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Comparison of the diaphragm thickness at end-expirium and end-inspirium according to the apnea subtype. Bold p values denote significance. End-expirium (right/left). Normal vs. mild OSAS: p = 0.681/p = 0.353. Normal vs. moderate OSAS: p = 0.699/p = 0.086. Normal vs. severe OSAS: p = 0.032/p = 0.012. Normal vs. OSAS+OHS: p < 0.001/p < 0.001. Mild vs. moderate OSAS: p = 0.971/p = 0.543. Mild OSAS vs. severe OAS: p = 0.110/p = 0.071. Mild OSAS vs. OSAS+OHS: p < 0.001/p = 0.001. Moderate OSAS vs. severe OSAS: p = 0.069/p = 0.358. Moderate OSAS vs. OSAS+OHS: p < 0.001/p = 0.013. Severe OSAS vs. OSAS+OHS: p = 0.010/p = 0.023. End-inspirium (right/left). Normal vs. mild OSAS: p = 0.549/p = 0.638. Normal vs. moderate OSAS: p = 0.388/p = 0.117. Normal vs. severe OSAS: p = 0.002/p = 0.005. Normal vs. OSAS+OHS: p < 0.001/p < 0.001. Mild OSAS vs. moderate OSAS: p = 0.771/p = 0.259. Mild OSAS vs. severe OAS: p = 0.003/p = 0.009. Mild OSAS vs. OSAS+OHS: p < 0.001/p < 0.001. Moderate OSAS vs. severe OSAS: p = 0.026/p = 0.278. Moderate OSAS vs. OSAS+OHS: p < 0.001/p = 0.004 Severe OSAS vs. OSAS+OHS: p = 0.063/p = 0.025
Source publication
Purpose
The aim of this study was to evaluate the diaphragm thickness in patients with obstructive sleep apnea syndrome (OSAS).
Methods
This prospective study included patients who underwent polysomnography evaluation for the first time with a clinical suspicion of OSAS. All patients underwent polysomnographic evaluation with a 55-channel Alice 6...
Citations
... It is a non-invasive, cost-effective, and easily operable alternative that provides dynamic imaging [13]. We found that T FRC and T TLC in the OSAHS group especially severe OSAHS group were significantly higher than those in the control group, which is consistent with other studies [22]. Previous studies have reported that obesity is a risk factor of diaphragmatic hypertrophy [4,23]. ...
... Additionally, obesity may impair diaphragmatic contractility by damaging diaphragmatic mitochondrial ultrastructural and dynamic imbalance, reducing the proportion of MHC-I muscle fibers with greater fatigue resistance, and lipid deposition which leads to a decrease in contractility per unit area [8,26]. Our study drew a conclusion that hypoxia is a risk factor of impaired diaphragmatic function which is beyond the previous study [22]. The underlying mechanism may be that intermittent hypoxia attenuates diaphragmatic discharge by inhibiting the respiratory center, induces oxidative stress, increases the density of MHC-IIB muscle fibers with weak fatigue resistance, and exacerbates diaphragmatic muscle cell apoptosis [27][28][29]. ...
Purpose
Diaphragmatic impairment has been reported in obstructive sleep apnea–hypopnea syndrome (OSAHS) patients. However, the risk factors of diaphragmatic dysfunction are unclear. This study was conducted to evaluate the diaphragmatic function and to investigate impact factors of ultrasonographic changes of the diaphragm in OSAHS patients.
Methods
This cross-sectional study recruited 150 snoring patients. All patients were divided into the control group (AHI < 5/h, n = 20), the mild-to-moderate OSAHS group (5/h ≤ AHI ≤ 30/h, n = 61), and the severe OSAHS group (AHI > 30/h, n = 69). Diaphragmatic thickness at function residual capacity (TFRC) and total lung capacity (TTLC) were measured by two-dimensional ultrasound, and the diaphragmatic excursion during tidal and deep breath was measured by M-mode ultrasound. The diaphragmatic thickening fraction (TF) was calculated. Spearman analysis and multiple linear stepwise regression analysis were conducted to analyze the impact factors of diaphragmatic function.
