Ultrassonografia diafragmática: uma revisão de seus aspectos metodológicos e usos clínicos

Santana, Pauliane Vieira; Cardenas, Leticia Zumpano; Albuquerque, André Luis Pereira de; Carvalho, Carlos Roberto Ribeiro de; Caruso, Pedro

Pauliane Vieira Santana

. Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

. Unidade de Terapia Intensiva, A.C. Camargo Cancer Center, São Paulo (SP) Brasil.

https://orcid.org/0000-0002-2278-4788

Leticia Zumpano Cardenas

. Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

. Unidade de Terapia Intensiva, A.C. Camargo Cancer Center, São Paulo (SP) Brasil.

https://orcid.org/0000-0003-1722-8928

André Luis Pereira de Albuquerque

. Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

. Hospital Sírio-Libanês, São Paulo (SP) Brasil.

https://orcid.org/0000-0003-3486-5240

Carlos Roberto Ribeiro de Carvalho

. Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

https://orcid.org/0000-0002-1618-8509

Pedro Caruso

. Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

. Unidade de Terapia Intensiva, A.C. Camargo Cancer Center, São Paulo (SP) Brasil.

https://orcid.org/0000-0002-1051-8458

Endereço para correspondência: Pauliane Vieira Santana. Avenida Dr. Enéas de Carvalho Aguiar, 45, 5º andar, Bloco 2, Sala 1, CEP 05403-900, São Paulo, SP, Brasil. Tel./Fax: 55 11 2661-5990. E-mail: paulivisa@gmail.com

CONTRIBUIÇÕES DOS AUTORES

PVS, LZC, ALPA, CRRC e PC participaram da concepção e desenho do estudo (análise formal e metodologia). PVS e PC participaram da redação do manuscrito. PVS, LZC, ALPA, CRRC e PC participaram da redação, revisão e correção do manuscrito. Todos os autores aprovaram a versão final do manuscrito.

Vantagens
Segurança	- Não invasiva - Não expõe os pacientes a radiação ionizante.⁸8 Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest. 2009;135(2):391-400. https://doi.org/10.1378/chest.08-1541 https://doi.org/10.1378/chest.08-1541...
Viabilidade	- Pode ser realizada em menos de 15 min⁹9 Testa A, Soldati G, Giannuzzi R, Berardi S, Portale G, Gentiloni Silveri N. Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects. Ultrasound Med Biol. 2011;37(1):44-52. https://doi.org/10.1016/j.ultrasmedbio.2010.10.004 https://doi.org/10.1016/j.ultrasmedbio.2... ou até mesmo em cerca de 5 min.⁸8 Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest. 2009;135(2):391-400. https://doi.org/10.1378/chest.08-1541 https://doi.org/10.1378/chest.08-1541... - Avaliação à beira do leito, o paciente não precisa ser transportado - Possibilidade de várias repetições
Disponibilidade	- Exige apenas equipamento ultrassonográfico básico, de modo geral amplamente disponível.
Precisão	- Alta resolução temporal,⁸8 Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest. 2009;135(2):391-400. https://doi.org/10.1378/chest.08-1541 https://doi.org/10.1378/chest.08-1541... ^,⁹9 Testa A, Soldati G, Giannuzzi R, Berardi S, Portale G, Gentiloni Silveri N. Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects. Ultrasound Med Biol. 2011;37(1):44-52. https://doi.org/10.1016/j.ultrasmedbio.2010.10.004 https://doi.org/10.1016/j.ultrasmedbio.2... alta reprodutibilidade e alta precisão, com coeficientes de correlação intraclasse de 0,876 a 0,999 para a concordância intraobservador e de 0,56 a 0,989 para a concordância interobservadores¹⁰10 Baldwin CE, Paratz JD, Bersten AD. Diaphragm and peripheral muscle thickness on ultrasound: intra-rater reliability and variability of a methodology using non-standard recumbent positions. Respirology. 2011;16(7):1136-1143. https://doi.org/10.1111/j.1440-1843.2011.02005.x https://doi.org/10.1111/j.1440-1843.2011... 11 Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Aprà F. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J. 2014;6(1):8. https://doi.org/10.1186/2036-7902-6-8 https://doi.org/10.1186/2036-7902-6-8... 12 Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D, et al. Evolution of Diaphragm Thickness during Mechanical Ventilation. Impact of Inspiratory Effort. Am J Respir Crit Care Med. 2015;192(9):1080-1088. https://doi.org/10.1164/rccm.201503-0620OC https://doi.org/10.1164/rccm.201503-0620... 13 Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627-2630. https://doi.org/10.1097/CCM.0b013e3182266408 https://doi.org/10.1097/CCM.0b013e318226... 14 Lerolle N, Guérot E, Dimassi S, Zegdi R, Faisy C, Fagon JY, et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest. 2009;135(2):401-407. https://doi.org/10.1378/chest.08-1531 https://doi.org/10.1378/chest.08-1531... 15 Schepens T, Verbrugghe W, Dams K, Corthouts B, Parizel PM, Jorens PG. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. Crit Care. 2015;19:422. https://doi.org/10.1186/s13054-015-1141-0 https://doi.org/10.1186/s13054-015-1141-... 16 Umbrello M, Formenti P, Longhi D, Galimberti A, Piva I, Pezzi A, et al. Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study. Crit Care. 2015;19(1):161. https://doi.org/10.1186/s13054-015-0894-9 https://doi.org/10.1186/s13054-015-0894-... 17 Vivier E, Dessap AM, Dimassi S, Vargas F, Lyazidi A, Thille AW, et al. Diaphragm ultrasonography to estimate the work of breathing during non-invasive ventilation. Intensive Care Med. 2012;38(5):796-803. https://doi.org/10.1007/s00134-012-2547-7 https://doi.org/10.1007/s00134-012-2547-... ^-¹⁸18 Zambon M, Beccaria P, Matsuno J, Gemma M, Frati E, Colombo S, et al. Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study. Crit Care Med. 2016;44(7):1347-1352. https://doi.org/10.1097/CCM.0000000000001657 https://doi.org/10.1097/CCM.000000000000... - Apresenta alta concordância intraobservador e interobservadores⁸8 Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest. 2009;135(2):391-400. https://doi.org/10.1378/chest.08-1541 https://doi.org/10.1378/chest.08-1541... quanto à excursão diafragmática⁹9 Testa A, Soldati G, Giannuzzi R, Berardi S, Portale G, Gentiloni Silveri N. Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects. Ultrasound Med Biol. 2011;37(1):44-52. https://doi.org/10.1016/j.ultrasmedbio.2010.10.004 https://doi.org/10.1016/j.ultrasmedbio.2... e à espessura do diafragma.¹⁰10 Baldwin CE, Paratz JD, Bersten AD. Diaphragm and peripheral muscle thickness on ultrasound: intra-rater reliability and variability of a methodology using non-standard recumbent positions. Respirology. 2011;16(7):1136-1143. https://doi.org/10.1111/j.1440-1843.2011.02005.x https://doi.org/10.1111/j.1440-1843.2011... - É superior à fluoroscopia no diagnóstico de disfunção diafragmática.¹⁹19 Houston JG, Fleet M, Cowan MD, McMillan NC. Comparison of ultrasound with fluoroscopy in the assessment of suspected hemidiaphragmatic movement abnormality. Clin Radiol. 1995;50(2):95-98. https://doi.org/10.1016/S0009-9260(05)82987-3 https://doi.org/10.1016/S0009-9260(05)82...
Desvantagens
Disponibilidade	- Embora seja necessário apenas o equipamento ultrassonográfico básico, não está disponível em todos os serviços. - É preciso que haja na equipe médicos que tenham sido treinados para usar a técnica.
Precisão	- Pode ser difícil visualizar o hemidiafragma esquerdo, particularmente em pacientes obesos.²⁰20 Sarwal A, Walker FO, Cartwright MS. Neuromuscular ultrasound for evaluation of the diaphragm. Muscle Nerve. 2013;47(3):319-329. https://doi.org/10.1002/mus.23671 https://doi.org/10.1002/mus.23671... - A excursão diafragmática depende do esforço inspiratório voluntário máximo dos pacientes e é influenciada pela posição do paciente.²¹21 Wait JL, Nahormek PA, Yost WT, Rochester DP. Diaphragmatic thickness-lung volume relationship in vivo. J Appl Physiol (1985). 1989;67(4):1560-1568. https://doi.org/10.1152/jappl.1989.67.4.1560 https://doi.org/10.1152/jappl.1989.67.4.... - A excursão diafragmática é afetada pela pressão e conteúdo abdominal, que limitam o deslocamento do diafragma.²²22 Houston JG, Angus RM, Cowan MD, McMillan NC, Thomson NC. Ultrasound assessment of normal hemidiaphragmatic movement: relation to inspiratory volume. Thorax. 1994;49(5):500-503. https://doi.org/10.1136/thx.49.5.500 https://doi.org/10.1136/thx.49.5.500...

