Diaphragmatic paralysis diagnostic study of choice

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

Overview

Fontal upright chest radiograph:
- Elevated hemidiaphragm in paralysed side^[1]^[2]
- Chest xray is then confirmed with fluoroscopic sniff test

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

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).
- 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.

	Sensitivity	Specificity
Test 1	✔	...%
Test 2	...%	✔

✔= The best test based on the feature

The following result of [investigation name] is confirmatory of [disease name]:

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.

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 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:

↑ 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.
↑ Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.
↑ Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.
↑ Alexander C (January 1966). "Diaphragm movements and the diagnosis of diaphragmatic paralysis". Clin Radiol. 17 (1): 79–83. PMID 4221861.
↑ 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.
↑ 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.
↑ McCool FD, Tzelepis GE (March 2012). "Dysfunction of the diaphragm". N. Engl. J. Med. 366 (10): 932–42. doi:10.1056/NEJMra1007236. PMID 22397655.