Giornate mediche canturine:

25 Ottobre 2019

“L’ecografia nella BPCO:

l’effetto dell’ostruzione
delle vie aeree sull’escursione
diaframmatica”

Dott. RT Angelo Longoni

SRRF-Riabilitazione Specialistica CardioRespiratoria
Master In Fisioterapia e Riabilitazione Respiratoria
 Ecografia del diaframma:
dal 19/09/2014 al 21/10/2019
1377 pazienti e + di 2500 esami
Eco del diaframma all’ingresso e alla dimissione dal reparto (quando è
possibile) in aggiunta ai classici test da campo usati in riabilitazione.

I have not potential conflict of interest

Poster n.1049

Clinical case n. P0957

CLINICAL EXPERTISE AIDED BY TECHNOLOGY: HINTS FROM THE PAST TO BET ON THE FUTURE
N°P2
“ Sonographic evaluation of the diaphragm muscle before
Treviso 21-23 Marzo 2019

+
!“DIAPHRAGMATIC MUSCLE SONOGRAPHY IN THE PHYSIOTHERAPIST
and after pulmonary rehabilitation “
“Sonographic evaluation of diaphragm excursion to strengthen non- CLINICAL PRACTICE AS FUNCTIONAL ASSESSMENT OF THE CARDIO-
A. Longoni Respiratory Therapist, A. Paddeu MD, D. Mangiacasale MD, P. Pozzi MD, A.D. Marco MD, RESPIRATORY PATIENT SUBJECT TO REHABILITATION TREATMENT”
L. Cattaneo MD, M. Vago Respiratory Therapist
invasive mechanical ventilation education program in a patient with
Asst Lariana -U.O. of Specialistic Cardio-Respiratory Rehabilitation 2, “Paola Giancola Foundation”, Cantù, Italy chronic respiratory insufficiency and claustrophobia “ Angelo Longoni1 RT, Mariele Vago1 RT, Dionigi Mangiacasale1 MD, Paolo Pozzi1 MD, Albino De Marco1 MD,
Laura Cattaneo1 MD, Francesca Perin2 FT, Antonio Paddeu1 MD.
angelo.longoni@asst-lariana.it
A. Longoni Respiratory Therapist, D. Mangiacasale MD, P. Pozzi MD, A.D. Marco MD, L. Cattaneo MD, 1. Cardio-Respiratory Rehabilitation “P. Giancola Foundation”, ASST Lariana S. Antony Abate Cantu’ Hospital , Como (Italy),
M. Vago Respiratory Therapist, A. Paddeu MD. 2. Physiotherapist, Varese
Asst Lariana - U.O. of Specialistic Cardio-Respiratory Rehabilitation 2, “Paola Giancola Foundation” Cantù, Italy Mail: angelo.longoni@asst-lariana.it

