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Point-of-care ultrasound of the diaphragm in a liver transplant patient with acute respiratory failure.

Barbariol F, Vetrugno L, Pompei L, De Flaviis A, Rocca GD - Crit Ultrasound J (2015)

Bottom Line: An initial bedside ultrasound evaluation applying the 'BLUE protocol' showed no pathological changes capable of explaining the clinical picture; however, by evaluating also the right and left hemidiaphragms, we made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the diaphragm ultrasound.We therefore decided to avoid intubation, transfer the patient to the intensive care unit, and treat him conservatively with non-invasive ventilation only.This feature is still held in little consideration, but it can affect the diagnosis and the treatment of critically ill patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesia and Intensive Care Medicine, University of Udine, P.le S. M. della Misericordia 15, 33100 Udine, Italy.

ABSTRACT
In some intensive care, nowadays, ultrasound diagnostics have become an extension of the physical examination (like a stethoscope). In this report, we discuss the case of an acute respiratory failure which arose immediately after the end of general anesthesia. An initial bedside ultrasound evaluation applying the 'BLUE protocol' showed no pathological changes capable of explaining the clinical picture; however, by evaluating also the right and left hemidiaphragms, we made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the diaphragm ultrasound. We therefore decided to avoid intubation, transfer the patient to the intensive care unit, and treat him conservatively with non-invasive ventilation only. To our knowledge, this is the first case report that has shown the usefulness of ultrasonography in detecting diaphragmatic dysfunction as a cause of acute respiratory failure with a subsequent change in patient management. The use of bedside ultrasonography provides practical functional information on the diaphragmatic function in patients with acute respiratory failure and can also be easily repeated if follow-up is required. This feature is still held in little consideration, but it can affect the diagnosis and the treatment of critically ill patients.

No MeSH data available.


Related in: MedlinePlus

The normal left hemidiaphragm of the patient. We can see the diaphragmatic excursion showing an inspiratory peak of 2.78 cm above the baseline.
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Fig1: The normal left hemidiaphragm of the patient. We can see the diaphragmatic excursion showing an inspiratory peak of 2.78 cm above the baseline.

Mentions: After removal of the laryngeal mask at the end of a general anesthesia, a 50-year-old male patient of 60 kg developed an acute respiratory failure with dyspnea, tachypnea, hypoxia, and hypercapnia. In his medical history, he had been subjected to a liver transplant complicated by wound infection; because of this infection, he has undergone a procedure of VAC therapy of the wound under general anesthesia. Since the cause of this clinical picture was not very clear, the physician in charge decided to perform an ultrasound examination in the operating room. He applied the ‘BLUE protocol’ [4] but without detecting pathological elements capable of explaining the clinical picture; he also evaluated the right and left hemidiaphragms with the patient in the supine position (Philips PA4-2/21422A Sector Array transducer with EnVisor systems, Saronno, VA, Italy). The US approach used to evaluate diaphragmatic kinetics was that proposed by Boussuges et al. [10] in which the liver and the spleen are used as acoustic windows. For the right hemidiaphragm, the probe was placed below the right costal margin in the midclavicular line and directed medially, cranially, and dorsally so that the ultrasound beam could reach perpendicularly the posterior third of the right hemidiaphragm. The left hemidiaphragm was studied from a subcostal probe position between the midaxillary and anterior axillary lines to obtain the imaging of the left hemidiaphragmatic dome. First, the two-dimensional (2D) mode was used to find the best approach and to select the exploration line of each hemidiaphragm; the M-mode was then used to display the movement of the anatomical structure along the selected line. In M-mode, an average of three measurements were performed for each of diaphragmatic excursion (DIA, cm), inspiratory (Tins, s), and expiratory (Tesp, s) time. We observed that the excursions were much larger in the left hemidiaphragm (Figure 1, Additional file 1: VideoClip 1) and that the movement of the right hemidiaphragm could not be measured (Figure 2, Additional file 2: VideoClip 2). On the basis of this information, we then made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the bedside ultrasound.Figure 1


Point-of-care ultrasound of the diaphragm in a liver transplant patient with acute respiratory failure.

