Analysis of diaphragmatic movement before and after pulmonary rehabilitation using fluoroscopy imaging in patients with COPD

Multi-modal evaluation of respiratory diaphragm motion in chronic obstructive pulmonary disease using MRI series and CT images

PURPOSE

Chronic obstructive pulmonary disease (COPD), characterized by airflow limitation and breathing difficulty, is usually caused by prolonged inhalation of toxic substances or long-term smoking habits. Some abnormal features of COPD can be observed using medical imaging methods, such as magnetic resonance imaging (MRI) and computed tomography (CT). This study aimed to conduct a multi-modal analysis of COPD, focusing on assessing respiratory diaphragm motion using MRI series in conjunction with low attenuation volume (LAV) data derived from CT images.

MATERIALS AND METHOD

This study utilized MRI series from 10 normal subjects and 24 COPD patients, along with thoracic CT images from the same patients. Diaphragm profiles in the sagittal thoracic MRI series were extracted using field segmentation, and diaphragm motion trajectories were generated from estimated diaphragm displacements via registration. Re-sliced sagittal CT images were used to calculate regional LAVs for four distinct lung regions. The similarities among diaphragm motion trajectories at various positions were assessed, and their correlations with regional LAVs were analyzed.

RESULTS

Compared with the normal subjects, patients with COPD typically exhibited fewer similarities in diaphragm motion, as indicated by the mean normalized correlation coefficient of the vertical motion component (0.96 for normal subjects vs. 0.76 for severity COPD patients). This reduction was significantly correlated with the LAV% in the two lower lung regions with a regression coefficient of 0.81.

CONCLUSION

Our proposed evaluation method may assist in the diagnosis and therapy planning for patients with COPD.

Effects of Baduanjin Exercise on lung function and 6 min walk in COPD patients: a systematic review and meta-analysis

COPD is a public health problem of global concern, which seriously affects the quality of life of patients and is also the third leading cause of death from non-communicable diseases. To investigate the effect of Ba duan jin exercise on lung function and the results of a 6-min walking trial in patients with stable COPD. Literature databases such as Web of Science, Embase, PubMed, Cochrane Library, Chinese Biomedical Literature (CBM), CNKI, Wanfang Data and VIP were searched by computer, the search period is up to January 2024. Literature screening, quality evaluation and data extraction were carried out independently by two researchers. And use RevMan 5.3 software and StataMP 18 (64-bit) software to process the relevant outcome indicators. A total of 16 RCT studies with 1184 patients were included. The meta-analysis results showed that compared with the control group, Ba Duan Jin exercise could improve FEV1 (MD = 0.29, 95% CI (0.20, 0.37), P < 0.0001), FEV1/FVC (%) (MD = 3.86, 95% CI (2.24, 5.47), P < 0.00001), and 6-min walking distance (MD = 45.41, 95% CI (33.93, 56.89), P < 0.00001) in stable COPD patients. The results of subgroup analysis based on the duration of the intervention cycle, research quality, and intervention frequency showed that periodic Ba Duan Jin exercise can significantly improve the relevant lung function levels to varying degrees. At the same time, the intervention effect of Ba Duan Jin exercise during the implementation process is also affected by the duration of the exercise cycle, exercise frequency, and the completion of the exercise plan. Ba Duan Jin exercise has a positive improvement effect on lung function and 6-min walking distance in stable COPD patients. In the process of exercise implementation, attention should be paid to cultivating exercise habits, stabilizing and improving attendance rates, and strictly implementing training techniques to achieve the best clinical outcomes for these patients.

