Measurement Technique
Diaphragm Kinetics using Ultrasound
Respiratory applications - Dyspnea -
AYOUB J, MD PhD
-# Ultrasound department, CHU Trousseau. Tours - France
INSERM U930 Imagerie & Ultrasons
Developped technique by Dr J.AYOUB, 1992
Thérèse Planiol Award March 1993, Paris.
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Interest to explore the diaphragm
Principal inspiratory muscle (70 % VT: JB West 1974)
Dyspnée par atteinte de l’effecteur:
Myopathies, paralysie diaphragmatique, cyphoscoliose invalidante
Direct & Indirect warning of Dyspnea
J. Ayoub - Presentation
Exploration methods
Indirect methods
Plethysmography, Transdiaphragmatic pressure (Pdi), Electromyography (EMG) …
L : Invasive, indirect, not precise
Direct methods
Fluoroscopy, MRI, CT
L : Invasive methods, indirect measurements, not real time
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Ultrasonography:
B mode : morphological study
M/B mode : allows morphological and dynamical study
(Our technique)
J Advantages of this technique:
Direct, non invasive, real-time, best resolution
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Exploration methods
J. Ayoub - Presentation
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La magnétostimulation & Echocinétique diaphragmatique
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Réponse:
Zone d’apposition diaphragmatique
Magnétostimulation
diaphragme
Avant stimulation
diaphragme
Après stimulation
J. Ayoub - Presentation
Non-invasive quantification of the diaphragm
kinetics: Our technique
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Right hemidiaphragm examination
Haut, dôme
Bas, sonde écho
Faisceau TM
J. Ayoub - Presentation
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Cycle respiratoire diaphragmatique
amplitude
time
a
t
Pente = A/D
J. Ayoub - Presentation
Non-invasive quantification of the diaphragm
kinetics: Our technique
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- Diaphragm kinetics in real time During quiet and deep inspiration
Flow signal & diaphragm curve
Volume signal
J. Ayoub - Presentation
Non-invasive quantification of the diaphragm kinetics
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Ttot
DIA
Schematic spirometry Volume
Time
Amplitude
ventilatory cycle
IT ET
IT diaph ET diaph
Ttot diaph
Time
Diaphragmatic respiratory cycle
TV
Schematic M-mode tracing
J. Ayoub - Presentation
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Mesure de l’épaisseur diaphragmatique en échographie
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Le diaphragme dans tout ses états
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Insp prof
pause
Expir prof
pause
Dyspnée de Kussmaul
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Dyspnée de Cheyne-Stokes
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Hyperventilation
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Blocage expiratoire
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Parler
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Acinésie
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TM – RX: Comparative study
low coefficient of variation in TM (6.95%)
compared to Rx (10.03%)
50% of excursion = 60% inspiratory capacity
(Ayoub et al. J Radiol.1997) J. Ayoub - Presentation
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Authors Method Number of
subjects
CI or CV (cm) SD
Wade (1954) Fluoroscopy 10 5,67 1,25
Harris (1983) B mode 50 5,4 1,7
Ayoub (1992) B/TM mode 100 6,07 0,61
Houston (1992) B mode
55 9,7 (CV right)
8,7 (CV left)
NP
Eugenio (2001) M mode 23 5,63 NP
Kantarci (2004) M mode NP 4,9 (right)
5 (left)
1,19
1,17
Normal values
TM - Spirometry
J. Ayoub - Presentation
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Before cholecystectomy After cholecystectomy
Arrows : beginning of inspiration and expiration
Diaphragm movement before and after cholecystectomy
Ayoub et al. Anaesthesia & Analgesia march 2001
J. Ayoub - Presentation
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Neuro-muscular and pulmonary diseases
Ayoub et al. Neuromuscular disorder 2002
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Diaphragmatic paralysis
Neuro-muscular and pulmonary diseases
3 types of the abnormal diaphragmatic excursion:
- Paradoxical motion
- Reduction or
- Total immobility.
