American Society of Regional Anesthesia and Pain Medicine February 2018 - 15
more freely, and an abdominal paradox is readily seen. During
the sniff test, Naik et al reported an upward spike during M-mode
sonography, indicating displacement of the hemidiaphragm
cranially instead of caudally (abdominal paradox), whereas a
normal diaphragm briefly descends during sniff testing, evident as
a downward spike.6
Other causes of abdominal paradox include a large pleural effusion,
negative pressure pneumothorax, subphrenic abscess, pulmonary
fibrosis, and atelectasis. Abdominal paradox can also be seen
in patients who have undergone lobectomy. These pre-existing
conditions can be identified on a chest radiograph.
SUMMARY AND RECOMMENDATIONS
Many patients presenting for shoulder surgery may have
asymptomatic unilateral diaphragm dysfunction. However, after
interscalene nerve block resulting in hemidiaphragm paralysis,
such patients may develop dyspnea severe enough to warrant
rescheduling their surgery.
Insonation of the diaphragm bilaterally at the ZOA preoperatively
can demonstrate evidence of diaphragm dysfunction. If the patients
have normal diaphragm thickening on the contralateral side to
the surgical site surgery may proceed safely. On the other hand,
diaphragm dysfunction on that contralateral side may necessitate
suprascapular and axillary nerve blocks that will spare the phrenic
nerve. Patients with bilateral diaphragm dysfunction typically
have severe dyspnea, rely heavily on their accessory muscles of
respiration, and are not candidates for interscalene blocks.
In conclusion, ultrasound of the diaphragm is a practical and
highly accurate diagnostic imaging modality to assess diaphragm
function, to determine which patients may be candidates for
interscalene brachial plexus blocks and to quantify diaphragm
contractibility prior to extubation.
REFERENCES
1.
Boon AJ, O'Gorman C. Ultrasound in the assessment of respiration. J Clin
Neurophysiol. 2016;33(2):112-119.
2.
Matamis D, Soilemezi E, Tsagourias M, et al. Sonographic evaluation of the
diaphragm in critically ill patients. Technique and clinical applications. Intensive
Care Med. 2013;39(5):801-810.
3.
Sarwal A, Walker FO, Cartwright MS. Neuromuscular ultrasound for evaluation of
the diaphragm. Muscle Nerve. 2013;47(3):319-329.
4.
Tsui JJ, Tsui BC. A novel systematic ABC approach to diaphragmatic evaluation
(ABCDE). Can J Anaesth. 2016;63(5):636-637.
5.
Zambon M, Greco M, Bocchino S, Cabrini L, Beccaria PF, Zangrillo A. Assessment
of diaphragmatic dysfunction in the critically ill patient with ultrasound: a
systematic review. Intensive Care Med. 2017;43(1):29-38.
6.
Naik LY, Sondekoppam RV, Jenkin Tsui J, Tsui BC. An ultrasound-guided ABCDE
approach with a sniff test to evaluate diaphragmatic function without acoustic
windows. Can J Anaesth. 2016;63(10):1199-1200.
American Society of Regional Anesthesia and Pain Medicine
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