Effect of 12-week head-down strong abdominal breathing on cognitive function in patients with stable chronic obstructive pulmonary disease: a single-centre randomised controlled trial protocol

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often suffer from a combination of mild cognitive impairment (MCI) and a significant reduction in their quality of life. In the exercise programme of pulmonary rehabilitation (PR), pulmonary rehabilitation intervention is often carried out by enhancing respiratory function. Strong abdominal breathing is a kind of breathing method, through which the diaphragm can be exercised, thereby enhancing the deflection distance of the diaphragm during breathing and improving respiratory function. The inversion trainer can meet the different angles of head-down training and also has the characteristics of low cost, easy to operate, and use a wide range of scenarios. According to currently available data, strong abdominal breathing in combination with head-down position has not yet been used in pulmonary rehabilitation in this type of rehabilitation programme. It is valuable to use this device to study PR of cognitive function in patients with COPD.

METHODS

This study was a 12-week single-centre randomised controlled trial and blinding the assessors and data processors of the test. Recruitment is planned for January 1, 2024. It is expected that 81 patients with stable COPD combined with MCI will be recruited and randomly assigned to the head-down strong abdominal breathing group (HG), the fitness qigong eight-duanjin group (BDJ), and the control group (CG) in a 1:1:1 ratio. Using fNIRS (functional near-infrared spectroscopy) to assess brain oxygen availability before and after pulmonary rehabilitation in three periods: before, during and after the intervention. Cognitive functioning is also assessed using the Overall Cognitive Assessment Scale, the Specific Cognitive Functioning Assessment Scale and the Cognitive Behavioural Ability Test.

TRIAL REGISTRATION

The Specialised Committee on Scientific Research and Academic Ethics of the Academic Committee of Anqing Normal University approved the project (ANU2023001). China Clinical Trial Registry approved the study (ChiCTR2300075400) with a registration date of 2023/09/04.

DISCUSSION

The aim of this study was to explore novel exercise rehabilitation methods to improve cognitive function in COPD patients. It results in a lower financial burden and higher participation in pulmonary rehabilitation and improves the quality of survival of patients with COPD.

The effects of inspiratory muscle warm-up prior to inspiratory muscle training during pulmonary rehabilitation in subjects with chronic obstructive pulmonary disease: a randomized trial

BACKGROUND

While a whole-body warm-up may not adequately prepare the inspiratory muscles for exercise, inspiratory warm-up is an effective approach in preparing the inspiratory muscles for exertion.

OBJECTIVES

To investigate the effects of inspiratory muscle warm-up performed prior to inspiratory muscle training (IMT) during pulmonary rehabilitation (PR) in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) and inspiratory muscle weakness.

METHODS

Pulmonary function tests, maximal inspiratory and expiratory pressures (MIP and MEP), 6-minute walk test distance (6MWD), modified Medical Research Council Dyspnea Scale(mMRC), St. George's respiratory questionnaire and the 36-item short-form health survey were evaluated. Both groups performed IMT during PR for 8 weeks. The warm-up group (n = 15), in addition to the standard IMT group (n = 15), performed an inspiratory muscle warm-up protocol before each IMT session.

RESULTS

At the end of the 8-week intervention, improvements in dyspnea (mMRC in score, p =0.033, effect size =0.76); exercise capacity (6MWD in meters, p =0.001, effect size =1.30); pulmonary function [forced expiratory volume in 1 second (FEV1) in %predicted, p =0.006, effect size =1.10]; and inspiratory muscle strength (MIP in cmH2O, p =0.001, effect siz e = 1.35) were significantly greater in the warm-up group. Moreover, there were significant improvements in health-related quality of life (HRQoL) sub-scores after the training in both groups (p <0.05).

CONCLUSIONS

This study demonstrated improvements in both groups, surpassing or closely approaching the established minimal clinically important difference values for the respective outcomes. Performing a warm-up for inspiratory muscles before IMT boosts benefits for pulmonary function, inspiratory muscle strength, exercise capacity, dyspnea, and HRQoL in subjects with moderate-to-severe COPD and inspiratory muscle weakness.

