sniff test for diaphragmatic paralysis

Spinal Cord. Nason L, Walker C, McNeeley M, Burivong W, Fligner C, Godwin J. Computerized tomography may be indicated in certain patients to evaluate for potential causes of diaphragmatic paralysis that are due to mediastinal pathology and malignancy. During continuous fluoroscopic examination, the patient makes a quick, short, strong inspiratory effort ("sniff"). The https:// ensures that you are connecting to the Please enable it to take advantage of the complete set of features! For confirmation, a sniff test is required. 1985 Jul. Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional PulmonologyDisclosure: Nothing to disclose. [QxMD MEDLINE Link]. government site. Gierada DS, Slone RM, Fleishman MJ. See Complications. Clin Sci (Lond). Lung. Murray and Nadels Textbook of Respiratory Medicine. During sniffing there is paradoxical movement of the right hemidiaphragm. 1997 May. The Sniff Test is performed using fluoroscopy, which uses a continuous beam of X-rays to see the diaphragm move up and down on inspiration and expiration. Before 15 - 30% Paradoxically, a paralyzed diaphragm moves up and further compresses the lung. 2007 Sep. 32(3):449-56. 2014 Jan. 97(1):260-6. Diagnosing a paralyzed diaphragm starts with describing all your symptoms and health history to your provider. 2005 Apr-Jun. Careers. On examination, with the patient lying flat, the abdominal wall moves inward during inhalation (instead of the normal outward movement). sharing sensitive information, make sure youre on a federal Acta Neurochir (Wien). MRI may be indicated in certain patients to determine the presence of pathologic conditions involving the spinal column or nerve roots that are causing diaphragmatic paralysis. . Murray and Nadels Textbook of Respiratory Medicine. We are a multidisciplinary team that includes the expertise ofcardiothoracic surgeons, pulmonologists, general surgeons, neurosurgeons, neurologists, and sleep specialists. 218492318805338. Diaphragmatic paralysis is more likely to affect the left hemidiaphragm. Bethesda, MD 20894, Web Policies In some cases, the diaphragm will move up during inspiration which is called paradoxical motion. The embryology, anatomy, and function of the diaphragm are reviewed and diaphragmatic dysfunction is discussed, with emphasis on diagnosis with functional imaging, especially the fluoroscopic sniff. Ann Thorac Surg. This study reveals elevated hemidiaphragms, small lung volumes, and atelectasis. I explain the test to the patients and have them practice a sniff maneuver, which is quick breaths with a closed mouth. These patients cannot generate high negative inspiratory pressures. Accessibility [3]. 2009 Feb 28. Muscle and nerve biopsies may be helpful in selected cases. Asian Cardiovasc Thorac Ann. Hemidiaphragmatic paralysis with recurrent lung infections due to degenerative motor root compression of C3 and C4. The fluoroscopic sniff test, also known as diaphragm fluoroscopy, is a quick and easy real time fluoroscopic assessment of diaphragmatic motor function (excursion). Pirompanich P, Romsaiyut S. Use of diaphragm thickening fraction combined with rapid shallow breathing index for predicting success of weaning from mechanical ventilator in medical patients. [10] At times, patients may spontaneously recover from idiopathic disease. Fluoroscopy. [QxMD MEDLINE Link]. 2009;135 (2): 391-400. Bethesda, MD 20894, Web Policies 133(3):737-43. [QxMD MEDLINE Link]. Harriet Paltiel. Radiograph of a patient with bilateral diaphragmatic paralysis displaying low lung volumes. Weiss C, Witt T, Grau S, Tonn JC. Unauthorized use of these marks is strictly prohibited. Medscape Education, Diagnosis and Management of West Nile Virus Infection: A Case-Based Approach, encoded search term (Diaphragmatic Paralysis) and Diaphragmatic Paralysis, Diaphragm Disorders (Diaphragmatic Dysfunction), Diaphragmatic Injury Management in the Emergency Department. Bedside ultrasound of the diaphragm while intubated revealed evidence of bilateral diaphragmatic paralysis. During the test, you will inhale rapidly through your nose (sniff), and your provider will watch your diaphragms movements. Patients develop compensatory mechanisms, and patients with phrenic injuries may recover fully or partially. I then have patients do a sniff maneuver and observe the diaphragms. The transdiaphragmatic pressure is measured by placing a thin-walled balloon transnasally at the lower end of the esophagus, allowing reflection of the changes in pleural pressure. Bedside ultrasound of the diaphragm while intubated revealed evidence of bilateral diaphragmatic paralysis. If you have a paralyzed diaphragm, treatment wont restore your diaphragms usual function. