Ultrasound diaphragmatic excursion during non-invasive ventilation in ICU: a prospective observational study

Main Article Content



acute respiratory failure, diaphragm ultrasound, diaphragm excursion, non-invasive ventilation


Background and aim: Diaphragmatic dysfunction is seen in up to 60% of critically ill patients with respiratory failure, and it is associated with worse outcomes. The functionality of the diaphragm can be studied with simple and codified bedside ultrasound evaluation. Diaphragm excursion is one of the most studied parameters.

The aim of this study was to assess the prevalence of diaphragmatic dysfunction in critically ill non-intubated patients admitted to a general intensive care unit with acute respiratory failure.

Methods: We collected data, including ultrasound diaphragm excursion, at 2 time points: at T0 (at the time of recruitment, just before starting NIV) and at T1 (after one hour of NIV).

Results: A total of 47 patients were enrolled. The prevalence of diaphragm dysfunction was 42.5% (95% CI 28, 3 - 57,8). Surgical patients showed a higher incidence (relative risk of 1.97) than medical patients. Mean DE was not significantly different between NIV responders (1,35 ± 0.78 cm) and non-responders (1.21 ± 0.85 cm, p 0,6). Patients with diaphragmatic dysfunction responded positively to NIV in 60% (95% CI 36.0 - 80.9%) of cases, while patients without diaphragmatic dysfunction responded positively to the NIV trial in 70.4% (95% CI 49.8 - 86.2%) of cases (p = 0.54). Taking the use of ultrasound diaphragm excursion as a potential predictor of NIV response, the corresponding ROC curve had an area under the curve of 0.53; the best balance between sensitivity (58.1%) and specificity (62.5%) was obtained with a cut-off diaphragm excursion of 1.37 cm.

Conclusions: Diaphragm dysfunction is particularly frequent in critically ill patients with respiratory failure. The functionality of the diaphragm can be effectively and easily tested by bedside ultrasound examination. Overall, our results point towards tentative evidence of a trend of a different response to NIV in patients with vs without diaphragmatic dysfunction.


Download data is not yet available.
Abstract 6 |


1. Vetrugno L, Guadagnin GM, Barbariol F, Langiano N, Zangrillo A, Bove T (2019) Ultrasound Imaging for Diaphragm Dysfunction: A Narrative Literature Review. J Cardiothorac Vasc Anesth 33:2525-2536. https://doi.org/10.1053/j.jvca.2019.01.003
2. Garofalo E, Bruni A, Pelaia C, Landoni G, Zangrillo A, Antonelli M, Conti G, Biasucci DG, Mercurio G, Cortegiani A, Giarratano A, Vetrugno L, Bove T, Forfori F, Corradi F, Vaschetto R, Cammarota G, Astuto M, Murabito P, Bellini V, Zambon M, Longhini F, Navalesi P, Bignami E. Comparisons of two diaphragm ultrasound-teaching programs: a multicenter randomized controlled educational study. Ultrasound J. 2019 Oct 3;11(1):21. doi: 10.1186/s13089-019-0137-4. PMID: 31578700; PMCID: PMC6775177.
3. Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, Albaladejo P, Chanques G, Molinari N, Jaber S (2016) Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med 42:853–861. https://doi.org/10.1007/s00134-015-4125-2
4. Demoule A, Jung B, Prodanovic H, Molinari N, Chanques G, Coirault C, Matecki S, Duguet A, Similowski T, Jaber S (2013) Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact-a prospective study. Am J Respir Crit Care Med 188:213-219. https://doi.org/10.1164/rccm.201209-1668OC
5. Jiang JR, Tsai TH, Jerng JS, Yu CJ, Wu HD, Yang PC (2004) Ultrasonographic evaluation of liver/spleen movements and extubation outcome. Chest 126:179-185.
6. Siafakas N, Mitrouska I, Bouros D, Georgopoulos D (1999) Surgery and the respiratory muscles. Thorax 54:458–465. https://doi.org/10.1136/thx.54.5.458.
7. Khan J, Harrison TB, Rich MM, Moss M (2006) Early development of critical illness 
myopathy and neuropathy in patients with severe sepsis. Neurology 67:1421–1425. 