Referência	n	Posição do paciente Posição da sonda Orientação da sonda	Medida	Valores de referência
Harris et al.³³33 Harris RS, Giovannetti M, Kim BK. Normal ventilatory movement of the right hemidiaphragm studied by ultrasonography and pneumotachography. Radiology. 1983;146(1):141-144. https://doi.org/10.1148/radiology.146.1.6849035 https://doi.org/10.1148/radiology.146.1....	50	Supina Subcostal LHC e longitudinal	Mobilidade RP	Terço anterior: 4,0 ± 1,6 cm Terço médio e posterior: 4,8 ± 1,6 cm 4,0 ± 1,2 cm (F); 5,4 ± 1,7 cm (M)
Gerscovich et al.³⁶36 Gerscovich EO, Cronan M, McGahan JP, Jain K, Jones CD, McDonald C. Ultrasonographic evaluation of diaphragmatic motion. J Ultrasound Med. 2001;20(6):597-604. https://doi.org/10.7863/jum.2001.20.6.597 https://doi.org/10.7863/jum.2001.20.6.59...	23	Supina Semicoronal longitudinal Subcostal ou intercostal inferior entre LHC e LAM	Mobilidade RT	Hemidiafragma direito - RT: 1,5 cm; RP: 5,7 cm; sniffing: 1,7 cm Hemidiafragma esquerdo - RT: 1,6 cm; RP: 6,7 cm; sniffing: 1,8 cm
Kantarci et al.³⁹39 Kantarci F, Mihmanli I, Demirel MK, Harmanci K, Akman C, Aydogan F, et al. Normal diaphragmatic motion and the effects of body composition: determination with M-mode sonography. J Ultrasound Med. 2004;23(2):255-260. https://doi.org/10.7863/jum.2004.23.2.255 https://doi.org/10.7863/jum.2004.23.2.25...	160	Supina Plano coronal Intercostal anterior inferior, subcostal ou ambas	Mobilidade RP	RP Direito: 4,7 ± 1,0 (F) vs. 5,3 ± 1,1 cm (M) Esquerdo: 4,8 ± 0,3 (F) vs. 5,4 ± 1,3 cm (F)
Boussuges et al.⁸8 Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest. 2009;135(2):391-400. https://doi.org/10.1378/chest.08-1541 https://doi.org/10.1378/chest.08-1541...	210	Em pé Subcostal direita entre LHC e LAA Espaços intercostais inferiores esquerdos ou subcostal, entre LAA e LAM	Mobilidade RT RP	RT - Direito: 1,6 ± 0,3 cm (F); 1,8 ± 0,3 cm (M) - Esquerdo: 1,6 ± 0,4 cm (F); 1,8 ± 0,4 cm (M) RP - Direito: 5,7 ± 1,0 cm (F); 7,0 ± 1,1 cm (M) - Esquerdo: 6,4 ± 1,0 cm (F); 7,5 ± 0,9 cm (M) Sniffing - Direito: 2,6 ± 0,5 cm (F); 2,9 ± 0,6 cm (M) - Esquerdo: 2,7 ± 0,5 cm (F); 3,1 ± 0,6 cm (M)
Testa et al.⁹9 Testa A, Soldati G, Giannuzzi R, Berardi S, Portale G, Gentiloni Silveri N. Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects. Ultrasound Med Biol. 2011;37(1):44-52. https://doi.org/10.1016/j.ultrasmedbio.2010.10.004 https://doi.org/10.1016/j.ultrasmedbio.2...	40	Supina, recostada a 45° Subcostal anterior na LHC Sonda em sentido transversal em direção cranial	Mobilidade RT RP	RT - Operador experiente: 1,8 ± 0,8 cm - Operador inexperiente: 2,2 ± 0,9 cm RP - Operador experiente: 6,9 ± 1,4 cm - Operador inexperiente: 7,9 ± 1,3 cm
Ueki et al.²⁷27 Ueki J, De Bruin PF, Pride NB. In vivo assessment of diaphragm contraction by ultrasound in normal subjects. Thorax. 1995;50(11):1157-1161. https://doi.org/10.1136/thx.50.11.1157 https://doi.org/10.1136/thx.50.11.1157...	13	Sentada ZA	Espessura	Tdi-exp: 1,7 ± 0,2 mm Tdi-insp: 4,5 ± 0,9 mm
Baldwin et al.¹⁰10 Baldwin CE, Paratz JD, Bersten AD. Diaphragm and peripheral muscle thickness on ultrasound: intra-rater reliability and variability of a methodology using non-standard recumbent positions. Respirology. 2011;16(7):1136-1143. https://doi.org/10.1111/j.1440-1843.2011.02005.x https://doi.org/10.1111/j.1440-1843.2011...	13	Recostada a 45° ZA, nono espaço intercostal	Espessura Tdi-exp	Tdi-exp: 1,7 [1,1-3,0] mm
Boon et al.²⁵25 Boon AJ, Harper CJ, Ghahfarokhi LS, Strommen JA, Watson JC, Sorenson EJ. Two-dimensional ultrasound imaging of the diaphragm: quantitative values in normal subjects. Muscle Nerve. 2013;47(6):884-889. https://doi.org/10.1002/mus.23702 https://doi.org/10.1002/mus.23702...	150	Supina Oitavo ou nono espaço intercostal, imediatamente anterior à LAA	Espessura Tdi-exp Taxa de espessamento	Tdi-exp: 2,7 ± 1 mm (F); 3,8 ± 1,5 mm (M) - LIN Tdi-exp: 1,4-1,7 mm - LIN taxa de espessamento: 1,2-1,3%
Carrillo-Esper et al.²⁹29 Carrillo-Esper R, Pérez-Calatayud ÁA, Arch-Tirado E, Díaz-Carrillo MA, Garrido-Aguirre E, Tapia-Velazco R, et al. Standardization of Sonographic Diaphragm Thickness Evaluations in Healthy Volunteers. Respir Care. 2016;61(7):920-924. https://doi.org/10.4187/respcare.03999 https://doi.org/10.4187/respcare.03999...	109	Supina ZA, em CRF	Espessura Tdi-exp	Tdi-exp: 1,6 ± 0,4 mm 1,4 ± 0,3 mm (F); 1,9 ± 0,4 mm (M)
Cardenas et al.²⁴24 Cardenas LZ, Santana PV, Caruso P, Ribeiro de Carvalho CR, Pereira de Albuquerque AL. Diaphragmatic Ultrasound Correlates with Inspiratory Muscle Strength and Pulmonary Function in Healthy Subjects. Ultrasound Med Biol. 2018;44(4):786-793. https://doi.org/10.1016/j.ultrasmedbio.2017.11.020 https://doi.org/10.1016/j.ultrasmedbio.2...	64	Recostada a 45° Mobilidade: anterior direita, região subcostal Espessura do diafragma: ZA entre LAA e LAM, em CRF e em CPT	Mobilidade RT RP Espessura Tdi-exp Tdi-insp FE	Mobilidade RT: 1,5 ± 0,4 cm RP: 6,41 ± 1,02 cm (F); 7,79 ± 0,82 cm (M) LIN mobilidade RP: 4,37 cm (F); 6,15 cm (M) Tdi-exp: 1,9 ± 0,3 mm (M) LIN em CRF: 1,2 mm (F); 1,3 mm (M) Tdi-insp: 4,81 ± 0,95 mm (F); 5,6 ± 0,9 mm (M) FE: 169 ± 43% (F); 204 ± 61% (M)

