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Evaluation of the diaphragm by a subcostal B-scan technique. When the patient inspires, each hand should rotate away from the midline equally. [1,2], Different imaging modalities can be employed for the evaluation of the diaphragm. 1978 Mar. [2, 3], Longstanding obstructive disease can lead to what is commonly known as barrel chest, in which the ribs lose their typical 45 downward angle, leading to an increase of the anteroposterior diameter of the chest. They are often characterized by secretions within the large airways and can be heard in a wide variety of pathologies, any of which cause increased secretions, such as in cystic fibrosis, pneumonia, bronchitis, pulmonary edema, or emphysema. By clicking Accept, you consent to the use of ALL the cookies. Differential Diagnoses of Crackles. (Chest wall motion may be attenuated compared to that on slow deep inspiration.) Examination of the shape of the chest is used to assess the structure of the ribs and spine. [1, 2]. Cheyne-Stokes respiration is characterized by periods of apnea that are interspersed between cycles of progressively increasing then decreasing respiratory rates, which often indicates uremia or congestive heart failure (CHF). https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTkwOTE1OS10ZWNobmlxdWU=. Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation. Richard S Tennant, MD Hospitalist in Internal Medicine, Olive View-UCLA Medical Center [QxMD MEDLINE Link]. Temporary or permanent, unilateral or bilateral diaphragmatic functional deficiencies can arise at three levels: The nervous system, the muscle, or the neuromuscular junction. Diaphragmatic motion: Fast gradient-recalledecho MR imaging in healthy subjects. The thorax and cardiovascular system. Always follow this sequence: inspection, auscultation, percussion, and palpation. There may be upward (paradoxical) motion on deep or even quiet breathing. . One important nonpulmonary sound is a mediastinal crunch, caused by pneumomediastinum. Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Diaphragmatic motion recorded by M-mode ultrasonography: limits of normality. Backward, physicians and radiologists should be aware of the undoubted advantages of MRI and confident about the normal or pathologic imaging features, to avoid misdiagnosis. Epler GR, Carrington CB, Gaensler EA. Am J Respir Crit Care Med. Careers. 355-65. Clin Chest Med. Diaphragmatic excursion is a quantitative measure of expiratory effort as validated by both lung and tracheal volumes in asthma patients, and may be more accurate than qualitative assessment based on tracheal morphology. Pulmonary Exam: Percussion & Inspection. On supine and semisupine views this mechanism is defeated, and excursion of the hemidiaphragms is severely reduced. 1987 Oct. 136(4):1016. [QxMD MEDLINE Link]. Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine Biomed Phys Eng Express 2015;1:045015. Often the finding of asymmetry is more important than the specific percussion note that is heard. Methods: A total of 400 healthy participants aged between 1 month and 16 years, divided into 4 . Spinal Cord 2006;44:505-8. On deep breathing excursion of the eventrated segment is less than the rest of the hemidiaphragm. Normal diaphragmatic excursion should be 35 cm, but can be increased in well-conditioned persons to 78 cm. This technique includes upright frontal and lateral views followed by semisupine and fully supine frontal views. [QxMD MEDLINE Link]. Normal breath sounds are classified as tracheal, bronchial, bronchovesicular, and vesicular sounds. Average diaphragmatic excursion was 2.5 cm between inspiratory and expiratory scans (2.7 cm in men, 2.3 cm in women; p = .5 . Pulmonary Examination Findings of Common Disorders, Table 2. Age, sex and BMI significantly affected the diaphragmatic motion. Maitre B, Similowski T, Derenne JP. Pulmonary examination findings of common disorders. Documentation of a basic, normal respiratory exam should look something along the lines of the following: The chest wall is symmetric, without deformity, and is atraumatic in appearance. A large eventration may be mistaken for a paralyzed or weak hemidiaphragm, but the pattern of elevation is different; in eventration the hemidiaphragm has a steeper arc and descends posteriorly to normal height, whereas a paralyzed or weak hemidiaphragm has a shallower arc and stays elevated posteriorly all the way to the chest wall. 78.2 ). The pitch is usually high, as the sounds arise from the bronchi, and the expiratory phase generally lasts longer and is as intense as, or more intense than, the inspiratory phase. [7], Bronchial breath sounds often