Objective: Working phases angelo.longoni@asst-lariana.it

To assess the diaphragmatic excursion before and Aim: B mode
The aim of this work is to describe how the Ultrasound of
after a pulmonary rehabilitation program and to Case history Investigations the diaphragm muscle can be useful in the clinical practice
compare its effectiveness with 6-minute walking A 56 year-old woman suffering from multiple sclerosis of the physiotherapist as a support to the classical clinical
We studied the diaphragmatic excursion with sonography
test (6MWT). was hospitalized for chronic respiratory insufficiency (US) in M-mode with a convex probe 1-5 MgHz in
tests such as wt 6 minutes and MIP/MEP pressures, after
with daily hypercapnia (pCO2: 69,4mmHg) to start a rehabilitation program in COPD patients.
spontaneous and in forced breathing in supine position.The
non invasive mechanical ventilation (NIMV). She was patient was placed in diurnal and nocturnal NIMV with nasal
Methods: Fig. 1: Patient position Fig. 2:Right Subcostal/lateral previously hospitalized for one month in another pillows to avoid claustrophobia. An educational experiment
Methods:
hospital but she drop out from NIMV due to For the study of the diaphragm muscle we a portable
234 participants (Fig.11): COPD=112, OSAS=65, was set by showing the patient the utility of NIMV through: ultrasound with a Convex probe (1-5 MHz). The patient
claustrophobia. The patient was also daily oxygen 1)The arterial blood testing in terms carbon dioxide levels was positioned in semi-supine position (40°). The B mode
Surgical=4, Neuromuscolar=17, Fibrothorax=7, therapy for room-air desaturation and she moved in (pCO2). modality scan, in anterior subcostal view, was used in
Bronchiectasis=7, Asthma=5, Pneumonia=6 wheelchair for severe back and lower limb pains. The order to indentify the diaphragm muscle whereas the M-
2) The utility of respiratory rehabilitation programs
Emphysema=4, Embolism=7, were investigated basal pulmonary function testings (PFT) were mode one was used to appreciate the diaphragmatic
( PRP) and the daily attendance of the gym for the kinetics, following the oscillation of the pleural/liver profile
with a sonographic measurements of the compatible with a severe reduction of the forced vital respiratory exercises and the cycle minibike of the upper WT 6’ MIP-MEP
MIP-MEP
generated during the respiratory acts. WT6 'and MIP/MEP
diaphragm excursion in B-mode and M-mode (Fig. capacity (FVC) as well as of the maximum inspiratory limbs. pressure were performed according to standard ATS. All
Fig. 3: U.S. machine Fig. 4:U.S. B-mode
4-5) in normal and forced breathing (Fig. 6-7). and expiratory pressures (Mip =40, Mep =55, 3) The difference in US diaphragmatic excursion without procedures were performed at the entrance and discharge
Improvements were then compared with those in FVC=54%,Fev1=52%, Fev1/FVC=104%, Pef=30%). NIMV (1 cm and 1,5 cm in normal and forced breathing, of COPD patients.
6MWT (Fig 9). The US machine (Fig.3) was a

v"
respectively) and under NIMV (1,6 cm and 3,9 cm,
portable one with a 1.3-4 MHz Sector Phased respectively) with the direct vision of the ultrasound Results:
examination. During the ultrasound view, in M-mode, the A total of 116 patients aged 51 to 91, 78 men and 38 women
Array Transducer. The sonography was completed were included in the study. The standard unit of measurement
by the same RT therapist at bedside with patient in The rehabilitative treatments excursion of the diaphragm movement was explained to the Portable sonography
is centimeter. The data was examined with SmallTalk, an
semirecumber position (Fig.1) in right anterior The patient has performed cycles of nighttime and patient, in simple words, the correspondence between the
programming language. This analysis shows a positive
ascent of the diaphragm during the inspiratory phase (for
subcostal or lateral approach (Fig.2). All patients diurnal NIMV in S/T mode with nasal pillows, single response of at least one ultrasound parameter despite the
Fig. 5: U.S. M-Mode Fig. 6: Normal breathe circuit with leak and integrated hot humidifier. The which the diaphragm is lowered approaching the probe) and values ​ ​ of MIP/MEP have not improved. This exception could
followed the same rehabilitation program (Fig.8),
program were integrated with daily treatments of the expiratory phase (where the diaphragm rises, moving probably underline a greater precision of the ultrasound in the
based on breathing and callisthenics exercises, away from the probe). specific analysis of the diaphragmatic dynamics. From the
theraband (30’ a day), minibike or cyclette and respiratory rehabilitation (pep bottle), fktr and motor
exercises with assisted minibike. Respiratory 4) The excursion of the diaphragm was then reevaluated, analysis of the data relative to the comparison between
tapis roulant (30’ twice a day). after adaptation, with US during ventilation with the use oral distance walked in 6MWT and amplitude of the diaphragmatic Convex probe 5 MHz Supine position at 40°
evaluation of diaphragmatic excursion with
mask M size (1,6 cm) and nasal pillow M size (2,9 cm). excursion measured in cm, the following results are obtained:
Ultrasound were performed at the admission and at considering 100 patients who improved walking test
the discharge in sitting position. performance (75.9% of the total), 80% also optimized
Results: diaphragmatic motility (72.29% with reference to 75.9%) while
the remaining 20% ​ ​ (3, 61%) did not improve the excursion
US diaphragmatic motion improved in 76% vs Fig. 7: Forced breath Fig. 8: Exercise parameter. As far as patients with unchanged distance in
56% of patients, as compared to 6MWT. In 20% of 6MWT are concerned (24.1% of total patients), 95.24% Data collection
patients the diaphragmatic motion remained (22.85% on the graph) has an increase in diaphragmatic
stationary 20% (38% 6MWT). Diaphragmatic excursion.
motion deteriorated in 4% of patients, as
Conclusions:
compared to a 5% in 6MWT. We registered the
The US of the diaphragm offers a valid, practical, rapid and
most improvements in critically-ill patients.
sensitive approach that could be overlapped with the
classical evaluation methods used by the physiotherapist in
Fig.9: Walking Test 6’ Fig.10: Results the daily practice to monitor treatment’s efficacy.
Conclusion: Improvements in ultrasound parameters correlate with
Our study suggests that US evaluation of the those of 6MWT and MIP/ MEP and we could claim that
diaphragmatic motion is a safe, fast and ultrasound is an excellent support in the functional
evaluation of the outcomes after rehabilitation of COPD
reliable modality to monitor the effectivenes of a patients if gold-standard methods are not applicable in
pulmonary rehabilitation program. It may offer a case of temporary disability of the patient (severe
stronger advance than the common field tests in symptomatology, acute pain, clinical instability). Despite the
terms of measuments of muscolar weakness, positive results found, these data are not sufficient and
especially in critically-ill patients (Fig. 10). Fig.11: Results from : 2014/2015 statistically significant in order to draw up a protocol. Future
Conclusion research work is required on the basis of the proposed
At the discharge (10/04 to 26/04/2018) the patient was able to carry the NIMV all night long with, almost the pCO2 value outcomes.
Bibliography: within
 
