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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 175 2007
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DOI: 10.1164/rccm.200612-1800ED
phy but usually not until patients have been treated with mechanical ventilation for several days. Clinical examination is focused
on detecting muscle weakness, which is a uniform manifestation
of CINM, regardless of whether the axon, muscle contractile
proteins, or muscle membrane excitability are involved alone or
in combination (4, 9). As the patient must be cooperative, daily
assessment from the beginning of mechanical ventilation is rarely
possible. Electroneuromyography is the alternative diagnostic
approach. Electroneuromyography allows earlier diagnosis but
its use requires considerable resources and can cause discomfort.
It is neither practical nor ethical to conduct repeat testing on a
daily basis for a clinical trial.
To date, only patients who remain in an ICU for 5 to 7 days
have been assessed for CINM, and because many patients will
have been discharged or will have died by this time, an intentionto-treat analysis of a clinical trial may appear impractical. However, the methodologic difculties can be overcome by asking the
right questions in the right population. We should ask whether a
treatment reduces the incidence of CINM and does that result
in better outcomes for patients. The study population should be
patients likely to receive at least 5 days of mechanical ventilation
and in whom the clinical diagnosis of CINM is feasible. This will
likely mean excluding patients with primary neurologic diseases
or brain injury. To determine if CINM is prevented, the outcome
measure could be the number of patients discharged alive from
ICU who were never diagnosed with CINM. To determine if
patients outcomes are improved, time to recovery from CINM
and long-term functional recovery of survivors should be reported.
Editorials
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Conflict of Interest Statement : Neither author has a financial relationship with a
commercial entity that has an interest in the subject of this manuscript.