result from consolidation within lung parenchyma with a patent airway leading to the involved area. One dog with bilateral diaphragmatic paralysis showed paradoxical movement of both crura at the end of inspiration. Tactile fremitus increases with pneumonia or pulmonary edema and decreases in pleural effusion or lung hyperinflation. References: [3 . The diaphragm is, MeSH These are sites where the major bronchi are closest to the chest wall. The supine view is needed to reveal bilateral hemidiaphragmatic paralysis when the apparently normal diaphragm excursion on upright views is actually passive movement from use of the abdominal muscles. Fluoroscopy (not shown) demonstrated absent downward motion on deep inspiration and paradoxical upward motion of the left hemidiaphragm on sniffing. %%EOF Murray and Nadel's Textbook of Respiratory Medicine. These sounds occur in addition to the breath sounds described above. This anatomy article is a stub. Left dominance is twice as common as right dominance and the mean left excursion is greater than the mean right excursion. Tilt the fluoroscopic table to 45 degrees elevation. The authors certify that they have obtained all appropriate patient consent forms. There was a statistically significant difference between right and left diaphragmatic excursion among all studied subjects. Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center On deep breathing downward excursion is nearly or completely absent. Measurement of diaphragmatic motion by ultrasound is being utilized in different aspects of clinical practice. Another important sound is a pleural rub, which can be appreciated as having a sandpaperlike quality and is typically present throughout the respiratory cycle. In some cases, a collapsed lung is caused by air blisters (blebs) that break open, sending air into the space around the lung. How to cite this article: Cicero G, Mazziotti S, Blandino A, Granata F, Gaeta M. Magnetic resonance imaging of the diaphragm: From normal to pathologic findings. The B-mode was applied for diaphragmatic identification, and the M-mode was employed for the recording of the amplitude of diaphragm contraction during quiet breathing, deep breathing and sniffing. The crus atrophies with paralysis but not with eventration ( Fig. [2, 3, 4], Table 1 illustrates changes in fremitus in several common disorders. Overall Chest Expansion: Take a tape and encircle chest around the level of nipple. It is generally defined as a zoonotic infection caused by the incidental ingestion of the eggs of a small tapeworm parasite (Echinococcus granulosus), and the involvement of the diaphragm is of rare occurrence. Excursion is usually one rib interspace or more. Table 1 shows possible tracheal findings in several common disorders. The left crus is normally slightly thinner than the right. During the pulmonary examination, inspection is a useful tool for the physician from which much information can be garnered. Haisam Abid, MBBS Resident Physician, Department of Internal Medicine, Bassett Healthcare Network For the rest of this chapter we will use eventration to mean partial eventration . The transmitted sounds will be louder over the area of consolidation. Crackles (rales) in the interstitial pulmonary diseases. The mean right hemidiaphragmatic excursion was 2.320.54, 5.541.26 and 2.900.63 for quiet breathing, deep breathing and sniffing, respectively, while the left hemidiaphragmatic excursion was 2.350.54, 5.301.21 and 2.970.56 cm for quiet breathing, deep breathing and sniffing, respectively. . This measures the contraction of the diaphragm. To assess for tactile fremitus, ask the patient to say 99 or blue moon. The injuries of the diaphragm are a relatively rare occurrence in subjects suffering from thoracic-abdominal trauma (0.88%) and can be related to blunt or penetrating traumas. Diaphragmatic anterior or posterior congenital defects account for some cases of herniation. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. (https://www.facebook.com/medschoolmadeeasy) Check out our website for TONS OF FREE REV. Unauthorized use of these marks is strictly prohibited. Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina. For the remaining normal dogs, the lower limit values of diaphragmatic excursion were 2.85-2.98 mm during normal breathing. Hence, the aim of this paper is to provide an overview of normal and pathological features of the diaphragm on MRI and, therefore, to demonstrate the usefulness of this technique in different clinical circumstances. government site. On supine position there may be excess elevation of the resting position of the eventrated segment. J Clin Imaging Sci 2020;10:1. Left dominance is twice as common as right dominance and the mean left excursion is greater than the . Turn the patient into the lateral position, with arms out of the field of view. The patient does not exhibit signs of respiratory distress. A rocking motion may ensue on lateral view, with the anterior eventrated segment moving upward while the posterior portion moves downward. Computed tomography (CT)-scan can provide morphological but not functional information about the diaphragm. No tenderness is appreciated upon palpation of the chest wall. That is where the provider marks the spot. Phrenic nerve stimulation may benefit patients with intact phrenic nerve function and absence of myopathy, such as those with high cervical spine injuries causing bilateral hemidiaphragmatic paralysis. Different imaging modalities can be employed for diaphragmatic evaluation. The use of accessory muscles can also indicate increased work of breathing and should be noted on initial assessment. The examiner places the ulnar edge of the hand on the chest wall while the patient repeats a specific phrase, typically ninety-nine or one, two, three. The strength of the vibrations felt indicates the attenuation of sounds transmitted through the lung tissues. Palpation of the chest includes evaluation of thoracic expansion, percussion, and evaluation of diaphragmatic excursion. Bronchophony is present if sounds can be heard clearly. Adventitious sounds are the medical term for respiratory noises beyond that of normal breath sounds. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. This reduced aeration also results in a change of the pitch of the transmitted sounds, called egophony. Crepitation refers to situations where noises are produced by the rubbing of parts one against the other, as in: Crepitus, a crunching sensation felt in certain medical problems. Maximal excursion of the diaphragm may be as much as 8 to 10 cm . c. assess respiratory excursion (expansive movements of the chest during breathing) d. assess skin condition (temperature, etc.) Again observe two deep breaths, then two quiet breaths, and note the resting positions of both hemidiaphragms at end expiration. Fremitus is abnormal when it is increased or decreased. Normal lung tissues have a substantial amount of airspace to attenuate and soften the sound. Graduated from ENSAT (national agronomic school of Toulouse) in plant sciences in 2018, I pursued a CIFRE doctorate under contract with SunAgri and INRAE in Avignon between 2019 and 2022. Bilateral paralysis occurs occasionally after cardioplegia for cardiac surgery; this form is usually reversible with time. Normal findings . The most common scenario, due to contiguity, consists of the direct extent from the liver (0.616%). The lung exam. In pitting one hemidiaphragm against the other, sniffing is analogous to arm wrestling, in which the arm of the stronger opponent pushes forward, forcing the weaker opponents arm backward (i.e., paradoxically), even though the weaker arm is not paralyzed. Diaphragmatic excursion during spontaneous ventilation (SV) in normal supine volunteers is greatest in the dependent regions (bottom). Although diaphragm fluoroscopy is often called the sniff test, sniffing is not the most important part, and sniffing by itself does not diagnose paralysis. Therefore, diaphragmatic dysfunction may cause a respiratory failure without any pathology of the lungs. Cystic echinococcosis (or hydatid disease) is considered a separate chapter in the field of cystic lesions. asymmetry, diaphragmatic excursion, crepitus, and vocal fremitus. Learn how and when to remove this template message, "Diaphragmatic Excursion-Posterior Lungs", https://en.wikipedia.org/w/index.php?title=Diaphragmatic_excursion&oldid=973014894, Articles needing additional references from January 2014, All articles needing additional references, Creative Commons Attribution-ShareAlike License 3.0, This page was last edited on 14 August 2020, at 22:53. Bilateral hemidiaphragmatic weakness can also occur after prolonged mechanical ventilation and may signal that the patient cannot be weaned from the ventilator. Whispered pectoriloquy can be elicited by having the patient whisper a repeated phrase (typically ninety nine). The lateral view also shows the anterior and upward movement of the chest wall on inspiration. You are being redirected to Those with comorbidities, skeletal deformity, acute or chronic respiratory illness were excluded. Complete eventration almost exclusively affects the left hemidiaphragm. Conservative management is indicated for asymptomatic patients with hemidiaphragmatic weakness or paralysis. Adventitious sounds can be classified as crackles, wheezes, rhonchi, or