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2023;22:1-10
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REVIEW ARTICLE

Diaphragm. Anatomy and evaluation by ultrasound

Diafragma. Anatomía y evaluación por ecografía
Aloisia P. Hernández-Morales*, Lya E. Pensado-Piedra, Fortunato Juárez-Hernández y Roberto Sotelo-Robledo
Departamento de Imagenología, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, México

ABSTRACT

The growing acceptance of ultrasound in the evaluation of the thorax has allowed us to be
more accurate in the diagnosis of patients with thoracic pathology; thus, ultrasound in the
evaluation of the diaphragm, as the main respiratory muscle, facilitates an easy and repro-
ducible diagnosis, with a short learning curve. So this review provides the ultrasound im-
aging characteristics of the diaphragm in terms of its anatomical and functional description.

Keywords: Diaphragm. Contraction. Excursion. Diaphragmatic thickness.

INTRODUCTION that involve the central and peripheral ner-

vous system to those that strictly speaking
Diaphragm evaluation by ultrasound has had cause muscle dysfunction, such as muscular
a growing acceptance, since morphology and
dystrophies and diseases of the neuromuscu-
function are easily assessed in a fast and ac-
lar junction. This spectrum of disease leads
curate way, either in critically ill patients as
to diaphragm dysfunction, defined as loss of
well as those hemodynamically stable.
muscle strength that gives rise to a reduction
There are numerous diseases that can dam- of the inspiratory capacity, limiting respiratory
age the diaphragm, ranging from diseases muscular resistance.

Correspondence to: Received in original form: 15-10-2020

*Aloisia P. Hernández-Morales Accepted in final form: 22-03-2021
E-mail: aloisia_hndz@yahoo.com.mx

This article must be quoted as: Hernández-Morales AP, Pensado-Piedra LE, Juárez-Hernández F, Sotelo-Robledo R. Diafragma. Anatomía y evaluación por ecografía.
Anales de Radiología México. 2022;22(1):43-52.
1665-2118/© 2021 Sociedad Mexicana de Radiologia e Imagen, AC. Published by Permanyer. This is an open access article under the CC CC BY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
 Anales de Radiología México. 2023;22
Currently, one of the most relevant applications
of ultrasound assessment of the diaphragm is
the prediction of ventilator-induced diaphrag-
matic dysfunction. The diaphragmatic lesion
induced by the ventilator may be present in
nearly 80% of patients in the Intensive Care
Unit and it happens as early as in the first 24
to 36 hours after initiation of mechanical ven-
tilation.
In this review we show the use of ultrasound
in the diagnosis of diaphragmatic paralysis
and diaphragmatic dysfunction, and its po-
tential use in patients in the Intensive Care
Unit.
METHOD
An extensive literary review in the Pub Med
data base was conducted to intentionally in-
vestigate about the first ultrasound descrip-
tions, using the following key words: dia-
phragmatic dysfunction and diaphragmatic
ultrasound; including original studies, edito-
rials and literature reviews. In most of the
studies, diaphragm function was estimated
through direct observation of the diaphrag-
matic excursion, while in small series it was
evaluated by means of the neighboring ana-
tomic structures, such as the liver and the
spleen (indirect technique); also, the dia-
phragmatic thickness was assessed.
REVIEW
Anatomy
The diaphragm is a musculotendinous struc-
ture shaped as a dome, separating the chest
2
and the abdomen. It is the main inspiratory
muscle and acts as a barrier for transmission
of abdominal and thoracic pressure.
The diaphragm has a muscle component and
a central tendon. The muscle component may
be subdivided in two parts: the costal dia-
phragm and the crural diaphragm. The costal
diaphragm originates anterior to the sternum,
laterally along the internal surface of the six
inferior ribs and anteromedially along the
costal cartilages. The crural diaphragm orig-
inates posteriorly along the three superior
lumbar vertebral bodies where the medial
and lateral arcuate ligaments arise.
The muscular component to the diaphragm
attaches to the fibrous central tendon, which
has a narrow, but strong fascia. The central
tendon of the diaphragm is variable in size
according to each individual: it may comprise
less than 10% of the diaphragm to 35% in
some individuals, and generally has a V
shape. Also, it has several openings, called
“hiatus” that communicate the abdominal
and thoracic cavities.
The phrenic nerve innervates the diaphragm.
It is mainly a motor nerve that originates
from C3, C4 and C5, with most of the motor
neurons originating in C4. Both phrenic
nerves, the right and the left, are divided into
three to five rami that innervate the antero-
lateral, posteriomedial, sternal and crural
portions of the diaphragm. The rami then run
inside the diaphragmatic muscle in a medial
plane between the pleura and the layers of
the peritoneum1.
Physiologically, when it contracts, it moves
caudally, increasing intraabdominal pressure
 A.P. Hernández-Morales et al.  Diaphragm. Anatomy and evaluation by ultrasound
and decreasing intrapleural pressure. This re-
duction in pleural pressure results in an intra
alveolar pressure decrease. Once the intra al-
veolar pressure becomes subatmospheric, the
air goes into the alveolus1. Then, the dia-
phragm relaxes and goes up during exhala-
tion, allowing air outlet. It also helps to in-
crease abdominal pressure for defecation,
micturition and crying, working jointly with
the esophageal sphincter to exert pressure on
the esophageal sphincter and prevent reflux2.
Normally, during rapid eye movement sleep,
the diaphragm is the only inspiratory muscle
that functions and the accessory inspiratory
muscles remain inactive. Consequently, indi-
viduals with weakness or diaphragmatic pa-
ralysis may have hypoventilation symptoms,
such as frequent nocturnal awakenings, noc-
turia, vivid nightmares, nocturnal sweat, hy-
persomnolence during daytime, depression
and morning headache3.
In general, a posteroanterior chest Xray should
initially be taken when diaphragmatic pathol-
ogy is suspected, aiming to:
– See diaphragmatic disease, frequently in-
cidental
– Take as a fact that the diaphragm is not
directly visible.
– Try to decide if the abnormality is, indeed,
located in the diaphragm, or secondary to
an adjacent disease to the diaphragm.
Due to the variability in the presentation of
the diaphragm, many changes found in a
chest Xray are not related to a disease, signif-
icant or not, and then decisions must be made
about the importance of the finding and if it
is necessary to perform additional imaging
modalities, such as ultrasound assessment.
In Table 1, the indications for ultrasound as-
sessment of the diaphragm are shown.
Ultrasound Assessment
With ultrasound, the diaphragm can be seen
with a direct technique including thickness,
excursion and integrity assessment, or
with an indirect technique using another
anatomical structure of reference for the
craniocaudal displacement, such as the left
intrahepatic ramus, the excursion of splenic
hilum, the liver, the pancreas and the kid-
neys.
For complete assessment, either morphologic
or functional, the diaphragm must be visual-
ized with two approaches: the dome and the
diaphragmatic costal muscle. (Fig. 1).
The diaphragmatic dome can easily be seen
in the subcostal area, between the clavicular
midline, using the liver or spleen as acoustic
window, with a 2-5 MHz low frequency trans-
ducer, and leaning the transducer cephalical-
ly and medially. The diaphragm is identified
as a hyperechoic line, convex and continuous
(Fig.  2A). With this approach the integrity,
echogenicity and cephalocaudal movement is
assessed in M mode.
The inspiratory diaphragmatic movement is
caudal, therefore the diaphragm moves to-
ward the transducer. In expiratory phase, the
movement is cephalic, so it moves away
from the transducer. M  mode is used
for the evaluation of diaphragmatic ex-
cursion (displacement, cm). With this dia-
phragmatic cephalocaudal displacement and
its sinusoidal curve, the contraction velocity
3
 Anales de Radiología México. 2023;22