Autores	n	Cenário	Medida	Ponto de corte/Correlato
Previsão do desfecho do desmame - FE
DiNino et al.⁴⁶46 DiNino E, Gartman EJ, Sethi JM, McCool FD. Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax. 2014;69(5):423-427. https://doi.org/10.1136/thoraxjnl-2013-204111 https://doi.org/10.1136/thoraxjnl-2013-2...	63	UTI clínica	FE durante TRE [VPS (5) ou tubo T]	Ponto de corte da FE: > 30%
Jung et al.⁴³43 Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, et al. Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med. 2016;42(5):853-861. https://doi.org/10.1007/s00134-015-4125-2 https://doi.org/10.1007/s00134-015-4125-...	33	UTI clínica e cirúrgica	FE durante TRE [VPS (5) ou tubo T] Somente pacientes com FAUTI	Ponto de corte da FE: > 20%
Dres et al.⁴⁰40 Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, et al. Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients. Am J Respir Crit Care Med. 2017;195(1):57-66. https://doi.org/10.1164/rccm.201602-0367OC https://doi.org/10.1164/rccm.201602-0367...	76	UTI clínica	FE durante TRE em VPS	Ponto de corte da FE: > 29%
Blumhof et al.⁶¹61 Blumhof S, Wheeler D, Thomas K, McCool FD, Mora J. Change in Diaphragmatic Thickness During the Respiratory Cycle Predicts Extubation Success at Various Levels of Pressure Support Ventilation. Lung. 2016;194(4):519-525. https://doi.org/10.1007/s00408-016-9911-2 https://doi.org/10.1007/s00408-016-9911-...	56	UTI clínica	FE durante TRE em VPS (5,10 e 15)	Ponto de corte da FE: > 20%
Farghaly et al.⁶²62 Farghaly S, Hasan AA. Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients. Aust Crit Care. 2017;30(1):37-43. https://doi.org/10.1016/j.aucc.2016.03.004 https://doi.org/10.1016/j.aucc.2016.03.0...	54	UTI respiratória	FE durante TRE em VPS (8)	Ponto de corte da FE: > 34%
Dres et al.⁶³63 Dres M, Goligher EC, Dubé BP, Morawiec E, Dangers L, Reuter D, et al. Diaphragm function and weaning from mechanical ventilation: an ultrasound and phrenic nerve stimulation clinical study. Ann Intensive Care. 2018;8(1):53. https://doi.org/10.1186/s13613-018-0401-y https://doi.org/10.1186/s13613-018-0401-...	76	UTI clínica	FE e PtrEstim alguns minutos antes do TRE TRE em VPS (7), ZEEP	Ponto de corte da FE: > 25,8% PtrEstim > 7,2 cm
Previsão do desfecho do desmame - ED
Jiang et al.⁵³53 Jiang JR, Tsai TH, Jerng JS, Yu CJ, Wu HD, Yang PC. Ultrasonographic evaluation of liver/spleen movements and extubation outcome. Chest. 2004;126(1):179-185. https://doi.org/10.1016/S0012-3692(15)32912-3 https://doi.org/10.1016/S0012-3692(15)32...	55	UTI clínica	ED durante TRE em VPS ou tubo T	Ponto de corte da ED: 1,1 cm
Kim et al.¹³13 Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627-2630. https://doi.org/10.1097/CCM.0b013e3182266408 https://doi.org/10.1097/CCM.0b013e318226...	82	UTI clínica	ED durante TRE em VPS ou tubo T	Ponto de corte da ED: 1,0 cm
Spadaro et al.⁵⁴54 Spadaro S, Grasso S, Mauri T, Dalla Corte F, Alvisi V, Ragazzi R, et al. Can diaphragmatic ultrasonography performed during the T-tube trial predict weaning failure? The role of diaphragmatic rapid shallow breathing index. Crit Care. 2016;20(1):305. https://doi.org/10.1186/s13054-016-1479-y https://doi.org/10.1186/s13054-016-1479-...	51	UTI clínica	ED durante TRE (não está claro)	Ponto de corte da ED: 1,4 cm
Dres et al.⁴⁰40 Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, et al. Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients. Am J Respir Crit Care Med. 2017;195(1):57-66. https://doi.org/10.1164/rccm.201602-0367OC https://doi.org/10.1164/rccm.201602-0367...	76	UTI clínica	ED durante TRE em VPS	Ponto de corte da ED: 0,95 cm
Farghaly et al.⁶²62 Farghaly S, Hasan AA. Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients. Aust Crit Care. 2017;30(1):37-43. https://doi.org/10.1016/j.aucc.2016.03.004 https://doi.org/10.1016/j.aucc.2016.03.0...	54	UTI respiratória	ED durante TRE em VPS	Ponto de corte da ED: 1,05 cm
Avaliação de atrofia durante VM
Grosu et al.⁵²52 Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM. Diaphragm muscle thinning in patients who are mechanically ventilated. Chest. 2012;142(6):1455-1460. https://doi.org/10.1378/chest.11-1638 https://doi.org/10.1378/chest.11-1638...	7	UTI clínica	Tdi-exp medida diariamente desde a intubação	Tdi-exp ⇓ 6%/dia de VM
Goligher et al.¹²12 Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D, et al. Evolution of Diaphragm Thickness during Mechanical Ventilation. Impact of Inspiratory Effort. Am J Respir Crit Care Med. 2015;192(9):1080-1088. https://doi.org/10.1164/rccm.201503-0620OC https://doi.org/10.1164/rccm.201503-0620...	107	UTI clínica	Tdi-exp e FE medidas diariamente desde a intubação até 72 h de VM -Tdi-exp ⇓ = redução da Tdi-exp > 10% - Tdi-exp ⇑ = aumento da Tdi-exp > 10%	Tdi-exp ⇓ em 44%; Tdi-exp ⇑ em 12% FE baixa correlacionou-se com ⇓ da Tdi-exp FE alta correlacionou-se com ⇑ da Tdi-exp. FE ⇓ com ⇑ pressão motriz e VMC
