Background: Skeletal muscle weakness with loss of fat-free mass (FFM) is one of the main systemic effects of chronic obstructive pulmonary disease (COPD). The diaphragm is also involved, leading to disadvantageous conditions and poor contractile capacities. Objectives: We measured the thickness of the diaphragm (TD) by ultrasonography to evaluate the relationships between echographic measurements, parameters of respiratory function and body composition data. Methods: Thirty-two patients (23 males) underwent (1) pulmonary function tests, (2) echographic assessment of TD in the zone of apposition at various lung volumes, i.e. TD at residual volume (TDRV), TD at functional residual capacity (TDFRC) and TD at total lung capacity (TDTLC), and (3) bioelectrical body impedance analysis. The BMI and the BODE (BMI-Obstruction-Dyspnea-Exercise) index values were reported. Results: TDRV, TDFRC and TDTLC measured 3.3, 3.6 and 6 mm, respectively, with good intraobserver reproducibility (0.97, 0.97 and 0.96, respectively). All the TDs were found to be related to FFM, with the relationship being greater for TDFRC (r2 = 0.39 and p = 0.0002). With regard to lung volumes, inspiratory capacity (IC) was found to be closely related to TDTLC (r2 = 0.42 and p = 0.0001). The difference between TDTLC and TDRV, as a thickening value (TDTLCRV), was closely related to FVC (r2 = 0.34 and p = 0.0004) and to air-trapping indices (RV/TLC, FRC/TLC and IC/TLC): the degree of lung hyperinflation was greater and the TDTLCRV was less. Finally, we found a progressive reduction of both thicknesses and thickenings as the severity of IC/TLC increased, with a significant p value for the trend in both analyses (p = 0.02). Conclusions: Ultrasonographic assessment of the diaphragm could be a useful tool for studying disease progression in COPD patients, in terms of lung hyperinflation and the loss of FFM.

Keywords:
Chronic obstructive pulmonary disease, Diaphragm, Chest ultrasound
1.
Barnes PJ, Celli BR: Systemic manifestation and comorbidities of COPD. Eur Respir J 2009;33:1165-1185.
2.
Decramer M, De Benedetto F, Del Ponte A, Marinari S: Systemic effects of COPD. Respir Med 2005;99(suppl B):S3-S10.
3.
Agusti A, Soriano JB: COPD as a systemic disease. COPD 2008;5:133-138.
4.
Kim HC, Mofarrahi M, Hussain SN: Skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2008;3:637-658.
5.
Decramer M, Lacquet LM, Fagard R, Rogiers P: Corticosteroids contribute to muscle weakness in chronic airflow obstruction. Am J Respir Crit Care Med 1994;150:11-16.
6.
Koerts-de Lang E, Schols AM, Rooyackers OE, Gayan-Ramirez G, Decramer M, Wouters EF: Different effects of corticosteroid-induced muscle wasting compared with undernutrition on rat diaphragm energy metabolism. Eur J Appl Physiol 2000;82:493-498.
7.
Montes de Oca M, Torres SH, Gonzalez Y, et al: Peripheral muscle composition and health status in patients with COPD. Respir Med 2006;100:1800-1806.
8.
Marquis K, Debigare R, Lacasse Y, et al: Midthigh muscle cross-sectional area is a better predictor of mortality than body mass index in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2002;166:809-813.
9.
Sabino PG, Silva BM, Brunetto AF: Nutritional status is related to fat-free mass, exercise capacity and inspiratory strength in severe chronic obstructive pulmonary disease patients. Clinics 2010;65:599-605.
10.
Ischaki E, Papatheodorou G, Gaki E, et al: Body mass and fat-free mass indices in COPD: relation with variables expressing disease severity. Chest 2007;132:164-169.
11.
Thurlbeck WM: Diaphragm and body weight in emphysema. Thorax 1978;33:483-487.
12.
Arora NS, Rochester DF: Effect of body weight and muscularity on human diaphragm muscle mass, thickness, and area. J Appl Physiol 1982;52:64-70.
