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Barchuk A, Barchuk SA, Roebken CK, Ahn J. Prevalence of Diaphragmatic Dysfunction in the Long-Term Acute Care Setting and Its Effects on Ventilator Weaning Outcomes: A Retrospective Cohort Study. Am J Phys Med Rehabil 2022; 101:555-560. [PMID: 34446645 DOI: 10.1097/phm.0000000000001863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the prevalence of undiagnosed diaphragmatic dysfunction in a long-term acute care hospital setting in patients on prolonged mechanical ventilation and its association with weaning outcomes. DESIGN This is a single-center, retrospective cohort study including 451 patients on prolonged mechanical ventilation admitted to a long-term acute care hospital facility between 2012 and 2017. Diaphragmatic dysfunction was assessed using fluoroscopy. RESULTS Three hundred nineteen patients on prolonged mechanical ventilation were assessed for diaphragmatic dysfunction. Nine patients were diagnosed with diaphragmatic dysfunction before admission. Eighty (72.7%) without diaphragmatic dysfunction were successfully weaned and 30 (27.3%) failed to wean, whereas 51 participants (31.9%) with diaphragmatic dysfunction were successfully weaned and 109 (68.1%) failed to wean (P < 0.001). When analyzing days to wean, the median was 13 days for those with no diaphragmatic dysfunction, 19 days with unilateral diaphragmatic dysfunction, and 28 days with bilateral diaphragmatic dysfunction (P < 0.001). Weaning success was not statistically associated with generalized neuromuscular disorders, age, sex, body mass index, smoking history, or diabetes. CONCLUSIONS Diaphragmatic dysfunction was found to be strongly associated with time to wean and weaning success in the long-term acute care hospital setting. Very few patients despite being on prolonged mechanical ventilation were diagnosed with diaphragmatic dysfunction before long-term acute care hospital admission. Given this information, early diagnosis of diaphragmatic dysfunction among prolonged mechanical ventilation patients in the long-term acute care hospital setting is paramount in preventing secondary complications associated with mechanical ventilation.
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Affiliation(s)
- Alex Barchuk
- From the Kentfield Hospital, Kentfield, California (AB, CKR); Icahn School of Medicine at Mount Sinai, New York, New York (SAB); and Georgetown University, Washington, DC (JA)
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Fanget F, Drevet G, Maury JM, Tronc F. Intestinal Air in the Mediastinum. Chest 2021; 160:e299-e303. [PMID: 34488972 DOI: 10.1016/j.chest.2021.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/30/2021] [Accepted: 04/11/2021] [Indexed: 11/15/2022] Open
Abstract
CASE PRESENTATION A 74-year-old man, in excellent physical condition and doing regular intense cycling, was evaluated for transient episodes of thoracic discomfort over a period of several months. His medical history only included a right inguinal hernia, surgically treated, and an abdominal aortic aneurysm measured at 46 mm and treated medically. Physical examination did not reveal much information. The patient did not report gastroesophageal reflux, dysphagia, or history of digestive occlusion. The patient had normal weight and had no trauma history. He had no nicotine or alcohol-dependent behaviors. Vital signs were within normal values. Laboratory test results were normal. Functional status was normal, without anomalies of pulmonary function tests or arterial blood gases. The ECG did not reveal any anomaly.
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Affiliation(s)
- Florian Fanget
- Department of Digestive and Endocrine Surgery, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Gabrielle Drevet
- Department of Thoracic Surgery and Lung Transplantation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France.
