Diaphragm Movement and Contractility Evaluation by Thoracic Ultrasound:  Ultrasonography Determination of Diaphragmatic Ex...
The Importance of the Diaphragm <ul><li>The most important of the respiratory muscles </li></ul><ul><li>Two components:  <...
Diaphragmatic Paralysis <ul><li>Unilateral vs. bilateral </li></ul><ul><li>Increase in load on the other respiratory acces...
 
Diagnosis of Diaphragmatic Paralysis <ul><li>Chest radiograph </li></ul><ul><ul><li>Elevated hemidiaphragm and atelectasis...
Diagnosis of Diaphragmatic Paralysis <ul><li>Pulmonary function tests  </li></ul><ul><ul><li>The decrease in VC from uprig...
Pleural Pressure: balloon at the lower third of the esophagus Gastric Pressure: balloon in the stomach Rib Cage movement A...
Diaphragmatic Movement Evaluation with Thoracic Ultrasound <ul><li>Thoracic ultrasound </li></ul><ul><ul><li>Lack of ioniz...
Equipment and Technique <ul><li>2.5 to 3.5 MHz transducer  (low frequency for deep tissue) </li></ul><ul><li>Probe positio...
 
 
 
Diaphragm Movements and M-mode Ultrasonographic Measurements  <ul><li>In inspiration the diaphragm descends, moving toward...
Diaphragm inspiratory time  Diaphragm expiratory time  Diaphragm inspiratory amplitude
Maneuver began at the end of normal expiration: Quiet Breathing (QB): Diaphragm excursion 1.5-2 cm Lower limit 0.9 cm for ...
Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST February 2009 vo...
Challenges <ul><li>During DB, the descending lung may obscure the diaphragm  </li></ul><ul><ul><li>The probe should be dis...
Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery <ul><li>After Cardiac Sur...
Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery CHEST February 2009 vol. ...
Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery <ul><li>Best E < 25 mm wa...
Diaphragmatic Paralysis: The Use of M Mode Ultrasound for Diagnosis in Adults <ul><li>Normal diaphragm </li></ul><ul><ul><...
Conclusion <ul><li>M mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphra...
References <ul><li>Alain Boussuges, MD, PhD, Yoann Gole, MSc and Philippe Blanc, MD. Diaphragmatic Motion Studied by M-Mod...
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Diaphragm Movement And Contractility Evaluation By Thoracic Ultrasound

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Diaphragm Movement And Contractility Evaluation By Thoracic Ultrasound