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. The trusted provider of medical information since 1899, Airflow, Lung Volumes, and Flow-Volume Loop, Last review/revision Apr 2022 | Modified Sep 2022. Additional coronal or sagittal M-mode can help quantify the degree of movement of each individual hemidiaphragm. McCool FD, Tzelepis GE. Dynamic MRI has been used by some institutions to evaluate diaphragmatic disorders. The diaphragm is the key muscle of respiration, especially in infants. [QxMD MEDLINE Link]. Payam Rohani, MD is a member of the following medical societies: American College of PhysiciansDisclosure: Nothing to disclose. Absence of downward motion on slow, deep inspiration is the critical finding that indicates paralysis. Ultrasound Ann Thorac Surg. The diaphragm is the primary muscle of ventilation. Patients with unilateral diaphragmatic paralysis do not require treatment. We are a national referral center that routinely performs operations to treat paralyzed diaphragms. Fast Five Quiz: Can You Identify Key Radiography Findings? Conclusion: Before arrest, he had been suffering from progressive dyspnea and muscle weakness. Conventional chest radiography appears to be a useful modality for assessment of the functional status of an elevated diaphragm. The MVV is the total volume of air exhaled during 12 seconds of rapid, deep breathing, which can be compared with a predicted MVV defined as the forced expiratory volume in 1 second (FEV1) 35 or 40. J Thorac Cardiovasc Surg. DiMarco AF, Onders RP, Ignagni A, Kowalski KE, Mortimer JT. [QxMD MEDLINE Link]. In fluoroscopic sniff testing, paradoxical elevation of the paralyzed diaphragm is observed with inspiration and confirms diaphragmatic paralysis (see the image below). Your doctor will use your history and presentation to determine the need for any more testing. o [teenager OR adolescent ]. Fast Five Quiz: Can You Identify Key Radiography Findings? 1985 Jul. You typically wont notice any changes in your breathing or other functions because the other half will compensate for the injured portion. 2009 Oct. 88(4):1112-7. Occasionally, electromyographic interrogation of the diaphragm and phrenic nerve is done, but carrying out and interpreting the results of this test require considerable expertise, and the diagnostic accuracy of the test is uncertain. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 69(1):91-6. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) measurements may aid in evaluating respiratory muscle weakness. In normal subjects, both hemidiaphragms descend with inspiration. M-mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphragm in the adult population and it can be performed at the bedside. Dysfunction of the diaphragm. At the time the article was last revised Mostafa El-Feky had no recorded disclosures. Your diaphragm is a thin muscle that separates your chest and abdomen. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 10. Surg Clin North Am. During inspiration, the diaphragm moves down and up during expiration or when you breathe out. In cases of unilateral diaphragmatic paralysis, the affected side demonstrates a paradoxical upward movement. Normal diaphragmatic excursion can also be impaired in patients with: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. [QxMD MEDLINE Link]. DM can involve other organs such as the lung, esophagus, and heart. Payam Rohani, MD Resident Physician, Department of Internal Medicine, Olive View-UCLA Medical Center A weakened hemidiaphragm may have decreased excursion compared with the contralateral diaphragm or may move upward paradoxically. o [ abdominal pain pediatric ] 218492318805338. Asian Cardiovasc Thorac Ann. Flouroscopy is considered the most reliable way to document diaphragmatic paralysis and the sniff test is necessary to confirm that abnormal hemidiaphragm excursion is due to paralysis rather than unilateral weakness.8Ultrasonography can help in establishing the diagnosis of partial eventration and in distinguishing it from diaphragmatic nerve Diaphragmatic paralysis is uncommon. [5, 6, 7]. Innervated by cervical motor neurons C3-C5 via the phrenic nerves, these two nerves provide both sensory and motor function to the diaphragm. Immunosuppressive therapy of tacrolimus for DM was recently discontinued due to renal toxicity. Although the diaphragm performs most of the work, normal ventilation also requires the simultaneous contraction of respiration accessory muscles (ie, scalene, parasternal portion of the internal and external intercostal muscles, sternocleidomastoid, trapezius). Acute unilateral left diaphragmatic paralysis in a patient with moderately severe chronic obstructive pulmonary disease. 1988;43 (3): 170-4. Chronic unilateral diaphragm paralysis is an uncommon and underdiagnosed cause of dyspnea with an unknown incidence [1,2].The fluoroscopic sniff test is often considered the imaging gold standard for diagnosing unilateral diaphragm paralysis .Recent research has identified paradoxical motion as a favorable prognosis factor in patients pursuing diaphragm plication . Talwar S, Agarwala S, Mittal C, Choudhary S, Airan B. Diaphragmatic Palsy After Cardiac Surgical Procedures in Patients with Congenital Heart. In our patient, extensive history, physical exam, neurologic evaluation, laboratory tests and imaging . Pulmonary function test results, however, are not always consistent and do not always correlate with the severity of dyspnea from diaphragmatic paralysis. [17] Unilateral diaphragmatic paralysis is associated with a maximal transdiaphragmatic pressure of greater than 70 cm water, and thus does not significantly effect transdiaphragmatic pressure generation during normal ventilatory behaviors, but can compromise higher-force, nonventilatory, behaviors like coughing or sneezing. An increased effort in the struggle to breathe may fatigue the accessory muscles and lead to ventilatory failure. Absence of diaphragmatic movement confirms phrenic nerve palsy in the appropriate clinical setting. The fluoroscopic sniff test, also known as diaphragm fluoroscopy, is a quick and easy real time fluoroscopic assessment of diaphragmatic motor function (excursion). 2018 Jan-Feb;19(1):111-118. doi: 10.3348/kjr.2018.19.1.111. The diaphragm position and shape for all patients were determined using measurements relating to skeletal structures and radius of curvature, respectively. Site Map, Paralyzed Diaphragm (Diaphragmatic Paralysis). 6. [9]. The patient was treated with high dose steroids and mycophenolate mofetil, following which he soon recovered. Esophageal pressure should become more negative during inspiration, demonstrating an increase in gradient during normal inspiration. Chest. Normal transdiaphragmatic pressure is approximately 148 cm water in men and 122 cm water in women. official website and that any information you provide is encrypted Summerhill EM, El-Sameed YA, Glidden TJ, McCool FD. Murray JF, Nadel JA, eds. The information available from these maneuvers is nonspecific, however, and cannot distinguish between insufficient effort, muscle weakness, and a neurologic disorder. In normal individuals, both hemidiaphragm will descend with inspiration. At the time the article was created Craig Hacking had no recorded disclosures. Fluoroscopy. This measurement can help differentiate diaphragmatic paralysis from other causes of respiratory failure. Careers. Chest radiograph demonstrating a newly elevated hemidiaphragm often precedes a sniff test. Epub 2010 Dec 15. You are being redirected to In contrast to bilateral disease, physicians can usually diagnose unilateral paralysis with only radiographic studies. On the day of your test, first report to the Admissions Desk just inside the Main Entrance. 