Diaphragm Movement And Contractility Evaluation By Thoracic Ultrasound

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Information about Diaphragm Movement And Contractility Evaluation By Thoracic Ultrasound
Health & Medicine

Published on February 26, 2009

Author: basselericsoussi

Source: slideshare.net

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

The Importance of the Diaphragm The most important of the respiratory muscles Two components: Non-contractile central tendon Contracting muscle fibers Innervated by phrenic nerve (C3-C5) Contraction of the diaphragm Decreases intrapleural pressure Generating positive intraabdominal pressure contributes to ¾ of inspiratory volumes at the vital capacity

The most important of the respiratory muscles

Two components:

Non-contractile central tendon

Contracting muscle fibers

Innervated by phrenic nerve (C3-C5)

Contraction of the diaphragm

Decreases intrapleural pressure

Generating positive intraabdominal pressure

contributes to ¾ of inspiratory volumes at the vital capacity

Diaphragmatic Paralysis Unilateral vs. bilateral Increase in load on the other respiratory accessory muscles Respiratory failure Clinical manifestations  DOE, Orthopnea Rapid shallow breathing Paradoxical abdominal wall retraction during inspiration Hypoxemia (due to the atelectasis ) Hypercapnia and hypoxemia Severe cases (ventilatory failure, severe pulmonary hypertension, and secondary erythrocytosis )

Unilateral vs. bilateral

Increase in load on the other respiratory accessory muscles

Respiratory failure

Clinical manifestations 

DOE, Orthopnea

Rapid shallow breathing

Paradoxical abdominal wall retraction during inspiration

Hypoxemia (due to the atelectasis )

Hypercapnia and hypoxemia

Severe cases (ventilatory failure, severe pulmonary hypertension, and secondary erythrocytosis )

 

Diagnosis of Diaphragmatic Paralysis Chest radiograph Elevated hemidiaphragm and atelectasis Fluoroscopy Requires patient transportation Uses ionizing radiation Sniff test: paradoxical elevation of the paralyzed hemidiaphragm with inspiration (>90%)

Chest radiograph

Elevated hemidiaphragm and atelectasis

Fluoroscopy

Requires patient transportation

Uses ionizing radiation

Sniff test: paradoxical elevation of the paralyzed hemidiaphragm with inspiration (>90%)

Diagnosis of Diaphragmatic Paralysis Pulmonary function tests The decrease in VC from upright to supine position Up to 10% in normal population (VC 70-80% of predicted) Up to 50% in bilateral diaphragmatic paralysis Maximal inspiratory pressures (PI-max) Bilateral paralysis: < -60 cmH2O Unilateral paralysis: WNL (due to preserved strength of the accessory muscles) Electromyography (EMG) and phrenic nerve stimulation

Pulmonary function tests

The decrease in VC from upright to supine position

Up to 10% in normal population (VC 70-80% of predicted)

Up to 50% in bilateral diaphragmatic paralysis

Maximal inspiratory pressures (PI-max)

Bilateral paralysis: < -60 cmH2O

Unilateral paralysis: WNL (due to preserved strength of the accessory muscles)

Electromyography (EMG) and phrenic nerve stimulation

Pleural Pressure: balloon at the lower third of the esophagus Gastric Pressure: balloon in the stomach Rib Cage movement Abdominal wall movement

Diaphragmatic Movement Evaluation with Thoracic Ultrasound Thoracic ultrasound Lack of ionizing radiation Bedside procedure Should be the method of choice in the investigation of suspected hemidiaphragmatic movement abnormality. Proposed techniques Changes in diaphragm thickness during contraction Chronically paralyzed diaphragm is atrophic and does not thicken during inspiration (contraction).

Thoracic ultrasound

Lack of ionizing radiation

Bedside procedure

Should be the method of choice in the investigation of suspected hemidiaphragmatic movement abnormality.

Proposed techniques

Changes in diaphragm thickness during contraction

Chronically paralyzed diaphragm is atrophic and does not thicken during inspiration (contraction).

Equipment and Technique 2.5 to 3.5 MHz transducer (low frequency for deep tissue) Probe position Right hemidiaphgragm Liver window: Right sub-costal between the midclavicular and anterior axillary lines Left hemidiaphgragm Spleen window: Left sub-costal between the midclavicular and anterior axillary lines The probe directed medially, cranially, and dorsally the ultrasound beam reached the posterior third of the diaphragm.

2.5 to 3.5 MHz transducer (low frequency for deep tissue)

Probe position

Right hemidiaphgragm

Liver window: Right sub-costal between the midclavicular and anterior axillary lines

Left hemidiaphgragm

Spleen window: Left sub-costal between the midclavicular and anterior axillary lines

The probe directed medially, cranially, and dorsally

the ultrasound beam reached the posterior third of the diaphragm.

