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240 oracic ultrasound
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➤ Updated bibliography
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and Emergency Department pneumonia. oracic ultrasound shows sensitivity and specificity values over 95%.
Chest radiograph is less accurate. About 8% of pneumonic lesions are not detectable by ultrasound.
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Meta-analysis including nine studies and 1080 subjects. It demonstrates sensitivity and specificity values for lung
ultrasound of 0.97 and 0.94 respectively for detecting pneumonia. e area under the receiver operating characteristic curve is 0.99.
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Parenchymal lung patology 241
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MA, Feldman CJ, Kalil RA, Sicari R, Picano E, Leiria TL. Lung ultrasound for the evaluation of pulmonary
congestion in outpatients: a comparison with clinical assessment, natriuretic peptides and echocardiography.
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G, De Giorgi M, Lupia M, Bruzzese V, Zoccali C. Chest ultrasound and hidden lung congestion in peritoneal
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Contribution for understanding the role of B-Lines for estimating extravascular lung water in peritoneal dialysis
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density and geometry.
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242 oracic ultrasound
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8
Pathology of the diaphragm
Diaphragmatic pathology is complex and concerns congenital and acquired diseases with variable gravity
ultrasound features of the diaphragm are discussed in chapter 4. In these
pages we will consider its diseases and dysfunctions from the ultrasound
perspective, highlighting their anatomic, artifactual and dynamic aspects
(Table 1).
Physiologically, the diaphragm is the most important respiratory muscle, its vertical movement is 1 to 2 cm during quiet breathing and 6 to 7 cm during deep breathing. Each cm of
vertical movement mobilizes 300 to 400 ml of air during normal breathing
Table 2 summarizes some dynamic aspects of the muscle useful for the ultrasound diagnosis
in diaphragm pathology.
e assessment of diaphragmatic excursion has some limitations when the probe is in intercostal or subcostal position (Fig. 1) by measuring the shift in M-Mode
1
. Anatomy, function and normal
2,3
.
4,5
:
Figure 1 – Ultrasound scans. A: Subcostal. B: Intercostal. C: With linear probe for the apposition zone.
D: Orthostatic subcostal.
243
244 oracic ultrasound
• On the left, the colic angle and the poor acoustic window of the spleen prevent the meas-
urement many times.
• On the right, the lung curtain can obscure the vision of the diaphragmatic dome in its
maximum displacement, if the scans are carried out with the probe in intercostals position (Fig. 2).
Figure 2 – On the left: The M Mode track is partially obscured by the inspiratory lung curtain. On the
right: inspiratory curtain in B Mode.
• ere is uncertainty related to the angle of incidence of the ultrasound on the diaphragm
that can make measurements not repeatable (Fig. 3).
• Consequently, when measuring diaphragmatic excursion, the exploring beam should be
as perpendicular as possible to the excursion line of the muscle.
e measurement with linear probe of the length and dynamics of the area of apposition of the
diaphragm, and of the inspiratory thickening of the diaphragm
Figure 3 – Sometimes it is not easy to keep the line of sight of M Mode perfectly orthogonal to the line
of the diaphragm (arrow).
6,7
is much more reproducible
Pathology of the diaphragm 245
and can be performed either on the right or left (Fig. 4). However, the thickness and thickening of the muscle are small (an average of 3-4 mm vital capacity and 30-60% during forced
inspiration), and then the measurements must be accurate (Fig. 5).
Figure 4 – Diaphragm in the apposition zone. A: B Mode visualization. Pleural and peritoneal fluid
contrasts the muscle. B: The diaphragm against the chest wall is made evident by the presence of ascites.
C: The lung curtain during inspiration shortens the muscle affixed to the wall. D: During maximum
inspiration the apposition zone of the diaphragm is greatly reduced and the muscle is thickened (4.4 mm).
Figure 5 – Thickening of the diaphragm at the apposition zone during inspiration. In this case the
fraction of thickening is 39%.
246 oracic ultrasound
Table 1 – Diaphragm diseases
Pathology Characteristics
Congenital hernias (CH)
• Bochdalek hernia
• Morgagni hernia
Acquired hernias
• Hiatal hernias
• Traumatic hernias
Tumors Benign
Eventration
Diaphragmatic dysfunction
(monolateral/bilateral)
• Paralysis
• Weakness
Mimics
• Increased intraabdominal pressure
• Lung volume loss
• Subpulmonic pleural effusion
• Pleural tethering of the diaphragm
CH with antenatal diagnosis
CH associated with pulmonary hypoplasia
CH diagnosed shortly after birth in patients with
respiratory distress
CH with postnatal diagnosis (symptomatic and
asymptomatic congenital hernias of the adult).
