Ventilatör İlişkili Diyafram Disfonksiyon’unda Diyafram Koruyucu Yaklaşım: Non-İnvaziv Frenik Sinir Stimülasyonu
Özet
Bu bölümde, invaziv mekanik ventilasyon sürecinde erken dönemde gelişen ventilatör ilişkili diyafram disfonksiyonunun (VIDD) tanı ve yönetimine yönelik diyafram koruyucu yaklaşım, non-invaziv frenik sinir stimülasyonu uygulanan bir olgu üzerinden ele alınmaktadır. Entübasyonun ilk 48 saatinde gerçekleştirilen seri diyafram ultrasonografisi ölçümlerinde diyafram kalınlığı ve kalınlaşma fraksiyonunda anlamlı azalma saptanmış, bu bulgular erken dönem VIDD ile uyumlu bulunmuştur. Diyafram atrofisini sınırlamak ve kontraktil fonksiyonu desteklemek amacıyla non-invaziv ekstratorasik nöromüsküler elektriksel stimülasyon (NMES) tedavisi başlatılmıştır. Takip sürecinde diyafram kalınlığı ve kalınlaşma fraksiyonunda progresif iyileşme gözlenmiş ve bu iyileşme başarılı ventilatörden ayrılma süreci ile sonuçlanmıştır. Bu olgu, yalnızca akciğer koruyucu ventilasyon stratejilerinin değil, diyafram fonksiyonunun korunmasına yönelik yaklaşımların da kritik bakım pratiğinde entegre edilmesi gerektiğini ortaya koymaktadır. Diyafram ultrasonografisinin erken tanı ve tedavi yanıtının objektif izlenmesinde güvenilir bir araç olduğu gösterilmiştir. Non-invaziv frenik sinir stimülasyonu, VIDD’nin önlenmesi ve weaning başarısının artırılmasında umut verici bir destekleyici yöntem olarak değerlendirilmektedir.
This chapter describes the early recognition and management of ventilator-induced diaphragm dysfunction (VIDD) using a diaphragm-protective strategy supported by non-invasive phrenic nerve stimulation. Serial diaphragm ultrasonography performed within the first 48 hours of mechanical ventilation demonstrated a significant reduction in diaphragm thickness and thickening fraction, consistent with early-onset VIDD. To mitigate diaphragmatic atrophy and preserve contractile function, non-invasive extrathoracic neuromuscular electrical stimulation (NMES) was initiated. Subsequent ultrasound assessments revealed progressive recovery in diaphragm thickness and thickening fraction, which translated into successful liberation from mechanical ventilation. This case underscores the clinical importance of integrating diaphragm-protective ventilation strategies alongside conventional lung-protective approaches in critically ill patients. Diaphragm ultrasonography proved to be a reliable and reproducible bedside tool for early diagnosis and monitoring of therapeutic response. Non-invasive phrenic nerve stimulation may represent a promising adjunctive strategy to prevent diaphragm dysfunction and improve weaning outcomes. Further large-scale prospective studies are warranted to establish its efficacy and safety in routine critical care practice.
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