Schepens et al.¹⁵15 Schepens T, Verbrugghe W, Dams K, Corthouts B, Parizel PM, Jorens PG. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. Crit Care. 2015;19:422. https://doi.org/10.1186/s13054-015-1141-0 https://doi.org/10.1186/s13054-015-1141-...	54	UTI clínica	Tdi-exp medida durante as primeiras 24 h de VM e, então, diariamente	Tdi-exp ⇓ ≈32% no ponto mais baixo (nadir) Relação entre tempo de VM e atrofia
Zambon et al.¹⁸18 Zambon M, Beccaria P, Matsuno J, Gemma M, Frati E, Colombo S, et al. Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study. Crit Care Med. 2016;44(7):1347-1352. https://doi.org/10.1097/CCM.0000000000001657 https://doi.org/10.1097/CCM.000000000000...	40	UTI clínica	Tdi-exp medida diariamente desde a intubação durante RE ou CPAP VPS alta (5-12) VPS baixa (> 12): VMC	Tdi-exp ⇓ ≈7,5%/dia em VMC Tdi-exp ⇓ ≈5,3%/dia em VPS alta Tdi-exp ⇓ ≈1,5%/ dia em VPS baixa Tdi-exp ⇑ ≈2,3%/dia em RE/CPAP
Goligher et al.⁶⁴64 Goligher EC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, et al. Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes. Am J Respir Crit Care Med. 2018;197(2):204-213. https://doi.org/10.1164/rccm.201703-0536OC https://doi.org/10.1164/rccm.201703-0536...	211	UTI clínica	Tdi-exp e FE medidas diariamente desde a intubação até 72 h de VM Esforço inspiratório → FE Tdi-exp ⇓ = redução da Tdi-exp > 10% Tdi-exp ⇑ = aumento da Tdi-exp > 10%	Tdi-exp ⇓ em 41%; Tdi-exp ⇑ em 24% Tdi-exp ⇓ relacionada com ⇑ VM, ⇑ admissão na UTI e ⇑ risco de complicações Tdi-exp ⇑ previu ⇑ VM. ⇓ Tdi-exp correlacionou-se com esforço inspiratório baixo. ⇑ Tdi-exp relacionou-se com esforço excessivo. FE (15-30%) → o menor tempo de VM
Avaliação de DD
Lerolle et al.¹⁴14 Lerolle N, Guérot E, Dimassi S, Zegdi R, Faisy C, Fagon JY, et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest. 2009;135(2):401-407. https://doi.org/10.1378/chest.08-1531 https://doi.org/10.1378/chest.08-1531...	28	UTI cardiológica de adultos	ED, Pdi e índice de Gilbert DD grave = melhor ED < 25 cm VM > 7 dias	Melhor ED < 25 correlacionou-se com índice de Gilbert < 0
Kim et al.¹³13 Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627-2630. https://doi.org/10.1097/CCM.0b013e3182266408 https://doi.org/10.1097/CCM.0b013e318226...	82	UTI clínica	Durante TRE em VPS ou tubo T VM > 48 h	DD em 24 (29%) ED < 1,0 cm previu o desfecho do desmame.
Valette et al.⁴⁸48 Valette X, Seguin A, Daubin C, Brunet J, Sauneuf B, Terzi N, et al. Diaphragmatic dysfunction at admission in intensive care unit: the value of diaphragmatic ultrasonography. Intensive Care Med. 2015;41(3):557-559. https://doi.org/10.1007/s00134-014-3636-6 https://doi.org/10.1007/s00134-014-3636-...	10	UTI clínica	ED durante a respiração não assistida DD = excursão paradoxal ou ausente, ou ED < 1,0 cm	DD em 10 pacientes Alta taxa de mortalidade (60%) de pacientes com DD e IRA
Mariani et al.⁴⁹49 Mariani LF, Bedel J, Gros A, Lerolle N, Milojevic K, Laurent V, et al. Ultrasonography for Screening and Follow-Up of Diaphragmatic Dysfunction in the ICU: A Pilot Study. J Intensive Care Med. 2016;31(5):338-343. https://doi.org/10.1177/0885066615583639 https://doi.org/10.1177/0885066615583639...	34	UTI clínica	ED durante TRE em tubo T DD = ED < 1,0 cm VM > 7 dias e apto(a) para TRE	DD em 13 (38%) DD bilateral em 8 DD unilateral (esquerda/direita) = 3/2
Lu et al.⁵⁰50 Lu Z, Xu Q, Yuan Y, Zhang G, Guo F, Ge H. Diaphragmatic Dysfunction Is Characterized by Increased Duration of Mechanical Ventilation in Subjects With Prolonged Weaning. Respir Care. 2016;61(10):1316-1322. https://doi.org/10.4187/respcare.04746 https://doi.org/10.4187/respcare.04746...	41	UTI clínica	FE durante TRE em VPS somente pacientes com VM prolongada DD = FE < 20%	Prevalência de DD em 14 (34,1%) ED < 1,0 cm previu o desfecho do desmame.
Dubé et al.⁴⁵45 Dubé BP, Dres M, Mayaux J, Demiri S, Similowski T, Demoule A. Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications. Thorax. 2017;72(9):811-818. https://doi.org/10.1136/thoraxjnl-2016-209459 https://doi.org/10.1136/thoraxjnl-2016-2...	112	UTI clínica	PtrEstim, FE e ED medidas durante as primeiras 24 h de VM ou durante VAC ou na mudança para VPS DD = PtrEstim < 11 cmH₂O	FE e ED correlacionaram-se com PtrEstim na mudança para VPS, mas não no início da VM. FE < 29% identificou DD. FE < 29% relacionou-se com ⇑ tempo de permanência na UTI, ⇑ tempo de VM e ⇑ mortalidade.

