Monitoring Recovery From Diaphragm Paralysis With Ultrasound

Summerhill, Eleanor M.; El-Sameed, Yaser Abu; Glidden, Theresa J.; McCool, F. Dennis

doi:10.1378/chest.07-2200

Cited by 215 publications

(211 citation statements)

References 35 publications

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“…Another study measured diaphragm thickness in subjects with diaphragm paralysis to monitor recovery of the muscle over time. 97 Interestingly, in this latter study, no thickening was observed by ultrasound in subjects who did not recover from paralysis, thus providing useful information for both diagnosing diaphragm paralysis and indicating recovery.…”

Section: B-modementioning

confidence: 64%

Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects

Umbrello

Formenti

2016

Respir Care

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The majority of patients admitted to the ICU require mechanical ventilation as a part of their process of care. However, mechanical ventilation itself or the underlying disease can lead to dysfunction of the diaphragm, a condition that may contribute to the failure of weaning from mechanical ventilation. However, extended time on the ventilator increases health-care costs and greatly increases patient morbidity and mortality. Nevertheless, symptoms and signs of muscle disease in a bedridden (or bed rest-only) ICU patient are often difficult to assess because of concomitant confounding factors. Conventional assessment of diaphragm function lacks specific, noninvasive, time-saving, and easily performed bedside tools or requires patient cooperation. Recently, the use of ultrasound has raised great interest as a simple, noninvasive method of quantification of diaphragm contractile activity. In this review, we discuss the physiology and the relevant pathophysiology of diaphragm function, and we summarize the recent findings concerning the evaluation of its (dys)function in critically ill patients, with a special focus on the role of ultrasounds. We describe how to assess diaphragm excursion and diaphragm thickening during breathing and the meaning of these measurements under spontaneous or mechanical ventilation as well as the reference values in health and disease. The spread of ultrasonographic assessment of diaphragm function may possibly result in timely identification of patients with diaphragm dysfunction and to a potential improvement in the assessment of recovery from diaphragm weakness.

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Section: B-modementioning

confidence: 64%

Ultrasonographic Assessment of Diaphragm Function in Critically Ill Subjects

Umbrello

Formenti

2016

Respir Care

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“…10,11 When used in isolation, diagnostic ultrasound can identify atrophy and impaired motion or contractility of the diaphragm. [12][13][14][15][16][17] Normal values for diaphragm muscle thickness and diaphragm thickening ratio imaged with B-mode ultrasound have been published, 11 but limited data assess the diagnostic utility of ultrasound in patients with neuromuscular diaphragm dysfunction, including phrenic neuropathy. Most studies to date have been case series, often with no reference standard, and have been limited by small numbers of patients.…”

mentioning

confidence: 99%

“…Most studies to date have been case series, often with no reference standard, and have been limited by small numbers of patients. [12][13][14][15][16][17] M-mode ultrasound appears superior to fluoroscopy, and several authors have concluded that ultrasound is a better test for diaphragm dysfunction than fluoroscopy. 17,18 We hypothesized that B-mode ultrasound imaging of the diaphragm would be more sensitive and specific than fluoroscopy, chest radiographs, or electrodiagnostic studies for diagnosis of neuromuscular diaphragm dysfunction.…”

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confidence: 99%

Sensitivity and specificity of diagnostic ultrasound in the diagnosis of phrenic neuropathy

et al. 2014

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Objectives: To determine the sensitivity and specificity of B-mode ultrasound in the diagnosis of neuromuscular diaphragmatic dysfunction, including phrenic neuropathy.Methods: A prospective study of patients with dyspnea referred to the EMG laboratory over a 2-year time frame for evaluation of neuromuscular respiratory failure who were recruited consecutively and examined with ultrasound for possible diaphragm dysfunction. Sonographic outcome measures were absolute thickness of the diaphragm and degree of increased thickness with maximal inspiration. The comparison standard for diagnosis of diaphragm dysfunction was the final clinical diagnosis of clinicians blinded to the diaphragm ultrasound results, but taking into account other diagnostic workup, including chest radiographs, fluoroscopy, phrenic nerve conduction studies, diaphragm EMG, and/or pulmonary function tests.Results: Of 82 patients recruited over a 2-year period, 66 were enrolled in the study. Sixteen patients were excluded because of inconclusive or insufficient reference testing. One hemidiaphragm could not be adequately visualized; therefore, hemidiaphragm assessment was conducted in a total of 131 hemidiaphragms in 66 patients. Of the 82 abnormal hemidiaphragms, 76 had abnormal sonographic findings (atrophy or decreased contractility). Of the 49 normal hemidiaphragms, none had a false-positive ultrasound. Diaphragmatic ultrasound was 93% sensitive and 100% specific for the diagnosis of neuromuscular diaphragmatic dysfunction.Conclusion: B-mode ultrasound imaging of the diaphragm is a highly sensitive and specific tool for diagnosis of neuromuscular diaphragm dysfunction. Classification of evidence:This study provides Class II evidence that diaphragmatic ultrasound performed by well-trained individuals accurately identifies patients with neuromuscular diaphragmatic respiratory failure (sensitivity 93%; specificity 100%). Neurology ® 2014;83:1264-1270 GLOSSARY CMAP 5 compound muscle action potential; NCS 5 nerve conduction study; T MAX 5 thickness at maximal inspiration; T MAX /T MIN 5 diaphragm thickening ratio; T MIN 5 thickness at resting end-expiration.Diaphragm dysfunction can be difficult to diagnose, particularly when diaphragm paralysis is bilateral. The usual workup of patients presenting with unexplained dyspnea may include chest radiographs, fluoroscopy, phrenic nerve conduction studies (NCS), needle EMG of the diaphragm, pulmonary function testing, and transdiaphragmatic pressure measurements; all of these diagnostic tests can produce false-positive and false-negative findings, and some tests are invasive or uncomfortable for the patient.

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“…We now use it routinely in our EMG laboratory in the workup of patients with shortness of breath, not only to enhance the safety and accuracy of needle EMG of the diaphragm, 4 but also to evaluate for atrophy and lack of motion of the muscle, which are readily apparent on ultrasound in patients with phrenic neuropathy. [5][6][7][8] Sonographic assessment of diaphragm structure and function would be a useful clinical tool in patients with COPD presenting for evaluation of possible coexisting neuromuscular respiratory weakness, particularly because needle EMG is relatively contraindicated in this patient population due to the potential for lung hyperinfl ation and associated diffi culty involved in accurately localizing the muscle. However, to use ultrasound in this way, there is a need for normal values for diaphragm thickness and contraction in patients with COPD.…”

mentioning

confidence: 99%