J. Ayoub - Presentation
Paralysie diaphragmatique
& Stimulation phrénique
En ventilation assistée et avant stimulation
phrénique
Chute d’un arbre avec section moelle niveau cervical: paraplégie
En ventilation assistée durant stimulation
phrénique: 16 mm amplitude pour 5 miliamp/s
En interscalénique droit
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Neuro-muscular and pulmonary diseases
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Neuro-muscular and pulmonary diseases
Guillain Barré
calm
CI
Right Left
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Diaphragmatic paralysis: (100 patients, étude en cours)
Indication Diaphragm
kinetics at
Rest
Deep
inspiration
Compensat Paradoxical
motion
Total
paralysis
Heightening = 30%
Surgery = 20%
Dyspnea = 16%
Neurological
disorders = 10%
Infection = 8%
Traumatism = 6%
Others = 8%
92% One sided-
affection.
Immobility = 40%
Decrease = 52%
Normal = 8%
Immobility = 34%
Diminution = 44%
Normal = 22%
64% of cases
by the healthy
side
28 % of cases 34% (rest
and deep
inspiration)
Neuro-muscular and pulmonary diseases
J. Ayoub - Presentation
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Before aspiration After aspiration
Diaphragm curve - Normal : (19%)
- oblate : (33%)
- reversed : (47%)
Normal ^ 100%
Diaphragm
kinetics
- Paradoxical : (90 %)
- Disappear liq << 500 ml
Normal : (38%)
Hypo kinetic: (47%)
paralysis : (10%)
Paradoxical : (5%) bridles +++
Ultrasonography contribution : Diaphragm curve – Mobility – Nature, quantity & situation of
pleural effusion – Pulmonary affection…
Diaphragm dysfunction in pleural effusion
Large pleural effusion : (25 patients), « congrès », étude en cours
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Bridle Inversion diaphragmatic curve
Large pleural effusion
Diaphragm dysfunction in pleural effusion
J. Ayoub - Presentation
Dyspnea :
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Diaphragm paradoxical motion
Diaphragm dysfunction in pleural effusion
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Right diaphragm
paradoxical motion Left diaphragm
compensation
Diaphragm dysfunction in pleural effusion
J. Ayoub - Presentation
Dyspnea (Infectious Pneumonia)
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Alveolar syndrome
J. Ayoub - Presentation
- Dyspnea -
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Interstitial syndrome
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- Dyspnée -
Syndrome Interstitiel ligne pulmonaire
Muscle
Comet-tails
Queues de comètes + Hyperventilation
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Cas 4: ChafJack
Résultat:
- Surélévation coupole droite sans anomalie sus ou sous diaphragmatique
- CIDI normale au repos et en CI
- Pas de paralysie diaphragmatique
J. Ayoub - Presentation
Surélévation coupole droite
Spirométrie normale
Paralysie diaphragmatique ?
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Cas 5: AudJac
Résultat:
- Importante surélévation coupole G
- Acinésie diaphragmatique gauche
- Compensation par la coupole droite au repos (3xN)
- Pas d’épanchement pleural
J. Ayoub - Presentation
Dyspnée d’effort
Surélévation coupole G
H1N1 avec complication pulmonaire
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Cas 6: CubiVan
Résultat:
- Acinésie diaphragmatique de repos et CI < de 70% à droite
- Compensation gauche x2,5
- Pas d’anomalie sus ou sous diaphragmatique
- Coupole peu surélevée
D calm
D en CI
G calm
G en CI
J. Ayoub - Presentation
Paralysie diaphragm D postop (sarcome médiastin)
Dyspnée effort
CV < 51%
Non-invasive quantification, with real time
New respiratory parameters
Performed at the patient’s bedside
Useful complement & can be coupled to others techniques
Rehabilitation and therapeutic surveillance.
CONCLUSION