Diaphragm In Patients Research Articles

Ultrasound examination in assessing the functional state of the diaphragm in patients with respiratory failure requiring respiratory support

Diaphragm dysfunction (DD) is diagnosed in 60% patients 24 hours after intubation. Diaphragm ultrasound (DU) facilitates non-invasive assessment of excursion and thickness of the diaphragm throughout the breathing cycle. Sonographically measured excursion and thickening fraction (TF) of the diaphragm show moderate correlation with reference methods for diaphragm dysfunction detection. Both increase and decrease in diaphragm thickness in mechanically ventilated patients are associated with prolonged mechanical ventilation. TF exceeding 25% increases probability of successful weaning. Maintaining TF within 15–40 % might shorten the duration of mechanical ventilation.

Long-Term Evaluation of the Shape of the Reconstructed Diaphragm in Patients with Left-Sided Congenital Diaphragmatic Hernia Using Serial Chest Radiographs and Correlation to Further Complications.

Background: Defining risk factors for long-term comorbidities in patients after neonatal repair of congenital diaphragmatic hernia (CDH) is an important cornerstone of the implementation of targeted longitudinal follow-up programs. Methods: This study systematically assessed serial chest radiographs of 89 patients with left-sided CDH throughout a mean follow-up of 8.2 years. These geometrical variables for the left and right side were recorded: diaphragmatic angle (LDA, RDA), diaphragmatic diameter (LDD, RDD), diaphragmatic height (LDH, RDH), diaphragmatic curvature index (LDCI, RDCI), lower lung diameter (LLLD, RLLD) and thoracic area (LTA, RTA). Results: It was demonstrated that the shape of the diaphragm in patients with large defects systematically differs from that of patients with small defects. Characteristically, patients with large defects present with a smaller LDCI (5.1 vs. 8.4, p < 0.001) at 6 months of age, which increases over time (11.4 vs. 7.0 at the age of 15.5 years, p = 0.727), representing a flattening of the patch and the attached rudimentary diaphragm as the child grows. Conclusions: Multiple variables during early follow-up were significantly associated with comorbidities such as recurrence, scoliotic curves of the spine and a reduced thoracic area. Some geometrical variables may serve as surrogate parameters for disease severity, which is associated with long-term comorbidities.

Effects of Pulmonary Rehabilitation on Respiratory Function and Thickness of the Diaphragm in Patients with Post-COVID-19 Syndrome: A Randomized Clinical Trial.

Rehabilitation is an effective method for improving the overall health of patients who have experienced the long-term effects of COVID-19. The double-blind, randomized prospective study assessed the effectiveness of a 6-week rehabilitation program among post-COVID-19 patients. A total of 59 patients under treatment following COVID-19 were randomly divided into two groups. Both groups completed the same six-week comprehensive exercise training program supported by a respiratory muscle trainer (Threshold IMT) during out-patient sessions. The control group performed placebo IMT. Respiratory muscle strength, chest wall expansion, spirometry, and diaphragm ultrasonography measurements were taken before and after the six weeks. The applied rehabilitation program improved respiratory muscle strength in both the study and control groups (p < 0.001). There was a significant chest circumference increase in the study group (p < 0.001). Spirometric parameters improved in both groups, with the study group showing a greater improvement: 8.02% in FEV1 (p < 0.001), 13.24% in FVC EX (p < 0.001) and 9.67% in PEF (p < 0.001). Rehabilitation also increased diaphragm thickness during maximum inhalation in both groups. Based on the study findings, the specialized outpatient rehabilitation program developed for post-COVID-19 patients has proven to be effective and safe.

