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Mu H, Zhang Q. The Application of Diaphragm Ultrasound in Chronic Obstructive Pulmonary Disease: A Narrative Review. COPD 2024; 21:2331202. [PMID: 38634575 DOI: 10.1080/15412555.2024.2331202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024]
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a prevalent condition that poses a significant burden on individuals and society due to its high morbidity and mortality rates. The diaphragm is the main respiratory muscle, its function has a direct impact on the quality of life and prognosis of COPD patients. This article aims to review the structural measurement and functional evaluation methods through the use of diaphragmatic ultrasound and relevant research on its application in clinical practice for COPD patients. Thus, it serves to provide valuable insights for clinical monitoring of diaphragm function in COPD patients, facilitating early clinical intervention and aiding in the recovery of diaphragm function.
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Affiliation(s)
- Heng Mu
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
- State Key Laboratory of Ultrasound in Medicine and Engineering of Chongqing Medical University, Chongqing, PR China
| | - Qunxia Zhang
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
- State Key Laboratory of Ultrasound in Medicine and Engineering of Chongqing Medical University, Chongqing, PR China
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Poddighe D, Van Hollebeke M, Choudhary YQ, Campos DR, Schaeffer MR, Verbakel JY, Hermans G, Gosselink R, Langer D. Accuracy of respiratory muscle assessments to predict weaning outcomes: a systematic review and comparative meta-analysis. Crit Care 2024; 28:70. [PMID: 38454487 PMCID: PMC10919035 DOI: 10.1186/s13054-024-04823-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Several bedside assessments are used to evaluate respiratory muscle function and to predict weaning from mechanical ventilation in patients on the intensive care unit. It remains unclear which assessments perform best in predicting weaning success. The primary aim of this systematic review and meta-analysis was to summarize and compare the accuracy of the following assessments to predict weaning success: maximal inspiratory (PImax) and expiratory pressures, diaphragm thickening fraction and excursion (DTF and DE), end-expiratory (Tdiee) and end-inspiratory (Tdiei) diaphragm thickness, airway occlusion pressure (P0.1), electrical activity of respiratory muscles, and volitional and non-volitional assessments of transdiaphragmatic and airway opening pressures. METHODS Medline (via Pubmed), EMBASE, Web of Science, Cochrane Library and CINAHL were comprehensively searched from inception to 04/05/2023. Studies including adult mechanically ventilated patients reporting data on predictive accuracy were included. Hierarchical summary receiver operating characteristic (HSROC) models were used to estimate the SROC curves of each assessment method. Meta-regression was used to compare SROC curves. Sensitivity analyses were conducted by excluding studies with high risk of bias, as assessed with QUADAS-2. Direct comparisons were performed using studies comparing each pair of assessments within the same sample of patients. RESULTS Ninety-four studies were identified of which 88 studies (n = 6296) reporting on either PImax, DTF, DE, Tdiee, Tdiei and P0.1 were included in the meta-analyses. The sensitivity to predict weaning success was 63% (95% CI 47-77%) for PImax, 75% (95% CI 67-82%) for DE, 77% (95% CI 61-87%) for DTF, 74% (95% CI 40-93%) for P0.1, 69% (95% CI 13-97%) for Tdiei, 37% (95% CI 13-70%) for Tdiee, at fixed 80% specificity. Accuracy of DE and DTF to predict weaning success was significantly higher when compared to PImax (p = 0.04 and p < 0.01, respectively). Sensitivity and direct comparisons analyses showed that the accuracy of DTF to predict weaning success was significantly higher when compared to DE (p < 0.01). CONCLUSIONS DTF and DE are superior to PImax and DTF seems to have the highest accuracy among all included respiratory muscle assessments for predicting weaning success. Further studies aiming at identifying the optimal threshold of DTF to predict weaning success are warranted. TRIAL REGISTRATION PROSPERO CRD42020209295, October 15, 2020.
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Affiliation(s)
- Diego Poddighe
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marine Van Hollebeke
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Yasir Qaiser Choudhary
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Débora Ribeiro Campos
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo (USP), Ribeirão Prêto, Brazil
| | - Michele R Schaeffer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, EPI-Centre, KU Leuven, Leuven, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Greet Hermans
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Health and Rehabilitation Sciences, Faculty of Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, 3000, Leuven, Belgium.
