Diaphragmatic paralysis diagnostic study of choice

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2] [3]

Overview

Studies of choice for unilateral diaphragmatic paralysis include upright chest radiograph and fluoroscopic sniff test. Studies of choice for bilateral diaphragmatic paralysis include measurement of transdiaphragmatic pressure (Pdi).

Diagnostic Study of Choice

Unilateral diaphragmatic paralysis

Upright chest radiograph:
- Elevated hemidiaphragm in paralysed side^[1]^[2]
- Chest xray is then confirmed with fluoroscopic sniff test

Fluoroscopic sniff test:
- Observation of diaphragamtic movement when patient sniffs forcefully^[3]
- Paradoxical elevation of the paralyzed hemidiaphragm during inspiration^[4]

Bilateral diaphragmatic paralysis

Measurement of transdiaphragmatic pressure (Pdi) is the gold standard test for the diagnosis of bilateral diaphragmatic paralysis.
- This test is performed with two catheters. One of them is placed in esophagus and it assesses changing pleural pressure (Ppl) and another one is placed in stomach and it detects changing gastric pressure (Pga).
- Pdi is the difference between Ppl and Pga (Pdi = Ppl – Pga).
- Normal transdiaphragmatic pressure:^[5]
  - Men: 148 cm water
  - Women: 122 cm water
The following result of transdiaphragmatic pressure (Pdi) is confirmatory of bilateral diaphragmatic paralysis:^[6]^[7]
- Unilateral diaphragmatic paralysis:
  - Maximal transdiaphragmatic pressure is more than 70 cm water and it does not effect normal ventilatory behaviors but it may compromise coughing or sneezing.
- Bilateral diaphragmatic paralysis:
  - Maximal transdiaphragmatic pressure is less than 40 cm water and it effects normal ventilatory behaviors.

References

↑ Chetta A, Rehman AK, Moxham J, Carr DH, Polkey MI (January 2005). "Chest radiography cannot predict diaphragm function". Respir Med. 99 (1): 39–44. PMID 15672847.
↑ Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.
↑ Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.
↑ Alexander C (January 1966). "Diaphragm movements and the diagnosis of diaphragmatic paralysis". Clin Radiol. 17 (1): 79–83. PMID 4221861.
↑ Miller JM, Moxham J, Green M (July 1985). "The maximal sniff in the assessment of diaphragm function in man". Clin. Sci. 69 (1): 91–6. PMID 4064560.
↑ Gill LC, Mantilla CB, Sieck GC (May 2015). "Impact of unilateral denervation on transdiaphragmatic pressure". Respir Physiol Neurobiol. 210: 14–21. doi:10.1016/j.resp.2015.01.013. PMC 4449269. PMID 25641347.
↑ McCool FD, Tzelepis GE (March 2012). "Dysfunction of the diaphragm". N. Engl. J. Med. 366 (10): 932–42. doi:10.1056/NEJMra1007236. PMID 22397655.

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[pmid15672847-1] Chetta A, Rehman AK, Moxham J, Carr DH, Polkey MI (January 2005). "Chest radiography cannot predict diaphragm function". Respir Med. 99 (1): 39–44. PMID 15672847.

[pmid96193042-2] Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.

[pmid9619304-3] Gierada DS, Slone RM, Fleishman MJ (May 1998). "Imaging evaluation of the diaphragm". Chest Surg. Clin. N. Am. 8 (2): 237–80. PMID 9619304.

[pmid4221861-4] Alexander C (January 1966). "Diaphragm movements and the diagnosis of diaphragmatic paralysis". Clin Radiol. 17 (1): 79–83. PMID 4221861.

[pmid4064560-5] Miller JM, Moxham J, Green M (July 1985). "The maximal sniff in the assessment of diaphragm function in man". Clin. Sci. 69 (1): 91–6. PMID 4064560.

[pmid25641347-6] Gill LC, Mantilla CB, Sieck GC (May 2015). "Impact of unilateral denervation on transdiaphragmatic pressure". Respir Physiol Neurobiol. 210: 14–21. doi:10.1016/j.resp.2015.01.013. PMC 4449269. PMID 25641347.

[pmid22397655-7] McCool FD, Tzelepis GE (March 2012). "Dysfunction of the diaphragm". N. Engl. J. Med. 366 (10): 932–42. doi:10.1056/NEJMra1007236. PMID 22397655.

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