Structural, morphological and functional changes of diaphragm in patients with chronic heart failure

Structural, morphological and functional changes of diaphragm in patients with chronic heart failure

Changes in intraocular pressure and biometric parameters of the anterior segment of the eye after intravitreal injections

This study compares the changes in the parameters of the anterior chamber of the eye using anterior segment optical coherence tomography (AS-OCT) in patients with a natural and artificial lens after treatment of neovascular age-related macular degeneration (nAMD) by multiple intravitreal injections (IVI) of anti-VEGF drugs. The patients were divided into 2 groups: group 1 (control) included 30 patients (30 eyes) with a natural lens, group 2 - 30 patients (30 eyes) with an intraocular lens (IOL). AS-OCT was performed using the Revo NX tomograph (Optopol, Poland) to analyze anterior chamber depth (ACD) and the parameters of anterior chamber angle (ACA). Intraocular pressure (IOP) was measured with a contact tonometer ICare Pro. In patients with an IOL, the IOP level 1 minute after intravitreal injection (IVI) of an anti-VEGF drug was statistically lower than in the control group, on average by 17.8% during the first IVI and by 28.7% after 1 year of observation (p<0.001). ACD before treatment was statistically significantly higher in patients with IOL compared to patients of group 1 by an average of 39.3% (p<0.001). ACA from the nasal and temporal sides in the meridian 0°-180° before the start of treatment was statistically significantly wider in phakic patients than in the control group, by an average of 15.9±9.3° (p<0.001) and 16.9±8.2° (p<0.001), respectively. According to AS-OCT, there was no shift of the iris-lens diaphragm in patients with an IOL after multiple IVI of an anti-VEGF drug, in contrast to the control group. AS-OCT was used to determine for the first time the changes in the parameters of the anterior chamber of the eye in patients with a natural and artificial lens after multiple injections of an anti-VEGF drug in the treatment of nAMD.

Comparison of breathing pattern and diaphragmatic motion in patients with unilateral cervical radiculopathy and asymptomatic group

BackgroundThe associations between neck pain and respiratory dysfunction were clarified in patients with neck pain. There is dearth of evidence on pulmonary dysfunction and diaphragmatic excursion in patients with unilateral cervical radiculopathy (CR). The purpose of this study was to compare the breathing pattern and diaphragmatic excursion in patients with unilateral CR with those in an asymptomatic group.MethodsTwenty-five patients with unilateral CR and 25 asymptomatic individuals aged between 30 and 55 participated in this study. Diaphragmatic motion, breathing pattern, active cervical range of motion and kinesiophobia were investigated in both groups by using fluoroscopy, manual assessment of respiratory motion (MARM), cervical range of motion device, and Tampa scale of kinesiophobia. Statistical significance was set at 0.05.ResultsNo statistically significant differences were found between the two groups with regard to sex, age and body mass index. The mean excursion of the hemi diaphragm on the involved side (the side of CR) was significantly lower than that on the uninvolved side in patients with unilateral CR with a large effect size. The excursion of the involved hemi diaphragm in patients was reduced compared to the matched hemi diaphragm in the control group. There was no significant difference between the hemi diaphragms excursion in the control group. The results of the MARM variables showed that the volume of breathing and the percentage rib cage motion in normal and deep breathing were significantly different between the two groups, but there was no significant difference in the balance of breathing between the two groups. Additionally, the active cervical range of motion was reduced in these patients in comparison to the control group, and it was less on the involved side than on the uninvolved side.ConclusionThe results of this study revealed a dysfunctional breathing pattern in normal and deep breathing and a unilateral reduction in diaphragmatic excursion on the side of radiculopathy in patients with unilateral CR compared to the control group.

ERS International Congress 2023: highlights from the Clinical Techniques, Imaging and Endoscopy Assembly.

The Clinical Techniques, Imaging and Endoscopy Assembly is involved in the diagnosis and treatment of several pulmonary diseases, as demonstrated at the 2023 European Respiratory Society (ERS) International Congress in Milan, Italy. From interventional pulmonology, the congress included several exciting results for the use of bronchoscopy in lung cancer, including augmented fluoroscopy, robotic-assisted bronchoscopy and cryobiopsies. In obstructive lung disease, the latest results on bronchoscopic treatment of emphysema with hyperinflation and chronic bronchitis were presented. Research on using cryobiopsies to diagnose interstitial lung disease was further explored, with the aims of elevating diagnostic yield and minimising risk. For imaging, the latest updates in using artificial intelligence to overcome the increased workload of radiologists were of great interest. Novel imaging in sarcoidosis explored the use of magnetic resonance imaging, photon-counting computed tomography and positron emission tomography/computed tomography in the diagnostic work-up. Lung cancer screening is still a hot topic and new results were presented regarding incorporation of biomarkers, identifying knowledge gaps and improving screening programmes. The use of ultrasound in respiratory medicine is an expanding field, which was demonstrated by the large variety in studies presented at the 2023 ERS Congress. Ultrasound of the diaphragm in patients with amyotrophic lateral sclerosis and myasthenia gravis was used to assess movements and predict respiratory fatigue. Furthermore, studies using ultrasound to diagnose or monitor pulmonary disease were presented. The congress also included studies regarding the training and assessment of competencies as an important part of implementing ultrasound in clinical practice.