Table 1. Indications for ultrasound assessment of the diaphragm

Total indication
– Diagnosis and monitoring of diaphragmatic paralysis
– Diaphragmatic elevation in the chest Xray
– Dysnea of unknown cause

Medical Arrest with respiratory failure

indication Neuromuscular disturbance
Electromyographic needle guidance
Evaluation of chronic disease (COPD)
Ventilatory support assessment

Surgical Traumatic rupture of diaphragm

indication F igure   1. Ultrasound approach of the diaphragm. The arrowhead
Detection of postoperative complication points to the diaphragmatic dome and the zone of diaphragmatic
apposition is indicated in the red box.
ICU Weaning difficulties
Estimation of ventilatory work
Estimation of ventilator‑induced diaphragm
dysfunction posterior part than its anterior border. The
Ventilatory support assessment
estimated motion of the posterior part of the
diaphragm is 40% greater than in its anterior
COPD: chronic obstructive pulmonary disease; ICU: intensive care unit.
part.5

There is a similar excursion of the two hemid-

(slope, cm/s), inspiratory time (Tinsp, s) and iaphragms, although the motion of the left
duration of the cycle (Ttot, s) are assessed. hemidiaphragm may be slightly greater than
(Fig 2B) 4. the right.

In healthy subjects, the excursion measure-
ment in spontaneous respiration measure-
ment and in supine decubitus position is
16 mm in males and 18 mm in females5. This
measurement changes according to the respi-
ratory technique desired in the patient for
complete assessment of the diaphragmatic
disease. With the sniff test, it ranges from 26
to 29  mm, and in forced respiration it is
58 mm in females and 70 in males5. However,
previous studies have reported average ex-
cursion values of 42 ± 16 a 79 ± 13  mm in
forced respiration and 11 ± 4  mm to 21 ±
6 mm in spontaneous respiration6.
The diaphragmatic dome motion is not uni-
form. Typically, there is greater caudal motion
of the medial region of the dome and of the
The right diaphragmatic dome is 1.9 cm more
cephalic than the left diaphragm at the end
of expiration and 1.3  cm at the end of
inspiration during spontaneous respiration.
In patients who are mechanically ventilated,
anesthesized, and patients with paralysis, the
difference from the right and left side is 1.7
and 1.6  cm at the end of expiration and the
end of inspiration respectively. In supine po-
sition, in ventilated, anesthetized or para-
lyzed patients, dependent regions show less
diaphragmatic motion5.
The M mode representation of a forced
expiration manouver (after a maximum inspi-
ration) is characterized by an initial slope fol-
lowed by a plateau in maximum expiration.
This curve is similar to the one obtained in