  1. 1. Diaphragm Movement and Contractility Evaluation by Thoracic Ultrasound: Ultrasonography Determination of Diaphragmatic Excursion Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois at Chicago
  2. 2. The Importance of the Diaphragm <ul><li>The most important of the respiratory muscles </li></ul><ul><li>Two components: </li></ul><ul><ul><li>Non-contractile central tendon </li></ul></ul><ul><ul><li>Contracting muscle fibers </li></ul></ul><ul><li>Innervated by phrenic nerve (C3-C5) </li></ul><ul><li>Contraction of the diaphragm </li></ul><ul><ul><li>Decreases intrapleural pressure </li></ul></ul><ul><ul><li>Generating positive intraabdominal pressure </li></ul></ul><ul><ul><li>contributes to ¾ of inspiratory volumes at the vital capacity </li></ul></ul>
  3. 3. Diaphragmatic Paralysis <ul><li>Unilateral vs. bilateral </li></ul><ul><li>Increase in load on the other respiratory accessory muscles </li></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><li>Clinical manifestations  </li></ul><ul><ul><li>DOE, Orthopnea </li></ul></ul><ul><ul><li>Rapid shallow breathing </li></ul></ul><ul><ul><li>Paradoxical abdominal wall retraction during inspiration </li></ul></ul><ul><ul><li>Hypoxemia (due to the atelectasis ) </li></ul></ul><ul><ul><li>Hypercapnia and hypoxemia </li></ul></ul><ul><ul><li>Severe cases (ventilatory failure, severe pulmonary hypertension, and secondary erythrocytosis ) </li></ul></ul>
  4. 5. Diagnosis of Diaphragmatic Paralysis <ul><li>Chest radiograph </li></ul><ul><ul><li>Elevated hemidiaphragm and atelectasis </li></ul></ul><ul><li>Fluoroscopy </li></ul><ul><ul><li>Requires patient transportation </li></ul></ul><ul><ul><li>Uses ionizing radiation </li></ul></ul><ul><ul><li>Sniff test: paradoxical elevation of the paralyzed hemidiaphragm with inspiration (>90%) </li></ul></ul>
  5. 6. Diagnosis of Diaphragmatic Paralysis <ul><li>Pulmonary function tests </li></ul><ul><ul><li>The decrease in VC from upright to supine position </li></ul></ul><ul><ul><ul><li>Up to 10% in normal population (VC 70-80% of predicted) </li></ul></ul></ul><ul><ul><ul><li>Up to 50% in bilateral diaphragmatic paralysis </li></ul></ul></ul><ul><li>Maximal inspiratory pressures (PI-max) </li></ul><ul><ul><li>Bilateral paralysis: < -60 cmH2O </li></ul></ul><ul><ul><li>Unilateral paralysis: WNL (due to preserved strength of the accessory muscles) </li></ul></ul><ul><li>Electromyography (EMG) and phrenic nerve stimulation </li></ul>
  6. 7. Pleural Pressure: balloon at the lower third of the esophagus Gastric Pressure: balloon in the stomach Rib Cage movement Abdominal wall movement
  7. 8. Diaphragmatic Movement Evaluation with Thoracic Ultrasound <ul><li>Thoracic ultrasound </li></ul><ul><ul><li>Lack of ionizing radiation </li></ul></ul><ul><ul><li>Bedside procedure </li></ul></ul><ul><ul><li>Should be the method of choice in the investigation of suspected hemidiaphragmatic movement abnormality. </li></ul></ul><ul><li>Proposed techniques </li></ul><ul><ul><li>Changes in diaphragm thickness during contraction </li></ul></ul><ul><ul><ul><li>Chronically paralyzed diaphragm is atrophic and does not thicken during inspiration (contraction). </li></ul></ul></ul>
  8. 9. Equipment and Technique <ul><li>2.5 to 3.5 MHz transducer (low frequency for deep tissue) </li></ul><ul><li>Probe position </li></ul><ul><ul><li>Right hemidiaphgragm </li></ul></ul><ul><ul><ul><li>Liver window: Right sub-costal between the midclavicular and anterior axillary lines </li></ul></ul></ul><ul><ul><li>Left hemidiaphgragm </li></ul></ul><ul><ul><ul><li>Spleen window: Left sub-costal between the midclavicular and anterior axillary lines </li></ul></ul></ul><ul><li>The probe directed medially, cranially, and dorsally </li></ul><ul><ul><li>the ultrasound beam reached the posterior third of the diaphragm. </li></ul></ul>
  9. 13. Diaphragm Movements and M-mode Ultrasonographic Measurements <ul><li>In inspiration the diaphragm descends, moving toward the ultrasound probe </li></ul><ul><ul><li>Upward inspiration slope on M-mode </li></ul></ul><ul><li>The diaphragm inspiratory excursion: The amplitude between the foot of the inspiration slope and the apex of this slope </li></ul><ul><ul><li>Always greater in men than in women </li></ul></ul><ul><ul><li>Always greater in the supine position than in the sitting or the standing positions </li></ul></ul><ul><ul><li>No significant correlation with age </li></ul></ul><ul><ul><li>Significant correlation with height and weight </li></ul></ul>
  10. 14. Diaphragm inspiratory time Diaphragm expiratory time Diaphragm inspiratory amplitude