Results
TFRC in the control group, mild-to-moderate OSAHS group, and severe OSAHS group was 1.23 (1.10, 1.39) mm, 1.60 (1.43, 1.85) mm, and 1.90 (1.70, 2.25) mm; TTLC was 2.75 (2.53, 2.93) mm, 3.25 (2.90, 3.55) mm, and 3.60 (3.33, 3.90) mm, and TF was 119.23% (102.94, 155.97), 96.55% (74.34, 119.11), and 85.29% (60.68,101.22). There were across-group significant differences in TFRC, TTLC, and TF (P < 0.05). The oxygen desaturation index was the influencing factor of TFRC, TTLC, and TF (P < 0.05).
Conclusion
The diaphragm is thickened and diaphragmatic contractility is decreased in OSAHS patients. Nocturnal intermittent hypoxia is a risk factor for diaphragmatic hypertrophy and impaired diaphragmatic contractility.
... Pazarlı et al observed a positive correlation between the severity of OSAS and an augmented diaphragm thickness in patients with OSAS, while finding no significant difference in the thickness ratio compared to individuals without OSAS. 48 Diaphragmatic exhaustion resulting from the exertion of inhaling against a blocked airway has also been suggested, 49 in addition to diaphragm contractility and heightened pressure across the diaphragm. 50,51 The development of dyspnea is predominantly influenced by dynamic lung hyperinflation, resulting in shortness of breath after activity, which is closely associated with the pathophysiology of COPD. ...
Purpose
We assess the predictive value of diaphragm excursion (DE) in enhancing exercise tolerance following pulmonary rehabilitation (PR) among patients with COPD-OSA overlap syndrome.
Material and Methods
This prospective cohort study enrolled 63 patients diagnosed with COPD-OSA overlap syndrome who actively participated in a PR program from January 2021 to May 2023. Among these, 58 patients successfully completed the 20-week PR program, with exercise tolerance assessed through the measurement of six-minute walk distance (6MWD), and DE evaluated by ultrasonography. The responder to PR in terms of exercise ability was defined as a patient who showed an increase of >30m in 6MWD. The cutoff value for predicting PR response based on DE was determined using receiver operating characteristic (ROC) curves.
Results
Following the PR program, significant improvements were observed in mMRC, 6MWD, DE during deep breathing, and diaphragm thickness fraction (DTF). Of the participants, 33 patients (57%) were classified as responders, while 25 patients (43%) were considered non-responders. Baseline values of FEV1% predicted, 6MWD, DE during deep breathing, DTF, and PaO2 exhibited a significant elevation in responders as compared to non-responders. The changes of 6MWD were positively associated with the baseline values of DTF and DE during deep breathing, FEV1% predicted and PaO2, while negatively correlated with baseline value of mMRC. The predictive performance in terms of the area under the ROC curve for determining responder’s DTF was found to be 0.769, accompanied by a sensitivity of 85% and specificity of 68%, using a cutoff value at 17.26%. Moreover, it was observed that DE during deep breathing could predict the area under the ROC curve for responders to be 0.753, with a sensitivity of 91% and specificity of 56% at a cutoff value of 3.61cm.
Conclusion
Diaphragm excursion serves as a valuable predictor for determining the enhancement of exercise tolerance following PR in patients with COPD-OSA overlap syndrome.
Trial Registration
ChiCTR1800020257, www.chictr.org.cn/index.aspx.
... Pazarlı et al. measured diaphragm thickness in OSA patients [74]. Thickness was measured as the distance between the peritoneum and the pleura. ...
