Ultrasonographic findings of the normal diaphragm: thickness and contractility

Jung Im Seok; Shin Yeop Kim; Francis O. Walker; Sang Gyu Kwak; Doo Hyuk Kwon

doi:10.14253/acn.2017.19.2.131

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Seok, Kim, Walker, Kwak, and Kwon: Ultrasonographic findings of the normal diaphragm: thickness and contractility

Original Article

J Rheum Dis 2017;19(2):131-135.

Published online: 5 January 2017

DOI: https://doi.org/10.14253/acn.2017.19.2.131

Ultrasonographic findings of the normal diaphragm: thickness and contractility

Jung Im Seok¹, Shin Yeop Kim¹, Francis O. Walker², Sang Gyu Kwak³, Doo Hyuk Kwon⁴

¹Department of Neurology, Catholic University of Daegu School of Medicine, Daegu, Korea

²Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

³Medical Statistics & Informatics, Catholic University of Daegu School of Medicine, Daegu, Korea

⁴Department of Neurology, CHA Gumi Medical Center, CHA University, Gumi, Korea

Correspondence to Francis O. Walker Department of Neurology, Wake Forest School of Medicine, Medical Center Bou-levard, Winston-Salem, NC 27157, USA Tel: +1-336-716-7548 Fax: +1-336-716-7794 E-mail: fwalker@wakehealth.edu

Received 9 March 201726 April 2017 Accepted 12 May 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

Background

Neuromuscular ultrasound can be used to assess the diaphragm. Before it can be used clinically, the reference ranges of diaphragm thickness and contractility must be determined.

Methods

We measured the thickness of the diaphragm and the diaphragmatic thickening fraction (DTF) in 80 healthy volunteers with ultrasound and collected their demographic infor-mation to determine if age, sex, and body mass index (BMI) influence these measures.

Results

The thickness of the diaphragm at resting end expiration was 0.193 ± 0.044 cm on the right side and 0.187 ± 0.039 cm on the left. The DTF was 104.8 ± 50.6% on the right side and 114.9 ± 49.2% on the left. Sex, weight, height, and BMI significantly affected the thickness of the diaphragm, but had little effect on the DTF.

Conclusions

Normal reference values for the diaphragm should be helpful when evaluating the diaphragm. The DTF appears more useful than resting diaphragm thickness because it is affected less by individual variation.

Keywords: Ultrasonography, Reference values, Diaphragm

REFERENCES

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Fig. 1.

Measurement of diaphragm thickness. (A) The transducer is positioned on the intercostal space in the anterior axillary line. (B) At the end of quiet expiration, the diaphragm is seen as a hypoechoic structure between two hyperechoic fascia bands. (C) At maximal inspiration, the diaphragm is seen ‘peeling away’ from the chest wall. The distance between the two marks (+) is the muscle thickness. D, diaphragm; IC, intercostal muscle.

Table 1.

Normal reference values for diaphragm thickness and the diaphragm thickness fraction (DTF)

	Side	Mean	SD	Percentiles	Reference range
	Side	Mean	SD	2.5^th, 97.5^th	Reference range
Diaphragm thickness (cm)
Resting	Rt	0.19	0.04	0.11, 0.32	0.11-0.28
	Lt	0.19	0.04	0.11, 0.26	0.11-0.27
Maximal inspiration	Rt	0.39	0.13	0.21, 0.66	0.14-0.65
	Lt	0.39	0.10	0.22, 0.60	0.20-0.60
DTF (%)	Rt	105	51	28, 258	28-258
	Lt	115	49	36, 216	17-213

The reference range was determined as the mean ± 2 SD for normally distributed data and from the 97.5 ^th percentile for non-normally distributed data.

Diaphragm thickness and DTF for the left side are distributed normally.

Rt, right; Lt, left; SD, standard deviation.

Table 2.

Diaphragm thickness and the diaphragm thickness fraction (DTF) according to demographic factors

	DT, resting		DT, maximal inspiration		DTF ^c
	Rt	Lt	Rt	Lt	Rt	Lt
Age, mean (SD)
3 ^rd decade	0.19 (0.04)	0.18 (0.04)	0.40 (0.09)	0.41 (0.11)	107 (41)	134 (47)
4 ^th decade	0.20 (0.06)	0.18 (0.04)	0.38 (0.13)	0.39 (0.10)	90 (43)	115 (54)
5 ^th decade	0.19 (0.04)	0.20 (0.04)	0.40 (0.13)	0.42 (0.09)	106 (48)	119 (44)
6 ^th decade	0.19 (0.03)	0.19 (0.04)	0.40 (0.15)	0.37 (0.09)	116 (66)	91 (45)
p-value	0.77	0.31	0.97	0.34	0.44	0.04 ^b
Sex, mean (SD)
Male	0.22 (0.05)	0.21 (0.03)	0.47 (0.12)	0.44 (0.10)	118 (56)	118 (50)
Female	0.17 (0.03)	0.17 (0.04)	0.32 (0.08)	0.35 (0.08)	92 (41)	112 (49)
p-value	<0.001 ^b	<0.001 ^b	<0.001 ^b	<0.001 ^b	0.02 ^b	0.56
Height
CC	0.659	0.567	0.512	0.340	0.071	–0.137
p-value	<0.001 ^b	<0.001 ^b	<0.001 ^b	<0.001 ^b	0.53	0.22
p-value ^a	<0.05 ^b	0.15	0.16	0.99	0.48	0.38
Weight
CC	0.596	0.454	0.540	0.380	0.164	0.013
p-value	<0.001 ^b	<0.001 ^b	<0.001 ^b	<0.001 ^b	0.15	0.90
p-value ^a	<0.001 ^b	<0.05 ^b	0.12	0.65	0.08	0.06
BMI
CC	0.513	0.496	0.339	0.213	–0.026	–0.222
p-value	<0.001 ^b	<0.001 ^b	<0.05 ^b	0.06	0.82	0.05
p-value ^a	<0.001 ^b	<0.05 ^b	0.24	0.52	0.08	0.07

DT, diaphragm thickness in cm; Rt, right; Lt, left; SD, standard deviation; CC, correlation coefficient; BMI, body mass index.

^a p-value adjusted for age and sex.

^b Significant values (p < 0.05).

^c Diaphragm thickness fraction as a %.

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