  11. 15. Maneuver began at the end of normal expiration: Quiet Breathing (QB): Diaphragm excursion 1.5-2 cm Lower limit 0.9 cm for women and 1 cm for men Voluntary Sniffing (VS) Diaphragm excursion 2.5-3 cm Lower limit 1.6 cm in women and 1.8 cm in men “normal caudal movement of the diaphragm during inspiration” Deep Breathing (DB) Diaphragm excursion 6-7 cm Lower limit 3.7 cm for women and 4.7 cm for men
  12. 16. Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST February 2009 vol. 135 no. 2 391-400
  13. 17. Challenges <ul><li>During DB, the descending lung may obscure the diaphragm </li></ul><ul><ul><li>The probe should be displaced caudally with an angle adjustment to maintain a perpendicular approach of the hemidiaphragmatic motion. </li></ul></ul><ul><li>Patients with respiratory disease and dyspnea </li></ul><ul><ul><li>Increased respiratory effort can result in greater chest wall movement and cause the ribs and lung to obscure the images </li></ul></ul><ul><li>Visualization of the left hemidiaphragm is recognized as more difficult due to the smaller window of the spleen as compared with the liver window </li></ul>
  14. 18. Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery <ul><li>After Cardiac Surgery </li></ul><ul><ul><li>Surgery-related phrenic nerve injury </li></ul></ul><ul><ul><li>Severe diaphragmatic dysfunction can prolong mechanical ventilation </li></ul></ul><ul><ul><li>(US) probe is positioned on right midaxillary line </li></ul></ul><ul><ul><li>visualization of the entire length of the diaphragm is frequently permitted by presence of some amount of pleural effusion and/or atelectasis </li></ul></ul><ul><ul><li>Diaphragmatic excursion measured from the end of normal expiration ( C ) to end of maximal inspiratory effort (D) </li></ul></ul>
  15. 19. Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery CHEST February 2009 vol. 135 no. 2 401-407 Diaphragm contribution to respiratory pressure severe diaphragmatic dysfunction
  16. 20. Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery <ul><li>Best E < 25 mm was associated with severe diaphragmatic dysfunction </li></ul><ul><li>None of the patients with uncomplicated postoperative course have Best E < 25 mm, either before or after surgery </li></ul><ul><li>Excellent negative likelihood ratio of Best E < 25 mm </li></ul>CHEST February 2009 vol. 135 no. 2 401-407
  17. 21. Diaphragmatic Paralysis: The Use of M Mode Ultrasound for Diagnosis in Adults <ul><li>Normal diaphragm </li></ul><ul><ul><li>Sniff test: sharp upstroke (normal caudal movement of the diaphragm during inspiration) </li></ul></ul><ul><li>Diaphragmatic paralysis </li></ul><ul><ul><li>No active caudal movement of the diaphragm with inspiration </li></ul></ul><ul><ul><li>Sniff test: Abnormal paradoxical movement (cranial movement on inspiration) </li></ul></ul>Spinal Cord. 2006 Aug;44(8):505-8. Epub 2005 Dec 6.
  18. 22. Conclusion <ul><li>M mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphragm </li></ul><ul><li>Diaphragmatic function assessment with ultrasound is important in patients with prolonged ventilation </li></ul><ul><li>Ultrasonography should be considered to exclude severe diaphragmatic dysfunction following cardiac surgery in daily practice with the advantages of being fully noninvasive and widely available in ICU </li></ul>
  19. 23. References <ul><li>Alain Boussuges, MD, PhD, Yoann Gole, MSc and Philippe Blanc, MD. Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST February 2009 vol. 135 no. 2 391-400 </li></ul><ul><li>Nicolas Lerolle, MD*, Emmanuel Guérot, MD, Saoussen Dimassi, MD, Rachid Zegdi, MD, PhD, Christophe Faisy, MD, PhD, Jean-Yves Fagon, MD, PhD and Jean-Luc Diehl, MD. Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery. CHEST February 2009 vol. 135 no. 2 401-407 </li></ul><ul><li>Ueki J, De Bruin PF, Pride NB (1995) In vivo assessment of diaphragm contraction by ultrasound in normal subjects. Thorax. 50:1157–1161 </li></ul><ul><li>Gottesman E, Mc Cool FD (1997) Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med 155:1570–1574. </li></ul><ul><li>Scott S, Fuld JP, Carter R, et al. (2006) Diaphragm ultrasonography as an alternative to whole-body plethysmography in pulmonary function testing. J Ultrasound Med 25:225–232 </li></ul><ul><li>Ayoub J, Cohendy R, Prioux J, et al. (2001) Diaphragm movement before and after cholecystectomy: a sonographic study. Anesth Analg 92:755–761 </li></ul><ul><li>Lloyd T, Tang YM, Benson MD, et al. (2006) Diaphragmatic paralysis: the use of M-mode ultrasound for diagnosis in adults. Spinal Cord 44:505–508 </li></ul>

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