CT征象诊断创伤性膈肌破裂

目的 探讨CT征象诊断创伤性膈肌破裂的价值。方法 回顾性分析256例可疑创伤性膈肌破裂的胸腹部损伤患者的资料,经手术证实膈肌破裂128例,膈肌无破裂128例。对所有患者术前均行CT检查,观察CT征象包括膈肌连续性中断或膈肌部分未显示、领口征、腹腔内容物进入胸腔、腹部内脏依靠、膈肌移位、膈肌增厚,计算各征象诊断创伤性膈肌破裂的敏感度和特异度。结果 膈肌连续性中断或部分未显示诊断创伤性膈肌破裂的敏感度和特异度分别为75.00%（96/128）和93.75%（120/128）,领口征为84.37%（108/128）和98.43%（126/128）,腹腔内容物进入胸腔为78.13%（100/128）和98.43%（126/128）,腹部内脏依靠为76.56%（98/128）和99.21%（127/128）,膈肌移位为54.68%（70/128）和93.75%（120/128）,膈肌增厚为46.87%（60/128）和84.38%（108/128）。MSCT征象综合诊断的敏感度为92.18%（118/128）,特异度为100%（128/128）。结论 MSCT征象对创伤性膈肌破裂有较高的诊断价值。     

Diaphragmatic rupture due to blunt trauma: morbidity and mortality in 42 cases

We present an analysis of 42 cases of acute rupture of the diaphragm by blunt trauma. There were 31 men (74%) and 11 women (26%); the mean age was 32.8 years +/- 2.4 SEM. At admission, hypovolemic shock was present in 45% of the cases, pelvic fracture in 36%, and severe respiratory distress in 21%. Diaphragmatic rupture was suggested before operation by unilateral elevation of the diaphragm, supradiaphragmatic densities, and displacement of abdominal organs into the thorax, as shown by chest films and GI series in 18 cases (43%). The left hemidiaphragm was injured in 24 cases (57%), the right in 15 (36%), and both sides in three (7%). Of the 17 patients (40%) found to have an abdominal organ in the thorax, 12 had had a left-sided rupture. Only four patients (10%) had solitary diaphragmatic injuries. Associated injuries (usually two or more) occurred in 38 cases (90%); they were abdominal in 34, musculoskeletal in 26, neurologic in 16, and thoracic in nine. The injuries were repaired through a celiotomy in 33 cases, by thoracotomy in six, and by separate celiotomy and thoracotomy in three. Postoperative complications occurred in 29 cases, the most common being pulmonary (18), systemic sepsis (six), and recurrent bleeding (three). There were 14 deaths, for a mortality of 33%. Seven were operative and due to massive hemorrhage; the late deaths were caused by systemic sepsis in five and neurologic trauma in two. We conclude that (1) diaphragmatic rupture after blunt trauma must be suspected when specific radiologic findings are present; (2) solitary diaphragmatic injuries seldom occur; (3) in most cases, morbidity or mortality is caused by the severity of the associated injuries; and (4) most diaphragmatic injuries can be repaired through a celiotomy, and all of them should be repaired to avoid the sequela of entrapment of abdominal organs in the thorax.     

Late presentation of blunt right diaphragmatic rupture (hepatic hernia)

Diaphragmatic rupture occurs in 0.8% to 3.6% of patients after blunt or penetrating thoracoabdominal trauma, and the preoperative diagnosis is difficult. The diagnosis of traumatic diaphragmatic rupture may be made on initial presentation or at any time later. Right-sided diaphragmatic rupture is rare and occurs in approximately 5% to 20% of all diaphragmatic disruptions. The incidence of herniation of the intra-abdominal organs into the pleural cavity is also low, observed in only about 19% of right-sided diaphragmatic ruptures. We present a case of right-sided traumatic rupture of the diaphragm diagnosed 15 years after the initial blunt trauma. A 22-year-old male patient fell 15 years before and was symptom-free since then. He was referred to our hospital with the signs of herniation of the right diaphragm, which was manifested in the chest x-rays. The definite diagnosis was made through thoracoabdominal computed tomography. The diaphragmatic rupture was repaired via abdominal approach.     