Current advances in pulmonary functional imaging

Recent advances in imaging analysis have enabled evaluation of ventilation and perfusion in specific regions by chest computed tomography (CT) and magnetic resonance imaging (MRI), in addition to modalities including dynamic chest radiography, scintigraphy, positron emission tomography (PET), ultrasound, and electrical impedance tomography (EIT). In this review, an overview of current functional imaging techniques is provided for each modality. Advances in chest CT have allowed for the analysis of local volume changes and small airway disease in addition to emphysema, using the Jacobian determinant and parametric response mapping with inspiratory and expiratory images. Airway analysis can reveal characteristics of airway lesions in chronic obstructive pulmonary disease (COPD) and bronchial asthma, and the contribution of dysanapsis to obstructive diseases. Chest CT is also employed to measure pulmonary blood vessels, interstitial lung abnormalities, and mediastinal and chest wall components including skeletal muscle and bone. Dynamic CT can visualize lung deformation in respective portions. Pulmonary MRI has been developed for the estimation of lung ventilation and perfusion, mainly using hyperpolarized 129Xe. Oxygen-enhanced and proton-based MRI, without a polarizer, has potential clinical applications. Dynamic chest radiography is gaining traction in Japan for ventilation and perfusion analysis. Single photon emission CT can be used to assess ventilation-perfusion (V˙/Q˙) mismatch in pulmonary vascular diseases and COPD. PET/CT V˙/Q˙ imaging has also been demonstrated using "Galligas". Both ultrasound and EIT can detect pulmonary edema caused by acute respiratory distress syndrome. Familiarity with these functional imaging techniques will enable clinicians to utilize these systems in clinical practice.

Comparison of breathing pattern and diaphragmatic motion in patients with unilateral cervical radiculopathy and asymptomatic group

BACKGROUND

The associations between neck pain and respiratory dysfunction were clarified in patients with neck pain. There is dearth of evidence on pulmonary dysfunction and diaphragmatic excursion in patients with unilateral cervical radiculopathy (CR). The purpose of this study was to compare the breathing pattern and diaphragmatic excursion in patients with unilateral CR with those in an asymptomatic group.

METHODS

Twenty-five patients with unilateral CR and 25 asymptomatic individuals aged between 30 and 55 participated in this study. Diaphragmatic motion, breathing pattern, active cervical range of motion and kinesiophobia were investigated in both groups by using fluoroscopy, manual assessment of respiratory motion (MARM), cervical range of motion device, and Tampa scale of kinesiophobia. Statistical significance was set at 0.05.

RESULTS

No statistically significant differences were found between the two groups with regard to sex, age and body mass index. The mean excursion of the hemi diaphragm on the involved side (the side of CR) was significantly lower than that on the uninvolved side in patients with unilateral CR with a large effect size. The excursion of the involved hemi diaphragm in patients was reduced compared to the matched hemi diaphragm in the control group. There was no significant difference between the hemi diaphragms excursion in the control group. The results of the MARM variables showed that the volume of breathing and the percentage rib cage motion in normal and deep breathing were significantly different between the two groups, but there was no significant difference in the balance of breathing between the two groups. Additionally, the active cervical range of motion was reduced in these patients in comparison to the control group, and it was less on the involved side than on the uninvolved side.

CONCLUSION

The results of this study revealed a dysfunctional breathing pattern in normal and deep breathing and a unilateral reduction in diaphragmatic excursion on the side of radiculopathy in patients with unilateral CR compared to the control group.