Prognostic Value of Diaphragmatic Ultrasound in Patients Admitted for COVID-19 Pneumonia

IntroductionCOVID-19 pneumonia results in an impairment of the diaphragmatic musculature that influences the development of respiratory failure during the patient's hospitalization. Diaphragmatic ultrasound is a useful, non-invasive, and accessible tool for measuring the function of this muscle. ObjectiveAssessing the morphological and functional ultrasound status of the diaphragm in patients admitted within the first 24h for COVID-related pneumonia and its association with hospital morbidity and mortality (NCT05805579). Material and methodsObservational, prospective cohort study that included 68 patients admitted for COVID-19 pneumonia with respiratory failure. Diaphragmatic ultrasound was performed within the first 24h of admission to the pulmonology ward. Clinical, analytical, and ultrasound variables were collected: excursion, thickness, and diaphragmatic shortening fraction (DSF). DSF<20% was used to define diaphragmatic dysfunction (DD). Patients who showed favorable progression and were managed on the ward (HCONV) were compared to those who required admission to the respiratory monitoring unit (RMU). ResultsA total of 68 patients were included, of which 22 (32.35%) were admitted to the RMU. Diaphragmatic excursion at maximum volume was higher in the HCONV group compared to the RMU group (58.41±17.83 vs. 50.03±16.23; p=0.123). Diaphragmatic dysfunction (DD) was observed in 21 (30.88%) patients, with a higher prevalence in the RMU group than in the HCONV group (15 (68.18%) vs. 6 (13.04%); p=0.0001). In the multivariate analysis, age and DSF at admission were the best predictors of failure to discharge. ConclusionsPerforming diaphragmatic ultrasound to assess mobility and DSF within the first 24h of admission for COVID-19 pneumonia proves valuable in determining short-term progression and the need for admission to a respiratory monitoring unit.

Selective dysfunction of the crural diaphragm in patients with chronic restrictive and obstructive lung disease.

Gastroesophageal reflux (GER) is known to be associated with chronic lung diseases. The driving force of GER is the transdiaphragmatic pressure (Pdi) generated mainly by costal and crural diaphragm contraction. The latter also enhances the esophagogastric junction (EGJ) pressure to guard against GER. The relationship between Pdi and EGJ pressure was determined using high resolution esophageal manometry in patients with interstitial lung disease (ILD, n = 26), obstructive lung disease (OLD, n- = 24), and healthy subjects (n = 20). The patient groups did not differ with respect to age, gender, BMI, and pulmonary rehabilitation history. Patients with ILD had significantly higher Pdi but lower EGJ pressures as compared to controls and OLD patients (p < 0.001). In control subjects, the increase in EGJ pressure at all-time points during inspiration was greater than Pdi. In contrast, the EGJ pressure during inspiration was less than Pdi in 14 patients with ILD and 7 patients with OLD. The drop in EGJ pressure was usually seen after the peak Pdi in ILD group (p < 0.0001) and before the peak Pdi in OLD group, (p = 0.08). Nine patients in the ILD group had sliding hiatus hernia, compared to none in control subjects (p = 0.003) and two patients in the OLD, (p = 0.04). A higher Pdi and low EGJ pressure, and dissociation between Pdi and EGJ pressure temporal relationship suggests selective dysfunction of the crural diaphragm in patients with chronic lung diseases and may explain the higher prevalence of GERD in ILD as seen in previous studies.