2010;3(1):50. Providence Resource Line The paralyzed side shows no active caudal movement of the diaphragm with inspiration and abnormal paradoxical movement (ie, cranial movement on inspiration), particularly with the sniff test. You will be given a hospital gown to wear. Federal government websites often end in .gov or .mil. A retrospective analysis of chest radiographs in 32 patients, whom underwent fluoroscopic sniff test for elevated diaphragm, was performed. Donate Now 89(6):S2146-50. Reinnervation of the paralyzed diaphragm: application of nerve surgery techniques following unilateral phrenic nerve injury. Gurses MS, Eren F, Trkmen Inanir N, Eren B, etin S. Mehrotra AK, Vaishnav K, Gupta PR, Khublani TK, Anupam, Soni S, Feroz A. 2285-2290. Sometimes, patients recover without any medical intervention. 69(1):91-6. Your treatment plan will depend on whether you have symptoms of a paralyzed diaphragm. All rights reserved. Diaphragm function was graded by a senior radiology resident, as either "paralyzed" or "non-paralyzed," based on appearance/shape of elevated hemidiaphragm on PA and lateral radiograph. Since the nerve travels from the neck and through the chest, CT scan of the neck and chest may be needed. Weakness is defined as reduced/delayed downward diaphragm motion during normal breathing, with or without paradoxical motion. [3, 16], Ultrasonography can also be used to serially monitor patients with diaphragmatic paralysis for recovery. The diaphragm does not move during expiration. Diaphragmatic plication offers functional improvement in dyspnoea and better pulmonary function with low morbidity. 69 (1):91-6. The link you have selected will take you to a third-party website. The sniff test is sometimes used in suspected cases of diaphragmatic paralysis or paresis. Normal movement of the left hemidiaphragm is seen. 2018 Sep 30. {"url":"/signup-modal-props.json?lang=us"}, V U, El-Feky M, Botz B, et al. Fluoroscopy of elevated left hemidiaphragm in a patient with unilateral diaphragmatic paralysis. Copyright 2020 Southern Society for Clinical Investigation. Neuromuscular assessment . Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Medical Director, Pulmonary Medicine General Practice Unit (F2), Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital It is used most often to confirm absence of muscular contraction of the diaphragm during inspiration in patients with phrenic nerve palsy or breathing difficulties following stroke. Acute unilateral left diaphragmatic paralysis in a patient with moderately severe chronic obstructive pulmonary disease. Emphysema / Lung Volume Reduction Surgery, Gastrointestinal and Hepatobiliary Tumors, Donald L. Morton Complex General Surgical Oncology Fellowship, Translational Molecular Medicine Fellowship, Urologic Oncology and Robotics Fellowship, Maps & Directions to Saint Johns Health Center. 133(3):737-43. Dyspnea as the predominant manifestation of bilateral phrenic neuropathy. 2285-2290. The thickening fraction of the intercostal muscles as an index of diaphragmatic dysfunction and the use of accessory muscles has a linear, negative relationship with the calculated thickening index of the diaphragm, although insufficient evidence exists to advocate its routine use at this time. 888-432-5464. All Rights Reserved. After placing an M-mode line, one may pause the recording and measure the end-expiratory and end-inspiratory figures, the latter of which should be larger, and calculate a diaphragmatic thickening fraction; values above 30%, indicating no sonographic diaphragmatic dysfunction, have been found to be 71% specific for extubation success 9. Kansal AP, Chopra V, Chahal AS, Grover CS, Singh H, Kansal S. Lung India. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Depending on the etiology of the diaphragmatic paralysis, the prognosis of unilateral disease usually is excellent unless the patient has significant underlying pulmonary disease. In a paralysed diaphragm, there is paradoxical (ie cranial) or absent movement when the patient sniffs Full size image M mode tracing of movement on the normal side demonstrated caudal movement. and transmitted securely. Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. Zouari M, Abid I, Mhiri R. Diaphragmatic paralysis following open-heart surgery in an 18-month-old child. Monitoring recovery from diaphragm paralysis with ultrasound. The radiologist or radiology practitioner assistant (RPA)operates the fluoroscopy equipment to take images of the diaphragm. 2022 May;40 Suppl 134(5):121-123. doi: 10.55563/clinexprheumatol/0u7vdc. The prognosis for bilateral paralysis also depends on the overall health of the patient but surgery may be the best option for patients who continue to have a poor quality of life. Your diaphragm has two halves, and most people only have paralysis in one half of their diaphragm. Gastric pressure should become more positive during inspiration. Turk J Anaesthesiol Reanim. View Umamaheswara Reddy V's current disclosures, View Mostafa El-Feky's current disclosures, see full revision history and disclosures, unilateral paralysis:asymptomatic in most of the patients as the other lung compensates, may have dyspnea, headaches, fatigue, insomnia and overall breathing difficulty, bilateral diaphragmatic palsy can be a medical emergency; they present with severe dyspnea, even with mild exertion, idiopathic:accounts for ~70% of the cases. Respir Physiol Neurobiol. Patient diaphragm function may recover if nerve injury is not permanent, while other patients may require long-term treatment as elaborated before. DiNino E, Gartman EJ, Sethi JM, McCool FD. Muscle Nerve. PMC The Sniff Test is performed using fluoroscopy, which uses a continuous beam of X-rays to see the diaphragm move up and down on inspiration and expiration. Philadelphia, Pa: Saunders; 2005. Intercostal thickening fractions >8% have, thus far, been deemed pathologic 10. Diaphragmatic paralysis(also considered very similar to the term diaphragmatic palsy) can be unilateral or bilateral. Patients who do not recover from unilateral diaphragmatic dysfunction generally lead relatively normal lives. Respiratory function after paralysis of the right hemidiaphragm. Chest. MIP is the pressure generated during maximal inspiratory effort against a closed system. Eur J Cardiothorac Surg. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMjk4MjAwLW92ZXJ2aWV3. Diaphragmatic tumors may be incidentally found with a . Paretic muscle dysfunction (partial paralysis) may also be diagnosed by . It is used most often to confirm absence of muscular contraction of the diaphragm during inspiration in patients with phrenic nerve palsy or breathing difficulties following stroke. The radiologist provides a medical diagnosis for your doctor. Bilateral diaphragmatic paralysis Clin Sci (Lond). 84132, Copyright 2023 University of Utah Health, How To Schedule An Evaluation With Our Cardiothoracic Specialists, Learn More About Our Cardiothoracic Surgery Services. Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-35785, View Motahare Yadegarfar's current disclosures, see full revision history and disclosures, ask the patient to practice sniffing before the study, with the patient either standing (preferred) or supine, perform frontal fluoroscopy of the diaphragm at rest, breathing quietly through an open mouth, ask the patient to take a few quick short breaths in with a closed mouth ('sniffs') causing rapid inspiration, occasionally, repeating (3) in the lateral projection is required to evaluate the posterior hemidiaphragms, the diaphragm relaxes during expiration:moves, in healthy patients 1-2.5 cm of excursion is normal in quiet breathing, 3.6-9.2 cm of excursion is normal in deep breathing, up to 9 cm can be seen in young or athletic individuals in deep inspiration, excursion in women is slightly less than men, the affected hemidiaphragm does not move downwards during inspiration. Published by Elsevier Inc. All rights reserved. 2012;32(2):E51-70. Kumar N, Folger WN, Bolton CF. [15], B-mode ultrasonography of diaphragm thickness in the zone of apposition of the diaphragm to the rib cage can also provide a sensitive and specific noninvasive assessment of diaphragmatic paralysis. Fluoroscopic evaluation ("sniff test") may also aid in the diagnosis of diaphragmatic paralysis. 