Respiratory Diaphragm Motion-Based Asynchronization and Limitation Evaluation on Chronic Obstructive Pulmonary Disease

Background: Chronic obstructive pulmonary disease (COPD) typically causes airflow blockage and breathing difficulties, which may result in the abnormal morphology and motion of the lungs or diaphragm. Purpose: This study aims to quantitatively evaluate respiratory diaphragm motion using a thoracic sagittal magnetic resonance imaging (MRI) series, including motion asynchronization and limitations. Method: First, the diaphragm profile is extracted using a deep-learning-based field segmentation approach. Next, by measuring the motion waveforms of each position in the extracted diaphragm profile, obvious differences in the independent respiration cycles, such as the period and peak amplitude, are verified. Finally, focusing on multiple breathing cycles, the similarity and amplitude of the motion waveforms are evaluated using the normalized correlation coefficient (NCC) and absolute amplitude. Results and Contributions: Compared with normal subjects, patients with severe COPD tend to have lower NCC and absolute amplitude values, suggesting motion asynchronization and limitation of their diaphragms. Our proposed diaphragmatic motion evaluation method may assist in the diagnosis and therapeutic planning of COPD.

Short-term effects of a novel bronchial drainage device: A pilot cohort study in subjects with cystic fibrosis

Background and Aims

In cystic fibrosis (CF) airways, impaired airway mucociliary clearance and mucus accumulation due to cystic fibrosis transmembrane conductance regulator defects contribute to inflammation, progressive structural lung damage, and decline of lung function. Physiotherapy is essential to promote mucus mobilization and removal in CF and is a key element of rehabilitation measures, but conventional techniques may be suboptimal to mobilize viscous mucus. This study aimed to test the specific effects of a novel bronchial drainage device (BDD) (Simeox®; PhysioAssist) in subjects with CF and evaluate lung function, diaphragm mobility, and sputum properties.

Methods

This prospective monocentric clinical cohort study in the setting of outpatient physiotherapy of CF patients (n = 21) with stable CF lung disease collected pulmonary lung function tests (PFT), diaphragm mobility, and sputum properties before and after two physiotherapy sessions using the novel BDD. PFT was assessed using spirometry and diaphragm mobility using m-mode ultrasound analysis. Spontaneous sputum samples were collected before and after using the BDD and analyzed for microstructure and DNA concentrations.

Results

PFT parameters (FEV1, FVC, MEF25/50/75) were not affected by the use of the BDD. Ultrasound analysis of diaphragm mobility revealed an increase in maximum diaphragm excursion upon the intervention. Mucus analysis demonstrated altered microstructure and higher DNA concentrations collected after using the BDD compared to samples collected before. Pearson correlation analysis showed significant correlations between changes in mucus properties and DNA levels in respective mucus samples.

Conclusion

Our results demonstrate that the novel BDD improves diaphragm mobility and alters sputum properties in subjects with CF. The novel BDD with unique properties may be further studied as a device in CF-specific physiotherapy to facilitate sputum mobilization of CF patients.

Dynamic Quantitative Magnetic Resonance Imaging Assessment of Areas of the Lung During Free-Breathing of Patients with Chronic Obstructive Pulmonary Disease

RATIONALE AND OBJECTIVES

Changes in the geometry of the chest wall due to lung hyperinflation occur in COPD. However, the quantitative assessment of impaired lung motions and its association with the clinical characteristics of COPD patients are unclear. This study aimed to investigate the respiratory kinetics of COPD patients by dynamic MRI.

MATERIALS AND METHODS

This study enrolled 22 COPD patients and 10 normal participants who underwent dynamic MRI and pulmonary function testing (PFT). Changes in the areas of the lung and mediastinum during respiration were compared between the COPD patients and the normal controls. Relationships between MRI, CT parameters, and clinical measures that included PFT results also were evaluated.

RESULTS

Asynchronous movements and decreased diaphragmatic motion were found in COPD patients. COPD patients had a larger ratio of MRI-measured lung areas at expiration to inspiration, a smaller magnitude of the peak area change ratio, and a smaller mediastinal-thoracic area ratio than the normal participants. The lung area ratio was associated with FEV₁/FVC, predicted RV%, and CT lung volume/predicted total lung capacity (pTLC). The lung area ratio of the right lower and left lower lungs was significantly correlated with emphysema of each lower lobe. The expiratory mediastinal-thoracic area ratio was associated with FEV₁% predicted and RV/TLC.