胸腔镜在创伤性膈肌破裂中的临床应用

目的探讨电视胸腔镜对创伤性膈肌破裂的诊断和治疗价值。方法通过16例胸腹联合伤应用电视胸腔镜,发现创伤性膈肌破裂5例。经胸腔镜下修补膈肌破裂2例,在胸腔镜配合下剖腹修补膈肌破裂3例。结果5例创伤性膈肌破裂均得到及时诊断和正确处理,取得满意效果。结论胸腔镜检查对判定膈肌损伤的是准确、有效的方法。     

MRI diagnosis of delayed presentation of traumatic diaphragmatic hernia

Traumatic rupture of the diaphragm may go unrecognized in patients with multiple injuries to the abdomen and chest. The majority of undiagnosed diaphragmatic ruptures will eventually become symptomatic and are associated with a high mortality rate if not treated immediately. Multiplanar imaging with magnetic resonance (MR) provided a definitive diagnosis of delayed presentation of traumatic diaphragmatic hernia.     

Delayed diagnosis of right-sided diaphragmatic rupture

Diaphragmatic rupture is uncommon and results from either blunt or penetrating trauma. Right-sided traumatic diaphragmatic ruptures are easily missed. We present a case of rupture of the right diaphragm, which highlights the difficulty of confirming the correct diagnosis.     

Thoracoscopic diaphragmatic plication in small infants

Introduction: Diaphragmatic eventration often causes progressive dyspnea on exertion or respiratory infection in small children, especially those under 2 years of age. Diaphragmatic plication by minimally invasive surgery is evaluated for quick recovery and has been performed on small children. Methods: Nine patients ranging in age from 1 to 33 months and in weight from 3 to 12 kg were treated by thoracoscopic diaphragmatic plication. Six of them needed preoperative support from a respirator or nasal directional positive airway pressure. Three patients had congenital heart disease with right‐to‐left shunt. The operations were performed with three ports. We put the optical port at the sixth intercostal space and had enough view with artificial pneumothorax at 4 mmHg using carbon dioxide. Single‐lung ventilation was never used. The redundant diaphragm was pulled and plicated with non‐absorbable 3‐0 sutures. Results: The thoracoscopic approach was successful in all nine patients. No conversion was needed. All patients were recovered well postoperatively, except for one patient with a pneumothorax. The patients who needed respiratory support before the operation no longer required it within 8 d of surgery. Conclusion: In conclusion, we showed the feasibility of performing the thoracoscopic plication procedures on small infants. In our series, six out of nine patients were <6 kg and four of them were as young as 1 month old. We placed the optical port near the diaphragm, and this may have been a major factor in helping the surgery succeed. In conclusion, early thoracoscopic plication should be considered even for the small infants with diaphragmatic eventration.     

Quantification of Diaphragm Function Using Ultrasound: Evaluation of a Novel Technique

A novel method of image analysis for quantifying diaphragmatic motion is described using ultrasound. Nineteen patients scheduled for thoracic surgery were evaluated with ultrasound preoperatively and through their postoperative hospital stay. Diaphragmatic motion was measured using a horizontal on-screen ruler, allowing for quantification and tracking of dynamic diaphragm function. A percentage (73.5%) of all attempted measurements was quantifiable. Preoperative measurements of left and right diaphragm movement were correlated and there was no significant difference between the two. Postoperative diaphragm movement ipsilateral to the incision was statistically significantly less when compared to the contralateral side (p = 0.02 vs. p = 0.19). While not universally feasible in all patients, this method for quantifying diaphragmatic function is the only known imaging technique that can be performed at the bedside. Further evaluation of the impact of diaphragmatic dysfunction on patients undergoing thoracic surgery and its correlation with dyspnea is planned. (E-mail: tgethin-jones@partners.org)     

