Diaphragmatic paralysis diagnostic study of choice: Difference between revisions

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__NOTOC__
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{{Diaphragmatic paralysis}}
{{Diaphragmatic paralysis}}
{{CMG}}; {{AE}}
{{CMG}}; {{AE}}{{MA}} [mailto:malihash@bidmc.harvard.edu]
== Overview ==
== Overview ==
Studies of choice for unilateral diaphragmatic paralysis include upright [[chest radiograph]] and fluoroscopic sniff test. Studies of choice for bilateral diaphragmatic paralysis include measurement of transdiaphragmatic pressure (Pdi).


== Diagnostic Study of Choice ==
== Diagnostic Study of Choice ==


===== Template statements =====
=== Unilateral diaphragmatic paralysis ===
 
* Upright [[chest radiograph]]:
=== Study of choice: ===
 
==== Unilateral diaphragmatic paralysis ====
* Fontal upright chest radiograph:
** Elevated hemidiaphragm in paralysed side<ref name="pmid15672847">{{cite journal |vauthors=Chetta A, Rehman AK, Moxham J, Carr DH, Polkey MI |title=Chest radiography cannot predict diaphragm function |journal=Respir Med |volume=99 |issue=1 |pages=39–44 |date=January 2005 |pmid=15672847 |doi= |url= |author=}}</ref><ref name="pmid96193042">{{cite journal |vauthors=Gierada DS, Slone RM, Fleishman MJ |title=Imaging evaluation of the diaphragm |journal=Chest Surg. Clin. N. Am. |volume=8 |issue=2 |pages=237–80 |date=May 1998 |pmid=9619304 |doi= |url= |author=}}</ref>
** Elevated hemidiaphragm in paralysed side<ref name="pmid15672847">{{cite journal |vauthors=Chetta A, Rehman AK, Moxham J, Carr DH, Polkey MI |title=Chest radiography cannot predict diaphragm function |journal=Respir Med |volume=99 |issue=1 |pages=39–44 |date=January 2005 |pmid=15672847 |doi= |url= |author=}}</ref><ref name="pmid96193042">{{cite journal |vauthors=Gierada DS, Slone RM, Fleishman MJ |title=Imaging evaluation of the diaphragm |journal=Chest Surg. Clin. N. Am. |volume=8 |issue=2 |pages=237–80 |date=May 1998 |pmid=9619304 |doi= |url= |author=}}</ref>
** Chest xray is then confirmed with fluoroscopic sniff test
** [[Chest X-ray|Chest xray]] is then confirmed with fluoroscopic sniff test


* Fluoroscopic sniff test:
* Fluoroscopic sniff test:
** Observation of diaphragamtic movement when patient sniffs forcefully <ref name="pmid9619304">{{cite journal |vauthors=Gierada DS, Slone RM, Fleishman MJ |title=Imaging evaluation of the diaphragm |journal=Chest Surg. Clin. N. Am. |volume=8 |issue=2 |pages=237–80 |date=May 1998 |pmid=9619304 |doi= |url= |author=}}</ref>
** Observation of diaphragamtic movement when patient sniffs forcefully<ref name="pmid9619304">{{cite journal |vauthors=Gierada DS, Slone RM, Fleishman MJ |title=Imaging evaluation of the diaphragm |journal=Chest Surg. Clin. N. Am. |volume=8 |issue=2 |pages=237–80 |date=May 1998 |pmid=9619304 |doi= |url= |author=}}</ref>
** Paradoxical elevation of the paralyzed hemidiaphragm during inspiration<ref name="pmid4221861">{{cite journal |vauthors=Alexander C |title=Diaphragm movements and the diagnosis of diaphragmatic paralysis |journal=Clin Radiol |volume=17 |issue=1 |pages=79–83 |date=January 1966 |pmid=4221861 |doi= |url= |author=}}</ref>
** Paradoxical elevation of the paralyzed hemidiaphragm during [[inspiration]]<ref name="pmid4221861">{{cite journal |vauthors=Alexander C |title=Diaphragm movements and the diagnosis of diaphragmatic paralysis |journal=Clin Radiol |volume=17 |issue=1 |pages=79–83 |date=January 1966 |pmid=4221861 |doi= |url= |author=}}</ref>