CONCLUSION

Changes in the lung areas of COPD patients as shown on MRI reflected the severity of airflow limitation, hyperinflation, and the extent of emphysema. Dynamic MRI provides essential information about respiratory kinetics in COPD.

Effects of pulmonary rehabilitation on diaphragm thickness and contractility in patients with chronic obstructive pulmonary disease

BACKGROUND

Studies are showing that pulmonary rehabilitation (PR) increases diaphragmatic excursion by decreasing hyperinflation in patients with chronic obstructive pulmonary disease (COPD). However, there is a lack of knowledge about its effects on the diaphragm thickness (dt) and contractility. This study aims to evaluate the dt and contractility before and after PR in patients with COPD.

METHODS

All subjects participated in an out-patient PR of 6 weeks and 3 sessions per week prospectively. Dyspnea severity, the disease-specific quality of life (St. Georges Respiratory Questionnaire-SGRQ), pulmonary function tests (PFT), exercise capacity, the dt at the end of the expiration and at maximal inspiration (B-mode ultrasound) were evaluated at baseline and after PR.

RESULTS

A total of 34 patients with a mean age and FEV1 61.05 ± 8.22 years and 57.9 ± 20.4% predicted respectively showed improvements in exercise capacity and some items of PFT and SGRQ. Diaphragmatic thickness at the end of the expiration also significantly improved regardless of the disease severity and was positively correlated with functional performance. The 6-weeks of PR didn't result in a significant difference in diaphragm contractility.

Respiratory muscle training program supplemented by a cell-phone application in COPD patients with severe airflow limitation

PURPOSE

The purpose of this study was to implement a respiratory muscle training program through a mobile phone application for COPD patients with severe airflow limitation.

METHODS

We conducted an experimental study to determine the efficacy of a six-month mobile phone application. At least three times a week for six months the patients would participate in an online training session. We evaluated the lung volumes, maximal inspiratory and expiratory pressure (MIP/MEP) and diaphragm amplitude. The tests were performed at the beginning and at the end of the study.

RESULTS

Thirty-four patients with severe COPD, aged between 44 and 67 years (Mean ± SD, 59.29 ± 6.063), accepted to follow a rehabilitation program based on the use of the Pneumocontrol application. We observed on increased of MEP from the pre-rehabilitation state (83.41 cmH2O) to the post-rehabilitation state (95.03 cmH2O), z = 5.087, p < 0.001. Also, the median MIP significantly increased from the pre-rehabilitation state to the post-rehabilitation state, z = 5.052, p < 0.001. Diaphragmatic distance also increased from 2.81 cm to 3.44 cm, z = 5.069, p < 0.001.

CONCLUSION

Respiratory muscle training supplemented through a cell phone-based application can improve respiratory muscle strength and diaphragm mobility.

CT-derived 3D-diaphragm motion in emphysema and IPF compared to normal subjects

Image registration-based local displacement analysis enables evaluation of respiratory motion between two computed tomography-captured lung volumes. The objective of this study was to compare diaphragm movement among emphysema, idiopathic pulmonary fibrosis (IPF) and normal subjects. 29 normal, 50 emphysema, and 51 IPF subjects were included. A mass preserving image registration technique was used to compute displacement vectors of local lung regions at an acinar scale. Movement of the diaphragm was assumed to be equivalent to movement of the basal lung within 5 mm from the diaphragm. Magnitudes and directions of displacement vectors were compared between the groups. Three-dimensional (3D) and apico-basal displacements were smaller in emphysema than normal subjects (P = 0.003, P = 0.002). Low lung attenuation area on expiration scan showed significant correlations with decreased 3D and apico-basal displacements (r = - 0.546, P < 0.0001; r = - 0.521, P < 0.0001) in emphysema patients. Dorsal-ventral displacement was smaller in IPF than normal subjects (P < 0.0001). The standard deviation of the displacement angle was greater in both emphysema and IPF patients than normal subjects (P < 0.0001). In conclusion, apico-basal movement of the diaphragm is reduced in emphysema while dorsal-ventral movement is reduced in IPF. Image registration technique to multi-volume CT scans provides insight into the pathophysiology of limited diaphragmatic motion in emphysema and IPF.

