Crural Diaphragm Density in Respiratory Complications after Video-Assisted Thoracoscopic Surgery Lobectomy

Abstract

Background

Respiratory muscle strength affects pulmonary function after lung resection; however, the role of diaphragm density, an emerging index of muscle quality, remains unexplored. We investigated the role of crural diaphragm density (CDD) in respiratory complications (RC) after video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

Methods

A total of 118 patients were retrospectively enrolled between 2015 and 2022. Exclusion criteria were neoadjuvant therapy, thoracic trauma, and previous cardiothoracic and abdominal surgery. Demographic, functional, and radiological data were collected. The CDD in Hounsfield Unit (HU) was defined as the average of the density of the right and left crural diaphragm at the level of the median arcuate ligament on computed tomography axial images. RC included sputum retention, respiratory infections, atelectasis, pneumonia, respiratory failure, and acute respiratory distress syndrome.

Results

The prevalence of postoperative RC was 41% (48 of 118). RC occurred mostly in males (64.6 vs. 44.3%, p = 0.04), current smokers (41.7 vs. 21.4%, p = 0.02), a longer surgical procedure (210 vs. 180 minutes, p = 0.04), and a lower CDD (42.5 vs. 48 HU, p = 0.05). The optimal cutoff of CDD was 39.75 HU (sensitivity 43%, specificity 82%, accuracy 65%, area under the curve: 0.62, p = 0.05), slightly above the threshold for reduced muscle mass (<30 HU). By multivariable logistic regression a CDD ≤ 39.75 HU (hazard ratio [HR]: 3.134 [95% confidence interval, CI: 1.111–8.844], p = 0.03) and current smoking (HR: 2.733 [95% CI: 1.012–7.380], p = 0.05) were both independent risk factors of postoperative RC.

Conclusion

The CDD seems to be a simple and useful tool for predicting RC after VATS lobectomy, especially among current smokers. Such patients, identified early, could benefit from preoperative functional and nutritional rehabilitation.

Keywords

diaphragm - lung cancer treatment (surgery medical) - thoracoscopy/VATS

Note

This paper has been the winner of “ERS Best Abstract—Assembly 8” at the European Respiratory Society International Congress, Milan, September 9 to 13, 2023.

