Diaphragm Kinetics using Ultrasound Respiratory ...tusar-centre-ouest.e-monsite.com/medias/files/dr-ayoub-diaphragme-211218-.pdf1 1 Ttot DIA Schematic spirometry Volume Time Amplitude

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

23/01/2018 3 J. Ayoub - Presentation

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


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La magnétostimulation & Echocinétique diaphragmatique


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Réponse:

Zone d’apposition diaphragmatique

Magnétostimulation

diaphragme

Avant stimulation

diaphragme

Après stimulation


Non-invasive quantification of the diaphragm

kinetics: Our technique

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Right hemidiaphragm examination

Haut, dôme

Bas, sonde écho

Faisceau TM



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Cycle respiratoire diaphragmatique

amplitude

time

a

t

Pente = A/D


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


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


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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


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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


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Neuro-muscular and pulmonary diseases

Ayoub et al. Neuromuscular disorder 2002


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Diaphragmatic paralysis


3 types of the abnormal diaphragmatic excursion:

- Paradoxical motion

- Reduction or

- Total immobility.


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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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)



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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



Dyspnea :

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Diaphragm paradoxical motion



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Right diaphragm

paradoxical motion Left diaphragm

compensation



Dyspnea (Infectious Pneumonia)

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Alveolar syndrome


- Dyspnea -

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Interstitial syndrome


- 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


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


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


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

Documents

Diaphragm Kinetics using Ultrasound Respiratory ...tusar-centre-ouest.e-monsite.com/medias/files/dr-ayoub-diaphragme-211218-.pdf1 1 Ttot DIA Schematic spirometry Volume Time Amplitude