Obstructive sleep apnea (OSA) is a sleeping disorder caused by complete or partial disturbance of breathing during the night. Existing screening methods include questionnaire-based evaluations which are time-consuming, vary in specificity, and are not globally adopted. Point-of-care ultrasound (PoCUS), on the other hand, is a painless, inexpensive, portable, and useful tool that has already been introduced for the evaluation of upper airways by anesthetists. PoCUS could also serve as a potential screening tool for the diagnosis of OSA by measuring different airway parameters, including retropalatal pharynx transverse diameter, tongue base thickness, distance between lingual arteries, lateral parapharyngeal wall thickness, palatine tonsil volume, and some non-airway parameters like carotid intima–media thickness, mesenteric fat thickness, and diaphragm characteristics. This study reviewed previously reported studies to highlight the importance of PoCUS as a potential screening tool for OSA.
... Remember the importance of DM in patients with OSA could make a difference in the clinical setting. What do we know about the adaptation of the DM with OSA? DM appears to have a greater thickness in patients, through ultrasound measurements, but we do not know if this increase in size is related to hypertrophy (overcoming constant air resistance) or fibrosis (constant inflammation) [115,116]. An increase in thickness could be the result of greater constant contraction of the muscle due to constant obstructions of the upper airways. ...
Obstructive sleep apnea (OSA) causes multiple local and systemic pathophysiological consequences, which lead to an increase in morbidity and mortality in patients suffering from this disorder. OSA presents with various nocturnal events of apnoeas or hypopneas and with sub-clinical airflow limitations during wakefulness. OSA involves a large percentage of the population, particularly men, but the estimate of OSA patients could be much broader than data from the literature. Most of the research carried out in the muscle field is to understand the causes of the presence of chronic nocturnal desaturation and focus on the genioglossus muscle and other muscles related to dilating the upper airways. Sparse research has been published regarding the diaphragm muscle, which is the main muscle structure to insufflate air into the airways. The article reviews the functional anatomy of the muscles used to open the upper respiratory tract and the non-physiological adaptation that follows in the presence of OSA, as well as the functional anatomy and pathological adaptive aspects of the diaphragm muscle. The intent of the text is to highlight the disparity of clinical interest between the dilator muscles and the diaphragm, trying to stimulate a broader approach to patient evaluation.
... A decrease in muscle mass and strength of the diaphragm is defined as an important risk factor for pneumonia and other respiratory tract infections [8]. There are studies investigating the relationship between respiratory tract diseases and diaphragm thickness (DT) using ultrasound (US) measurements [9][10][11]. A low baseline DT measured by US has been associated with an increased rate of ICU admission, prolonged mechanical ventilation (MV), and increased mortality [12]. ...
Introduction
A decrease in muscle mass of the diaphragm could be a significant risk factor for pneumonia. The aim of our study was to evaluate whether diaphragm thickness (DT) and density measured on chest computed tomography (CT) were associated with clinical course and mortality in adult patients with coronavirus disease 2019 (COVID-19) in emergency department admission.
Methods
We retrospectively analyzed 404 patients with a positive polymerase chain reaction test for COVID-19 and pneumonia findings on chest CT between September 1 and November 1, 2020. Bilateral DT measurements were performed at the level of the celiac artery origin, and the total mean diaphragm thickness (TMDT) was estimated. Hemidiaphragm density was measured at the level of the celiac artery origin. The relationship between demographic characteristics, comorbidities, TMDT, mean hemidiaphragm density (MHD) and clinical outcomes was investigated using the logistic regression analyses. The reliability of the measurement of the two observers was evaluated by intraclass correlation analyses.
Results
Intraclass correlation analyses demonstrated almost perfect inter-observer agreement for TMDT and substantial agreement for MHD. There was a statistically significant relationship between the presence of a thinner diaphragm and mortality (p < 0.001). Bilateral diaphragm densities were lower in the patients with severe disease and mortality (p < 0.001). The threshold values of TMDT were 3.67 mm and 3.47 mm for the prediction of ICU admission and mortality, respectively. TMDT (odds ratio [OR]: 0.634, 95% confidence interval [CI]: 0.447–0.901), age (OR: 1.053, 95% CI: 1.027–1.081) and MHD (OR: 0.920, 95% CI: 0.883–0.959) were found to be independent predictors for severe disease in the multivariable model. In addition, MHD (OR: 0.883, 95% CI: 0.827–0.942) and age (OR: 1.040, 95% CI: 1.003–1.078) were independent risk factors for mortality.