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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Marques MR, Pereira JM, Paiva JA, de Casasola-Sánchez GG, Tung-Chen Y. Ultrasonography to Access Diaphragm Dysfunction and Predict the Success of Mechanical Ventilation Weaning in Critical Care: A Narrative Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:223-236. [PMID: 37915259 DOI: 10.1002/jum.16363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Weaning failure is common in mechanically ventilated patients, and whether ultrasound (US) can predict weaning outcome remains controversial. This review aims to evaluate the diaphragmatic function measured by US as a predictor of weaning outcome. METHODS PubMed was searched to identify original articles about the use of diaphragmatic US in ICU patients. A total of 61 citations were retrieved initially; available data of 26 studies were included in this review. RESULTS To assess diaphragmatic dysfunction in adults, six studies evaluated excursion, five evaluated thickening fraction, and both in nine. Despite heterogeneity in the diagnostic accuracy of diaphragm US among the studies, the sonographic indices showed good diagnostic performance for predicting weaning outcome. CONCLUSIONS Diaphragmatic US can be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients and predict weaning outcome.
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Affiliation(s)
- Marta Rafael Marques
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Manuel Pereira
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Artur Paiva
- Department of Intensive Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Alfonso X, Villanueva de la Cañada, Madrid, Spain
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Toledo TG, Bacci MR. Value of Diaphragm Ultrasonography for Extubation: A Single-Blinded Randomized Clinical Trial. Crit Care Res Pract 2023; 2023:8403971. [PMID: 37766780 PMCID: PMC10522420 DOI: 10.1155/2023/8403971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Daily evaluation of mechanically ventilated (MV) patients is essential for successful extubation. Proper withdrawal prevents complications and reduces the cost of hospitalization in the intensive care unit (ICU). Diaphragm ultrasonography (DUS) has emerged as a potential instrument for determining whether a patient is ready to be extubated. This study compared the efficacy rate of extubation using a standard withdrawal protocol and DUS in patients with MV. Methods A randomized, parallel, single-blind, controlled study was conducted on ICU patients undergoing MV. Patients were randomly assigned to either the control (conventional weaning protocol) group or intervention (DUS-guided weaning) group in a 1 : 1 ratio. The primary outcome measure was the rate of reintubation and hospital mortality. Results Forty patients were randomized to the trial. The mean age of the sample was 70 years, representing an older population. The extubation success rate was 90% in both groups. There was no reintubation in the first 48 hours and only two reintubations in both groups between the second and seventh days. The hospital mortality risk in patients with acute kidney injury was positively correlated with age and the need for hemodialysis. Discussion. This study demonstrates the usefulness of DUS measurement protocols for withdrawing MV. The rate of reintubation was low for both cessation methods. As a parameter, the diaphragm thickness fraction comprehensively evaluates the diaphragm function. The results demonstrate that DUS has the potential to serve as a noninvasive tool for guiding extubation decisions. In conclusion, using DUS in patients with respiratory failure revealed no difference in reintubation rates or mortality compared with the conventional method. Future research should concentrate on larger, multicentered, randomized trials employing a multimodal strategy that combines diaphragmatic parameters with traditional clinical withdrawal indices.
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Affiliation(s)
| | - M. R. Bacci
- Centro Universitario FMABC, Santo Andre, Brazil
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Elsayed AA, Mousa MR, Beshey BN. Impact of early versus late tracheotomy on diaphragmatic function assessed by ultrasonography in mechanically ventilated stroke patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2067679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Amr Abdalla Elsayed
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohammed Refaat Mousa
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Bassem Nashaat Beshey
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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El Gharib K, Assaad M, Chalhoub M. Diaphragmatic ultrasound in weaning ventilated patients: a reliable predictor? Expert Rev Respir Med 2022; 16:853-855. [PMID: 35949151 DOI: 10.1080/17476348.2022.2112670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Timely weaning of mechanical ventilation is clinically difficult, as both early and late discontinuations are associated with adverse events impeding the patient's favorable course in the critical care unit. Many parameters aid in judging whether the patient is going to be safely extubated; however, some remain deficient. We herein describe diaphragmatic ultrasound as a new modality for this purpose, detailing diaphragm excursion and thickness as means of it.
