Elevated Diaphragmatic Tonic Activity in PICU Patients: Age-Specific Definitions, Prevalence, and Associations* : Pediatric Critical Care Medicine

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Elevated Diaphragmatic Tonic Activity in PICU Patients: Age-Specific Definitions, Prevalence, and Associations*

Plante, Virginie MD1; Poirier, Clarice BScN1; Guay, Hélène1; Said, Carla MSc1,2; Sauthier, Michael MD, PhD, MBI1; Al-Omar, Sally PhD1; Harrington, Karen MD, MSc1; Emeriaud, Guillaume MD, PhD1

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Pediatric Critical Care Medicine 24(6):p 447-457, June 2023. | DOI: 10.1097/PCC.0000000000003193



Tonic diaphragmatic activity (tonic Edi, i.e., sustained diaphragm activation throughout expiration) reflects diaphragmatic effort to defend end-expiratory lung volumes. Detection of such elevated tonic Edi may be useful in identifying patients who need increased positive end-expiratory pressure. We aimed to: 1) identify age-specific definitions for elevated tonic Edi in ventilated PICU patients and 2) describe the prevalence and factors associated with sustained episodes of high tonic Edi.


Retrospective study using a high-resolution database.


Single-center tertiary PICU.


Four hundred thirty-one children admitted between 2015 and 2020 with continuous Edi monitoring.




We characterized our definition of tonic Edi using data from the recovery phase of respiratory illness (i.e., final 3 hr of Edi monitoring, excluding patients with significant persistent disease or with diaphragm pathology). High tonic Edi was defined as population data exceeding the 97.5th percentile, which for infants younger than 1 year was greater than 3.2 μV and for older children as greater than 1.9 μV. These thresholds were then used to identify patients with episodes of sustained elevated tonic Edi in the first 48 hours of ventilation (acute phase). Overall, 62 of 200 (31%) of intubated patients and 138 of 222 (62%) of patients on noninvasive ventilation (NIV) had at least one episode of high tonic Edi. These episodes were independently associated with the diagnosis of bronchiolitis (intubated patients: adjusted odds [aOR], 2.79 [95% CI, 1.12–7.11]); NIV patients: aOR, 2.71 [1.24–6.0]). There was also an association with tachypnea and, in NIV patients, more severe hypoxemia.


Our proposed definition of elevated tonic Edi quantifies abnormal diaphragmatic activity during expiration. Such a definition may help clinicians to identify those patients using abnormal effort to defend end-expiratory lung volume. In our experience, high tonic Edi episodes are frequent, especially during NIV and in patients with bronchiolitis.

Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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