The antenatal diagnosis of diaphragmatic anomalies

In an evaluation of eight fetal diaphragmatic anomalies a number of suggestive antenatal ultrasound findings were identified. The feature most suggestive of a posterolateral hernia (foramen of Bochdalek) is malposition of the heart. Peristalsis of chest contents or movement of abdominal contents into the chest on inspiration are more specific findings. Absence of an intra-abdominal stomach, a small abdominal circumference, and a cystic or solid mass in the chest are suggestive but not specific. It may be difficult or impossible to distinguish a posterolateral diaphragmatic defect from the much less frequent eventration of the diaphragm. An anteromedial defect of the diaphragm (foramen of Morgagni) presented as an intrathoracic anterior solid mass and should be considered in the differential diagnosis of an anterior chest mass. Although all three types of defects are frequently associated with additional anomalies, severe pulmonary hypoplasia is not a complication of eventration or anteromedial defects.     

超声测量膈肌运动诊断慢性阻塞性肺疾病

目的 探讨M型超声测量膈肌头尾向运动幅度与运动时间变化诊断慢性阻塞性肺疾病（COPD）的价值。方法 运用M型超声观察68例稳定期COPD患者（COPD组）和68名健康志愿者（对照组）膈肌头尾向运动幅度与运动时间,比较两组间平静呼吸与深呼吸时膈肌运动幅度与运动时间,分析膈肌运动幅度与肺功能的相关性,采用ROC曲线判断M型超声诊断COPD的效能。结果 平静呼吸时,COPD组双侧膈肌运动幅度大于对照组;深呼吸时,对照组双侧膈肌运动幅度大于COPD组;平静呼吸和深呼吸时,对照组右侧的膈肌运动时间均大于COPD组（P均<0.05）。深呼吸时,膈肌运动幅度与第1秒用力呼气容积（FEV1）、FEV1/用力肺活量均呈正相关（P均<0.05）。平静呼吸和深呼吸时,膈肌运动幅度诊断COPD的ROC曲线下面积（AUC）为0.823、0.858;膈肌运动时间诊断COPD的AUC分别为0.620、0.678。结论 M型超声可通过判断膈肌运动情况快捷地评估膈肌功能,可辅助诊断COPD。     

Diaphragm Dysfunction after Cardiac Surgery: Insights from Ultrasound Imaging during Cardiac Rehabilitation

Diaphragm dysfunction is common after cardiac surgery and can be evaluated with ultrasonography (US). We aimed at assessing with US the incidence of diaphragmatic dysfunction and the impact of cardiovascular rehabilitation (CR) on its recovery. A single-center cohort study was performed. Patients were enrolled after cardiac surgery. The 6-min walking test (6MWT) and diaphragm US were performed at CR admission and after 10 rehabilitative sessions. One hundred eighty-five patients were eligible for final analysis. One hundred thirty-one patients (70.8%) were found to have diaphragm dysfunction (excursion <2 cm). After CR, 68 patients regained normal diaphragmatic function; those with persistent dysfunction had a lower level of functional performance on the 6MWT (metabolic equivalents of tasks: 3.3 vs. 3.6, p = 0.013). The patients who underwent combined surgery (adjusted odds ratio [aOR] = 4.09, p = 0.001) and those with post-operative pneumothorax (aOR = 3.02, p = 0.042) were at increased risk of failure to improve diaphragmatic excursion. US parameters were more powerful tools in predicting diaphragmatic evolution compared with the 6MWT indexes: baseline diaphragm excursion and thickening fraction were associated with complete diaphragmatic functional recovery after CR (aOR = 9.101, p < 0.001, and aOR = 1.058, p = 0.020 respectively). US is a valuable tool for the assessment of post-operative diaphragmatic dysfunction and can identify patients at risk of diaphragmatic recovery failure.     