Effects of core-postural stabilisation on fluoroscopy diaphragmatic measurement and dyspnea in chronic obstructive pulmonary disease: A randomized single-blinded clinical trial

BACKGROUND:

While respiratory and core-postural stabilisation has recently gained a widespread acceptance to improve pulmonary function and dyspena, the therapeutic effects of and rationale underlying the use of respiratory and core-postural stabilisation in the management of patients with chronic obstructive pulmonary disease have not been investigated.

OBJECTIVE:

This study aimed to compare the effects of abdominal breathing and respiratory and core-postural stabilisation on diaphragmatic movement and pulmonary function.

METHODS:

Fourteen patients with moderate chronic obstructive pulmonary disease were randomly assigned to either the respiratory and core-postural stabilisation or abdominal breathing group. All patients underwent fluoroscopy-guided chest X-ray imaging and pulmonary function tests before and after the interventions; the modified Medical Research Council questionnaire was also administered before and after the interventions. Six sessions of either intervention were consistently provided. The obtained data were assessed using independent t-tests and Wilcoxon signed-rank test with a significance threshold of P< 0.05.

RESULTS:

Respiratory and core-postural stabilisation was more effective in increasing diaphragmatic movements than abdominal breathing (P< 0.05). Pulmonary function tests revealed more significant differences in the forced vital capacity (FVC(%)predicted) only after respiratory and core-postural stabilisation (P= 0.004). The Medical Research Council questionnaire score was significantly different within the Respiratory and core-postural stabilisation group (P= 0.014).

CONCLUSIONS:

Our novel results suggest that the effects of respiratory and core-postural stabilisation breathing on diaphragmatic movement and pulmonary function were superior to those of abdominal breathing in patients with chronic obstructive pulmonary disease.

Differences in Lung and Lobe Volumes between Supine and Standing Positions Scanned with Conventional and Newly Developed 320-Detector-Row Upright CT: Intra-Individual Comparison

BACKGROUND

No clinical studies to date have compared unilateral lung or lobe volumes between the supine and standing positions.

OBJECTIVES

To compare lung/lobe volumes on computed tomography (CT) between these two positions and evaluate the correlation between the total lung volume and total lung capacity (TLC) on pulmonary function tests (PFTs).

METHODS

Thirty-two asymptomatic volunteers underwent both conventional CT (supine position) and upright CT (standing position), during deep inspiration breath-hold, and PFTs on the same day. We measured lung/lobe volumes on CT in each position. Paired t tests were used for statistical analysis.

RESULTS

The volumes of the total lung (10.9% increase), right lung (10.3% increase), right upper lobe (8.6% increase), right lower lobe (14.6% increase), left lung (11.6% increase), left upper lobe (7.1% increase), and left lower lobe (16.0% increase) were significantly greater in the standing position than in the supine position (all p < 0.0001). The right middle lobe volume was similar between the two positions (p = 0.16). Intraclass correlation coefficients for agreement between total lung volumes on CT in the supine/standing positions and the TLC on PFT were 0.891/0.938, respectively.

CONCLUSIONS

While the volumes of the bilateral upper and lower lobes and bilateral lungs were significantly greater in the standing than in the supine position, with lower lobes showing larger changes, the right middle lobe volume did not change significantly between positions. The total lung volume on upright CT in the standing position was more similar to TLC on PFT than that in the supine position.

Diaphragmatic motor cortex hyperexcitability in patients with chronic obstructive pulmonary disease

Background and objectives

Respiratory muscles dysfunction has been reported in COPD. Transcranial magnetic stimulation (TMS) has been used for assessing the respiratory corticospinal pathways particularly of diaphragm. We aimed to study the cortico-diaphragmatic motor system changes in COPD using TMS and to correlate the findings with the pulmonary function.

