Debate on the Role of Eccentric Contraction of the Diaphragm: Is It Always Harmful?

Gallardo A, Castro-Sayat M, Alcaraz M, Colaianni-Alfonso N, Vetrugno L. Debate on the Role of Eccentric Contraction of the Diaphragm: Is It Always Harmful? Healthcare. 2025; 13(5):565. https://doi.org/10.3390/healthcare13050565

Summary of "Debate on the Role of Eccentric Contraction of the Diaphragm: Is It Always Harmful?"

Abstract

The diaphragm plays a central role in mechanical ventilation, and its dysfunction significantly impacts patient outcomes. Eccentric contractions of the diaphragm, which occur when the muscle contracts during lung inflation or during the expiratory phase, have been considered harmful due to their association with diaphragmatic injury, increased ventilator-induced lung injury (VILI), and prolonged mechanical ventilation. However, emerging evidence suggests that under specific conditions, eccentric contractions may contribute to diaphragmatic strength maintenance and could be beneficial. This review critically examines the current understanding of eccentric diaphragm contraction and its implications for mechanical ventilation management.

Key Points

1. Diaphragmatic Dysfunction and Mechanical Ventilation: Prolonged mechanical ventilation can lead to diaphragmatic myotrauma, which includes muscle atrophy, contractile dysfunction, and structural damage.
2. Mechanisms of Eccentric Contraction in the Diaphragm: Eccentric contractions occur when the diaphragm remains active during exhalation, leading to increased mechanical stress and potential myotrauma, particularly in cases of ventilator asynchrony.
3. Patient-Ventilator Asynchrony and Reverse Triggering: Reverse triggering, where the ventilator cycle initiates diaphragmatic contraction, may lead to harmful eccentric contractions, increasing the risk of lung injury and impaired weaning.
4. Impact of Eccentric Contractions on Diaphragm Function: Some studies suggest that eccentric contractions may preserve diaphragmatic function by preventing disuse atrophy, but excessive contractions contribute to injury and prolonged ventilator dependence.
5. Role of Positive End-Expiratory Pressure (PEEP) and Inspiratory Effort: High PEEP can alter diaphragm position and function, leading to excessive eccentric contractions. Balancing PEEP and inspiratory effort is critical in mechanical ventilation strategies.
6. Use of Monitoring Tools for Respiratory Effort: Esophageal manometry, electrical activity of the diaphragm (EAdi), and ultrasound can help assess diaphragmatic function and guide ventilation settings to minimize eccentric contractions.
7. Potential Therapeutic Approaches: Neuromuscular blockade (NMB) in early severe ARDS may prevent harmful diaphragm contractions, while strategies like phrenic nerve stimulation are being explored to maintain diaphragmatic function.
8. Controversy Surrounding Eccentric Contractions: While current clinical evidence suggests avoiding eccentric diaphragm contractions, some physiological models propose that controlled eccentric activity may enhance diaphragmatic resilience.
9. Clinical Implications for Mechanical Ventilation: Optimizing ventilator settings to minimize patient-ventilator asynchrony and avoid excessive respiratory drive is essential for diaphragm protection and successful weaning.
10. Future Research Directions: More studies are needed to determine the conditions under which eccentric diaphragm contractions are harmful versus beneficial, particularly in relation to weaning strategies and long-term diaphragm function.

Conclusion

Eccentric contractions of the diaphragm remain a debated phenomenon in mechanical ventilation. While excessive contractions can contribute to diaphragm dysfunction and ventilator-induced lung injury, controlled eccentric activity may help maintain muscle function. The key challenge is identifying patient-specific thresholds for beneficial versus harmful contraction patterns. Future research should focus on individualized monitoring strategies and targeted interventions to optimize diaphragmatic protection in ventilated patients.

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Watch the following video on "Ventilator Induced Diaphragm Dysfunction" by USADraeger

Discussion Questions

1. Should eccentric diaphragmatic contractions be completely avoided, or can controlled eccentric activity contribute to improved diaphragm function?
2. How can monitoring tools like esophageal manometry and EAdi be better integrated into routine mechanical ventilation management?
3. What role could phrenic nerve stimulation play in maintaining diaphragm function during prolonged mechanical ventilation?

Javier Amador-Casta?eda, BHS, RRT, FCCM

Interprofessional Critical Care Network (ICCN)

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? 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).