5,69,82 Diaphragmatic weakness is determined where there is decreased amplitude of movement during deep breathing - with or without This site needs JavaScript to work properly. Reinnervation of the paralyzed diaphragm: application of nerve surgery techniques following unilateral phrenic nerve injury. (2013). Chronic unilateral diaphragm paralysis is an uncommon and underdiagnosed cause of dyspnea with an unknown incidence [1,2]. Patients with bilateral diaphragmatic paralysis are usually symptomatic and, when symptoms are severe or in the presence of underlying lung pathology, may develop ventilatory failure without medical intervention. 8(2):237-80. When there is a paralyzed diaphragm or phrenic nerve palsy, there will be limited or no movement of the diaphragm. We encourage you to get a referral from your primary care provider, but we accept self-referrals. Key learning points: incidence of phrenic nerve palsy post cardiac surgery is reported between 10-60% usually unilateral but very rarely may be bilateral INTRODUCTION: Establishing a diagnosis of diaphragmatic paralysis is conventionally performed with fluoroscopy to demonstrate abscence of diaphragmatic excursion during voluntary sniffing ("sniff test"). Le Pimpec-Barthes F, Gonzalez-Bermejo J, Hubsch JP, Duguet A, Morelot-Panzini C, Riquet M, et al. Diaphragm plication for eventration or paralysis: a review of the literature. (2018) Journal of intensive care. Your provider may use a stethoscope to listen to your breathing. 2012 Mar 8. 2011 Jul. Aldrich TK, Tso R. The lungs and neuromuscular diseases. Ann Pediatr Card. for: Medscape. This maneuver minimizes the contribution of the other muscles of respiration (eg, intercostals). MEP is measured during a similar maneuver at total lung capacity (TLC) because expiratory muscle strength is directly related to lung volume (again in a curvilinear fashion). Payam Rohani, MD is a member of the following medical societies: American College of PhysiciansDisclosure: Nothing to disclose. Diaphragm plication for eventration or paralysis: a review of the literature. Diaphragmatic paralyses encompass a spectrum of diseases involving a single leaflet, known as unilateral diaphragmatic paralysis (UDP), and that involving both leaflets, known as bilateral diaphragmatic paralysis (BDP). ADVERTISEMENT: Supporters see fewer/no ads. A paralyzed diaphragm sometimes occurs because of damage to your phrenic nerve (the nerve that runs through your cervical spine, neck, heart, and lungs and controls the two halves of your diaphragm). Orthopnea (shortness of breath worse lying down and better sitting up), Surgical trauma, such as unintentional injury after a heart or neck procedure, Neurological diseases, such as ALS, multiple sclerosis, muscular dystrophy, Guillain-Barre syndrome, Chest Surgery where the phrenic nerve is cut or removed to remove a tumor, Chronic pneumonia, bronchitis or cardiac arrhythmias, Patients with bilateral diaphragmatic paralysis may experience a 70 to 80 percent reduction in lung capacity while patients with unilateral diaphragmatic paralysis may experience a 50 percent reduction. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea. After extubation, supine and upright pulmonary function tests (PFT) and sniff test results strengthened the diagnosis of diaphragmatic paralysis. Diaphragm strength in patients with recent hemidiaphragm paralysis. 2011 Jul. Dermatomyositis; Diaphragmatic Paralysis; Diaphragmatic Ultrasound; Diaphragmatic weakness; Hypercapnic respiratory failure; Supine and Upright PFT. 2004 Dec. 79(12):1563-5. Because most cases of unilateral diaphragmatic paralysis are found incidentally during imaging studies, many patients have no symptoms. Diaphragm fluoroscopy (also called a Sniff Test) is done to evaluate the function of your diaphragm. No paradoxical diaphragmatic excursion was identified to suggest phrenic nerve palsy. 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 153(3):597-9. [QxMD MEDLINE Link]. Bedside ultrasound has been used in a critical care setting for the detection of diaphragmatic dysfunction with a high degree of specificity; the lower limit of normal was defined as 1 cm when observing diaphragmatic craniocaudal excursion in the mid-clavicular line 8. athletics victoria results,

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