Pacientes em estado crítico com insuficiência respiratória em ventilação mecânica
Principais achados	Possíveis implicações clínicas
1. Para diagnosticar DD ED < 1,0 cm¹³13 Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627-2630. https://doi.org/10.1097/CCM.0b013e3182266408 https://doi.org/10.1097/CCM.0b013e318226... ^,⁴⁸48 Valette X, Seguin A, Daubin C, Brunet J, Sauneuf B, Terzi N, et al. Diaphragmatic dysfunction at admission in intensive care unit: the value of diaphragmatic ultrasonography. Intensive Care Med. 2015;41(3):557-559. https://doi.org/10.1007/s00134-014-3636-6 https://doi.org/10.1007/s00134-014-3636-... ^,⁴⁹49 Mariani LF, Bedel J, Gros A, Lerolle N, Milojevic K, Laurent V, et al. Ultrasonography for Screening and Follow-Up of Diaphragmatic Dysfunction in the ICU: A Pilot Study. J Intensive Care Med. 2016;31(5):338-343. https://doi.org/10.1177/0885066615583639 https://doi.org/10.1177/0885066615583639... FE < 20-29%⁴⁵45 Dubé BP, Dres M, Mayaux J, Demiri S, Similowski T, Demoule A. Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications. Thorax. 2017;72(9):811-818. https://doi.org/10.1136/thoraxjnl-2016-209459 https://doi.org/10.1136/thoraxjnl-2016-2... ^,⁵⁰50 Lu Z, Xu Q, Yuan Y, Zhang G, Guo F, Ge H. Diaphragmatic Dysfunction Is Characterized by Increased Duration of Mechanical Ventilation in Subjects With Prolonged Weaning. Respir Care. 2016;61(10):1316-1322. https://doi.org/10.4187/respcare.04746 https://doi.org/10.4187/respcare.04746...	DD (ED < 1,0 cm) relacionou-se com alta taxa de mortalidade (60%) em pacientes com DD e IRA⁴⁸48 Valette X, Seguin A, Daubin C, Brunet J, Sauneuf B, Terzi N, et al. Diaphragmatic dysfunction at admission in intensive care unit: the value of diaphragmatic ultrasonography. Intensive Care Med. 2015;41(3):557-559. https://doi.org/10.1007/s00134-014-3636-6 https://doi.org/10.1007/s00134-014-3636-... , e previu o desfecho do desmame¹³13 Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627-2630. https://doi.org/10.1097/CCM.0b013e3182266408 https://doi.org/10.1097/CCM.0b013e318226... ^,⁵⁰50 Lu Z, Xu Q, Yuan Y, Zhang G, Guo F, Ge H. Diaphragmatic Dysfunction Is Characterized by Increased Duration of Mechanical Ventilation in Subjects With Prolonged Weaning. Respir Care. 2016;61(10):1316-1322. https://doi.org/10.4187/respcare.04746 https://doi.org/10.4187/respcare.04746... ; DD (FE < 29%) relacionou-se com maior tempo de permanência na UTI, VM prolongada e aumento da mortalidade.⁴⁵45 Dubé BP, Dres M, Mayaux J, Demiri S, Similowski T, Demoule A. Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications. Thorax. 2017;72(9):811-818. https://doi.org/10.1136/thoraxjnl-2016-209459 https://doi.org/10.1136/thoraxjnl-2016-2...
2. Para avaliar atrofia do diafragma durante a VM Tdi-exp diminui 6,0-7,5%/dia de VM (especialmente em VMC).¹⁸18 Zambon M, Beccaria P, Matsuno J, Gemma M, Frati E, Colombo S, et al. Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study. Crit Care Med. 2016;44(7):1347-1352. https://doi.org/10.1097/CCM.0000000000001657 https://doi.org/10.1097/CCM.000000000000... ^,²⁸28 Cohn D, Benditt JO, Eveloff S, McCool FD. Diaphragm thickening during inspiration. J Appl Physiol (1985). 1997;83(1):291-296. https://doi.org/10.1152/jappl.1997.83.1.291 https://doi.org/10.1152/jappl.1997.83.1.... ^,⁵²52 Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM. Diaphragm muscle thinning in patients who are mechanically ventilated. Chest. 2012;142(6):1455-1460. https://doi.org/10.1378/chest.11-1638 https://doi.org/10.1378/chest.11-1638... Tdi-exp reduz mais que 10% em 44% dos pacientes e permanece inalterada em 44%.¹²12 Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D, et al. Evolution of Diaphragm Thickness during Mechanical Ventilation. Impact of Inspiratory Effort. Am J Respir Crit Care Med. 2015;192(9):1080-1088. https://doi.org/10.1164/rccm.201503-0620OC https://doi.org/10.1164/rccm.201503-0620...	Atrofia do diafragma (Tdi-exp ⇓ > 10%) relacionada com ⇑ VM,¹⁵15 Schepens T, Verbrugghe W, Dams K, Corthouts B, Parizel PM, Jorens PG. The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study. Crit Care. 2015;19:422. https://doi.org/10.1186/s13054-015-1141-0 https://doi.org/10.1186/s13054-015-1141-... ^,⁶⁴64 Goligher EC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, et al. Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes. Am J Respir Crit Care Med. 2018;197(2):204-213. https://doi.org/10.1164/rccm.201703-0536OC https://doi.org/10.1164/rccm.201703-0536... ⇑ admissão na UTI e ⇑ risco de complicações⁶⁴64 Goligher EC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, et al. Mechanical Ventilation-induced Diaphragm Atrophy Strongly Impacts Clinical Outcomes. Am J Respir Crit Care Med. 2018;197(2):204-213. https://doi.org/10.1164/rccm.201703-0536OC https://doi.org/10.1164/rccm.201703-0536... Hipertrofia do diafragma (Tdi-exp ⇑ > 10%) relacionada com aumento do tempo de VM³⁹39 Kantarci F, Mihmanli I, Demirel MK, Harmanci K, Akman C, Aydogan F, et al. Normal diaphragmatic motion and the effects of body composition: determination with M-mode sonography. J Ultrasound Med. 2004;23(2):255-260. https://doi.org/10.7863/jum.2004.23.2.255 https://doi.org/10.7863/jum.2004.23.2.25...