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Affiliation(s)
- Khalil El Gharib
- Department of Medicine, Staten Island University Hospital, New York, USA 10305
| | - Marc Assaad
- Department of Medicine, Staten Island University Hospital, New York, USA 10305
| | - Michel Chalhoub
- Department of Pulmonary and Critical Care, Staten Island University Hospital, New York, USA 10305
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Jia Y, Zhang Q. Research Progress on Diaphragm Ultrasound in Chronic Obstructive Pulmonary Disease: A Narrative Review. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:587-597. [PMID: 35065813 DOI: 10.1016/j.ultrasmedbio.2021.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 06/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a common disease of the respiratory system, and its prevalence and mortality remain high. COPD results in continuous impairment of lung function, which severely affects the patient's work and life. In severe cases, there will be acute respiratory failure, which endangers the lives of patients, and respiratory muscle dysfunction is one of the main reasons for this result. As the diaphragm is the most important inspiratory muscle, its dysfunction has a great impact on the deterioration of respiratory function in COPD patients. With the development of ultrasound, more and more studies have found that diaphragm ultrasound can play an important role in the diagnosis and treatment of COPD patients. The main purpose of this article is to review the research progress on diaphragm ultrasound in COPD and briefly introduce diaphragmatic ultrasound examination methods.
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Affiliation(s)
- Yuhao Jia
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Qunxia Zhang
- Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China.
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AN PENG, QIN PING, WANG JIANRU, RONG ZHOU HE. CORRELATION BETWEEN DIAPHRAGM EXCURSION WITH BOTH THE QUALITY OF LIFE AND EXERCISE CAPACITY FOR PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE STUDIED BY ULTRASOUND. J MECH MED BIOL 2021. [DOI: 10.1142/s0219519421400297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective: To study the correlation between diaphragm excursion and both the quality of life and exercise capacity in patients with chronic obstructive pulmonary disease (COPD) by ultrasound and to reveal the factors affecting diaphragm excursion. Methods: A total of 42 COPD patients who were treated in our hospital from October 2015 to March 2020 and 42 healthy volunteers (control group) were included in the present study. The participants’ height, weight, and diaphragm excursion (the amplitude of diaphragm movement during deep breathing measured by M-mode ultrasound ([Formula: see text])), diaphragm movement time, degree of airflow obstruction (the forced expiratory volume in one second (FEV1) as a percentage of its predicted level, FEV1%pred), and exercise capacity (six-minute walk distance, 6MWD) were measured. The St. George’s Respiratory Questionnaire (SGRQ) was used to evaluate the patients’ quality of life. The correlation between the amplitude of diaphragm movement and lung function was analyzed. The receiver operating characteristics (ROC) curve was used to determine the COPD diagnosis efficacy of M-mode ultrasound, and its influencing factors were further analyzed. Results: During tidal breathing, the movement amplitudes of both hemidiaphragms in the COPD group were greater than those in the control group. During deep breathing, the movement amplitudes of both hemidiaphragms in the control group were greater than those in the COPD group. Moreover, during both tidal and deep breathing, the movement time of the right hemidiaphragm in the control group was longer than that in the COPD group (all P < 0.001). During deep breathing, the amplitude of diaphragm movement was positively correlated with FEV1 and FEV1%pred (both P < 0.001). During both tidal and deep breathing, the area under the ROC curve (AUC) for the diagnosis of COPD according to the diaphragm movement amplitude was 0.833 and 0.887, respectively, and the AUC for the diagnosis of COPD according to the diaphragm movement time was 0.625 and 0.732, respectively. The [Formula: see text] was correlated with the SGRQ score, symptom score, impact score, activity score, and 6MWD, with correlation coefficients of −0.474, −0.416, −0.432, −0.502, and 0.536, respectively. The factors affecting the [Formula: see text] were height ([Formula: see text], P < 0.001) and FEV1%pred ([Formula: see text], P < 0.001). Conclusion: The diaphragm excursion in COPD was closely related to patients’ quality of life. Height and FEV1%pred had the greatest impact on diaphragm excursion. The lower the diaphragm excursion of the patient, the worse their quality of life and the lower their exercise capacity.
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Affiliation(s)
- PENG AN
- Department of Radiology, Xiangyang NO.1 People’s Hospital, Hubei University of Medicine Xiangyang 441000, P. R. China
| | - PING QIN
- Department of Nursing, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang 441000, P. R. ;China
| | - JIANRU WANG
- Department of Clinical Laboratory, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang 441000, P. R. China
| | - HE RONG ZHOU
- Department of gastroenterology, Xiangyang No. 1 People’s Hospital, Hubei University of Medicine, Xiangyang 441000, P. R. China
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The Use of Diaphragm Ultrasonography in Pulmonary Physiotherapy of COPD Patients: A Literature Review. J Clin Med 2020; 9:jcm9113525. [PMID: 33142746 PMCID: PMC7692245 DOI: 10.3390/jcm9113525] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/25/2020] [Accepted: 10/29/2020] [Indexed: 12/24/2022] Open
Abstract
There is potentially a broad range of patient populations in which ultrasound imaging (US) might be beneficial form of physiotherapy process support. Among them, the group of patients with chronic obstructive pulmonary disease (COPD) is of great importance, as in this individuals the diaphragm dysfunction is frequently observed. Pulmonary physiotherapy often includes techniques which are intended to influence the diaphragm muscle but its anatomy does not allow for variety of techniques to assess function. Lack of easily available and reliable measures complicates outcomes interpretation and makes decision-making process difficult. A review of the electronic literature was conducted to identify studies related to the US assessment of physiotherapy process and its outcome in COPD patients. As a consequence, seven papers were identified. Based on the results obtained, it can be concluded that the diaphragm excursion is US measure that is most often described in context of diaphragm-related physiotherapy in COPD patients. The methodology applied, however, varies greatly making it difficult to compare results. Thus, developing standards of outcome assessment methods and therapy monitoring systems which are supported by evidence should be of paramount importance. Future studies could also focus on identifying which components of physiotherapeutic diaphragm-targeted approach provide acceptable level of evidence.