床边超声对机械通气患者膈肌功能评估的研究进展

膈肌功能障碍在重症患者中发病率高,是导致患者呼吸衰竭和延迟机械通气撤离的重要原因,且易被忽视。以往传统评估膈肌结构和功能的方法具有创伤性,缺乏特异性,且不便于床旁应用,而超声评估膈肌功能和结构具有准确、安全、无创等优点。床旁超声通过测量膈肌活动度、膈肌厚度和膈肌厚度变化率评估膈肌功能,临床用于鉴定膈肌功能障碍及膈肌功能丧失,监测膈肌萎缩程度和做功能力及人机同步性,并用于预测撤机结果。本文阐述床边超声对机械通气患者膈肌功能评估的进展及存在的问题,为临床采用该技术提供指导和帮助。     

Case-based discussion: an unusual manifestation of diaphragmatic hernia mimicking pneumothorax in an adult male

Diaphragmatic hernia is an important cause of emergency hospital admission associated with significant morbidity. It usually results from congenital defect or rupture in the diaphragm due to trauma. Prompt and appropriate diagnosis is necessary in patients with this condition, as surgical intervention by either abdominal or thoracic approach may be necessary. Here, we report a case of left-sided diaphragmatic hernia presenting with sudden onset of breathlessness, respiratory distress and left-sided chest pain radiating to the abdomen, mimicking pneumothorax, treated successfully with surgical intervention.     

Massive bilateral diaphragmatic rupture after an apparently minor automobile accident

A case of massive bilateral diaphragmatic rupture following a low impact motor vehicle accident is described. The patient experienced herniation of intraabdominal contents into the thoracic cavity, but suffered no additional injuries. Few cases of bilateral diaphragmatic rupture have been reported and no cases of acute bilateral rupture have been described as an isolated injury. Diaphragmatic rupture in general may be a difficult injury to recognize. Based on our review of recent cases of diaphragmatic rupture (1979-1990), most patients presenting acutely have additional trauma (89.9%) but only vague symptoms related to their diaphragmatic insult. A chest roentgenogram may be a useful diagnostic tool, although many patients with diaphragmatic rupture have only nonspecific findings. A nasogastric tube placed prior to chest roentgenogram may enable the physician to recognize the injury more readily. A high index of suspicion is required to recognize diaphragmatic rupture and should be maintained for all victims of motor vehicle accidents with abnormal but nondiagnostic chest roentgenograms.     

体外膈肌起搏对ICU获得性衰弱患者膈肌功能障碍有效性的研究分析

目的:观察体外膈肌起搏对ICU获得性衰弱患者膈肌功能的疗效。方法:收集ICU获得性衰弱患者61例,随机分成对照组20例、观察组A 21例、观察组B 20例,分别给予常规治疗,常规治疗+早期心肺康复,常规治疗+早期心肺康复+体外膈肌起搏。在2周后进行膈肌活动度、膈肌厚度、最大吸气压(MIP)、Barthel指数、ICU住院时间测量,并记录。结果:治疗2周后,3组患者膈肌活动度、MIP均较治疗前明显提高(均P0.05)。膈肌活动度组间两两比较,结果示观察组B观察组A对照组(P0.05),对照组和观察组A无统计学差异(P=0.362),观察组B分别与对照组及观察组A差异有统计学意义(P0.01)。MIP:观察组B观察组A对照组(P0.01);膈肌厚度及Barthel指数比较:观察组B观察组A对照组(P0.01);ICU住院时间:观察组B观察组A对照组(P0.01)。结论:体外膈肌起搏能够有效增加ICU获得性衰弱患者的膈肌肌力和耐力,改善患者通气功能,提高日常生活活动能力和生活质量,缩短ICU住院时间,具有较高的临床使用价值。     