3. Para prever o desmame da VM ED < 1,0-1,4 cm¹³13 Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39(12):2627-2630. https://doi.org/10.1097/CCM.0b013e3182266408 https://doi.org/10.1097/CCM.0b013e318226... ^,⁴⁰40 Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, et al. Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients. Am J Respir Crit Care Med. 2017;195(1):57-66. https://doi.org/10.1164/rccm.201602-0367OC https://doi.org/10.1164/rccm.201602-0367... ^,⁵³53 Jiang JR, Tsai TH, Jerng JS, Yu CJ, Wu HD, Yang PC. Ultrasonographic evaluation of liver/spleen movements and extubation outcome. Chest. 2004;126(1):179-185. https://doi.org/10.1016/S0012-3692(15)32912-3 https://doi.org/10.1016/S0012-3692(15)32... ^,⁵⁴54 Spadaro S, Grasso S, Mauri T, Dalla Corte F, Alvisi V, Ragazzi R, et al. Can diaphragmatic ultrasonography performed during the T-tube trial predict weaning failure? The role of diaphragmatic rapid shallow breathing index. Crit Care. 2016;20(1):305. https://doi.org/10.1186/s13054-016-1479-y https://doi.org/10.1186/s13054-016-1479-... ^,⁶²62 Farghaly S, Hasan AA. Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients. Aust Crit Care. 2017;30(1):37-43. https://doi.org/10.1016/j.aucc.2016.03.004 https://doi.org/10.1016/j.aucc.2016.03.0... FE < 20-30%⁴⁰40 Dres M, Dubé BP, Mayaux J, Delemazure J, Reuter D, Brochard L, et al. Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients. Am J Respir Crit Care Med. 2017;195(1):57-66. https://doi.org/10.1164/rccm.201602-0367OC https://doi.org/10.1164/rccm.201602-0367... ^,⁴³43 Jung B, Moury PH, Mahul M, de Jong A, Galia F, Prades A, et al. Diaphragmatic dysfunction in patients with ICU-acquired weakness and its impact on extubation failure. Intensive Care Med. 2016;42(5):853-861. https://doi.org/10.1007/s00134-015-4125-2 https://doi.org/10.1007/s00134-015-4125-... ^,⁴⁶46 DiNino E, Gartman EJ, Sethi JM, McCool FD. Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation. Thorax. 2014;69(5):423-427. https://doi.org/10.1136/thoraxjnl-2013-204111 https://doi.org/10.1136/thoraxjnl-2013-2... ^,⁶¹61 Blumhof S, Wheeler D, Thomas K, McCool FD, Mora J. Change in Diaphragmatic Thickness During the Respiratory Cycle Predicts Extubation Success at Various Levels of Pressure Support Ventilation. Lung. 2016;194(4):519-525. https://doi.org/10.1007/s00408-016-9911-2 https://doi.org/10.1007/s00408-016-9911-... 62 Farghaly S, Hasan AA. Diaphragm ultrasound as a new method to predict extubation outcome in mechanically ventilated patients. Aust Crit Care. 2017;30(1):37-43. https://doi.org/10.1016/j.aucc.2016.03.004 https://doi.org/10.1016/j.aucc.2016.03.0... ^-⁶³63 Dres M, Goligher EC, Dubé BP, Morawiec E, Dangers L, Reuter D, et al. Diaphragm function and weaning from mechanical ventilation: an ultrasound and phrenic nerve stimulation clinical study. Ann Intensive Care. 2018;8(1):53. https://doi.org/10.1186/s13613-018-0401-y https://doi.org/10.1186/s13613-018-0401-...	Ultrassonografia diafragmática e previsão do desmame ED < 1 cm e FE < 20-30% relacionadas com aumento de desmame malsucedido
Paralisia diafragmática
Principais achados	Possíveis implicações clínicas
1. Paralisia crônica Atrofia: Tdi-exp < 0,11-0,12 cm (LIN)⁷7 Caleffi-Pereira M, Pletsch-Assunção R, Cardenas LZ, Santana PV, Ferreira JG, Iamonti VC, et al. Unilateral diaphragm paralysis: a dysfunction restricted not just to one hemidiaphragm. BMC Pulm Med. 2018;18(1):126. https://doi.org/10.1186/s12890-018-0698-1 https://doi.org/10.1186/s12890-018-0698-... FE < 20%, até mesmo negativa²⁶26 Gottesman E, McCool FD. Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med. 1997;155(5):1570-1574. https://doi.org/10.1164/ajrccm.155.5.9154859 https://doi.org/10.1164/ajrccm.155.5.915... ED ausente ou fraca/paradoxal durante RT³⁴34 Boussuges A, Brégeon F, Blanc P, Gil JM, Poirette L. Characteristics of the paralysed diaphragm studied by M-mode ultrasonography. Clin Physiol Funct Imaging. 2019;39(2):143-149. https://doi.org/10.1111/cpf.12549 https://doi.org/10.1111/cpf.12549... ^,³⁵35 Lloyd T, Tang YM, Benson MD, King S. Diaphragmatic paralysis: the use of M mode ultrasound for diagnosis in adults. Spinal Cord. 2006;44(8):505-508. https://doi.org/10.1038/sj.sc.3101889 https://doi.org/10.1038/sj.sc.3101889... ED reduzida, ausente ou paradoxal durante RP e sniffing³⁴34 Boussuges A, Brégeon F, Blanc P, Gil JM, Poirette L. Characteristics of the paralysed diaphragm studied by M-mode ultrasonography. Clin Physiol Funct Imaging. 2019;39(2):143-149. https://doi.org/10.1111/cpf.12549 https://doi.org/10.1111/cpf.12549... 2. Paralisia aguda ou subaguda Tdi-exp inalterada (Tdi-exp > 0,15 cm) com FE anormal (FE < 20% ou mesmo negativa)³⁷37 Santana PV, Prina E, Caruso P, Carvalho CR, Albuquerque AL. Dyspnea of unknown cause. Think about diaphragm. Ann Am Thorac Soc. 2014;11(10):1656-1659. https://doi.org/10.1513/AnnalsATS.201404-181CC https://doi.org/10.1513/AnnalsATS.201404...	Em caso de suspeita de paralisia diafragmática: ED reduzida, ausente ou paradoxal apoia o diagnóstico. Tdi-exp reduzida (< 0,11 cm) e FE reduzida (< 20%) apoiam o diagnóstico de paralisia diafragmática crônica. ED reduzida, ausente ou paradoxal e FE reduzida < 20% apoiam o diagnóstico de paralisia diafragmática aguda/subaguda (a Tdi-exp pode permanecer inalterada). A ultrassonografia diafragmática pode acompanhar a recuperação da paralisia diafragmática.³⁸38 Summerhill EM, El-Sameed YA, Glidden TJ, McCool FD. Monitoring recovery from diaphragm paralysis with ultrasound. Chest. 2008;133(3):737-743. https://doi.org/10.1378/chest.07-2200 https://doi.org/10.1378/chest.07-2200...
Fibrose cística
Principais achados	Possíveis implicações clínicas