Diagnostics of disturbances in the functional state of the diaphragm in patients with chronic obstructive pulmonary disease after COVID-19

Aim. Assessment of the functional state of the diaphragm in patients with COPD who underwent COVID-19.Materials and methods. The study included 35 patients with COPD complicated by compensated chronic cor pulmonale (CCP): group 1 included 15 patients with COPD who had COVID-19, group 2 included 20 patients with COPD. Patients were examined 3 months after suffering COVID-19. The functional state of the diaphragm was studied using the VIVID S70N ultrasound diagnostic system.Results. The greatest decrease in the diaphragm dome height was detected in the 1st group (p=0.001). The excursion of the diaphragm during quiet breathing was increased in both groups, in the 2nd group the indicator was 11% more than in the 1st group. The diaphragm excursion during forced breathing was reduced in the 1st group (p=0.02). The rate of diaphragm excursion during inhalation and exhalation during quiet and forced breathing in both groups was significantly increased compared to the control group. However, in the 1st group, the rate of diaphragm excursion on expiration was 49% higher. These changes may indicate respiratory muscle fatigue in COPD patients who have had COVID-19. The thickness of the muscular part of the diaphragm during inhalation and exhalation during quiet breathing in both groups compared to the control group was significantly higher. These indicators in both groups did not significantly differ from each other. There was a decrease in the thickening fraction of the muscular part of the diaphragm during calm (p=0.01) and forced breathing (p=0.001) in both groups, which indicates the onset of fatigue of the muscles of the diaphragm in the 2nd group and the initial development of weakness of the diaphragm in the 1st group who had the greatest decrease in this indicator during forced breathing.Conclusion. Ultrasonic diagnostic methods significantly expand the possibilities for assessing the functional state of the diaphragm. Patients with COPD who have undergone COVID-19 are characterized by a significant increase in the thickness of the diaphragm, limitation of its mobility, and a slowdown in the rate of relaxation of the muscular part of the diaphragm.

Ultrasonic Evaluation of Diaphragm in Patients with Systemic Sclerosis.

The diaphragm is the most important muscle in respiration. Nevertheless, its function is rarely evaluated. Patients with systemic sclerosis (SSc) could be at risk of diaphragmatic dysfunction because of multiple factors. These patients often develop interstitial lung disease (SSc-ILD) and earlier studies have indicated that patients with different ILDs have decreased diaphragmatic mobility on ultrasound (US). This study aimed to evaluate diaphragmatic function in SSc patients using US with regard to the ILD, evaluated with the Warrick score on high-resolution computed tomography (HRCT), and to investigate associations between ultrasonic parameters and dyspnea, lung function, and other important clinical parameters. In this cross-sectional study, we analyzed diaphragm mobility, thickness, lung function, HRCT findings, Modified Medical Research Council (mMRC) dyspnea scale, modified Rodnan skin score (mRSS), autoantibodies, and esophageal diameters on HRCT in patients with SSc. Fifty patients were enrolled in the study. Patients with SSc-ILD had lower diaphragmatic mobility in deep breathing than patients without ILD. The results demonstrated negative correlations between diaphragmatic mobility and mMRC, mRSS, anti-Scl-70 antibodies, esophageal diameters on HRCT, and a positive correlation with lung function. Patients with SSc who experience dyspnea should be evaluated for diaphragmatic dysfunction for accurate symptom phenotyping and personalized pulmonary rehabilitation treatment.

Correlation between Upper and Lower Diaphragm in Patients with Low Back Pain associated with Urinary Incontinence

Correlation between Upper and Lower Diaphragm in Patients with Low Back Pain associated with Urinary Incontinence

Evaluation of diaphragm in patients with chronic obstructive pulmonary disease using ultrasonography in relation to disease severity in Fayoum University Hospital

Evaluation of diaphragm in patients with chronic obstructive pulmonary disease using ultrasonography in relation to disease severity in Fayoum University Hospital

Motility Analysis of Diaphragm in Patients With Chronic Pulmonary Lung Disease Based on Computed Tomography Technique

Motility Analysis of Diaphragm in Patients With Chronic Pulmonary Lung Disease Based on Computed Tomography Technique

Skeletal muscle Nox4 knockout prevents and Nox2 knockout blunts loss of maximal diaphragm force in mice with heart failure with reduced ejection fraction.