| | - Jean-Michel Maury
- Department of Thoracic Surgery and Lung Transplantation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - François Tronc
- Department of Thoracic Surgery and Lung Transplantation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
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Nardini M, Jayakumar S, Migliore M, Nosotti M, Paul I, Dunning J. Minimally Invasive Plication of the Diaphragm: A Single-Center Prospective Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:343-349. [PMID: 34130535 DOI: 10.1177/15569845211011583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Plication of the diaphragm is a life-changing procedure for patients affected by diaphragm paralysis. Traditionally, this procedure is performed through a thoracotomy. Access to the diaphragm via this incision is poor and the indications for surgery are limited to patients who can actually sustain such an invasive approach and associated morbidities. A minimally invasive approach was developed to improve the surgical management of diaphragm paralysis. METHODS Patients underwent minimally invasive diaphragm plication either by video-assisted or robotic surgery through a 3-port technique with CO2 insufflation. Patients were followed at the routine 6-week clinic and also by telephone consultation 6 to 12 months postoperatively. Data were collected on postoperative complications, postoperative pain or numbness, symptomatic improvement, and change to quality of life following surgery. RESULTS Forty-eight patients underwent 49 minimally invasive diaphragm plication. Median postoperative length of hospital stay was 4 days (range: 2 to 34 days) and there were no cases of mortality. Mean reduction in Medical Research Council dyspnea score per patient was 2.2 points (mode: 3 points). Twenty-eight patients (77.8%) reported a significant symptomatic improvement enabling improvements in quality of life, and 97.2% (n = 35) were satisfied with the surgical outcome. CONCLUSIONS Minimally invasive diaphragm plication is a safe procedure associated with prompt postoperative recovery. It is effective at reducing debilitating dyspnea and improving quality of life.
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Affiliation(s)
- Marco Nardini
- 9304 Department of Thoracic Surgery and Lung Transplantation, University of Milan, Italy.,4964 Department of Cardiothoracic Surgery, Royal Brompton and Harefield Hospitals, London, UK
| | - Shruti Jayakumar
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Marcello Migliore
- 8903 Department of Thoracic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mario Nosotti
- 9304 Department of Thoracic Surgery and Lung Transplantation, University of Milan, Italy
| | - Ian Paul
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Joel Dunning
- 156705 Department of Thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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do Nascimento IB, Fleig R. Mobility impact and methods of diaphragm monitoring in patients with chronic obstructive pulmonary disease: a systematic review. Clinics (Sao Paulo) 2020; 75:e1428. [PMID: 31939562 PMCID: PMC6943239 DOI: 10.6061/clinics/2020/e1428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/08/2019] [Indexed: 12/23/2022] Open
Abstract
The objectives of the study were to identify the factors that limit diaphragmatic mobility and evaluate the therapeutic results of the monitoring methods previously used in patients with chronic obstructive pulmonary disease. The PubMed, Web of Science, Scopus, and LILACS databases were used. A gray literature search was conducted with Google scholar. PRISMA was used, and the bias risk analysis adapted from the Cochrane Handbook for clinical trials and, for other studies, the Downs and Black checklist were used. Twenty-five articles were included in the qualitative synthesis analysis on physiotherapeutic techniques and diaphragmatic mobility. Eight clinical trials indicated satisfactory domains, and on the Downs and Black scale, 17 cohort studies were evaluated to have an acceptable score. Different conditions must be observed; for example, for postoperative assessments the supine position is suggested to be the most appropriate position to verify diaphragm excursion, although it has been shown to be associated with difficulty of restriction and matching in samples. Therefore, we identified the need for contemporary adjustments and strategies that used imaging instruments, preferably in the dorsal position. Therapeutic evidence on the association between the instrumental method and diaphragmatic mobility can be controversial. The ultrasound measurements indicated some relevance for different analyses, for pulmonary hyperinflation as well as diaphragm thickness and mobilization, in COPD patients. In particular, the study suggests that the ultrasound technique with B-mode for analysis and M-mode for diaphragmatic excursion be used with a 2 - 5 MHz with the patient in the supine position. However, the methods used to monitor diaphragm excursion should be adapted to the conditions of the patients, and additional investigations of their characteristics should be performed. More selective inclusion criteria and better matching in the samples are very important. In addition, more narrow age, sex and weight categories are important, especially in patients with chronic obstructive pulmonary disease.
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Affiliation(s)
- Iramar Baptistella do Nascimento
- Departamento de Tecnologia Industrial, Universidade do Estado de Santa Catarina, São Bento do Sul, SC, BR
- *Corresponding author. E-mail:
| | - Raquel Fleig
- Departamento de Tecnologia Industrial, Universidade do Estado de Santa Catarina, São Bento do Sul, SC, BR
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Diaphragmatic dysfunction. Pulmonology 2019; 25:223-235. [DOI: 10.1016/j.pulmoe.2018.10.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 10/16/2018] [Accepted: 10/28/2018] [Indexed: 12/13/2022] Open
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Abstract
The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.