1. Aumento da Tdi-exp (efeito do treinamento do diafragma)⁶⁷67 Pinet C, Cassart M, Scillia P, Lamotte M, Knoop C, Casimir G, et al. Function and bulk of respiratory and limb muscles in patients with cystic fibrosis. Am J Respir Crit Care Med. 2003;168(8):989-994. https://doi.org/10.1164/rccm.200303-398OC https://doi.org/10.1164/rccm.200303-398O... ^,⁶⁸68 Dufresne V, Knoop C, Van Muylem A, Malfroot A, Lamotte M, Opdekamp C, et al. Effect of systemic inflammation on inspiratory and limb muscle strength and bulk in cystic fibrosis. Am J Respir Crit Care Med. 2009;180(2):153-158. https://doi.org/10.1164/rccm.200802-232OC https://doi.org/10.1164/rccm.200802-232O... 2. Redução da Tdi-exp na doença pulmonar grave e massa magra baixa⁶⁹69 Enright S, Chatham K, Ionescu AA, Unnithan VB, Shale DJ. The influence of body composition on respiratory muscle, lung function and diaphragm thickness in adults with cystic fibrosis. J Cyst Fibros. 2007;6(6):384-390. https://doi.org/10.1016/j.jcf.2007.02.006 https://doi.org/10.1016/j.jcf.2007.02.00...	Aumento da Tdi-exp (em virtude do efeito do treinamento do diafragma) ou redução da Tdi-exp (em virtude de efeitos deletérios na função muscular respiratória)
DPOC
Principais achados	Possíveis implicações clínicas
1. Mobilidade diafragmática reduzida,⁷⁰70 Paulin E, Yamaguti WP, Chammas MC, Shibao S, Stelmach R, Cukier A, et al. Influence of diaphragmatic mobility on exercise tolerance and dyspnea in patients with COPD. Respir Med. 2007;101(10):2113-2118. https://doi.org/10.1016/j.rmed.2007.05.024 https://doi.org/10.1016/j.rmed.2007.05.0... ^,⁷¹71 Dos Santos Yamaguti WP, Paulin E, Shibao S, Chammas MC, Salge JM, Ribeiro M, et al. Air trapping: The major factor limiting diaphragm mobility in chronic obstructive pulmonary disease patients. Respirology. 2008;13(1):138-144. https://doi.org/10.1111/j.1440-1843.2007.01194.x https://doi.org/10.1111/j.1440-1843.2007... que se correlacionou inversamente com aprisionamento aéreo⁷¹71 Dos Santos Yamaguti WP, Paulin E, Shibao S, Chammas MC, Salge JM, Ribeiro M, et al. Air trapping: The major factor limiting diaphragm mobility in chronic obstructive pulmonary disease patients. Respirology. 2008;13(1):138-144. https://doi.org/10.1111/j.1440-1843.2007.01194.x https://doi.org/10.1111/j.1440-1843.2007... e dispneia,⁷⁰70 Paulin E, Yamaguti WP, Chammas MC, Shibao S, Stelmach R, Cukier A, et al. Influence of diaphragmatic mobility on exercise tolerance and dyspnea in patients with COPD. Respir Med. 2007;101(10):2113-2118. https://doi.org/10.1016/j.rmed.2007.05.024 https://doi.org/10.1016/j.rmed.2007.05.0... e positivamente com a DTC6⁷⁰70 Paulin E, Yamaguti WP, Chammas MC, Shibao S, Stelmach R, Cukier A, et al. Influence of diaphragmatic mobility on exercise tolerance and dyspnea in patients with COPD. Respir Med. 2007;101(10):2113-2118. https://doi.org/10.1016/j.rmed.2007.05.024 https://doi.org/10.1016/j.rmed.2007.05.0... 2. Tdi-exp e FE semelhantes às do grupo controle⁷²72 Baria MR, Shahgholi L, Sorenson EJ, Harper CJ, Lim KG, Strommen JA, et al. B-mode ultrasound assessment of diaphragm structure and function in patients with COPD. Chest. 2014;146(3):680-685. https://doi.org/10.1378/chest.13-2306 https://doi.org/10.1378/chest.13-2306... 3. Tdi-exp e FE correlacionaram-se inversamente com aprisionamento aéreo⁷³73 Smargiassi A, Inchingolo R, Tagliaboschi L, Di Marco Berardino A, Valente S, Corbo GM. Ultrasonographic assessment of the diaphragm in chronic obstructive pulmonary disease patients: relationships with pulmonary function and the influence of body composition - a pilot study. Respiration. 2014;87(5):364-371. https://doi.org/10.1159/000358564 https://doi.org/10.1159/000358564... 4. Durante a exacerbação aguda da DPOC: DD (FE < 20%) relacionou-se com piores desfechos (VNI malsucedida, maior tempo de permanência na UTI, VM prolongada, necessidade de traqueostomia).⁷⁴74 Antenora F, Fantini R, Iattoni A, Castaniere I, Sdanganelli A, Livrieri F, et al. Prevalence and outcomes of diaphragmatic dysfunction assessed by ultrasound technology during acute exacerbation of COPD: A pilot study. Respirology. 2017;22(2):338-344. https://doi.org/10.1111/resp.12916 https://doi.org/10.1111/resp.12916... ED previu VNI malsucedida.⁷⁶76 Cammarota G, Sguazzotti I, Zanoni M, Messina A, Colombo D, Vignazia GL, et al. Diaphragmatic Ultrasound Assessment in Subjects With Acute Hypercapnic Respiratory Failure Admitted to the Emergency Department. Respir Care. 2019;64(12):1469-1477. https://doi.org/10.4187/respcare.06803 https://doi.org/10.4187/respcare.06803...	O aprisionamento aéreo correlacionou-se com redução da mobilidade, espessura e espessamento diafragmático. A redução da mobilidade diafragmática correlacionou-se com aumento da dispneia aos esforços. A redução da FE (< 20%) e da mobilidade durante a exacerbação aguda da DPOC correlaciona-se com piores desfechos. A ED previu falha precoce da VNI. A ED foi maior nos casos de VNI bem-sucedida do que nos de VNI malsucedida.
Doenças pulmonares intersticiais
Principais achados	Possíveis implicações clínicas
1. A redução da mobilidade diafragmática durante a RP correlacionou-se com a função pulmonar.⁷⁸78 Santana PV, Prina E, Albuquerque AL, Carvalho CR, Caruso P. Identifying decreased diaphragmatic mobility and diaphragm thickening in interstitial lung disease: the utility of ultrasound imaging. J Bras Pneumol. 2016;42(2):88-94. https://doi.org/10.1590/S1806-37562015000000266 https://doi.org/10.1590/S1806-3756201500... 79 Boccatonda A, Decorato V, Cocco G, Marinari S, Schiavone C. Ultrasound evaluation of diaphragmatic mobility in patients with idiopathic lung fibrosis: a pilot study. Multidiscip Respir Med. 2018;14:1. https://doi.org/10.1186/s40248-018-0159-y https://doi.org/10.1186/s40248-018-0159-... ^-⁸⁰80 Santana PV, Cardenas LZ, de Albuquerque ALP, de Carvalho CRR, Caruso P. Diaphragmatic ultrasound findings correlate with dyspnea, exercise tolerance, health-related quality of life and lung function in patients with fibrotic interstitial lung disease. BMC Pulm Med. 2019;19(1):183. https://doi.org/10.1186/s12890-019-0936-1 https://doi.org/10.1186/s12890-019-0936-... 