Four-Dimensional Computed Tomography of Paradoxical Motion of Eventrated Diaphragm Induced by Reverse Triggering
Four-Dimensional Computed Tomography of Paradoxical Motion of Eventrated Diaphragm Induced by Reverse Triggering
复制标题
反向触发引起的事件隔膜反常运动的四维计算机断层扫描
DOI：
10.1164/rccm.202201-0120im
复制
发表时间：
2022
影响因子：
24.7
通讯作者：
Nunomiya Shin
中科院分区：
文献类型：
--
作者：
Tonai Ken;Katayama Shinshu;Koyama Kansuke;Nunomiya Shin
一名患有冠状病毒病（COVID-19）的44岁男性接受插管和机械通气。胸部冠状位计算机断层扫描显示右侧膈肌抬高（图1）。诊断后第12天，在机械通气期间进行了四维计算机断层扫描（4D-CT）扫描（见在线补充），并进行了周期中反向触发（1）（图2）。他的矢状面4D-CT扫描显示，在开始指令性呼吸时，右膈向下移动，在发生反向触发时，其背侧进一步向下移动。相反，在反向触发过程中，右隔膜的腹侧到中间向上移动。左侧不存在这种向上运动（图3和视频E1和E2 [在线补充]）。我们将右膈功能障碍诊断为膈膨出，因为这种仅在右膈腹侧至中侧的局灶性向上运动与膈神经麻痹中观察到的整个向上运动不同，膈神经麻痹通常会损害整个半侧膈的运动，并导致其在荧光镜嗅测中向上运动（2）。膈肌膨出是先天性膈肌变薄和节段性无力（2），可能随着COVID-19引起的肺容量减少或肌肉无力而变得更加明显（图1）。4D-CT扫描表明，反向触发损害了膈肌膨出患者的膈肌协调运动，这可能会意外地增加局部肺伸展。没有报告在反向触发期间左右横膈膜表现不同的病例。
A 44-year-old man with coronavirus disease (COVID-19) was intubated and mechanically ventilated. Chest coronal computed tomography scans showed an elevated right hemidiaphragm (Figure 1). A four-dimensional computed tomography (4D-CT) scan (see the online supplement) was performed during mechanical ventilation with midcycle reverse triggering (1)(Figure 2) on Day 12 after diagnosis. His sagittal 4D-CT scan revealed that the right diaphragm moved downwards at the initiation of mandatory breath and its dorsal aspect moved further down at the occurrence of reverse triggering. In contrast, the ventral-to-mid aspect of the right diaphragm moved upward during reverse triggering. This upward motion was absent on the left side (Figure 3 and Videos E1 and E2 [online supplement]). We diagnosed the right diaphragm dysfunction as eventration of the diaphragm because this focal upward motion in only the ventral-to-mid aspect of the right diaphragm differed from the entire upward motion observed in phrenic nerve paralysis, which generally impairs the movement of an entire hemidiaphragm and causes its upward motion on the fluoroscopic sniff test (2). The eventration of the diaphragm, which is a congenital thinning and segmental weakness of the diaphragmatic muscle (2), might have become more pronounced with decreased lung volume or muscle weakness caused by COVID-19 (Figure 1). The 4D-CT scan demonstrated that reverse triggering impairs the coordinated diaphragm movement in patients with eventration of the diaphragm, which might unexpectedly augment local lung stretch. No cases have been reported in which the left and right diaphragms behaved differently during reverse triggering.