Discussion
diaphragm dysfunction, cough
ADVERSE EFFECTS
This study is the first to compare the use of transcutaneous electrical stimulation of the diaphragm with a sham intervention on diaphragm function in intubated and ventilated patients in the ICU. We found that: (1) TEDS did not significantly decrease the risk of diaphragm dysfunction; (2) both groups had similar decreases in diaphragmatic thickness during ventilation; (3) TEDS would not result in a statistically significant improvement in inspiratory muscle strength or peak expiratory flow during cough and (4) TEDS would not optimise weaning from mechanical ventilation and extubation success rate.Limiting the adverse effects of mechanical ventilation on the diaphragm is challenging but essential because these effects lead to poor outcomes. ICU teams are seeking new methods to maintain a sufficient level of diaphragm activity while also maintaining lung-protective ventilation and avoiding excessive respiratory effort [Our study has several limitations. First, the attrition rate was greater than we had estimated. Although we included 20% more participants than required according to the sample size calculation, we had 27% missing data. However, the intention-to-treat and per-protocol analysis results did not differ and reached the same conclusions. Also, there was no difference between participants who dropped out and those who were analysed. Second, although the diaphragm thickening fraction is accepted as an indicator of diaphragm function and a predictor for extubation failure, some recent data suggest that the correlation between ultrasonography and diaphragm pressure output is unsatisfactory, is highly variable and depends on body position [Finally, the stimulation induced noise in the cardiac monitoring data, which may disturb monitoring processes by other clinicians (see Additional file 