Type 1,2,3,4
Malignant
Neurogenic
• Multiple sclerosis
• Stroke
• Arnold-Chiari malformation
• Quadriplegia
• Amyotrophic lateral sclerosis
• Poliomyelitis
• Spinal muscular atrophy
• Syringomyelia
• Guillain-Barrè syndrome
• Tumor compression
• Neuralgic neuropathy
Myogenic or neuro-myogenic
• Myastenia gravis
• Lambert Eaton syndrome
• Muscular dystrophies
• Myositis
• Acid maltase deficiency
Toxic or drug related
• Organophosphates
• Glucocorticoids
• Paralyzing agents
• Botulism
Pneumogenic
• Hyperinflation (COPD, Asthma)
Critical illness polyneuropathy
Chronic inflammatory demyelinating
polyneuropathy
Idiopatic
Disuse atrophy (ventilator dependency)
Obesity, ascites, hepatomegaly, splenomegaly,
subphrenic abscesses
Atelectasis, pulmonary fibrosis, lung resection
Pathology of the diaphragm 247
Table 2 – Sonographic measures concerning the diaphragm
Diaphragmatic excursion in echography
(M-Mode, hemicoronal)
Diaphragmatic excursion in echography
(M-Mode, intercostal)
Diaphragmatic excursion (M-Mode, subcostal)
quiet breathing
Diaphragmatic excursion (M-Mode, subcostal)
deep breathing
Diaphragmatic excursion (M-Mode, subcostal)
voluntary sniffing
Thickness of the diaphragmatic zone of
apposition
Length of diaphragmatic zone of apposition to
mid-axillary line
Maximum inspiratory lowering of 4.9 cm to the
right and 5 cm to the left
1.8 +/- 0.76 to 7.9 +/- 1.3 cm, forced inspiration
1.8 +/- 0.3 (males), 1.6 +/- 0.3 (females)
7+/- 0.6 (males), 5.7 +/- 0.1 (females)
2.9 +/- 0.6 (males), 2.6 +/- 0.5 (females)
3.2 +/- 0.8 to over 4 mm
0.7 +/- 0.6 cm at Total Lung Capacity, 7.1 +/-
0.9 cm at RFC, 11 +/- 1.2 cm at Residual Volume
Diaphragmatic thickness measurements during spontaneous breathing are influenced by lung
volume in a non linear relationship. ickness of the diaphragm changes according to lung
volumes, increasing slightly from residual volume to functional residual capacity (FRC), and
sharply from FRC to total lung capacity.
In diaphragmatic ultrasound some principles have general validity.
• Diaphragmatic dysfunction is an underdiagnosed cause of dyspnea and should always be
considered in the differential diagnosis of unexplained dyspnea8.
• Diaphragmatic anatomy and function are affected by disorders of contiguous structures
(free and loculated pleural effusion, atelectasis, pulmonary fibrosis, pulmonary hyperinflation, supradiaphragmatic pneumonia, subdiaphragmatic abscess, ascites, peritonitis,
pyelonephritis, pleural adhesions, tumors, etc…). Before attributing a dysfunction to a
primitive neuromuscular disease, these diagnoses must be excluded9.
• A state of lung hyperinflation10 or, on the contrary, pleuropulmonary restriction respec-
tively show a decrease or an increase of the area of apposition of the diaphragm (Fig. 6).
• e bronchial obstructive pathology alters the movement of the diaphragm but also the
duration of the expiratory movement (Fig. 7).
• e diaphragmatic hernia involves occupation of the pleural cavity by omental tissue or
abdominal organs, resulting in pulmonary compression (or hypoplasia).
• An elevation of the diaphragm on chest X-ray11 always requires an echographic evaluation
of lung, pleura and of the subdiaphragmatic peritoneum.
• Elevation caused by paralysis or weakness involves an entire hemidiaphragm, whereas eleva-
tion secondary to eventration involves only a portion of hemidiaphragm, most commonly
the anteromedial portion of the right hemidiaphragm.
• In diaphragmatic weakness the impaired hemidiaphragm may be thinned by atrophy of
the muscle12; in diaphragmatic paralysis that lasts few days the involved hemidiaphragm
is thinned.
248 oracic ultrasound
Figure 6 – Air trapping in a patient with CPOD. A: Standard chest X-ray. B: Specular
pattern of the lung (hypermirror). C: the opening of the costophrenic angle during
maximum inspiration is minimal and the length of the apposition zone of the diaphragm
is minimal. D: Muscle hypertrophy with marked thickening at the end of inspiration.
Figure 7 – Assessement of diaphragmatic mobility in M Mode. A: Quiet breathing. B:
Maximum inspiration. C: Maximum exhalation from inspiratory reserve volume. D: The
normal subject, in 1 second exhales over 80% of vital capacity.
Pathology of the diaphragm 249
• Unilateral diaphragmatic involvement is often asymptomatic and discovered incidentally.
Bilateral diaphragmatic dysfunction is usually symptomatic and may lead to ventilator failure13.
• Functional imaging allows further evaluation after diaphragmatic elevation is recognized.
Diaphragmatic ultrasound may be used as an alternative to fluoroscopic tests.
➣ Clinical features
Patients with diaphragmatic pathology may be asymptomatic, may have dyspnea on exertion
and limited ability to exercise, or may be critically ill with severe respiratory distress. Often
these patients show signs and symptoms related to the causal pathology (pain, fever, neurologic disturbances) and a progressive and/or evocative history (recurrent respiratory failure
and infections, mediastinal mass, chest surgery, trauma, spinal and neuromuscular disease,
mechanical ventilation)
e distinction between monolateral and bilateral diaphragmatic dysfunction represents the
first evaluative step.
In the case of unilateral diaphragmatic paralysis, motility and inspiratory thickening of
the involved hemidiaphragm are abolished, while motility and thickening of the opposite
hemidiaphragm remain preserved. e concerned hemidiaphragm is raised and there is a
paradoxical (cephalad) movement of this muscle during a short, sharp inspiratory effort
through the nostrils (sniff test).
Unilateral muscle weakness involves a reduced movement and thickening. Sonographic features
of hypoventilation or atelectasis appear in the lower lobe in a patient with diaphragmatic
dysfunction or paralysis (Fig. 8). Table 3 illustrates the clinical and sonographic features
distinguishing between mono- and bilateral paralysis of the diaphragm
14,15
.
1,8,14,16
.
Figure 8 – Atelectasis of the right inferior lobe in case of right diaphragmatic paralysis.
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