normality (47 mmHg.), improved PFTs (Mip=53, Mep=74, FVC=56%,Fev1=55%, Fev1/FVC=106%, Pef=59%. ) and a
satisfactory diaphragmatic excursion with 2,2 cm and 4,5 cm in normal and forced breathing while 3,1 cm during
1 G. Soldati, R. Copetti, Ecografia toracica (2012)
2 F. Feletti, G. Gardelli, M. Mughetti, L'ecografia toracica. Applicazioni ed imaging integrato. (2010) ventilation. Diaphragmatic Sonography can be an excellent educational tool, safe, fast, not expensive method to be
3 Winfocus’ Lung ultrasound for anesthesia & intensive care (WLUS-AIC) performed ,at the patient's bed, to strengthen a cardio-respiratory pulmonary rehabilitation program of non invasive
4 A. Sarwal, F. O. Walker, M. S. Cartwright, Neuromuscular Ultrasound for evaluation of diaphragm. Muscle Nerve (2013), 47(3): 319-329;
5 A.Zanforlin, Applicazioni cliniche e sperimentali dell’ecografia toracica in pneumologia: la diagnostica precoce delle patologie pleuropolmonari (2012) ventilation in patient's with problem's of Niv adaptation.
6 E. O. Gerscovich, M. Cronan. J. P. McGahan, K. Jain, C. D. Jones, C. McDonald, Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med (2001) 597-604;
7 G. Ferrari, G. De Filippi, F. Elia, F. Panero, G. Volpicelly, F. Aprà, Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. C. U. J. (2014) 6:8
8 A. Boussuges, Y. Gole, P. Blanc, Diaphragmatic motion studied by M-mode ultrasonography: Methods, reproducibility and normal values. Chest (2009) 135(2):391-40089 Contact

Poster n. 475
“M-mode sonography of diaphragmatic motion in order to set the cough-assist
machine in the uncooperative patients”
A. Longoni Respiratory Therapist, A. Paddeu MD, D. Mangiacasale MD, P. Pozzi MD, A.D. Marco MD, L. Cattaneo MD, M. Vago Respiratory Therapist
Asst Lariana -U.O. of Specialistic Cardio-Respiratory Rehabilitation 2, “Paola Giancola Foundation”, Cantù, Italy
angelo.longoni@asst-lariana.it

Objective: M-mode sonograpny (US) of the diaphragmatic

motion may be an aid for the respiratory therapist to better Working phases
calibrate the cough-assist machine in uncooperative patients (Fig.1).