Methods

A case control study recruited 30 stable COPD from the out-patient respiratory clinic of Main Alexandria University hospital- Egypt and 17 healthy control subjects who were subjected to spirometry. Cortical conduction of the diaphragm was performed by TMS to all participants followed by cervical magnetic stimulation of the phrenic nerve roots. Diaphragmatic resting motor threshold (DRMT), cortical motor evoked potential latency (CMEPL), CMEP amplitude (CMEPA), peripheral motor evoked potential latency (PMEPL), PMEP amplitude (PMEPA) and central motor conduction time (CMCT) were measured.

Results

66.7% of COPD patients had severe and very severe COPD with median age of 59 (55–63) years. There was statistically significant bilateral decrease in DRMT, CMEPA and PMEPA in COPD group versus healthy subjects and significant increase in CMEPL and PMEPL (p <0.01). Left CMCT was significantly prolonged in COPD group versus healthy subjects (p <0.0001) but not right CMCT. Further, there was significant increase in CMEPL and CMCT of left versus right diaphragm in COPD group (p = 0.003 and 0.001 respectively) that inversely correlated with FEV₁% and FVC% predicted. Right and left DRMT were insignificantly different in COPD group (p >0.05) but positively correlated with FEV₁/FVC, FEV₁% and FVC% predicted.

Conclusion

Central cortico-diaphragmatic motor system is affected in COPD patients with heterogeneity of both sides that is correlated with pulmonary function.

Significance

Coticospinal pathway affection could be a factor for development of diaphragmatic dysfunction in COPD patients accordingly its evaluation could help in personalization of COPD management especially pulmonary rehabilitation programs.

Decreased and slower diaphragmatic motion during forced breathing in severe COPD patients: Time-resolved quantitative analysis using dynamic chest radiography with a flat panel detector system

OBJECTIVE

To assess the diaphragmatic motion in chronic obstructive pulmonary disease (COPD) patients during forced breathing by time-resolved quantitative analysis using dynamic chest radiography and to demonstrate the characteristics and the difference from that in normal subjects.

MATERIALS AND METHODS

Thirty-one COPD patients and a matched control of 31 normal subjects on age, sex, height, and weight, who underwent chest radiographs during forced breathing using dynamic chest radiography, were included in this study. COPD patients were classified based on the criteria of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (GOLD 1, n = 3; GOLD 2, n = 12; GOLD 3, n = 13; GOLD 4, n = 3). We measured excursions and peak motion speeds of the diaphragms for each participant. We compared the results among GOLD 1/2, GOLD 3/4 groups and normal subjects and investigated associations between the data, and participants' demographics, or pulmonary function.

RESULTS

The excursions of bilateral diaphragms were significantly decreased in the GOLD 3/4 group relative to normal subjects (right, 39.8 ± 15.3 mm vs. 52.7 ± 15.1 mm, P = 0.030; left, 43.7 ± 14.0 mm vs. 56.9 ± 15.5 mm, P = 0.017; mean ± standard deviation) and the GOLD 1/2 group (right, 39.8 ± 15.3 mm vs. 54.4 ± 16.7 mm, P = 0.036; left, 43.7 ± 14.0 mm vs. 60.5 ± 13.9 mm, P = 0.008). The peak motion speeds of the left diaphragm in the inspiratory phase were slower in the GOLD 1/2 group than in normal subjects (24.5 ± 8.0 mm/s vs. 33.6 ± 14.0 mm/s, P =  0.038), and in the GOLD 3/4 group than in normal subjects (25.6 ± 6.8 mm/s vs. 33.6 ± 14.0 mm/s, P =  0.067). The excursions of the diaphragms showed correlation with VC, %VC, and FEV₁, while the peak motion speeds showed no significant correlation with pulmonary function tests.