Patients with heart failure with reduced ejection fraction (HFrEF) experience diaphragm weakness that contributes to the primary disease symptoms of fatigue, dyspnea, and exercise intolerance. Weakness in the diaphragm is related to excessive production of reactive oxygen species (ROS), but the exact source of ROS remains unknown. NAD(P)H Oxidases (Nox), particularly the Nox2 and 4 isoforms, are important sources of ROS within skeletal muscle that contribute to optimal cell function. There are reports of increased Nox activity in the diaphragm of patients and animal models of HFrEF, implicating these complexes as possible sources of diaphragm dysfunction in HFrEF. To investigate the role of these proteins on diaphragm weakness in HFrEF, we generated inducible skeletal muscle specific knockouts of Nox2 or Nox4 using the Cre-Lox system and assessed diaphragm function in a mouse model of HFrEF induced by myocardial infarction. Diaphragm maximal specific force measured in vitro was depressed by ∼20% with HFrEF. Skeletal muscle knockout of Nox4 provided full protection against the loss of maximal force (p<0.01), while the knockout of Nox2 provided partial protection (7% depression, p<0.01). Knockout of Nox2 from skeletal myofibers improved survival from 50 to 80% following myocardial infarction (p=0.026). Our findings show an important role for skeletal muscle NAD(P)H Oxidases contributing to loss of diaphragm maximal force in HFrEF, along with systemic pathophysiological responses following myocardial infarction.

Functional state of the diaphragm in patients with cervical spinal cord injury at the stages of respiratory support

Objective. To analyze the role of the functional state of the diaphragm in patients with cervical spinal cord injury at the stages of respiratory support and to substantiate additional criteria for their readiness to transfer to spontaneous breathing.Material and Methods. The state of the diaphragm was assessed by ultrasound in 24 patients with spinal cord injury. The excursion of the diaphragm during quiet breathing, the excursion and thickness of the diaphragm during forced breathing, and the change in forced expiratory volume from the moment of admission till the end of mechanical ventilation were analyzed.Results. On the first day, on the background of mechanical ventilation, there was a significant decrease in the excursion and thickness of the diaphragm during forced breathing (p = 0.002; p = 0.008) which persisted up to 3 days (p &lt; 0.001; p &lt; 0.001); by the fifth day of mechanical ventilation, the indicators increased to the initial levels (p = 0.112; p = 0.433); and by the 10th day they exceeded the initial values (p &lt; 0.001). When comparing the excursion and thickness of the diaphragm during the transfer of patients to spontaneous breathing with the data on their admission, a significant difference was obtained (p &lt; 0.001; p &lt; 0.001). The dynamics of forced expiratory volume indicators was similar to those of diaphragm excursion during forced breathing.Conclusion. A peculiarity of the functional state of the diaphragm in patients with cervical spinal cord injury in the acute period was a significant decrease in diaphragm excursion and the development of ventilator-induced diaphragm dysfunction (VIDD) associated with mechanical ventilation in replacement modes. The tactics of early tracheostomy and the use of auxiliary ventilation modes determined the absence of progression of VIDD during prolonged mechanical ventilation. The presence of a strong correlation between the diaphragm excursion during forced breathing and the forced expiratory volume allows concluding that these indicators can be additional objective criteria for the readiness of patients with cervical SC injury to transfer to spontaneous breathing, since they reflect not only the functional state of the diaphragm, but also the state of the lung tissue.

Efficacy of a rehabilitation protocol on pulmonary and respiratory muscle function and ultrasound evaluation of diaphragm and quadriceps femoris in patients with post-COVID-19 syndrome: a series of cases.

This study assessed the efficacy of a pulmonary rehabilitation (PR) on pulmonary and respiratory muscle function and thickness of quadriceps femoris and diaphragm of patients with post-COVID-19 syndrome. This series of cases followed nine patients who performed PR twice a week for six weeks. Patients received the following PR program: lung expansion therapy; respiratory muscle training; upper limb strength exercises; aerobic exercises on a treadmill. After the program, we observed increased peak expiratory flow (26.03%), forced vital capacity (FVC) (7.14%), forced expiratory volume in the first second (FEV1) (9.55%), and ratio between FEV1/FVC (6.19%). All parameters of respiratory muscle strength and endurance were improved. Diaphragmatic thickening fraction and thickness of quadriceps femoris also improved, whereas echo intensity of quadriceps reduced. Thus, RP protocol improved pulmonary function, respiratory muscle strength and endurance, and thickness of diaphragm and quadriceps femoris, and reduced echo intensity of quadriceps in patients with post-COVID-19 syndrome.