Methods: 10 uncooperative patients (Fig.13) in spontaneous

breathing and mechanically ventilated were studied. The US machine,
a portable one with a 1.3-4 MHz Sector Phased Array Transducer, was
set in B and M-Mode modality (Fig.2-3). US sonography were
performed in an anterior subcostal approach (Fig. 4) on semi- Fig. 1: Uncooperative pz. Fig. 2: Ecography –B mode Fig. 3: M-Mode Fig. 4:Subcostal approch
recumbent position (Fig. 5), initially during normal breathing (Fig.

v"
6),then with the cough assistant machine (Fig.7). The cough machine
pressures were: PI/E=+-10, 20, 25, 30, 35 ,40 cmH2O (Fig .
8,9,10,11,12 are of patient n. 5) while the Inspiratory Time (TI=3s.),
Expiratory Time (TE=2s.) and the Pause (P=1s.) were unchanged.

Results: The treatments were completed at patient bedside with

Fig. 5 :Position Fig. 6: Normal breath Fig. 7: Cough machine Fig.8: Pz n.5=+- 10
a considerable saving of time by two RT therapists. The best cough cm H2O

machine value was achieved by considering the best ratio between

the diaphragm recruitment/excursion and the less pressure of work
(Fig. 10). A high pressure of the cough machine didn’t always offer
effectiveness and comfort in the majority of patients (Fig. 11).

Conclusion: Our study suggests that the diaphragmatic

Fig.9: Pz n.5=+- 20 cm H2O Fig. 10: Pz n.5=+- 30 cm H2O Fig. 11: Pz n.5=+- 40 cm H2O Fig.12: Cough parameters
sonography is a safe, reliable, fast and useful modality to set the
cough-assist machine. It can be performed at the patient bedside
and it may help clinicians and therapists in offering uncooperative
patients a tailored therapy.

Bibliography:
1 G. Soldati, R. Copetti, Ecografia toracica (2012)
2 Winfocus’ Lung ultrasound for anesthesia & intensive care (WLUS-AIC)

I have not potential conflict of interest

3 A. Sarwal, F. O. Walker, M. S. Cartwright, Neuromuscular Ultrasound for evaluation of diaphragm. Muscle Nerve (2013), 47(3): 319-329;
4 A.Zanforlin, Applicazioni cliniche e sperimentali dell’ecografia toracica in pneumologia: la diagnostica precoce delle patologie pleuropolmonari (2012) Contacts
5.E. O. Gerscovich, M. Cronan. J. P. McGahan, K. Jain, C. D. Jones, C. McDonald, Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med (2001) 597-604;
6 G. Ferrari, G. De Filippi, F. Elia, F. Panero, G. Volpicelly, F. Aprà, Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. C. U. J. (2014) 6:8
7 A. Boussuges, Y. Gole, P. Blanc, Diaphragmatic motion studied by M-mode ultrasonography: Methods, reproducibility and normal values. Chest (2009) 135(2):391-40089
Fig.13: Uncooperative respiratory patient’s

 
 BPCO"
L’ostruzione delle vie aeree produce:

1)  Aumento delle resistenze respiratorie che causano

2)  Air trapping nei polmoni che
3)  Aumentano lo sforzo inspiratorio che provocano
4)  Iperinflazione dinamica.
IPERINFLAZIONE"""DINAMICA"

PNEUMACARE""""THORA"3D"
 Diaframma:"rappor="anatomici"
Il diaframma dividendo i
segmenti toraco-addominali
contrae rapporti diretti nella sua
parte cefalica:
- con i polmoni
-  con il cuore

Nella parte inferiore invece i

rapporti anatomici sono:
-  con il fegato
- milza
-  con lo stomaco
Eseguiamo 12-28 atti respiratori al minuto per un totale di 40000 atti al giorno
 Il"diaframma"è"una""fisarmonica"
Il movimento verticale del diaframma permette di misurare
la sua escursione.

Inspirazione: si Epirazione: si alza ed

abbassa e fa entrare aria espelle aria
 Valutazione"del"diaframma""
Manovre non invasive (indirette)
-  MIP ( massima pressione inspiratoria)
-  MEP ( massima pressione espiratoria)
-  SNIP ( massima pressione inspiratoria nasale)

Manovre invasive ( dirette)

- RX del torace
-  PES ( massima pressione esofagea)
-  Fluoroscopia
-  Elettromiografia del diaframma
-  Risonanza magnetica dinamica
 Key""""Ques=on""

?
L’ecografia puo’ aiutarci nella
valutazione del torace e del
muscolo diaframma?
 BPCO"
Nel BPCO abbiamo una
condizione di eccessivo contenuto Pleura

aereo del polmone. Dal punto di

vista ecografico il parenchima
assomiglia sempre più all’aria.
Normale la presenza di artefatti
orizzontali come le linee A e
qualche linea B. A causa della
rigidità del sistema, lo
sliding sign (scivolamento
della linea pleurica) può risultare
ridotto.
 Misura"del"diaframma""
Per misurare il diaframma abbiamo due tecniche. La prima è la misura
dello spessore del diaframma .