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Brüggemann AKV, Leal BE, Gonçalves MA, Lisboa L, Tavares MGDS, Paulin E. Mobilidade diafragmática direita e esquerda em indivíduos saudáveis e na doença pulmonar obstrutiva crônica. FISIOTERAPIA E PESQUISA 2018. [DOI: 10.1590/1809-2950/16155925022018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RESUMO Avaliar o músculo diafragma é importante para verificar suas possíveis alterações ou disfunções. Existem várias formas de avaliar a mobilidade diafragmática, mas poucos estudos que comparam a mobilidade do hemidiafragma direito com o esquerdo. O objetivo deste estudo é avaliar se existem diferenças entre a mobilidade diafragmática das hemicúpulas direita e esquerda em indivíduos saudáveis e em indivíduos com Doença Pulmonar Obstrutiva Crônica (DOCP), bem como comparar a mobilidade diafragmática entre homens e mulheres, e entre pacientes saudáveis e com DPOC. Foram avaliados 40 indivíduos saudáveis e 40 indivíduos com diagnóstico clínico de DPOC. Utilizaram-se os parâmetros antropométricos, cardiopulmonares e avaliação da mobilidade diafragmática pelo método radiográfico. Os dados foram analisados estatisticamente e tratados com análise descritiva (média e desvio-padrão) e análise inferencial. Para comparar a mobilidade das hemicúpulas diafragmáticas direita e esquerda, utilizou-se o teste t pareado. O nível de significância adotado para o tratamento estatístico foi de 5% (p<0,05). Não houve diferença da mobilidade diafragmática tanto do lado direito quanto do lado esquerdo nos indivíduos saudáveis (p=0,45) e nos indivíduos com DPOC (p=0,77), assim como não houve diferenças quando os grupos foram separados por sexo. Foi encontrada uma diferença importante comparando tanto a mobilidade diafragmática do lado direito quanto do lado esquerdo entre indivíduos saudáveis e DPOC (p<0,001). Concluiu-se que a mobilidade diafragmática das hemicúpulas direita e esquerda em indivíduos saudáveis e em indivíduos com DPOC é a mesma. Não há diferença da mobilidade entre homens e mulheres. A mobilidade diafragmática é reduzida em paciente com DPOC.
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Leal BE, Gonçalves MA, Lisboa LG, Linné LMS, Tavares MGDS, Yamaguti WP, Paulin E. Validity and reliability of fluoroscopy for digital radiography: a new way to evaluate diaphragmatic mobility. BMC Pulm Med 2017; 17:62. [PMID: 28415987 PMCID: PMC5392964 DOI: 10.1186/s12890-017-0402-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 03/28/2017] [Indexed: 12/21/2022] Open
Abstract
Background Fluoroscopy is considered the most accurate method to evaluate the diaphragm, yet most existing methods for measuring diaphragmatic mobility using fluoroscopy are complex. To assess the validity and reliability of a new evaluation method of diaphragmatic motion using fluoroscopy by digital radiography of healthy adults. Methods Twenty-six adults were evaluated, according to the parameters: anthropometry and pulmonary function test. The evaluation of diaphragm mobility by means of fluoroscopy by digital radiography method was randomly conducted by two raters (A and B). The Pearson correlation coefficient and the intraclass correlation coefficient (ICC) were used to assess the concurrent validity. The inter-rater and intra-rater reliability of the measurement of diaphragmatic motion was determined using ICC and a confidence interval of 95%. Results There was a relationship in the assessment of the concurrent validity. There was good inter-rater reliability for right hemidiaphragm mobility and moderate reliability for left hemidiaphragm in the first assessment. In the second assessment, there was good reliability for the mobility of both hemidiaphragms. There was good intra-rater reliability in the mobility of both hemidiaphragms for raters A and B. Conclusion The evaluation of diaphragmatic motion using fluoroscopy by digital radiography proved to be a valid and reliable method of healthy adults.
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Affiliation(s)
- Bruna Estima Leal
- Physical Therapy Department,Santa Catarina State University (UDESC), Florianopolis, SC, Brazil
| | | | | | | | | | | | - Elaine Paulin
- Physical Therapy Department,Santa Catarina State University (UDESC), Florianopolis, SC, Brazil. .,Santa Catarina State University (UDESC), Rua Pascoal Simone, 358, Coqueiros, Florianópolis, SC, Brazil, CEP: 88080-350.