stridor. Dyspnea with mild to moderate effort may develop in patients with underlying lung disease. Eight of the clinically normal dogs were excluded due to abnormal thoracic radiographic findings. While the patient is speaking, palpate the chest from one side to the other. Pleural effusion the buildup of pleural fluid in the pleural cavity. When examining for tactile fremitus, it is important is: C.Palpate the chest symmetrically. This website also contains material copyrighted by 3rd parties. Bookshelf What is the ICD-10-CM code for skin rash? Within the formers, the left hemidiaphragm has demonstrated to be the most vulnerable, due to the lack of liver protection and the inherent structural weakness. The liver is used as an echogenic window. M-mode sonography of diaphragmatic motion: Description of technique and experience in 278 pediatric patients. 5376 Diaphragmatic Excursion in Healthy Adults: Normal alues. Axial CT (A) near level of celiac artery and coronal reformat (B) in a patient with elevation of the left hemidiaphragm by large eventration show normal thickness of the right crus, Key Points: Abnormalities of Diaphragmatic Motion, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Lymphangioleiomyomatosis and Tuberous Sclerosis, Occasional transient upward motion of right anterior hemidiaphragm during strong sniffing, Weakness more evident on rapid deep inspiration with weak hemidiaphragm lagging behind normal side, Adjacent basal atelectasis; ipsilateral crus thinning on CT, Absent downward motion or bilateral upward motion, Adjacent basal atelectasis; supine imaging necessary to show absent motion; bilateral crus thinning on CT, Reduced downward motion of affected segment; occasional upward motion. Bronchiectasis, which can be secondary to the following: Wheezes are continuous, high-pitched, musical, predominantly expiratory sounds that are produced by air flowing through narrowed bronchi, causing fluttering and resonance of the bronchial walls. Continuous adventitious lung sounds. [4], In particular, the latter considerations are particularly important in the challenging differential diagnosis of lung diseases from diaphragm weakness in patients suffering from respiratory failure.[6]. The author shows that unequal excursion of the two leaves of the diaphragm is a normal finding. On supine views there may excess elevation of the resting position of the hemidiaphragm. Turn the patient back into the frontal position. The lower cervical canal measures 12-14 mm. Small eventration of the right hemidiaphragm. Areas of well-aerated lung will be resonant, or tympanic, to percussion. Would you like email updates of new search results? [6], Normally the diaphragm looks like a thin band with low signal intensity on both the T1-w and T2-w images.[3]. An important role of computed tomography (CT) in the assessment of patients with diaphragmatic paralysis is to rule out tumor, lymphadenopathy, aneurysm, or other lesion that may be compromising the phrenic nerve ( Fig. and transmitted securely. [8,14], Benign entities are usually asymptomatic unless their size leads to a mass-effect, generally with respiratory impairment. Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic SocietyDisclosure: Nothing to disclose. However, US limitations consist in the restricted field of view, the possible impairment of lung air or bowel gas superimposition, and the strictly reliance on the operator's expertise. Inspiratory crackles and mechanical events of breathing. 8. It affects men and women with equal frequency. 1. Assessing your patients abdomen can provide critical information about his internal organs. These cookies track visitors across websites and collect information to provide customized ads. The doctor then percusses down their back in the intercostal margins (bone will be dull), starting below the scapula, until sounds change from resonant to dull (lungs are resonant, solid organs should be dull). The https:// ensures that you are connecting to the The diaphragm is a musculotendinous structure that divides the chest from the abdomen. The ratio of right to left diaphragmatic excursion during quiet breathing was (1.0090.19); maximum 181% and minimum 28%. On lateral view excursion is usually greater posteriorly, particularly on the right; it may be slightly asymmetric, and the right side may lag, particularly anteriorly. The main role of CT in patients with eventration is in distinguishing the abnormality from a focal bulge along the diaphragm that might represent hernia or even tumor. These muscles include the sternocleidomastoid, upper trapezius, pectoralis major, and others. endstream endobj startxref Percussion produces sounds on a spectrum