Clinical case n.

P0957

+“Sonographic evaluation of diaphragm excursion to strengthen non-

invasive mechanical ventilation education program in a patient with
chronic respiratory insufficiency and claustrophobia “
A. Longoni Respiratory Therapist, D. Mangiacasale MD, P. Pozzi MD, A.D. Marco MD, L. Cattaneo MD,
M. Vago Respiratory Therapist, A. Paddeu MD.
Asst Lariana - U.O. of Specialistic Cardio-Respiratory Rehabilitation 2, “Paola Giancola Foundation” Cantù, Italy
angelo.longoni@asst-lariana.it

Case history Investigations

A 56 year-old woman suffering from multiple sclerosis
was hospitalized for chronic respiratory insufficiency
with daily hypercapnia (pCO2: 69,4mmHg) to start
non invasive mechanical ventilation (NIMV). She was
previously hospitalized for one month in another
hospital but she drop out from NIMV due to
claustrophobia. The patient was also daily oxygen
therapy for room-air desaturation and she moved in
wheelchair for severe back and lower limb pains. The
basal pulmonary function testings (PFT) were
compatible with a severe reduction of the forced vital
capacity (FVC) as well as of the maximum inspiratory
and expiratory pressures (Mip=40, Mep=55,
FVC=54%,Fev1=52%, Fev1/FVC=104%, Pef=30%).
The rehabilitative treatments
The patient has performed cycles of nighttime and
diurnal NIMV in S/T mode with nasal pillows, single
circuit with leak and integrated hot humidifier. The
program were integrated with daily treatments of
respiratory rehabilitation (pep bottle), fktr and motor
exercises with assisted minibike. Respiratory
evaluation of diaphragmatic excursion with
Ultrasound were performed at the admission and at
the discharge in sitting position.
We studied the diaphragmatic excursion with sonography
(US) in M-mode with a convex probe 1-5 MgHz in
spontaneous and in forced breathing in supine position.The
patient was placed in diurnal and nocturnal NIMV with nasal
pillows to avoid claustrophobia. An educational experiment
was set by showing the patient the utility of NIMV through:
1)The arterial blood testing in terms carbon dioxide levels
(pCO2).
2) The utility of respiratory rehabilitation programs
( PRP) and the daily attendance of the gym for the
respiratory exercises and the cycle minibike of the upper
limbs.
3) The difference in US diaphragmatic excursion without
NIMV (1 cm and 1,5 cm in normal and forced breathing,
respectively) and under NIMV (1,6 cm and 3,9 cm,
respectively) with the direct vision of the ultrasound
examination. During the ultrasound view, in M-mode, the
excursion of the diaphragm movement was explained to the
patient, in simple words, the correspondence between the
ascent of the diaphragm during the inspiratory phase (for
which the diaphragm is lowered approaching the probe) and
the expiratory phase (where the diaphragm rises, moving
away from the probe).
4) The excursion of the diaphragm was then reevaluated,
after adaptation, with US during ventilation with the use oral
mask M size (1,6 cm) and nasal pillow M size (2,9 cm).

Conclusion
At the discharge (10/04 to 26/04/2018) the patient was able to carry the NIMV all night long with, almost the pCO2 value
within
 
normality (47 mmHg.), improved PFTs (Mip=53, Mep=74, FVC=56%,Fev1=55%, Fev1/FVC=106%, Pef=59%. ) and a
satisfactory diaphragmatic excursion with 2,2 cm and 4,5 cm in normal and forced breathing while 3,1 cm during
ventilation. Diaphragmatic Sonography can be an excellent educational tool, safe, fast, not expensive method to be
performed ,at the patient's bed, to strengthen a cardio-respiratory pulmonary rehabilitation program of non invasive
ventilation in patient's with problem's of Niv adaptation.