==== Bilateral diaphragmatic paralysis ====
=== Bilateral diaphragmatic paralysis ===
* Measurement of transdiaphragmatic pressure (Pdi) is the gold standard test for the diagnosis of bilateral diaphragmatic paralysis.
* Measurement of transdiaphragmatic pressure (Pdi) is the gold standard test for the diagnosis of bilateral diaphragmatic paralysis.
** This test is performed with two catheters. One of them is placed in esophagus and it assesses changing pleural pressure (Ppl) and another one is placed in stomach and it detects changing abdominal or gastric pressure (Pga).   
** This test is performed with two catheters. One of them is placed in [[esophagus]] and it assesses changing [[pleural]] [[pressure]] (Ppl) and another one is placed in [[stomach]] and it detects changing [[gastric]] [[pressure]] (Pga).   
** Pdi is the difference between Ppl and Pga (Pdi = Ppl – Pga).  
** Pdi is the difference between Ppl and Pga (Pdi = Ppl – Pga).  
** Normal transdiaphragmatic pressure:<ref name="pmid4064560">{{cite journal |vauthors=Miller JM, Moxham J, Green M |title=The maximal sniff in the assessment of diaphragm function in man |journal=Clin. Sci. |volume=69 |issue=1 |pages=91–6 |date=July 1985 |pmid=4064560 |doi= |url= |author=}}</ref>
** Normal transdiaphragmatic pressure:<ref name="pmid4064560">{{cite journal |vauthors=Miller JM, Moxham J, Green M |title=The maximal sniff in the assessment of diaphragm function in man |journal=Clin. Sci. |volume=69 |issue=1 |pages=91–6 |date=July 1985 |pmid=4064560 |doi= |url= |author=}}</ref>
*** Men: 148 cm water  
*** Men: 148 cm water  
*** Women: 122 cm water  
*** Women: 122 cm water  
* The following result of transdiaphragmatic pressure (Pdi) is confirmatory of bilateral diaphragmatic paralysis:<ref name="pmid25641347">{{cite journal |vauthors=Gill LC, Mantilla CB, Sieck GC |title=Impact of unilateral denervation on transdiaphragmatic pressure |journal=Respir Physiol Neurobiol |volume=210 |issue= |pages=14–21 |date=May 2015 |pmid=25641347 |pmc=4449269 |doi=10.1016/j.resp.2015.01.013 |url= |author=}}</ref>
* The following result of transdiaphragmatic pressure (Pdi) is confirmatory of bilateral diaphragmatic paralysis:<ref name="pmid25641347">{{cite journal |vauthors=Gill LC, Mantilla CB, Sieck GC |title=Impact of unilateral denervation on transdiaphragmatic pressure |journal=Respir Physiol Neurobiol |volume=210 |issue= |pages=14–21 |date=May 2015 |pmid=25641347 |pmc=4449269 |doi=10.1016/j.resp.2015.01.013 |url= |author=}}</ref><ref name="pmid22397655">{{cite journal |vauthors=McCool FD, Tzelepis GE |title=Dysfunction of the diaphragm |journal=N. Engl. J. Med. |volume=366 |issue=10 |pages=932–42 |date=March 2012 |pmid=22397655 |doi=10.1056/NEJMra1007236 |url= |author=}}</ref>
** Unilateral diaphragmatic paralysis:  
** Unilateral diaphragmatic paralysis:  
*** Maximal transdiaphragmatic pressure is more than 70 cm water and it does not effect normal ventilatory behaviors but it may compromise coughing or sneezing.
*** Maximal transdiaphragmatic pressure is more than 70 cm water and it does not effect normal ventilatory behaviors but it may compromise [[coughing]] or [[sneezing]].
** Bilateral diaphragmatic paralysis:
** Bilateral diaphragmatic paralysis:
*** Maximal transdiaphragmatic pressure is less than 40 cm water and it effects normal ventilatory behaviors.
*** Maximal transdiaphragmatic pressure is less than 40 cm water and it effects normal ventilatory behaviors.
* his test is performed via the transnasal placement of two thin-walled balloon-tipped catheters (waveform 1). One is placed in the lower third of the esophagus above the diaphragm to assess changing pleural pressure (Ppl); the location is adjusted to avoid cardiac contraction signals that can modify the tracing [31]. The second balloon is placed in the stomach, to reflect changing abdominal or gastric pressure (Pga) (waveform 1). In adults, the distance between the nostril and the tip of the balloon is 35 to 40 cm for the esophageal balloon and 50 to 60 cm for the gastric balloon [31].  The Pdi is the difference between Ppl and Pga (Pdi = Ppl – Pga). The Pdi can be measured at rest, during tidal breathing (Pdi) at end inspiration or end expiration, with voluntary maneuvers such as a deep breath [32], a sniff (sniff Pdi) [33,34], or a maximal inspiratory force maneuver with airflow limited by a partially closed shutter (Pdi-max) [11,35]. At peak tidal volume inspiration, the value for Pdi is negative in diaphragm paralysis, but positive if the diaphragm is working normally (waveform 1).  The normal value for Pdi depends upon the method used to obtain it. Reliability is also an issue since there is great variation even in the same individual. In an attempt to avert this problem, Pdi may be measured independent of the patient's effort. This is done by electrically stimulating the phrenic nerve and measuring the twitch Pdi [36].
*
* Normal transdiaphragmatic pressure is approximately 148 cm water in men and 122 cm water in women.<sup> [[null 14]] </sup>Unilateral diaphragmatic paralysis is associated with a maximal transdiaphragmatic pressure of greater than 70 cm water, and thus does not significantly effect transdiaphragmatic pressure generation during normal ventilatory behaviors, but can compromise higher-force, nonventilatory, behaviors like coughing or sneezing. Bilateral diaphragmatic paralysis, however, can impair normal ventilatory behaviors as it is associated with a maximal transdiaphragmatic pressure of less than 40 cm water.<sup> [[null 15], [null 16], [null 17]]</sup>
** Result 1
** Result 2
* The [name of the investigation] should be performed when:
** The patient presented with symptoms/signs 1. 2, 3.
** A positive [test] is detected in the patient.
* [Name of the investigation] is the gold standard test for the diagnosis of [disease name].
* The diagnostic study of choice for [disease name] is [name of the investigation].
* There is no single diagnostic study of choice for the diagnosis of [disease name].
* There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
* [Disease name] is mainly diagnosed based on clinical presentation.
* Investigations:
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
** Among patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.
==== The comparison table for diagnostic studies of choice for [disease name] ====
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! style="background: #FFFFFF; color: #FFFFFF; text-align: center;" |
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 1
| style="background: #DCDCDC; padding: 5px; text-align: center;" |✔
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 2
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |✔
|}
<small> ✔= The best test based on the feature </small>
===== Diagnostic results =====
The following result of [investigation name] is confirmatory of [disease name]:
* Result 1
* Result 2
===== Sequence of Diagnostic Studies =====
The [name of investigation] should be performed when:
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
* A positive [test] is detected in the patient, to confirm the diagnosis.
=== Diagnostic Criteria ===
* Here you should describe the details of the diagnostic criteria.
*Always mention the name of the criteria/definition you are about to list (e.g. modified Duke criteria for the diagnosis of endocarditis / 3rd universal definition of MI) and cite the primary source of where this criteria/definition is found.
*Although not necessary, it is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.
*Be very clear as to the number of criteria (or threshold) that needs to be met out of the total number of criteria.
*Distinguish criteria based on their nature (e.g. clinical criteria / pathological criteria/ imaging criteria) before discussing them in details.
*To view an example (endocarditis diagnostic criteria), click [[Endocarditis diagnosis|here]]
*If relevant, add additional information that might help the reader distinguish various criteria or the evolution of criteria (e.g. original criteria vs. modified criteria).
*You may also add information about the sensitivity and specificity of the criteria, the pre-test probability, and other figures that may help the reader understand how valuable the criteria are clinically.
* [Disease name] is mainly diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
* There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
* The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
* The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
* [Disease name] may be diagnosed at any time if one or more of the following criteria are met:
** Criteria 1
** Criteria 2
** Criteria 3
IF there are clear, established diagnostic criteria:
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
*The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
*The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].
IF there are no established diagnostic criteria: 
*There are no established criteria for the diagnosis of [disease name].