The myokine Fibcd1 is an endogenous determinant of myofiber size and mitigates cancer-induced myofiber atrophy

Decline in skeletal muscle cell size (myofiber atrophy) is a key feature of cancer-induced wasting (cachexia). In particular, atrophy of the diaphragm, the major muscle responsible for breathing, is an important determinant of cancer-associated mortality. However, therapeutic options are limited. Here, we have used Drosophila transgenic screening to identify muscle-secreted factors (myokines) that act as paracrine regulators of myofiber growth. Subsequent testing in mouse myotubes revealed that mouse Fibcd1 is an evolutionary-conserved myokine that preserves myofiber size via ERK signaling. Local administration of recombinant Fibcd1 (rFibcd1) ameliorates cachexia-induced myofiber atrophy in the diaphragm of mice bearing patient-derived melanoma xenografts and LLC carcinomas. Moreover, rFibcd1 impedes cachexia-associated transcriptional changes in the diaphragm. Fibcd1-induced signaling appears to be muscle selective because rFibcd1 increases ERK activity in myotubes but not in several cancer cell lines tested. We propose that rFibcd1 may help reinstate myofiber size in the diaphragm of patients with cancer cachexia.

Development of Diaphragmatic Hernia in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

This study aimed to investigate the consequences of repairing versus not repairing diaphragmatic injury caused by penetrating left thoracoabdominal stab wounds. Diagnostic laparoscopy was performed to evaluate the left diaphragm in patients with penetrating left thoracoabdominal stab wounds who did not have an indication for emergency laparotomy. Patients who did not consent to laparoscopy were discharged without undergoing surgery. Post-discharge radiological images of patients who underwent diaphragmatic repair and radiological images of patients who could not undergo laparoscopy, both during hospitalization and after discharge, were evaluated and compared. Diagnostic laparoscopy was performed on 109 patients. Diaphragmatic injuries were detected and repaired in 32 (29.36%) of these patients. Seventeen patients were lost to follow-up. After a mean follow-up of 57.67months, none of the remaining 15 patients developed a diaphragmatic hernia. On the other hand, 43 patients refused to undergo diagnostic laparoscopy. Twenty of them were lost from follow-up. The diaphragmatic injury was detected in seven of the remaining 23 patients (30.44%) during initial computed tomography (CT) examinations. In this group, the mean follow-up time was 42.57months, and delayed diaphragmatic hernia developed in one patient (14.30%). Patients who underwent diaphragmatic repair were compared to patients who did not undergo diagnostic laparoscopy but had diaphragmatic injuries detected on their CT. No statistical differences were detected. Diaphragmatic injuries caused by penetrating stab wounds can sometimes heal spontaneously. However, diagnostic laparoscopy is still relevant for revealing and repairing possible diaphragmatic injuries.

Video-assisted transthoracic liver resection in patients with marginal liver function: a retrospective cohort study.

Laparoscopic hepatectomy has been widely performed by hepatobiliary surgeons for malignancy of liver and gained wide acceptance for various liver tumors, thanks to advances in surgical techniques and devices. But, there are some challenges for right side tumor in patients of cirrhotic liver. Especially, tumor located in right upper area is difficult for wedge resection in patients with marginal liver function, because trans-abdominal approach requires normal parenchymal dissection. Radiofrequency wave ablation is also difficult for such a lesion. So, we demonstrate unique technique of video-assisted transthoracic liver resection (VTLR) for overcome right upper side tumor abutting diaphragm. Four patients underwent VTLR. Four ports in right chest wall were created by a chest surgeon and diaphragm was open. Then traction of the diaphragm was done by suture. After exposure of liver surface, tumor localization was done by ultrasound. The mass excision was done by ultrasonic shear. Four patients were discharged without complications within 11.3 days (range, 6-15 days). On average, patients started to consume a normal diet on an average of 2.4 days (range, 1-4 days). VTLR is could be performed by an experienced surgeon and chest surgeon for right upper liver malignancy abutting diaphragm in patient of marginal liver function.