膈肌超声评分预测机械通气撤机的价值探讨

目的探讨膈肌超声评分在预测机械通气患者成功撤机中的价值。方法对64例机械通气患者行床旁超声检查,记录其自主呼吸试验时膈肌厚度的变化、双侧膈肌的运动幅度、膈肌相关的浅快呼吸指数(D-RSBI)。根据患者撤机是否成功分为撤机成功组39例和撤机失败组25例。绘制受试者工作特征(ROC)曲线分析自主呼吸试验时膈肌增厚率、膈肌运动幅度、D-RSBI对撤机失败的预测价值,根据最佳临界值将相关的连续性变量转化为二分类变量,进行多因素Logistic回归分析,建立膈肌超声评分系统,预测患者撤机失败率。结果撤机成功组和撤机失败组膈肌增厚率、膈肌运动幅度、D-RSBI比较差异均有统计学意义(均P<0.05)。ROC曲线分析显示撤机成功患者膈肌增厚率的最佳临界值53%,敏感性89.6%,特异性45.4%,约登指数0.283;膈肌运动幅度的最佳临界值11.8 mm,敏感性62.3%,特异性79.4%,约登指数0.413;D-RSBI的最佳临界值1.7 mm·min/n,敏感性58.6%,特异性81.3%,约登指数0.312。膈肌增厚率≥53%、膈肌运动幅度≥11.8 mm及D-RSBI≤1.7 mm·min/n均是呼吸机撤机失败的独立影响因素(OR=5.982、2.966、4.356)。根据膈肌超声评分情况将25例撤机失败患者分为低危8例(0~2分)、中危11例(3~6分)和高危6例(7~8分),其撤机失败发生率分别为11.4%、52.6%、89.7%。结论膈肌超声评分可较准确地预测机械通气患者撤机结局,具有较好的临床应用价值。     

膈肌移动度与肺切除术后肺部并发症及近期预后的关系

目的应用超声测量膈肌移动度,分析其与肺切除术后肺部并发症和近期预后的关系,探讨导致膈肌功能障碍的危险因素。方法选取我院胸外科行单侧肺切除术的患者90例,应用床旁超声分别于术前和术后24 h、48 h、72 h监测患者双侧膈肌移动度。根据术后膈肌移动度分为膈肌功能障碍组(DD组)54例和膈肌功能正常组(ND组)36例,比较两组术后肺部并发症发生情况及近期预后的差异,Logistic回归分析导致膈肌功能障碍的危险因素。结果DD组术后肺部并发症(肺复张不全、术后残腔、胸腔积液、肺部感染)发生率均高于ND组,差异均有统计学意义(均P<0.05);DD组近期预后(肺完全复张时间、术后带管时间)均较ND组差,差异均有统计学意义(均P<0.05)。两组患者术侧膈肌移动度均呈先下降后回升的趋势,健侧膈肌移动度术后48 h保持不变,从术后72 h开始代偿性增加。Logistic回归分析表明吸烟史、肺叶切除均为术后膈肌功能障碍的危险因素(OR=4.347、3.153,均P<0.05)。结论肺切除术后膈肌功能障碍导致肺部并发症发生率增高,不利于近期预后;床旁超声可用于测量围术期膈肌移动度,早期发现膈肌功能不全,为临床制定治疗方案提供依据。     

Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound: a systematic review

Purpose

Diaphragmatic dysfunction (DD) has a high incidence in critically ill patients and is an under-recognized cause of respiratory failure and prolonged weaning from mechanical ventilation. Among different methods to assess diaphragmatic function, diaphragm ultrasonography (DU) is noninvasive, rapid, and easy to perform at the bedside. We systematically reviewed the current literature assessing the usefulness and accuracy of DU in intensive care unit (ICU) patients.

Methods

Pubmed, Cochrane Database of Systematic Reviews, Embase, Scopus, and Google Scholar Databases were searched for pertinent studies. We included all original, peer-reviewed studies about the use of DU in ICU patients.