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Alqahtani JS, Oyelade T, Sreedharan J, Aldhahir AM, Alghamdi SM, Alrajeh AM, Alqahtani AS, Alsulayyim A, Aldabayan YS, Alobaidi NY, AlAhmari MD. Diagnostic and clinical values of non-cardiac ultrasound in COPD: A systematic review. BMJ Open Respir Res 2020; 7:e000717. [PMID: 32978244 PMCID: PMC7520906 DOI: 10.1136/bmjresp-2020-000717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clinical and research utility of non-cardiac ultrasound (US) in chronic obstructive pulmonary disease (COPD) has been widely investigated. However, there is no systematic review assessing the clinical values of non-cardiac US techniques in COPD. METHODS We systematically searched electronic databases from inception to 24 June 2020. Two independent reviewers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines extracted data. A narrative synthesis of the results was conducted considering non-cardiac US techniques that looked for diaphragm, muscles and bones in patients with COPD. RESULTS In total, 2573 abstracts were screened, and 94 full-text papers were reviewed. A total of 54 studies met the inclusion criteria. Thirty-five studies assessed the diaphragm, while 19 studies evaluated different muscles, including limb muscles and pulmonary lesions in COPD using US. Of the 54 included studies, 30% (16/54) evaluated the changes in either limb muscles or diaphragmatic features before and after physical interventions; 67% (36/54) assessed the correlations between sonographic features and COPD severity. Indeed, 14/15 and 9/13 studies reported a significant reduction in diaphragm excursion and thickness in COPD compared with healthy subjects, respectively; this was correlated significantly with the severity and prognosis of COPD. Three studies reported links between diaphragm length and COPD, where lower diaphragm length correlated with poorer prognosis and outcomes. Quadriceps (rectus femoris), ankle dorsiflexor (tibialis anterior) and vastus lateralis were the most common muscles in COPD assessed by US. More than 70% (12/17) of the studies reported a significant reduction in the cross-sectional area (CSA) of the rectus femoris, rectus femoris and vastus lateralis thickness in COPD compared with healthy subjects. Quadriceps CSA and thickness correlated positively with COPD prognosis, in which patients with reduced quadriceps CSA and thickness have higher risk of exacerbation, readmission and death. CONCLUSION US measurements of diaphragm excursion and thickness, as well as lower limb muscles strength, size and thickness, may provide a safe, portable and effective alternative to radiation-based techniques in diagnosis and prognosis as well as tracking improvement postintervention in patients with COPD.
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Affiliation(s)
- Jaber S Alqahtani
- Respiratory Medicine, University College London, London, UK
- Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Tope Oyelade
- Division of Medicine, University College London, London, UK
| | - Jithin Sreedharan
- Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Abdulelah M Aldhahir
- Respiratory Medicine, University College London, London, UK
- Department of Respiratory Care, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Saeed M Alghamdi
- National Heart and Lung Institute, Imperial College London, London, UK
- Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ahmed M Alrajeh
- Respiratory Care Department, College of Applied Medical Sciences, King Faisal University, Al-Hasa, Saudi Arabia
| | - Abdullah S Alqahtani
- Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
- Anaesthesia & Critical Care, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Abdullah Alsulayyim
- Department of Respiratory Care, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Yousef S Aldabayan
- Respiratory Care Department, College of Applied Medical Sciences, King Faisal University, Al-Hasa, Saudi Arabia
| | - Nowaf Y Alobaidi
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Respiratory Therapy Department, King Saud bin Abdulaziz University for Health Sciences, Alahsa, Saudi Arabia
| | - Mohammed D AlAhmari
- Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
- Dammam Health Network, Dammam, Saudi Arabia
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