8. McAlister VC, Grant DR, Roy A, Brown WF, Hutton LC, Leasa DJ, Ghent CN, Veitch JE, Wall WJ (1993) Right phrenic nerve injury in orthotopic liver transplantation. Transplantation 55:826-830.
9. Barbariol F, Vetrugno L, Pompei L, De Flaviis A, Rocca GD (2015) Point-of-care ultrasound of the diaphragm in a liver transplant patient with acute respiratory failure. Crit Ultrasound J 7:3. https://doi.org/10.1186/s13089-015-0021-9
10. Dubé BP, Dres M (2016) Diaphragm dysfunction: diagnostic approaches and management strategies. J Clin Med 5:E113.
11. Dres M, Demoule A (2020). Monitoring diaphragm function in the ICU. Curr Opin Crit Care 26:18-25. https://doi.org/10.1097/MCC.0000000000000682
12. Matamis D, Soilemezi E, Tsagourias M, Akoumianaki E, Dimassi S, Boroli F, Richard JC, Brochard L (2013) Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications. Intensive Care Med 39:801–810. https://doi.org/10.1007/s00134-013-2823-1
13. Pasero D, Koeltz A, Placido R, Fontes Lima M, Haun O, Rienzo M, Marrache D, Pirracchio R, Safran D, Cholley B (2015) Improving ultrasonic measurement of diaphragmatic excursion after cardiac surgery using the anatomical M-mode: A randomized crossover study. Intensive Care Med 41:650–656. https://doi.org/10.1007/s00134-014-3625-9
14. Khurana J, Gartner SC, Naik L, Tsui BCH (2018) Ultrasound identification of diaphragm by novices using ABCDE technique. Reg Anesth Pain Med 43:161–165. https://doi.org/10.1097/AAP.0000000000000718.
15. Umbrello M, Formenti P (2016) Ultrasonographic assessment of diaphragm function in critically ill subjects. Respiratory Care 61:542–555. https://doi.org/10.4187/respcare.04412
16. Boussuges A, Gole Y, Blanc P (2009) Diaphragmatic motion studied by M-mode ultrasonography: methods, reproducibility, and normal values. Chest 135:391-400. https://doi.org/10.1378/chest.08-1541
17. Vivier E, Muller M, Putegnat JB, Steyer J, Barrau S, Boissier F, Bourdin G, Mekontso-Dessap A, Levrat A, Pommier C, Thille AW (2019) Inability of Diaphragm Ultrasound to Predict Extubation Failure: A Multicenter Study. Chest 155:1131-1139. https://doi.org/10.1016/j.chest.2019.03.004
18. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P Members Of The Steering Committee, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S Members Of The Task Force (2017) Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 50. pii: 1602426. https://doi.org/10.1183/13993003.02426-2016
19. Vivier E, Mekontso Dessap A, Dimassi S, Vargas F, Lyazidi A, Thille AW, Brochard L (2012) Diaphragm ultrasonography to estimate the work of breathing during non-invasive ventilation. Intensive Care Med 38:796–803. https://doi.org/10.1007/s00134-012-2547-7
20. Cammarota G, Sguazzotti I, Zanoni M, Messina A, Colombo D, Vignazia GL, Vetrugno L, Garofalo E, Bruni A, Navalesi P, Avanzi GC, Della Corte F, Volpicelli G, Vaschetto R (2019) Diaphragmatic Ultrasound Assessment in Subjects With Acute Hypercapnic Respiratory Failure Admitted to the Emergency Department. Respir Care 64:1469-1477. https://doi.org/10.4187/respcare.06803
21. Cohen E, Mier A, Heywood P, Murphy K, Boultbee J, Guz A (1994) Excursion-volume relation of the right hemidiaphragm measured by ultrasonography and respiratory airflow measurements. Thorax 49:885-889.
22. Umbrello M, Formenti P, Longhi D, Galimberti A, Piva I, Pezzi A, Mistraletti G, Marini JJ, Iapichino G (2015) Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study. Crit Care 19:161. https://doi.org/10.1186/s13054-015-0894-9
23. Summerhill EM, El-Sameed YA, Glidden TJ, McCool FD (2008) Monitoring recovery from diaphragm paralysis with ultrasound. Chest 133:737-743. https://doi.org/ 10.1378/chest.07-2200
24. Diaz O, Iglesia R, Ferrer M, Zavala E, Santos C, Wagner PD, Roca J, Rodriguez-Roisin R (1997) Effects of noninvasive ventilation on pulmonary gas exchange and hemodynamics during acute hypercapnic exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 156:1840-1845.

Most read articles by the same author(s)