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Latest revision as of 21:21, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2] [3]

Overview

Studies of choice for unilateral diaphragmatic paralysis include upright chest radiograph and fluoroscopic sniff test. Studies of choice for bilateral diaphragmatic paralysis include measurement of transdiaphragmatic pressure (Pdi).

Diagnostic Study of Choice

Unilateral diaphragmatic paralysis

  • Fluoroscopic sniff test:
    • Observation of diaphragamtic movement when patient sniffs forcefully[3]
    • Paradoxical elevation of the paralyzed hemidiaphragm during inspiration[4]

Bilateral diaphragmatic paralysis

  • Measurement of transdiaphragmatic pressure (Pdi) is the gold standard test for the diagnosis of bilateral diaphragmatic paralysis.
    • This test is performed with two catheters. One of them is placed in esophagus and it assesses changing pleural pressure (Ppl) and another one is placed in stomach and it detects changing gastric pressure (Pga).
    • Pdi is the difference between Ppl and Pga (Pdi = Ppl – Pga).
    • Normal transdiaphragmatic pressure:[5]
      • Men: 148 cm water
      • Women: 122 cm water
  • The following result of transdiaphragmatic pressure (Pdi) is confirmatory of bilateral diaphragmatic paralysis:[6][7]
    • Unilateral diaphragmatic paralysis:
      • Maximal transdiaphragmatic pressure is more than 70 cm water and it does not effect normal ventilatory behaviors but it may compromise coughing or sneezing.
    • Bilateral diaphragmatic paralysis:
      • Maximal transdiaphragmatic pressure is less than 40 cm water and it effects normal ventilatory behaviors.


References

  1. ↑ Chetta A, Rehman AK, Moxham J, Carr DH, Polkey MI (January 2005). "Chest radiography cannot predict diaphragm function". Respir Med. 99 (1): 39–44. PMID 15672847.
  2. ↑ Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.
  3. ↑ Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.
  4. ↑ Alexander C (January 1966). "Diaphragm movements and the diagnosis of diaphragmatic paralysis". Clin Radiol. 17 (1): 79–83. PMID 4221861.
  5. ↑ Miller JM, Moxham J, Green M (July 1985). "The maximal sniff in the assessment of diaphragm function in man". Clin. Sci. 69 (1): 91–6. PMID 4064560.
  6. ↑ Gill LC, Mantilla CB, Sieck GC (May 2015). "Impact of unilateral denervation on transdiaphragmatic pressure". Respir Physiol Neurobiol. 210: 14–21. doi:10.1016/j.resp.2015.01.013. PMC 4449269. PMID 25641347.
  7. ↑ McCool FD, Tzelepis GE (March 2012). "Dysfunction of the diaphragm". N. Engl. J. Med. 366 (10): 932–42. doi:10.1056/NEJMra1007236. PMID 22397655.

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