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• W1998657941 abstract "We read with great interest the article by Baria et al1Baria MR Shahgholi L Sorenson EJ et al.B-mode ultrasound assessment of diaphragm structure and function in patients with COPD.Chest. 2014; 146: 680-685Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar in a recent issue of CHEST (September 2014). In this article, the authors have studied diaphragm thickness (Tdi) and thickening ratio using B-mode ultrasound in patients with COPD. However, a few pertinent points should be highlighted before these values are accepted into clinical practice. First, the authors have hypothesized that in COPD with moderate airflow obstruction, the diaphragm would show physiologic, compensatory overuse hypertrophy. Contradicting this view, it has been shown that oxidative stress and sarcomeric injury in COPD activate proteolytic machinery, leading to contractile protein wasting and, consequently, loss of force-generating capacity of diaphragm fibers.2Ottenheijm CA Heunks LM Dekhuijzen PN Diaphragm muscle fiber dysfunction in chronic obstructive pulmonary disease: toward a pathophysiological concept.Am J Respir Crit Care Med. 2007; 175: 1233-1240Crossref PubMed Scopus (104) Google Scholar This accelerated protein degradation actually leads to diaphragmatic atrophy and not hypertrophy. Indeed, loss of myosin in the diaphragm fibers occurs even in mild to moderate COPD. However, despite the chronically reduced muscle length of the diaphragm in COPD, the pressure-generating ability is largely preserved at functional residual capacity (FRC). During tidal breathing, the firing rate of diaphragmatic motor units in patients with COPD is 70% greater than that of matched control subjects.2Ottenheijm CA Heunks LM Dekhuijzen PN Diaphragm muscle fiber dysfunction in chronic obstructive pulmonary disease: toward a pathophysiological concept.Am J Respir Crit Care Med. 2007; 175: 1233-1240Crossref PubMed Scopus (104) Google Scholar Second, the authors have measured Tdi both at end-expiration (Tmin) and at maximal inspiration (Tmax), and the thickening ratio was calculated as Tmax / Tmin. However, Tdi measurements during spontaneous breathing may be influenced by lung volume in a nonlinear relationship. The Tdi is more pronounced above 50% of the vital capacity, and there is a large increase in thickness between relaxation and 10% of the inspiratory effort.3Cohn D Benditt JO Eveloff S McCool FD Diaphragm thickening during inspiration.J Appl Physiol (1985). 1997; 83: 291-296Crossref PubMed Scopus (170) Google Scholar In this context, Gottesman and McCool4Gottesman E McCool FD Ultrasound evaluation of the paralyzed diaphragm.Am J Respir Crit Care Med. 1997; 155: 1570-1574Crossref PubMed Scopus (196) Google Scholar found that Tdi alone cannot distinguish between a chronically paralyzed atrophic diaphragm and a functioning diaphragm in patients with generalized muscle wasting or in small individuals. Change in thickness during inspiration or thickening fraction (TF or ΔTdi), calculated as TF = (thickness at peak inspiration or total lung capacity − thickness at end expiration or FRC)/thickness at end expiration or FRC, might be more definitive. The function, TF vs lung volume, for a range of volumes is linear.5Wait JL Nahormek PA Yost WT Rochester DP Diaphragmatic thickness-lung volume relationship in vivo.J Appl Physiol (1985). 1989; 67: 1560-1568Crossref PubMed Scopus (119) Google Scholar Moreover, as the diaphragm shortens during contraction, it thickens, and measures of ΔTdi are inversely related to changes in diaphragm length (Ldi) (ΔTdi is approximately 1/ΔLdi). Hence, it is intriguing to compare a diaphragm with chronically reduced length, as in COPD, with that of a normal population by measuring ΔTdi with respect to per unit change in Ldi. This might shed some light on the pathophysiologic differences in diaphragm between COPD and normal population. ResponseCHESTVol. 146Issue 4PreviewWe thank Drs Kumar and Chandra for their interest in our work1 and the opportunity to discuss the use of ultrasound imaging of the diaphragm in the clinical context. Regarding our hypothesis that the diaphragm might show hypertrophy in COPD, this was based on the assumption that the diaphragm may be more active in patients with COPD during quiet breathing than in healthy subjects with normal lung function. This would be consistent with the increased firing rate of diaphragm motor unit potentials reported by Ottenheijm et al2 during tidal breathing in patients with COPD. Full-Text PDF" @default.
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• W1998657941 date "2014-10-01" @default.
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• W1998657941 title "Ultrasound Assessment of the Diaphragm in Patients With COPD" @default.
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• W1998657941 doi "https://doi.org/10.1378/chest.14-1095" @default.
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