Tecnica di esecuzione:
-  Nella zona di apposizione
-  Sonda lineare
- Valori medi: 3,2 +-0,8 mm

Nel BPCO lo spessore può essere ridotto

 Zona"di"apposizione"
Problemi:
"
- La zona di apposizione cambia con gli anni per l’appiattimento del
diaframma.
- Serve una sonda lineare di alta definizione perché la misurazione è
millimetrica.
- E’ necessario stabilire delle regole comuni per la misura.

normale Bpco
 Zona"di"apposizione"
Problemi:
"
- Prendere i parametri all’interno o all’esterno della linea diaframmatica?
Necessità di standardizzazione (A)
- Sonda lineare vecchia con bassa definizione o deteriorata (A)
- I pazienti con respiro spontaneo (non sedati come in rianimazione) sono
in grado, durante il respiro forzato, di esercitare una notevole escursione
diaframmatica con difficoltà nel freezare l’immagine o rischio di fuoriscita
della visuale dal monitor (B)
- l punti della linea diaframmatica non sono uniformi. Quale è corretto? (B)

A B ?
 Escursione"del"diaframma"
Tecnica di esecuzione:
-  Sottocostale (a dx) in M mode
-  Sonda convex
-  Valori medi escursione : 59-81mm uomini
47-67 mm donne

espirazione

inspirazione

inspirazione

espirazione
 Escursione"del"diaframma"

1° sec Massima

Si registra l’escursione al primo

secondo e l’escursione massima
 Escursione"del"diaframma"
Punti a favore:

-  Di facile esecuzione.
-  Di facile apprendimento ( gli allievi di fisioterapia dell’Universita’ di
Varese imparano ad usare la sonda e localizzare il diaframma in pochi
giorni).
-  In parte metodica standardizzata.
-  Eseguibili anche con vecchi strumenti.
-  Esame più facile rispetto alla spirometria.
 "
Diaframma"""nel"BPCO"e.."
Respiro normale Respiro forzato

Paziente""""""""""""""""""""sano"
Respiro normale Respiro forzato
 Escursione

Spessore Spessore

Massima Normale
inspirazione
Pub"Med"
 AIR"""TRAPPING"

INSPIRAZIONE ESPIRAZIONE

Fegato
Diaframma + addominali

Air trapping

Polmone
AIR"""TRAPPING"
 INDICE"""""“MIO”"

Valori di MIO <78,09 “suggerisce” la presenza di una ostruzione.

 Indice di Tiffeneau: FEV1/FVC
L’osservazione nasce dalla similitudine della curva
spirometrica con quella ecografica. Dai volumi espiratori si
passa ai cm. dell’escursione del diaframma.
Indice MIO: FEDE1 (+) / EDEMax (X)

Inspirazione
-
+
X
Espirazione
a)Espirazione forzata in M-mode (+=misura di FEDE1 X=misura di EDEMax )
b)curva spirometrica volume-tempo
 Ostruito""""""""""""""""""""Sano"

Inspirazione

Inspirazione

Espirazione
Espirazione

Nel paziente ostruito la parte discendente espiratoria della

curva ha una pendenza minore rispetto ai soggetti sani.
 BPCO:"ingresso"spirometria"
Correlazione tra l’immagine della spirometria e ecografia diaframmatica.
 BPCO:"dimissione"spirometria"
Notare la correlazione tra le due curve per lo sforzo ecessivo del paziente.
Pz."stabile"""""""""""""""""""""""""Pz.riacu=zzato"

Tempo inspiratorio
Tempo espiratorio

Pz BPCO con rapporto I:E 1:2/3. Nel paziente riacutizzato

la FR è aumentata mentre l’escursione del diaframma è
piu’ alta rispetto ai soggetti stabili.
 IPERINFLAZIONE"""DINAMICA"

Inspirazione

Espirazione
Obesita’U"ipoven=lazione"

Apnea
Grazie"per"l’aVenzione!!"