Results

Twenty studies including 875 patients were included in the final analysis. DU was performed with different techniques to measure diaphragmatic inspiratory excursion, thickness of diaphragm (Tdi), and thickening fraction (TF). DU is feasible, highly reproducible, and allows one to detect diaphragmatic dysfunction in critically ill patients. During weaning from mechanical ventilation and spontaneous breathing trials, both diaphragmatic excursion and diaphragmatic thickening measurements have been used to predict extubation success or failure. Optimal cutoffs ranged from 10 to 14 mm for excursion and 30–36 % for thickening fraction. During assisted mechanical ventilation, diaphragmatic thickening has been found to be an accurate index of respiratory muscles workload. Observational studies suggest DU as a reliable method to assess diaphragm atrophy in patients undergoing mechanical ventilation.

Conclusions

Current literature suggests that DU could be a useful and accurate tool to detect diaphragmatic dysfunction in critically ill patients, to predict extubation success or failure, to monitor respiratory workload, and to assess atrophy in patients who are mechanically ventilated.

     

Paradoxical Motion

Objective. The purpose of this series was to determine whether paradoxical motion of the diaphragm reliably identifies congenital diaphragmatic hernias (CDHs). Methods. Sonographic evaluation of diaphragmatic motion was attempted in all fetuses undergoing a targeted examination for findings suggestive of a possible CDH. During any respiratory motion or hiccupping, the posterior chest and abdomen were visualized in a coronal plane at the level of the descending aorta to evaluate ascent and descent of the hemidiaphragms. Normal motion was defined as descent of both during inspiration. Paradoxical motion was defined as descent of one hemidiaphragm and ascent of the opposite one during inspiration. If no breathing motion was observed during the examination, the results were termed “poor visualization.” If there was poor visualization, the diaphragm was reevaluated at any return visits. In the second part of this study, diaphragmatic motion in 120 fetuses of at least 15 weeks' gestational age without abnormalities was evaluated. The diagnosis of a CDH needed to be confirmed by pathologic examination or surgery. Results. No fetus without abnormalities showed paradoxical breathing. There were 15 fetuses who had a confirmed CDH and showed breathing during an examination. Fourteen of 15 had paradoxical motion; the fetus who did not had a very small defect containing a single loop of bowel. Thirteen fetuses had CDHs, and 2 had eventrations. Conclusions. Paradoxical motion is specific for CDHs and eventrations and can be seen as early as 17 weeks' gestation.     

Ultrasonographic evaluation of diaphragmatic motion.

OBJECTIVE: To evaluate the technical feasibility and utility of ultrasonography in the study of diaphragmatic motion at our institution. METHODS: The study consisted of 2 parts. For part I, in 23 volunteers we performed 23 studies on 46 hemidiaphragms with excursions documented on M-mode ultrasonography For part II, in 22 patients we performed 52 studies in 102 hemidiaphragms. In 50 studies both hemidiaphragms were studied, and in another 2 studies only 1 hemidiaphragm was studied. Patients' ages ranged from birth to 66 years (mean, 23 years). There were 16 male and 6 female patients. Indications for the study were (1) suggestion of paralysis of the diaphragm (n = 22); (2) if the diaphragm was already known to be paralyzed, for evaluation of response to phrenic nerve or pacer stimulation (n = 9); and (3) follow-up of previous findings (n = 21). Patients were examined in the supine position in the longitudinal semicoronal plane from a subcostal or low intercostal approach. Motion was documented with real-time ultrasonography and measured with M-mode ultrasonography. RESULTS: Of the 102 clinical hemidiaphragms studied, findings included normal motion (n = 42), decreased motion (n = 22), no motion (n = 6), paradoxical motion (n = 10), positive pacer response (n = 13), negative pacer response (n = 2), positive phrenic stimulation (n = 6), and negative phrenic stimulation (n = 1). There were no failures of visualization. CONCLUSIONS: Ultrasonography proved feasible and useful in evaluating diaphragmatic motion. In our practice it has replaced fluoroscopy. Ultrasonography has advantages over traditional fluoroscopy, including portability, lack of ionizing radiation, visualization of structures of the thoracic bases and upper abdomen, and the ability to quantify diaphragmatic motion.