0.01). Geen verhouding is gevind tussen diafragma dikte en uithouvermoë nie (r= -0.15; r2 = 0.02; p = 0.29). Daar is ook geen verhouding waargeneem tussen diafragma krag en diafragma uithouvermoë nie. (r= 0.19; r2 = 0.04; p = 0.16). Gevolgtrekking: Daar bestaan wel riglyne vir die meting van die diafragma se funksie, maar in die meerderheid van studies word dit nie nagekom nie. Studie prosedures is nie konsekwent weergegee nie en dit kan die resultate van tegnieke beinvloed in toekomende studies. ‘n Matige sterk verhouding is waargeneem tussen diafragmatiese dikte en krag. Die gebruik van ultraklank om die diafragma se dikte te meet is betroubare tegnologie en kan n redelike aanduiding gee oor die krag van die diafragma. Hierdie tegnologie kan praktisyne help om enige disfunksie van die diafragma te identifiseer en te monitor in die vroeë stadiums van toelating tot die akute omgewing.
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Masters Degrees (Physiotherapy)63
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