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Bordoni B, Marelli F, Morabito B, Sacconi B. Manual evaluation of the diaphragm muscle. Int J Chron Obstruct Pulmon Dis 2016; 11:1949-56. [PMID: 27574419 PMCID: PMC4993263 DOI: 10.2147/copd.s111634] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The respiratory diaphragm is the most important muscle for breathing. It contributes to various processes such as expectoration, vomiting, swallowing, urination, and defecation. It facilitates the venous and lymphatic return and helps viscera located above and below the diaphragm to work properly. Its activity is fundamental in the maintenance of posture and body position changes. It can affect the pain perception and emotional state. Many authors reported on diaphragmatic training by using special instruments, whereas only a few studies focused on manual therapy approaches. To the knowledge of the authors, the existing scientific literature does not exhaustively examines the manual evaluation of the diaphragm in its different portions. A complete evaluation of the diaphragm is mandatory for several professional subjects, such as physiotherapists, osteopaths, and chiropractors not only to elaborate a treatment strategy but also to obtain information on the validity of the training performed on the patient. This article aims to describe a strategy of manual evaluation of the diaphragm, with particular attention to anatomical fundamentals, in order to stimulate further research on this less explored field.
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Affiliation(s)
- Bruno Bordoni
- Department of Cardiology, Foundation Don Carlo Gnocchi IRCCS, Institute of Hospitalization and Care with Scientific Address, Milan; CRESO, School of Osteopathic Centre for Research and Studies, Castellanza; CRESO, School of Osteopathic Centre for Research and Studies, Falconara Marittima
| | - F Marelli
- CRESO, School of Osteopathic Centre for Research and Studies, Castellanza; CRESO, School of Osteopathic Centre for Research and Studies, Falconara Marittima
| | - B Morabito
- CRESO, School of Osteopathic Centre for Research and Studies, Castellanza; CRESO, School of Osteopathic Centre for Research and Studies, Falconara Marittima; Foundation Polyclinic University A Gemelli, University Cattolica del Sacro Cuore
| | - B Sacconi
- Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
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Langness S, Bernard Stover L, Shayan K, Saenz N. Benign vascular malformation of the diaphragm. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Grams ST, von Saltiél R, Mayer AF, Schivinski CIS, de S. Nobre LF, Nóbrega IS, Jacomino MEMLP, Paulin E. Assessment of the reproducibility of the indirect ultrasound method of measuring diaphragm mobility. Clin Physiol Funct Imaging 2013; 34:18-25. [DOI: 10.1111/cpf.12058] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Samantha T. Grams
- Health and Sports Science Centre; Santa Catarina State University (CEFID/UDESC); Florianópolis-SC Brazil
| | - Rossana von Saltiél
- Health and Sports Science Centre; Santa Catarina State University (CEFID/UDESC); Florianópolis-SC Brazil
| | - Anamaria F. Mayer
- Health and Sports Science Centre; Santa Catarina State University (CEFID/UDESC); Florianópolis-SC Brazil
| | - Camila I. S. Schivinski
- Health and Sports Science Centre; Santa Catarina State University (CEFID/UDESC); Florianópolis-SC Brazil
| | - Luiz Felipe de S. Nobre
- University Hospital of Federal University of Santa Catarina (HU/UFSC); Florianópolis-SC Brazil
| | - Isadora S. Nóbrega
- University Hospital of Federal University of Santa Catarina (HU/UFSC); Florianópolis-SC Brazil
| | | | - Elaine Paulin
- Health and Sports Science Centre; Santa Catarina State University (CEFID/UDESC); Florianópolis-SC Brazil
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Venkatesh V, Verdini D, Ghoshhajra B. Normal Magnetic Resonance Imaging of the Thorax. Magn Reson Imaging Clin N Am 2011; 19:489-506, viii. [DOI: 10.1016/j.mric.2011.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Reply to De Cecco et al. Eur J Cardiothorac Surg 2011. [DOI: 10.1016/j.ejcts.2010.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
This article discusses the diaphragm from a surgical perspective. Although it is a relatively simple organ compared with other structures, the diaphragm serves important anatomic and functional roles necessary for proper respiratory function. It is an organ of little irregularity or disease, and easily manipulated in the operating room by those who have a basic understanding of its anatomic details.
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