Diaphragmatic Thickening Fraction as a Predictor of Early Treatment Failure in Acute Exacerbation of COPD
DOI:
https://doi.org/10.53350/pjmhs02026208.2Keywords:
acute exacerbation of COPD; diaphragmatic thickening fraction; diaphragm ultrasonography; noninvasive ventilation; respiratory failure; treatment failureAbstract
Background: If acute exacerbation of chronic obstructive pulmonary disease is not prevented, it can develop into hypercapnic respiratory failure and noninvasive ventilation failure. Bedside ultrasonography of diaphragm thickening fraction could be used as an early predictor of respiratory muscle dysfunction.
Objective: To determine whether diaphragmatic thickening fraction predicts early treatment failure in patients with acute exacerbation of chronic obstructive pulmonary disease receiving noninvasive ventilation.
Methods: This was a prospective observational cohort study of 200 adults who were admitted in Jinnah Hospital Lahore from March 2024 to March 2026. Diaphragm thickness was measured at end-expiration and peak inspiration at baseline and two hours after starting noninvasive ventilation. The thickness of the diaphragm was measured and the average difference between the inspiratory and expiratory thickness was expressed as a percent of the inspiratory thickness, as the diaphragmatic thickness fraction. Failure of treatment was defined as endotracheal intubation or death in less than 72 hours.
Results: Early treatment failure occurred in 52 patients (26.0%). The baseline diaphragmatic thickening fraction was lower in the patients who failed treatment, as compared to those who were successfully treated (18.5 ± 6.3% vs 28.2 ± 7.6%, p<0.001). The difference was greater after two hours (17.9 ± 6.2% versus 32.4 ± 7.5%; p<0.001). A two hour threshold of ≤23% detected failure with sensitivity of 86.5%, specificity of 82.4% and area under the curve of 0.91. Diaphragmatic thickening fraction ≤23% was the best independent predictor of failure (adjusted odds ratio 9.72; 95% confidence interval 4.16–22.71; p<0.001) after adjustment. It has a high negative predictive value, potentially helping to identify those patients who are likely to continue to receive noninvasive ventilation successfully.
Conclusion: The 2-hour diaphragmatic thickening fraction was an independent predictor of early treatment failure and might help guide timely escalation of respiratory care.
Keywords: acute exacerbation of COPD; diaphragmatic thickening fraction; diaphragm ultrasonography; noninvasive ventilation; respiratory failure; treatment failure
References
Qu L, Zhao W, Zhang W, Li J. Predictive value analysis of diaphragmatic ultrasound evaluation for mechanical ventilation outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease. BMC Pulm Med. 2025;25(1):478. doi:10.1186/s12890-025-03567-3.
Suttapanit K, Lerdpaisarn P, Charoensuksombun C, Sanguanwit P, Supatanakij P. Diaphragmatic ultrasonographic evaluation as an assessment guide for predicting noninvasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med. 2025;93:13–20. doi:10.1016/j.ajem.2025.03.025.
Malhotra N, Gothi D, Kumar R, Patro M, Kumar S, Jain A, et al. Ultrasound-guided diaphragm evaluation and outcomes in severe acute exacerbation of chronic obstructive pulmonary disease (uDISCO Study): an observational study. Monaldi Arch Chest Dis. 2025. doi:10.4081/monaldi.2025.3483.
Itagaki T, Akimoto Y, Takashima T, Oto J. Ultrasonographic assessment of the diaphragm. Diagnostics (Basel). 2024;14(14):1481. doi:10.3390/diagnostics14141481.
Kakhaki HES, Alesaeidi S, Siri G, Arya A, Sarafraz H, Otadi K, et al. Diaphragmatic ultrasound advantages in chronic obstructive pulmonary disease patients: a systematic review and meta-analysis. Ethiop J Health Sci. 2023;33(5):903–912. doi:10.4314/ejhs.v33i5.20.
Patel NB, Jain G, Chauhan U, Bhadoria AS, Chandrakar S, Indulekha H. Evaluating diaphragmatic dysfunction and predicting non-invasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease in India. Acute Crit Care. 2023;38(2):200–208. doi:10.4266/acc.2022.01060.
Saad M, Pini S, Danzo F, Mandurino Mirizzi F, Arena C, Tursi F, et al. Ultrasonographic assessment of diaphragmatic function and its clinical application in the management of patients with acute respiratory failure. Diagnostics (Basel). 2023;13(3):411. doi:10.3390/diagnostics13030411.