Barbariol F, Vetrugno L, Pompei L, De Flaviis A, Rocca GD - Crit Ultrasound J (2015)

The normal left hemidiaphragm of the patient. We can see the diaphragmatic excursion showing an inspiratory peak of 2.78 cm above the baseline.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4388066&req=5

Fig1: The normal left hemidiaphragm of the patient. We can see the diaphragmatic excursion showing an inspiratory peak of 2.78 cm above the baseline.
Mentions: After removal of the laryngeal mask at the end of a general anesthesia, a 50-year-old male patient of 60 kg developed an acute respiratory failure with dyspnea, tachypnea, hypoxia, and hypercapnia. In his medical history, he had been subjected to a liver transplant complicated by wound infection; because of this infection, he has undergone a procedure of VAC therapy of the wound under general anesthesia. Since the cause of this clinical picture was not very clear, the physician in charge decided to perform an ultrasound examination in the operating room. He applied the ‘BLUE protocol’ [4] but without detecting pathological elements capable of explaining the clinical picture; he also evaluated the right and left hemidiaphragms with the patient in the supine position (Philips PA4-2/21422A Sector Array transducer with EnVisor systems, Saronno, VA, Italy). The US approach used to evaluate diaphragmatic kinetics was that proposed by Boussuges et al. [10] in which the liver and the spleen are used as acoustic windows. For the right hemidiaphragm, the probe was placed below the right costal margin in the midclavicular line and directed medially, cranially, and dorsally so that the ultrasound beam could reach perpendicularly the posterior third of the right hemidiaphragm. The left hemidiaphragm was studied from a subcostal probe position between the midaxillary and anterior axillary lines to obtain the imaging of the left hemidiaphragmatic dome. First, the two-dimensional (2D) mode was used to find the best approach and to select the exploration line of each hemidiaphragm; the M-mode was then used to display the movement of the anatomical structure along the selected line. In M-mode, an average of three measurements were performed for each of diaphragmatic excursion (DIA, cm), inspiratory (Tins, s), and expiratory (Tesp, s) time. We observed that the excursions were much larger in the left hemidiaphragm (Figure 1, Additional file 1: VideoClip 1) and that the movement of the right hemidiaphragm could not be measured (Figure 2, Additional file 2: VideoClip 2). On the basis of this information, we then made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the bedside ultrasound.Figure 1

Bottom Line: An initial bedside ultrasound evaluation applying the 'BLUE protocol' showed no pathological changes capable of explaining the clinical picture; however, by evaluating also the right and left hemidiaphragms, we made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the diaphragm ultrasound.We therefore decided to avoid intubation, transfer the patient to the intensive care unit, and treat him conservatively with non-invasive ventilation only.This feature is still held in little consideration, but it can affect the diagnosis and the treatment of critically ill patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesia and Intensive Care Medicine, University of Udine, P.le S. M. della Misericordia 15, 33100 Udine, Italy.

ABSTRACT
In some intensive care, nowadays, ultrasound diagnostics have become an extension of the physical examination (like a stethoscope). In this report, we discuss the case of an acute respiratory failure which arose immediately after the end of general anesthesia. An initial bedside ultrasound evaluation applying the 'BLUE protocol' showed no pathological changes capable of explaining the clinical picture; however, by evaluating also the right and left hemidiaphragms, we made a diagnosis of diaphragmatic dysfunction, which would probably have been difficult to diagnose without the aid of the diaphragm ultrasound. We therefore decided to avoid intubation, transfer the patient to the intensive care unit, and treat him conservatively with non-invasive ventilation only. To our knowledge, this is the first case report that has shown the usefulness of ultrasonography in detecting diaphragmatic dysfunction as a cause of acute respiratory failure with a subsequent change in patient management. The use of bedside ultrasonography provides practical functional information on the diaphragmatic function in patients with acute respiratory failure and can also be easily repeated if follow-up is required. This feature is still held in little consideration, but it can affect the diagnosis and the treatment of critically ill patients.

No MeSH data available.


Related in: MedlinePlus