Utility of ultrasound assessment of diaphragmatic function before and after pulmonary rehabilitation in COPD patients

Claudia Crimi, Enrico Heffler, Teresa Augelletti, Raffaele Campisi, Alberto Noto, Carlo Vancheri, Nunzio Crimi, Claudia Crimi, Enrico Heffler, Teresa Augelletti, Raffaele Campisi, Alberto Noto, Carlo Vancheri, Nunzio Crimi

Abstract

Background: Pulmonary rehabilitation (PR) may improve respiratory symptoms and skeletal muscle strength in patients with COPD. We aimed to evaluate changes in ultrasound (US) measurements of diaphragmatic mobility and thickness after PR in COPD patients and to test its correlation with PR outcomes.

Methods: Twenty-five COPD patients were enrolled and underwent a diaphragm US assessment before and after a 12-week PR program.

Results: We found a correlation between the intraindividual percentage of change in the diaphragmatic length of zone of apposition at functional residual capacity (ΔLzapp%) and the change in 6-minute walking distance (6MWD) after PR (rho=0.49, P=0.02). ΔLzapp% was significantly higher in patients with improved 6MWD and COPD Assessment Test (CAT) score (mean rank=12.03±2.57 vs 6.88±4.37; P=0.02). A ΔLzapp% of ≥10% was able to discriminate among patients with improved 6MWD, with a sensitivity of 83% and a specificity of 74%. The area under the receiver operating characteristic curve for ΔLzapp% was 0.83. A cutoff value of ≥9% of ΔLzapp% had a positive predictive value in discriminating a reduction in ≥2 points of CAT score after PR, with a sensitivity and a specificity of 80% and 62%, respectively.

Conclusion: Diaphragm US assessment represents a useful prognostic marker of PR outcomes in COPD patients.

Keywords: COPD; diaphragm ultrasound; pulmonary rehabilitation.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Correlation between Lzapp and 6MWT. Note: Spearman rank order correlation between the change (%) of Lzapp at FRC and the change (delta meters) in 6MWD before and after PR (rho=0.49, P=0.02). Abbreviations: Lzapp, diaphragm zone of apposition length; FRC, functional residual capacity; 6MWD, 6-minute walking distance; 6MWT, 6-minute walking test.
Figure 2
Figure 2
Difference in ΔLzapp% between patients with a minimal clinically significant difference for 6MWD after PR. Notes: Box plots illustrating the change (%) of Lzapp at FRC between patients who “slightly improved” (who performed a 6MWD of <54 m) or “markedly improved” (who performed a 6MWD of >54 m) at the 6MWT after PR, *P<0.05 (Mann–Whitney U-test). The red line represents the ΔLzapp% cutoff value determined by the receiver operating characteristic (ROC) curve analysis showed in Figure 4. Abbreviations: Lzapp, length of diaphragm zone of apposition; FRC, functional residual capacity; 6MWD, 6-minute walking distance; 6MWT, 6-minute walking test; PR, pulmonary rehabilitation.
Figure 3
Figure 3
Difference in ΔLzapp% between patients with a minimal clinically significant difference for CAT after PR. Notes: Box plots illustrating the change (%) of Lzapp at FRC between patients “slightly improved” (who achieved a <2 points reduction of CAT score) or “markedly improved” (who achieved ≥2 points reduction in CAT score), *P<0.05 (Mann–Whitney U-test). The red line represents the ΔLzapp% cutoff value determined by the receiver operating characteristic (ROC) curve analysis showed in Figure 5. Abbreviations: Lzapp, length of diaphragm zone of apposition; FRC, functional residual capacity; CAT, COPD Assessment Test; PR, pulmonary rehabilitation.
Figure 4
Figure 4
Receiver operating characteristic (ROC) curve for ΔLzapp% in relation to 6MWD. Note: ROC curves estimate the ability of Lzapp change (as percentage of baseline) to predict a significant improvement in 6MWD after PR (AUC=0.83, cutoff ≥10%, sensitivity=83%, specificity=74%). Abbreviations: AUC, area under the curve; Lzapp, length of diaphragm zone of apposition; FRC, functional residual capacity; 6MWD, 6-minute walking distance; 6MWT, 6-minute walking test; PR, pulmonary rehabilitation.
Figure 5
Figure 5
Receiver operating characteristic (ROC) curve for ΔLzapp% in relation to CAT. Note: ROC curves estimate the ability of Lzapp change (as percentage of baseline) to predict a significant improvement in CAT after PR (AUC=0.76, cutoff >9%, sensitivity=80%, specificity=62%). Abbreviations: AUC, area under the curve; Lzapp, length of diaphragm zone of apposition; FRC, functional residual capacity; CAT, COPD Assessment Test; PR, pulmonary rehabilitation.

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