Santana PV, Cardenas LZ, Albuquerque ALP. Diaphragm ultrasound in critically ill patients on mechanical ventilation: evolving concepts. Diagnostics (Basel). 2023;13(6):1116. doi:10.3390/diagnostics13061116.
Topcuoğlu C, Yümin ET, Hizal M, Konuk S. Examination of diaphragm thickness, mobility and thickening fraction in individuals with COPD of different severity. Turk J Med Sci. 2022;52(4):1288–1298. doi:10.55730/1300-0144.5435.
An TJ, Yoo YJ, Lim JU, Seo W, Park CK, Rhee CK, et al. Diaphragm ultrasound is an imaging biomarker that distinguishes exacerbation status from stable chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2022;17:3–12. doi:10.2147/COPD.S341484.
Hernandez-Voth A, Sayas Catalan J, Corral Blanco M, Alonso Moralejo R, Perez Gonzalez V, De Pablo Gafas A, et al. Long-term effect of noninvasive ventilation on diaphragm in chronic respiratory failure. Int J Chron Obstruct Pulmon Dis. 2022;17:205–212. doi:10.2147/COPD.S339498.
Mercurio G, D’Arrigo S, Moroni R, Grieco DL, Menga LS, Romano A, et al. Diaphragm thickening fraction predicts noninvasive ventilation outcome: a preliminary physiological study. Crit Care. 2021;25(1):219. doi:10.1186/s13054-021-03638-x.
Kocyigit H, Gunalp M, Genc S, Oguz AB, Koca A, Polat O. Diaphragm dysfunction detected with ultrasound to predict noninvasive mechanical ventilation failure: a prospective cohort study. Am J Emerg Med. 2021;45:202–207. doi:10.1016/j.ajem.2020.08.014.
Boussuges A, Finance J, Chaumet G, Brégeon F. Ultrasound assessment of diaphragm thickness and thickening: reference values and limits of normality when in a seated position. Front Med (Lausanne). 2021;8:742703. doi:10.3389/fmed.2021.742703.
Alqahtani JS, Oyelade T, Sreedharan J, Aldhahir AM, Alghamdi SM, Alqahtani AS, et al. Diagnostic and clinical values of non-cardiac ultrasound in COPD: a systematic review. BMJ Open Respir Res. 2020;7(1):e000717. doi:10.1136/bmjresp-2020-000717.
Boussuges A, Rives S, Finance J, Brégeon F. Assessment of diaphragmatic function by ultrasonography: current approach and perspectives. World J Clin Cases. 2020;8(12):2408–2424. doi:10.12998/wjcc.v8.i12.2408.
Zhang X, Yuan J, Zhan Y, Wu J, Liu B, Zhang P, et al. Evaluation of diaphragm ultrasound in predicting extubation outcome in mechanically ventilated patients with COPD. Ir J Med Sci. 2020;189(2):661–668. doi:10.1007/s11845-019-02117-1.
Lim SY, Lim G, Lee YJ, Cho YJ, Park JS, Yoon HI, et al. Ultrasound assessment of diaphragmatic function during acute exacerbation of chronic obstructive pulmonary disease: a pilot study. Int J Chron Obstruct Pulmon Dis. 2019;14:2479–2484. doi:10.2147/COPD.S214716.
Cammarota G, Sguazzotti I, Zanoni M, Messina A, Colombo D, Vignazia GL, et al. Diaphragmatic ultrasound assessment in subjects with acute hypercapnic respiratory failure admitted to the emergency department. Respir Care. 2019;64(12):1469–1477. doi:10.4187/respcare.06803.
Marchioni A, Castaniere I, Tonelli R, Fantini R, Fontana M, Tabbì L, et al. Ultrasound-assessed diaphragmatic impairment is a predictor of outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease undergoing noninvasive ventilation. Crit Care. 2018;22(1):109. doi:10.1186/s13054-018-2033-x.
Downloads
How to Cite
Issue
Section
License
Copyright (c) 2026 Rimsha Ali Sheaikh, Hina Awan, Muntaqa Butt, Akhtar Ali, Noor E Seher, Hamza Akram, Muhammad Kashif
This work is licensed under a Creative Commons Attribution 4.0 International License.