CONCLUSIONS

Time-resolved quantitative analysis of diaphragms with dynamic chest radiography indicated differences in diaphragmatic motion between COPD groups and normal subjects during forced breathing. The excursions of the diaphragms during forced breathing were significantly lower in the GOLD 3/4 group than those in the GOLD 1/2 group and normal subjects.

Utility of ultrasound assessment of diaphragmatic function before and after pulmonary rehabilitation in COPD patients

Background

Pulmonary rehabilitation (PR) may improve respiratory symptoms and skeletal muscle strength in patients with COPD. We aimed to evaluate changes in ultrasound (US) measurements of diaphragmatic mobility and thickness after PR in COPD patients and to test its correlation with PR outcomes.

Methods

Twenty-five COPD patients were enrolled and underwent a diaphragm US assessment before and after a 12-week PR program.

Results

We found a correlation between the intraindividual percentage of change in the diaphragmatic length of zone of apposition at functional residual capacity (ΔLzapp%) and the change in 6-minute walking distance (6MWD) after PR (rho=0.49, P=0.02). ΔLzapp% was significantly higher in patients with improved 6MWD and COPD Assessment Test (CAT) score (mean rank=12.03±2.57 vs 6.88±4.37; P=0.02). A ΔLzapp% of ≥10% was able to discriminate among patients with improved 6MWD, with a sensitivity of 83% and a specificity of 74%. The area under the receiver operating characteristic curve for ΔLzapp% was 0.83. A cutoff value of ≥9% of ΔLzapp% had a positive predictive value in discriminating a reduction in ≥2 points of CAT score after PR, with a sensitivity and a specificity of 80% and 62%, respectively.

Conclusion

Diaphragm US assessment represents a useful prognostic marker of PR outcomes in COPD patients.

Cycle ergometer and inspiratory muscle training offer modest benefit compared with cycle ergometer alone: a comprehensive assessment in stable COPD patients

BACKGROUND

Cycle ergometer training (CET) has been shown to improve exercise performance of the quadriceps muscles in patients with COPD, and inspiratory muscle training (IMT) may improve the pressure-generating capacity of the inspiratory muscles. However, the effects of combined CET and IMT remain unclear and there is a lack of comprehensive assessment.

MATERIALS AND METHODS

Eighty-one patients with COPD were randomly allocated to three groups: 28 received 8 weeks of CET + IMT (combined training group), 27 received 8 weeks of CET alone (CET group), and 26 only received 8 weeks of free walking (control group). Comprehensive assessment including respiratory muscle strength, exercise capacity, pulmonary function, dyspnea, quality of life, emotional status, nutritional status, and body mass index, airflow obstruction, and exercise capacity index were measured before and after the pulmonary rehabilitation program.

RESULTS

Respiratory muscle strength, exercise capacity, inspiratory capacity, dyspnea, quality of life, depression and anxiety, and nutritional status were all improved in the combined training and CET groups when compared with that in the control group (P<0.05) after pulmonary rehabilitation program. Inspiratory muscle strength increased significantly in the combined training group when compared with that in the CET group (ΔPI_max [maximal inspiratory pressure] 5.20±0.89 cmH₂O vs 1.32±0.91 cmH₂O; P<0.05). However, there were no significant differences in the other indices between the two groups (P>0.05). Patients with weakened respiratory muscles in the combined training group derived no greater benefit than those without respiratory muscle weakness (P>0.05). There were no significant differences in these indices between the patients with malnutrition and normal nutrition after pulmonary rehabilitation program (P>0.05).

CONCLUSION

Combined training is more effective than CET alone for increasing inspiratory muscle strength. IMT may not be useful when combined with CET in patients with weakened inspiratory muscles. Nutritional status had slight impact on the effects of pulmonary rehabilitation. A comprehensive assessment approach can be more objective to evaluate the effects of combined CET and IMT.

Manual evaluation of the diaphragm muscle

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.