from flat to dull depending on the density of the underlying tissue. J Clin Imaging Sci. The usual imaging test to demonstrate hemidiaphragmatic paralysis, weakness, or eventration is fluoroscopy, but ultrasonography or dynamic magnetic resonance (MRI) can be used. Visualization and measurement of right diaphragmatic excursion by M-mode ultrasound. Ultrasonography recordings were . Table 2. New York: McGraw-Hill; 1994. An adult male without spinal stenosis has a diameter of 16-17 mm in the upper and middle cervical levels. From this site, the infection can easily diffuse into the thorax, involving mediastinum, pleura, and lung parenchyma with the formation of a bronchial fistula. Note the hyper-resonance of the left lower anterior chest due to air filled stomach. [QxMD MEDLINE Link]. Hemidiaphragmatic weakness often becomes more obvious on rapid, deep inspiration, with the weak hemidiaphragm lagging behind the normal side. Table 1. This measures the contraction of the diaphragm. 7-8 cm. studies are probably needed to determine whether there is any correlation between the patient's age and the range of normal diaphragmatic excursion. Take in a deep breathnow let it out.now close your mouth and sniff!). In well-conditioned clients, excursion can measure up to. An official website of the United States government. Cugell DW. Areas of increased vibration or fremitus correspond to areas of increased tissue density such as those caused by consolidation by pneumonia or malignancy. This should be performed over the anterior and posterior chest. Afterward, the images can be displayed in a cine-loop viewing, thus providing a dynamic report about diaphragmatic motion.[7]. Differential breathing patterns can give clues to diseases of multiple different organ systems as much as the respiratory system itself. [QxMD MEDLINE Link]. RI: Right Index, REXI: Right Membranatic Excursion, SAFI: ratio regarding saturation to inspired oxygen fraction (SO 2 /FiO 2), LI: Lefts Index, LEXI: Left Diaphragmatic Excursion.. Consonant to previously published recommendations, the manner of weigh right and left diaphragmatic excursion was performed [].B-mode was first utilized to find the our focus and to select an scan line the each . Repeat. M-mode ultrasound is used to measure diaphragmatic motion, and interpretation is similar to that used in fluoroscopy. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Analytical cookies are used to understand how visitors interact with the website. Excursion should be equally bilaterally and measure 3-5 cm in. On quiet and deep inspiration both hemidiaphragms move downward as the anterior chest wall moves upward. Methods: 23 hemiplegic patients who were diagnosed with a single-hemisphere lesion (mean age 60.5 years; 13 males and 10 females) and a control group of 20 patients (13 males and 7 females) were all evaluated by ultrasonography. When spoken words travel through aerated lung, they are attenuated by airspaces as they move toward the periphery. When auscultating, the patient should inhale and exhale through the mouth, deeper than their usual breaths. Posteroanterior (A) and lateral (B) chest radiographs show focal elevation. Only 19 cases showed a right to left ratio of less than 50% (5 men and 14 women). Unequal movement, or a minute amount of movement, indicates asymmetry and poor diaphragmatic excursion, respectively. Inflammation or neoplasia can cause thickening of the pleural surfaces, which then creates more friction when sliding along one another, creating this sound. A patient with asthma or chronic obstructive pulmonary disease (COPD) exacerbation may be seen sitting and leaning forward with shoulders arched forward to assist the accessory muscles of respiration. Copyright 2023 Journal of Clinical Imaging Science All rights reserved. Eventration involving the anterior right hemidiaphragm can be distinguished from a Morgagni hernia by its contour on the lateral radiograph. Normally, fremitus is most prominent between the scapulae and around the sternum. 146(7):1411-2. As a result, weakness or paralysis with impaired excursion and cranial dislocation of the diaphragm can be detected, with consequent lung parenchyma atelectasis and respiratory distress. Author: A. Chandrasekhar, MD . On sniffing both hemidiaphragms move downward as the chest wall moves upward. ; Decreased tactile fremitus, because vibrations travel poorly through air filled spaces. Nath AR, Capel LH. Therefore, radiologists and physicians should be aware of the diagnostic possibilities of this safe and valuable technique and confident with the images achievable. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. The easiest place to observe muscle thickness is the crus of the hemidiaphragm. Crackles can be classified as fine or coarse, depending on their sound quality. Am Rev Respir Dis. Diaphragm movements and the diagnosis of diaphragmatic paralysis. Lloyd T, Tang YM, Benson MD, King S. Diaphragmatic paralysis: The use of M mode ultrasound for diagnosis in adults. Among all, magnetic resonance imaging (MRI) has demonstrated to be the most accurate technique in providing a morphologic and functional assessment of the diaphragm as well as information about the adjacent structures. One dog with bilateral diaphragmatic paralysis showed paradoxical movement of both crura at the end of inspiration. [5, 6, 12], Stridor is a loud, rough, continuous, high-pitched sound that is pronounced during inspiration; it indicates proximal airway obstruction. Listen to the chest with a stethoscope. Before Richard S Tennant, MD is a member of the following medical societies: American College of PhysiciansDisclosure: Nothing to disclose. The sounds heard during auscultation can be classified as breath sounds, created by air movement through the airways, and adventitious, or added sounds, which have multiple mechanisms of generation. Diaphragmatic excursion is the movement of the thoracic diaphragm during breathing. M-mode ultrasound; diaphragmatic excursion; diaphragmatic motion; diaphragmatic ultrasound; normal values; reference values. A real-time imaging of diaphragmatic function can be performed through fluoroscopy, US, and MRI during normal respiration, deep breathing, or sniffing. Average diaphragmatic excursion was 2.5 cm between inspiratory and expiratory scans (2.7 cm in men, 2.3 cm in women; p . Tracheal deviation may occur ipsilateral to an abnormality (such as in collapse or mucous plugging) or contralateral to an abnormality (such as in pleural effusion or pneumothorax). [6, 8] Typically, there is a pause between inspiratory and expiratory sounds, as the involved parenchyma does not fill with air during this time in inspiration. This indicates the presence of subcutaneous air, which is often associated with a pneumothorax on the side of the abnormality. National Library of Medicine -Bronchovesicuclar moderate pitch, moderate amplitude, inspiration = expiration, mixed quality, over major bronchi with few alveoli; posterior = b/n scapulae, more on right side. [3,4], As well as the US, MR imaging (MRI) is a radiation-free technique that can provide a static or dynamic evaluation with the further benefit of a wider field of view and a more detailed soft tissue characterization. Epub 2008 Nov 18. MRI has demonstrated to be particularly accurate in the detection and characterization of the fluid and solid components of the cysts [Figure 9].[15-17]. The diagnosis of paralysis requires observing quiet and deep inspiration. Beyond the limits of a time-consuming exam and the indispensable patients compliance, MRI is currently the most comprehensive imaging modality in the evaluation of diaphragmatic pathologies. 8600 Rockville Pike On pathologic examination a totally eventrated hemidiaphragm consists of a thin membranous sheet attached peripherally to normal muscle at points of origin from the rib cage. Bettencourt PE, Del Bono EA, Spiegelman D, Hertzmark E, Murphy RL Jr. Clinical utility of chest auscultation in common pulmonary diseases. (Reproduced from Nason LK, Walker CM, McNeely MF, etal. Because sound is transmitted more strongly through nonair-filled lung, increased fremitus suggests a loss or decrease in ventilation in the underlying lung. [1, 2]. It is considered the main inspiratory muscle, since its contraction causes the enlargement of the chest with consequent pressure lowering and airways gas filling. Dullness noted to the left of the ster-num between the third and fifth intercostal spaces is a normal finding because it is the location of the heart. See Table 78.1 for a summary of fluoroscopic findings in the various conditions. The patient can be asked to temporarily cease respiration to appreciate this difference. . 8(2):265-72. A paralyzed hemidiaphragm will lack downward motion on inspiration and may have paradoxical motion on sniffing. The diaphragmatic excursion was higher in males than females. 73(3):333-9. Kussmaul breathing is a rapid, large-volume breathing caused by acidotic stimulation of the respiratory center; it can indicate metabolic acidosis. The patterns of normal breath sounds are created by the effect of body structures on air moving through airways. In eventration the diaphragm, although thin, remains visible as a continuous layer over the elevated abdominal viscera and retroperitoneal or omental fat.

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