 

 

 

Diaphragm Movements and M-mode Ultrasonographic Measurements In inspiration the diaphragm descends, moving toward the ultrasound probe Upward inspiration slope on M-mode The diaphragm inspiratory excursion: The amplitude between the foot of the inspiration slope and the apex of this slope Always greater in men than in women Always greater in the supine position than in the sitting or the standing positions No significant correlation with age Significant correlation with height and weight

In inspiration the diaphragm descends, moving toward the ultrasound probe

Upward inspiration slope on M-mode

The diaphragm inspiratory excursion: The amplitude between the foot of the inspiration slope and the apex of this slope

Always greater in men than in women

Always greater in the supine position than in the sitting or the standing positions

No significant correlation with age

Significant correlation with height and weight

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 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

Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST February 2009 vol. 135 no. 2 391-400

Challenges During DB, the descending lung may obscure the diaphragm The probe should be displaced caudally with an angle adjustment to maintain a perpendicular approach of the hemidiaphragmatic motion. Patients with respiratory disease and dyspnea Increased respiratory effort can result in greater chest wall movement and cause the ribs and lung to obscure the images Visualization of the left hemidiaphragm is recognized as more difficult due to the smaller window of the spleen as compared with the liver window

During DB, the descending lung may obscure the diaphragm

The probe should be displaced caudally with an angle adjustment to maintain a perpendicular approach of the hemidiaphragmatic motion.

Patients with respiratory disease and dyspnea

Increased respiratory effort can result in greater chest wall movement and cause the ribs and lung to obscure the images

Visualization of the left hemidiaphragm is recognized as more difficult due to the smaller window of the spleen as compared with the liver window

Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery After Cardiac Surgery Surgery-related phrenic nerve injury Severe diaphragmatic dysfunction can prolong mechanical ventilation (US) probe is positioned on right midaxillary line visualization of the entire length of the diaphragm is frequently permitted by presence of some amount of pleural effusion and/or atelectasis Diaphragmatic excursion measured from the end of normal expiration ( C ) to end of maximal inspiratory effort (D)

After Cardiac Surgery

Surgery-related phrenic nerve injury

Severe diaphragmatic dysfunction can prolong mechanical ventilation

(US) probe is positioned on right midaxillary line

visualization of the entire length of the diaphragm is frequently permitted by presence of some amount of pleural effusion and/or atelectasis

Diaphragmatic excursion measured from the end of normal expiration ( C ) to end of maximal inspiratory effort (D)

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

Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After Cardiac Surgery Best E < 25 mm was associated with severe diaphragmatic dysfunction None of the patients with uncomplicated postoperative course have Best E < 25 mm, either before or after surgery Excellent negative likelihood ratio of Best E < 25 mm CHEST February 2009 vol. 135 no. 2 401-407

Best E < 25 mm was associated with severe diaphragmatic dysfunction

None of the patients with uncomplicated postoperative course have Best E < 25 mm, either before or after surgery

Excellent negative likelihood ratio of Best E < 25 mm

Diaphragmatic Paralysis: The Use of M Mode Ultrasound for Diagnosis in Adults Normal diaphragm Sniff test: sharp upstroke (normal caudal movement of the diaphragm during inspiration) Diaphragmatic paralysis No active caudal movement of the diaphragm with inspiration Sniff test: Abnormal paradoxical movement (cranial movement on inspiration) Spinal Cord. 2006 Aug;44(8):505-8. Epub 2005 Dec 6.

Normal diaphragm

Sniff test: sharp upstroke (normal caudal movement of the diaphragm during inspiration)

Diaphragmatic paralysis

No active caudal movement of the diaphragm with inspiration

Sniff test: Abnormal paradoxical movement (cranial movement on inspiration)

Conclusion M mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphragm Diaphragmatic function assessment with ultrasound is important in patients with prolonged ventilation 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

M mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphragm

Diaphragmatic function assessment with ultrasound is important in patients with prolonged ventilation

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

References 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 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 Ueki J, De Bruin PF, Pride NB (1995) In vivo assessment of diaphragm contraction by ultrasound in normal subjects. Thorax. 50:1157–1161 Gottesman E, Mc Cool FD (1997) Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med 155:1570–1574. 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 Ayoub J, Cohendy R, Prioux J, et al. (2001) Diaphragm movement before and after cholecystectomy: a sonographic study. Anesth Analg 92:755–761 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

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

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

Ueki J, De Bruin PF, Pride NB (1995) In vivo assessment of diaphragm contraction by ultrasound in normal subjects. Thorax. 50:1157–1161

Gottesman E, Mc Cool FD (1997) Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med 155:1570–1574.

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

Ayoub J, Cohendy R, Prioux J, et al. (2001) Diaphragm movement before and after cholecystectomy: a sonographic study. Anesth Analg 92:755–761

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

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