2. O aumento da Tdi-exp é um efeito do treinamento do diafragma.⁷⁸78 Santana PV, Prina E, Albuquerque AL, Carvalho CR, Caruso P. Identifying decreased diaphragmatic mobility and diaphragm thickening in interstitial lung disease: the utility of ultrasound imaging. J Bras Pneumol. 2016;42(2):88-94. https://doi.org/10.1590/S1806-37562015000000266 https://doi.org/10.1590/S1806-3756201500... ^,⁸⁰80 Santana PV, Cardenas LZ, de Albuquerque ALP, de Carvalho CRR, Caruso P. Diaphragmatic ultrasound findings correlate with dyspnea, exercise tolerance, health-related quality of life and lung function in patients with fibrotic interstitial lung disease. BMC Pulm Med. 2019;19(1):183. https://doi.org/10.1186/s12890-019-0936-1 https://doi.org/10.1186/s12890-019-0936-... 3. A redução da mobilidade e do espessamento durante a RP correlacionou-se positivamente com função pulmonar, tolerância ao exercício e QVRS, e negativamente com dispneia.⁸⁰80 Santana PV, Cardenas LZ, de Albuquerque ALP, de Carvalho CRR, Caruso P. Diaphragmatic ultrasound findings correlate with dyspnea, exercise tolerance, health-related quality of life and lung function in patients with fibrotic interstitial lung disease. BMC Pulm Med. 2019;19(1):183. https://doi.org/10.1186/s12890-019-0936-1 https://doi.org/10.1186/s12890-019-0936-...	A restrição pulmonar (volumes pulmonares reduzidos) reduz a mobilidade e o espessamento diafragmático. A mobilidade e o espessamento diafragmático máximo relacionam-se com parâmetros clinicamente relevantes (tolerância ao exercício, QVRS e dispneia).
Doenças neuromusculares
Principais achados	Possíveis implicações clínicas
1. Redução da Tdi-exp e do espessamento em pacientes com ELA com capacidade vital < 80% do previsto⁸⁵85 Hiwatani Y, Sakata M, Miwa H. Ultrasonography of the diaphragm in amyotrophic lateral sclerosis: clinical significance in assessment of respiratory functions. Amyotroph Lateral Scler Frontotemporal Degener. 2013;14(2):127-131. https://doi.org/10.3109/17482968.2012.729595 https://doi.org/10.3109/17482968.2012.72... e naqueles com ELA de início bulbar⁸⁶86 Sartucci F, Pelagatti A, Santin M, Bocci T, Dolciotti C, Bongioanni P. Diaphragm ultrasonography in amyotrophic lateral sclerosis: a diagnostic tool to assess ventilatory dysfunction and disease severity. Neurol Sci. 2019;40(10):2065-2071. https://doi.org/10.1007/s10072-019-03938-9 https://doi.org/10.1007/s10072-019-03938... 2. O espessamento com a inspiração correlacionou-se com SNIP e PEmáx⁸⁴84 Pinto S, Alves P, Pimentel B, Swash M, de Carvalho M. Ultrasound for assessment of diaphragm in ALS. Clin Neurophysiol. 2016;127(1):892-897. https://doi.org/10.1016/j.clinph.2015.03.024 https://doi.org/10.1016/j.clinph.2015.03... e função pulmonar.⁸³83 Fantini R, Mandrioli J, Zona S, Antenora F, Iattoni A, Monelli M, et al. Ultrasound assessment of diaphragmatic function in patients with amyotrophic lateral sclerosis. Respirology. 2016;21(5):932-938. https://doi.org/10.1111/resp.12759 https://doi.org/10.1111/resp.12759... 3. A excursão máxima correlacionou-se com a CVF.⁸⁷87 Carrié C, Bonnardel E, Vally R, Revel P, Marthan R, Marthan R. Vital Capacity Impairment due to Neuromuscular Disease and its Correlation with Diaphragmatic Ultrasound: A Preliminary Study. Ultrasound Med Biol. 2016;42(1):143-149. https://doi.org/10.1016/j.ultrasmedbio.2015.09.020 https://doi.org/10.1016/j.ultrasmedbio.2... 4. A relação Tdi em VC/Tdi em CPT indica fraqueza e pode prever o início de VNI na ELA.⁸⁸88 Fantini R, Tonelli R, Castaniere I, Tabbì L, Pellegrino MR, Cerri S, et al. Serial ultrasound assessment of diaphragmatic function and clinical outcome in patients with amyotrophic lateral sclerosis. BMC Pulm Med. 2019;19(1):160. https://doi.org/10.1186/s12890-019-0924-5 https://doi.org/10.1186/s12890-019-0924-... 5. Distrofia muscular de Duchenne e distrofia miotônica tipo 1: Mobilidade reduzida durante a RP e sniffing⁸⁹89 Fayssoil A, Nguyen LS, Ogna A, Stojkovic T, Meng P, Mompoint D, et al. Diaphragm sniff ultrasound: Normal values, relationship with sniff nasal pressure and accuracy for predicting respiratory involvement in patients with neuromuscular disorders. PLoS One. 2019;14(4):e0214288. https://doi.org/10.1371/journal.pone.0214288 https://doi.org/10.1371/journal.pone.021... A excursão durante a RP correlacionou-se com valores de CVF.⁸⁹89 Fayssoil A, Nguyen LS, Ogna A, Stojkovic T, Meng P, Mompoint D, et al. Diaphragm sniff ultrasound: Normal values, relationship with sniff nasal pressure and accuracy for predicting respiratory involvement in patients with neuromuscular disorders. PLoS One. 2019;14(4):e0214288. https://doi.org/10.1371/journal.pone.0214288 https://doi.org/10.1371/journal.pone.021...	A espessura e excursão diafragmática diminuem e correlacionam-se com a função pulmonar na ELA. O espessamento diafragmático pode estar relacionado com a força muscular respiratória na ELA. A relação Tdi em VC/Tdi em CPT pode sugerir a presença de fraqueza e prever o início de VNI na ELA. A mobilidade diafragmática durante a RP e sniffing pode estar relacionada com SNIP e função pulmonar na distrofia muscular de Duchenne e distrofia miotônica tipo 1.

[1] Endereço para correspondência: Pauliane Vieira Santana. Avenida Dr. Enéas de Carvalho Aguiar, 45, 5º andar, Bloco 2, Sala 1, CEP 05403-900, São Paulo, SP, Brasil. Tel./Fax: 55 11 2661-5990. E-mail: paulivisa@gmail.com

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Ultrassonografia diafragmática: uma revisão de seus aspectos metodológicos e usos clínicos

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