Conclusion
Our study demonstrated that a low diaphragm thickness and density measured on chest CT were associated with severe disease in patients with COVID-19 and could be evaluated as poor prognostic markers.
... Pazarli et al. conducted a study with 108 patients. Based on the US measurements, it has been concluded that the thickness of the diaphragm was significantly higher in the OSA group contrasting with the results of the control subjects [25] which is similar to our results. However, the authors mentioned above did not investigate the diaphragmatic motion, in contrast to our study. ...
Purpose
The aim of this study was to analyze the effect of obstructive sleep apnea (OSA) on the ultrasound (US) features of the diaphragm and to determine if diaphragmatic US may be a useful screening tool for patients with possible OSA.
Methods
Patients complaining of snoring were prospectively enrolled for overnight polygraphy using the ApneaLink Air device. Thickness and motion of the diaphragm during tidal and deep inspiration were measured. Logistic regression was used to assess parameters of the diaphragm associated with OSA.
Results
Of 100 patients, 64 were defined as having OSA. Thicknesses of the left and right hemidiaphragms were significantly different between OSA and control groups. Using a combination of diaphragmatic dimensions, diaphragm dilation, age, sex, and BMI, we developed an algorithm that predicted the presence of OSA with 91% sensitivity and 81% specificity.
Conclusion
A combination of anthropometric measurements, demographic factors, and US imaging may be useful for screening patients for possible OSA. These findings need to be confirmed in larger sample sizes in different clinical settings.
... En este estudio no se produjo ningún cambio en el grosor del diafragma tras la intervención, resultado que esperaban los autores ya que era improbable que se produjera con un único tratamiento, pudiendo investigarse en un futuro los efectos a largo plazo de la terapia manual del diafragma tras someter a los sujetos a varios tratamientos. Cambios en el grosor del diafragma valorados con ecografía han sido asociados a mayor predisposición de dolor lumbopélvico (369) y de patología respiratoria (370). ...
Effects of diaphragm muscle treatment in shoulder pain and mobility in subjects with rotator cuff injuries.
Introduction: The rotator cuff inflammatory or degenerative pathology is the main cause of shoulder pain. The shoulder and diaphragm muscle have a clear relation through innervation and the connection through myofascial tissue. In the case of nervous system, according to several studies the phrenic nerve has communicating branches to the brachial plexus with connections to shoulder key nerves including the suprascapular, lateral pectoral, musculocutaneous, and axillary nerves, besides, the vagal innervation that receives the diaphragm and their connections with the sympathetic system could make this muscle treatment a remarkable way of pain modulation in patients with rotator cuff pathology. To these should be added a possible common embryological origin in some type of vertebrates. Considering the connection through myofascial system, the improving of chest wall mobility via diaphragm manual therapy could achieve a better function of shoulder girdle muscles with insertion or origin at ribs and those that are influenced by the fascia such as the pectoralis major muscle, latissimus dorsi and subscapularis.
Objectives:
• Main objective:
To compare the immediate effect of diaphragm physical therapy in the symptoms of patients with rotator cuff pathology regarding a manual treatment over shoulder muscles.
• Specific objectives:
1. To evaluate the immediate effectiveness of each of the three groups in shoulder pain using a numerical pain rating scale (NPRS) and compare between them.
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2. To evaluate the immediate effectiveness of each of the three groups in shoulder range of motion (ROM) using an inclinometer and compare between them. 3. To evaluate the immediate effectiveness of each of the three groups in pressure pain threshold (PPT) using an algometer and compare between them.
Material and method: A prospective, randomized, controlled, single-blind (assessor) trial with a previous pilot study in which a final sample size of 45 subjects was determined to people diagnosed with rotator cuff injuries and with clinical diagnosis of myofascial pain syndrome at shoulder. The sample were divided into 3 groups of treatment (15 subjects per group):
1. A direct treatment over the shoulder by ischemic compression of myofascial trigger points (MTP) (control / rotator cuff group).