Publication History

Received: 06 March 2024

Accepted: 16 October 2024

Article published online:
19 November 2024

• References

• 1 McCool FD, Tzelepis GE. Dysfunction of the diaphragm. N Engl J Med 2012; 366 (10) 932-942
• 2 Cruz-Jentoft AJ, Bahat G, Bauer J. et al; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48 (01) 16-31
• 3 Welch C. K Hassan-Smith Z, A Greig C, M Lord J, A Jackson T. Acute sarcopenia secondary to hospitalisation - an emerging condition affecting older adults. Aging Dis 2018; 9 (01) 151-164
• 4 Chargi N, Bril SI, Emmelot-Vonk MH, de Bree R. Sarcopenia is a prognostic factor for overall survival in elderly patients with head-and-neck cancer. Eur Arch Otorhinolaryngol 2019; 276 (05) 1475-1486
• 5 Ekin EE, Altunrende ME. The association of reduced bone density with paraspinal muscle atrophy and adipose tissue in geriatric patients: a cross-sectional CT study. Turk J Med Sci 2019; 49 (02) 538-542
• 6 Martone AM, Bianchi L, Abete P. et al. The incidence of sarcopenia among hospitalized older patients: results from the Glisten study. J Cachexia Sarcopenia Muscle 2017; 8 (06) 907-914
• 7 Looijaard WGPM, Molinger J, Weijs PJM. Measuring and monitoring lean body mass in critical illness. Curr Opin Crit Care 2018; 24 (04) 241-247
• 8 Goodpaster BH, Thaete FL, Kelley DE. Composition of skeletal muscle evaluated with computed tomography. Ann N Y Acad Sci 2000; 904: 18-24
• 9 Aubrey J, Esfandiari N, Baracos VE. et al. Measurement of skeletal muscle radiation attenuation and basis of its biological variation. Acta Physiol (Oxf) 2014; 210 (03) 489-497
• 10 Vellas B, Fielding RA, Bens C. et al. Implications of ICD-10 for sarcopenia clinical practice and clinical trials: report by the International Conference on Frailty and Sarcopenia Research Task Force. J Frailty Aging 2018; 7 (01) 2-9
• 11 Lieffers JR, Bathe OF, Fassbender K, Winget M, Baracos VE. Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery. Br J Cancer 2012; 107 (06) 931-936
• 12 Barreiro E, Gea J. Respiratory and limb muscle dysfunction in COPD. COPD 2015; 12 (04) 413-426
• 13 Donovan AA, Johnston G, Moore M. et al. Diaphragm morphology assessed by computed tomography in chronic obstructive pulmonary disease. Ann Am Thorac Soc 2021; 18 (06) 955-962
• 14 Parlak S, Beşler MS, Gökhan MB. Association of diaphragm thickness and density measured on chest CT with disease severity in COVID-19 patients. Am J Emerg Med 2022; 61: 29-33
• 15 Similowski T, Yan S, Gauthier AP, Macklem PT, Bellemare F. Contractile properties of the human diaphragm during chronic hyperinflation. N Engl J Med 1991; 325 (13) 917-923
• 16 Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics 2012; 32 (02) E51-E70
• 17 Nomori H, Kobayashi R, Fuyuno G, Morinaga S, Yashima H. Preoperative respiratory muscle training. Assessment in thoracic surgery patients with special reference to postoperative pulmonary complications. Chest 1994; 105 (06) 1782-1788
• 18 Hansen HJ, Petersen RH. Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach—the Copenhagen experience. Ann Cardiothorac Surg 2012; 1 (01) 70-76
• 19 Jammer I, Wickboldt N, Sander M. et al; European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM), European Society of Anaesthesiology, European Society of Intensive Care Medicine. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM Joint Taskforce on perioperative outcome measures. Eur J Anaesthesiol 2015; 32 (02) 88-105
• 20 Giraudo C, Librizzi G, Fichera G. et al. Reduced muscle mass as predictor of intensive care unit hospitalization in COVID-19 patients. PLoS One 2021; 16 (06) e0253433
• 21 García-Miguel FJ, Serrano-Aguilar PG, López-Bastida J. Preoperative assessment. Lancet 2003; 362 (9397) 1749-1757
• 22 Agostini P, Cieslik H, Rathinam S. et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors?. Thorax 2010; 65 (09) 815-818
• 23 Pipanmekaporn T, Bunchungmongkol N, Punjasawadwong Y, Lapisatepun W, Tantraworasin A, Saokaew S. A risk score for predicting respiratory complications after thoracic surgery. Asian Cardiovasc Thorac Ann 2019; 27 (04) 278-287
• 24 Amar D, Munoz D, Shi W, Zhang H, Thaler HT. A clinical prediction rule for pulmonary complications after thoracic surgery for primary lung cancer. Anesth Analg 2010; 110 (05) 1343-1348
• 25 Martini K, Chassagnon G, Fournel L. et al. Sarcopenia as independent risk factor of postpneumonectomy respiratory failure, ARDS and mortality. Lung Cancer 2020; 149: 130-136
• 26 Ota H, Matsumoto H. Impact of the crural diaphragm thickness on pulmonary function after lobectomy. Asian Cardiovasc Thorac Ann 2019; 27 (05) 388-393
• 27 Crimi C, Heffler E, Augelletti T. et al. Utility of ultrasound assessment of diaphragmatic function before and after pulmonary rehabilitation in COPD patients. Int J Chron Obstruct Pulmon Dis 2018; 13: 3131-3139
• 28 Ogan N, Aydemir Y, EVrin T. et al. Diaphragmatic thickness in chronic obstructive lung disease and relationship with clinical severity parameters. Turk J Med Sci 2019; 49 (04) 1073-1078
• 29 Gorman RB, McKenzie DK, Pride NB, Tolman JF, Gandevia SC. Diaphragm length during tidal breathing in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2002; 166 (11) 1461-1469
• 30 Nagano A, Wakabayashi H, Maeda K. et al. Respiratory sarcopenia and sarcopenic respiratory disability: concepts, diagnosis, and treatment. J Nutr Health Aging 2021; 25 (04) 507-515