13.
Rochester D: The diaphragm: contractile properties and fatigue. J Clin Invest 1985;75:1397-1402.
14.
Iwasawa T, Takahashi H, Ogura T, et al: Influence of the distribution of emphysema on diaphragmatic motion in patients with chronic obstructive pulmonary disease. Jpn J Radiol 2011;29:256-264.
15.
Podnar S, Harlander M: Phrenic nerve conduction studies in patients with chronic obstructive pulmonary disease. Muscle Nerve 2013;47:504-509.
16.
Lopez-Navas K, Brandt S, Strutz M, et al: Comparison of two methods to assess transdiaphragmatic pressure at different levels of work of breathing. Biomed Tech 2012, DOI: 10.1515/bmt-2012-4124.
17.
Boussuges A, Gole Y, Blanc P: Diaphragmatic motion studied by M-mode ultrasonography: methods, reproducibility, and normal values. Chest 2009;135:391-400.
18.
Testa A, Soldati G, Giannuzzi R, et al: Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects. Ultrasound Med Biol 2011;37:44-52.
19.
Ueki J, De Bruin PF, Pride NB: In vivo assessment of diaphragm contraction by ultrasound in normal subjects. Thorax 1995;50:1157-1161.
20.
Enright S, Chatham K, Ionescu AA, et al: The influence of body composition on respiratory muscle, lung function and diaphragm thickness in adults with cystic fibrosis. J Cyst Fibros 2007;6:384-390.
21.
ATS/ERS Task Force: Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932-946.
22.
ATS/ERS Task Force: Standardisation of spirometry. Eur Respir J 2005;26:319-338.
23.
ATS/ERS Task Force: Standardisation of the measurement of lung volumes. Eur Respir J 2005;26:511-522.
24.
ATS/ERS Task Force: Standardisation of the single-breath determination of carbon monoxide uptake in the lung. Eur Respir J 2005;26:720-735.
25.
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories: ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111-117.
26.
Mahler D, Wells C: Evaluation of clinical methods for rating dyspnea. Chest 1988;93:580-586.
27.
Celli BR, Cote CG, Marin JM: The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005-1012.
28.
Kyle UG, Bosaeus I, De Lorenzo AD, et al: Bioelectrical impedance analysis. Part I: review of principles and methods. Clin Nutr 2004;23:1226-1243.
29.
Kyle UG, Bosaeus I, De Lorenzo AD, et al: Bioelectrical impedance analysis. Part II: utilization in clinical practice. Clin Nutr 2004;23:1430-1453.
30.
Walter-Kroker A, Kroker A, Mattiucci-Guehlke M, et al: A practical guide to bioelectrical impedance analysis using the example of chronic obstructive pulmonary disease. Nutr J 2011;10:35.
31.
Bland JM, Altman DG: Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307-310.
32.
Vestbo J, Hurd SS, Agustí AG, Jones PW, Vogelmeier C, Anzueto A, Barnes PJ, Fabbri LM, Martinez FJ, Nishimura M, Stockley RA, Sin DD, Rodriguez-Roisin R: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013;187:347-365.
33.
Cohn D, Benditt JO, Eveloff S, et al: Diaphragm thickening during inspiration. J Appl Physiol 1997;83:291-296.
34.
Casanova C, Cote C, de Torres JP, et al: Inspiratory-to-total lung capacity ratio predicts mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005;171:591-597.
35.
Pinto-Plata VM, Cote C, Cabral H, et al: The 6-min walk distance: change over time and value as a predictor of survival in severe COPD. Eur Respir J 2004;23:28-33.
36.
Scott S, Fuld JP, Carter R, et al: Diaphragm ultrasonography as an alternative to whole-body plethysmography in pulmonary function testing. J Ultrasound Med 2006;25:225-232.
37.
Dos Santos Yamaguti WP, Paulin E, Shibao S: Air trapping: The major factor limiting diaphragm mobility in chronic obstructive pulmonary disease patients. Respirology 2008;13:138-144.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.