2. Diaphragm manual therapy techniques (diaphragm group).
3. Active diaphragm mobilization by hipopressive gymnastic (hipopressive group).
The pain and range of shoulder motion were assessed before and after treatment in all the participants by inclinometry, NPRS of pain in shoulder movements and algometry. The data obtained were analyzed by an independent (blinded) statistician, who compared the effects of each one of the treatments using the Student’s t-test for paired samples or the Wilcoxon signed rank test, and calculated the post -intervention percentage of change in every variable. An analysis of variance (ANOVA) followed by the post-hoc test or a non-parametric Kruskal-Wallis test for non-parametric multiple-groups comparisons were performed to compare pre- to post-intervention outcomes between groups. Effect-size estimates of each intervention and between groups were calculated to allow interpretation of results in a more functional and meaningful way.
Results:
Both the control group and diaphragm group showed a statistically (p< 0.005) and clinically significant improvement, as well as a significant effect size (moderate to strong), on the NPRS in shoulder flexion and abduction movements. Regarding NPRS in shoulder external rotation, only the control group obtained a significant effect size. There was a significant increase in shoulder abduction and external rotation ROM (p<
Efectos del tratamiento del músculo diafragma en el dolor y la movilidad del hombro en sujetos con patología del manguito rotador.
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0.001) with a significant effect size in the control group. The PPT at the xiphoid process of the sternum showed a statistically (p< 0.001) and clinically significant improvement in the diaphragm group. The hipopressive gymnastic treatment was found to be no clinically effective in the shoulder pain and mobility, and showed a less efficacy than the other two groups.
Conclusion:
Both the shoulder non-direct treatment by a protocol of diaphragm manual therapy techniques and the rotator cuff MTP intervention showed been clinically effective in reducing pain (NPRS) immediately in shoulder flexion and abduction movements. The ROM assessment improvements obtained post- intervention by the diaphragm group have not been enough to consider them as clinically significant. The control group has obtained a significant effect size in shoulder abduction and external rotation ROM improvement. Both the control group and the diaphragm group treatments have been more effective in improving shoulder pain and mobility than the hipopressive group. The control group intervention has been the most effective in improving shoulder external rotation pain and mobility. The diaphragm group intervention was more effective in improving PPT at the xiphoid process than the other groups. Neither the effect size nor clinical significance proves the short-term benefit of the hipopressive gymnastic treatment in shoulder pain and mobility. Future studies are necessary to show the effectiveness of the diaphragm manual therapy applied in several sessions to determine its long-term effects in shoulder pain and mobility.
Purpose:
This study aimed to measure diaphragm thickness using ultrasound in adult patients with severe idiopathic scoliosis.
Methods:
This prospective case-control study included patients with severe idiopathic scoliosis and a healthy control group. The control and patient groups' demographic features, pulmonary function tests, diaphragm thickness, and thickening fraction measured using ultrasonography were compared.
Results:
End-expirium values were similar between the two groups (p = 0.902). However, end of inspirium, change level, and diaphragm thickening fraction were significantly lower in the scoliosis group (p < 0.001 for all). Cobb degree values were inversely correlated with forced expiratory volume in 1 s (%) (r = - 0.909, p < 0.001), forced vital capacity (%) (r = - 0.887, p < 0.001), and end-inspirium thickness (r = - 0.673 and p < 0.001) values. Furthermore, diaphragm thickness at the end of inspirium was positively correlated with forced expiratory volume in 1 s (%) (r = 0.636, p = 0.001) and forced vital capacity (%) (r = 0.646, p = 0.001) values. No significant correlation was found between diaphragm thickening fraction and forced expiratory volume in 1 s or forced vital capacity.
Conclusion:
Ultrasound can provide valuable information about diaphragm morphology and quantify diaphragm contraction.
