Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR
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This pathway provides guidance on the imaging investigation of adult patients with a raised hemi-diaphragm on previous chest radiographs.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
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- Common causes of elevation of a hemidiaphragm include
- Lung volume loss
- Abdominal disease
- Phrenic nerve palsy
- Comparison with previous films of the chest is the initial assessment
- Further investigations may include fluoroscopy, ultrasound and CT of the chest based on the suspicion of an underlying clinical diagnosis
Computed Tomography (CT)
- Simplest, quickest, and most practical method of assessing diaphragm movement
- Primarily a qualitative method, quantitative information being indirectly obtained and limited geometrically by the divergent beam and object to film distance
- Reduced, absent or paradoxical movement of the hemidiaphragm, especially during sniffing infers hemidiaphragmatic paresis or paralysis ,,
- Limitations - diaphragm motion may be diminished due to inflammatory processes such as pneumonia, pleuritis, pleural effusion, peritonitis, and subphrenic abscess, so fluoroscopic assessment is best delayed until reversible conditions that may affect the diaphragm have been treated to resolution
- Common causes of unilateral hemidiaphragm elevation include
- Lung volume loss (atelectasis, lobar collapse, partial lung resection, radiation fibrosis, congenital hypoplasia)
- Abdominal disease (dilated stomach or colon, hepatomegaly, splenomegaly, subphrenic abscess)
- Phrenic nerve paralysis
- Mimics (subpulmonic pleural effusion, large pleural mass, diaphragmatic hernia)
- Diaphragmatic paralysis is most frequently caused by interruption of the phrenic nerve, and may be unilateral or bilateral. Phrenic nerve invasion by a malignant neoplasm and trauma related to cardiothoracic surgery (stretch, crush, or transection) are the most common causes, although many cases are idiopathic
- Useful in the evaluation of patients with suspected abnormalities of diaphragmatic movement ,,
- Equivalent to fluoroscopy in diagnosing diaphragm dysfunction
- Superior to plain radiographs in the assessment of some supradiaphragmatic causes (e.g. pleural effusion, pleural masses) and most subdiaphragmatic causes (hepatomegaly, subphrenic collections, etc) of elevated hemidiaphragm
- Advantages- direct quantitative, quick and portable method of assessing hemidiaphragmatic movement
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Gierada DS, Slone RM, Fleishman MJ. Imaging evaluation of the diaphragm. Chest Surg Clin N Am. 1998;8:237-80. (Review article)
- Tarver RD, Conces DJ Jr, Cory DA, et al. Imaging of the diaphragm and its disorders. J Thorac Imag. 1989;4:1-18. (Review article)
- Houston JG, Fleet M, Cowan MD, et al. Comparison of ultrasound with fluoroscopy in the assessment of suspected hemidiaphragmatic movement abnormality. Clin Radiol. 1995;50:95-8. (Level III evidence)
- Gottesman E, McCool D. Ultrasound evaluation of the paralysed diaphragm. Am J Respir Crit Care Med. 1997;155:1570-4. (Level III evidence)
- Cohen E, Mier A, Heywood P, et al. Excursion-volume relation of the right hemidiaphragm measured by ultrasonography and respiratory airflow measurements. Thorax. 1994;49:885-9. (Level III evidence)
- Brink JA, Heiken JP, Semenkovich J, et al. Abnormalities of the diaphragm and adjacent structures: findings on multiplanar spiral CT scans. AJR Am J Roentgenol. 1994;163:307-10. (Pictorial essay)
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