Myotrauma in mechanically ventilated patients

  • Ewan C. GoligherEmail author
Understanding the Disease
In 1988, Knisely et al. “noted marked thinning of the muscular portions of the diaphragm” in neonates following prolonged mechanical ventilation [ 1]. This provided the first evidence that adverse patient–ventilator interactions can cause deleterious structural changes in the diaphragm, a phenomenon recently termed myotrauma [ 2]. Extensive experimental and clinical investigation has confirmed the existence of myotrauma and characterized its prevalence and clinical impact [ 2, 3]. Diaphragm myotrauma is a serious concern because it leads to acute diaphragm weakness (referred to as ventilator-induced diaphragm dysfunction; see Table 1 for terminology) and can therefore impair patients’ ability to be liberated from mechanical ventilation. Prolonged mechanical ventilation predisposes patients to nosocomial complications and strongly predicts long-term morbidity and mortality [ 4]. Preventing myotrauma might therefore accelerate liberation from mechanical ventilation and significantly improve...



The author thanks Thomas Piraino, RRT, and Laurent Brochard, MD, for helpful suggestions on this manuscript.

Compliance with ethical standards

Conflicts of interest

Dr. Goligher’s laboratory has received non-financial support in the form of equipment from Getinge and GE. Dr. Goligher reports receiving speaking honoraria from Getinge.

Ethical approval

An approval by an ethics committee was not applicable.


  1. 1.
    Knisely AS, Leal SM, Singer DB (1988) Abnormalities of diaphragmatic muscle in neonates with ventilated lungs. J Pediatr 113:1074–1077CrossRefGoogle Scholar
  2. 2.
    Goligher EC, Brochard LJ, Reid WD et al (2018) Diaphragmatic myotrauma: a mediator of prolonged ventilation and poor patient outcomes in acute respiratory failure. Lancet Respir Med. Google Scholar
  3. 3.
    Dres M, Goligher EC, Heunks LMA, Brochard LJ (2017) Critical illness-associated diaphragm weakness. Intensive Care Med 43:1–12. CrossRefGoogle Scholar
  4. 4.
    Damuth E, Mitchell JA, Bartock JL et al (2015) Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med 3:544–553. CrossRefGoogle Scholar
  5. 5.
    Petrof BJ (2018) Diaphragm weakness in the critically ill: basic mechanisms reveal therapeutic opportunities. Chest 154:1395–1403. CrossRefGoogle Scholar
  6. 6.
    Goligher EC, Fan E, Herridge MS et al (2015) Evolution of diaphragm thickness during mechanical ventilation: impact of inspiratory effort. Am J Respir Crit Care Med 192:1080–1088. CrossRefGoogle Scholar
  7. 7.
    Levine S, Nguyen T, Taylor N et al (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358:1327–1335. CrossRefGoogle Scholar
  8. 8.
    Laghi F, Topeli A, Tobin MJ (1998) Does resistive loading decrease diaphragmatic contractility before task failure? J Appl Physiol 85:1103–1112CrossRefGoogle Scholar
  9. 9.
    Reid WD, Belcastro AN (2000) Time course of diaphragm injury and calpain activity during resistive loading. Am J Respir Crit Care Med 162:1801–1806. CrossRefGoogle Scholar
  10. 10.
    Goligher EC, Dres M, Fan E et al (2018) Mechanical ventilation-induced diaphragm atrophy strongly impacts clinical outcomes. Am J Respir Crit Care Med 197:204–213. CrossRefGoogle Scholar
  11. 11.
    Pellegrini M, Hedenstierna G, Roneus A et al (2016) The diaphragm acts as a brake during expiration to prevent lung collapse. Am J Respir Crit Care Med 195:1608–1616. CrossRefGoogle Scholar
  12. 12.
    Lindqvist J, van den Berg M, van der Pijl R et al (2018) Positive end-expiratory pressure ventilation induces longitudinal atrophy in diaphragm fibers. Am J Respir Crit Care Med 198:472–485. CrossRefGoogle Scholar
  13. 13.
    Dres M, Dubé B-P, Mayaux J et al (2017) Coexistence and impact of limb muscle and diaphragm weakness at time of liberation from mechanical ventilation in medical intensive care unit patients. Am J Respir Crit Care Med 195:57–66. CrossRefGoogle Scholar
  14. 14.
    Morais CCA, Koyama Y, Yoshida T et al (2018) High positive end-expiratory pressure renders spontaneous effort noninjurious. Am J Respir Crit Care Med 197:1285–1296. CrossRefGoogle Scholar
  15. 15.
    Doorduin J, Nollet JL, Roesthuis LH et al (2016) Partial neuromuscular blockade during partial ventilatory support in sedated patients with high tidal volumes. Am J Respir Crit Care Med 195:1033–1042. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Interdepartmental Division of Critical Care MedicineUniversity of TorontoTorontoCanada
  2. 2.Department of Medicine, Division of RespirologyUniversity Health NetworkTorontoCanada
  3. 3.Toronto General Hospital Research InstituteTorontoCanada

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