4
 A.P. Hernández-Morales et al.  Diaphragm. Anatomy and evaluation by ultrasound
A B
F igure   2. A: Ultrasound image of the diaphragmatic dome. Continuity, echogenicity, integrity and cephalo-caudal movement are assessed
with this approach. B: M mode. In the motion tracing, the maximal height is excursion, and the cycle is the sum or inspiration (orange)
and expiration (blue).
the time/volume measurement in spirometry.
The analysis of this spirometric curve allows
to measure expiratory volume in the first sec-
ond (FEV1) and the vital capacity (VC), and
calculate the FEV1/VC6 ratio.
Preliminary observation in M mode of the
diaphragmatic excursion during expiration in
healthy volunteers and patients with obstruc-
tive airway disease indicate that the initial
fall of the curve in expiration is deeper in
healthy subjects that in those with obstructive
airway disease, suggesting that the excursion
may be delayed in patients with airway ob-
struction and air trapping6.
The second approach for visualization of the
costal diaphragm is the zone of diaphragmat-
ic apposition: between the eighth and tenth
intercostal spaces, anterior or medial axillary
line, 0.5-2  cm below the costophrenic sinus
(Fig. 3). This approach is used to assess thick-
ness; normal in this zone is 1.7 ± 0.2  cm in
relaxed respiration, increasing to a 4.5 ±
0.9 mm when total pulmonary capacity respi-
ration takes place5.
The zone of diaphragmatic apposition ac-
counts for 25% of the total surface of the rib
cage during respiration, but may vary from
0% to total pulmonary capacity at more than
50% residual volume.
During inspiration, the contraction of the cos-
tal and crural muscles results in a caudal
motion of the diaphragm. This leads to the
creation of appositional forces resulting in the
coupling of the abdominal muscles, the dia-
phragm and the rib cage. This force is trans-
mitted through the zone of apposition and
originates the expansion of the inferior ribs.
The appositional force is proportional to the
zone of apposition and the abdominal pres-
sure. Simultaneously, the contracted costal
movement exerts another force to the inser-
tion sites of the inferior ribs, creating a respi-
ratory impulse and a «bucket handle or grip»
motion.5.
To obtain proper images of the diaphragm
thickness a high frequency transducer is need-
ed. At 1.5-3  cm two parallel echogenic lines
can be easily identified: the closest line is the
5
 Anales de Radiología México. 2023;22
F igure   3. Zone of diaphragmatic apposition. This zone is located
between the eighth and the tenth intercostal space, between the
anterior and medial axillary line, in the costophrenic angle. The
diaphragmatic thickness must be measured at 0.5-2 cm from the
angle.
pleura and the deeper one is the peritoneum.
The diaphragm is a hypoechoic structure be-
tween those two lines, with some interspersed
lines from the intermuscular fascia (Fig. 4).
The diaphragmatic thickening during active
respiration reflects the magnitude of the re-
spiratory effort. The best descriptor of this
phenomenon is the diaphragmatic contrac-
tion fraction, calculated as the difference be-
tween thickness at the end of inspiration and
at the end of expiration (Fig. 5)7:
6
F igure   4. Normal ultrasound anatomy. At the zone of apposition
(below) is a three-layered structure: pleura, diaphragmatic
muscle and peritoneum. The pleura and peritoneum are seen
lineal and hypoechoic, and the hypoechoic muscle has
interposed hyperechoic lines.
F igure   5. The contraction fraction is calculated by the difference
in inspiration and expiration.
Contraction fraction 
 Thickness at the end of inspiration 
 Grosor – end of expiration 
 
Thickness at the end of expi ration  100
Harper et al.8 describe an average contraction
fraction of 20%, during tidal respiration, with
no significant difference between the right
hemidiaphragm and the left hemidiaphragm
in patients with mechanical ventilation. Oth-
er authors have reported that the measure-
ments of the left diaphragm may not be con-
sistently obtained as in the right, due to the
apposition of the bowel loops, obscuring the
 A.P. Hernández-Morales et al.  Diaphragm. Anatomy and evaluation by ultrasound
acoustic window and in our experience, to
the more complex location of the left zone of
apposition.
Diaphragmatic Paralysis and
Weakness
Diaphragmatic paralysis and weakness may
be unilateral or bilateral, temporal or perma-
nent, depending on the cause.
The differential diagnosis of a diaphragmatic
elevation in an Xray includes a film when
inspiration is poor, obesity with decreased
compliance, subpulmonary pleural effusion
and pleural adhesions, subdiaphragmatic
processes such as ascites, ileus and enlarged
organs, among others.
In unilateral ascites, chest Xray sensitivity is
as high as 90%, while specificity is low
(44%)9.
In weakness of one or both hemidiaphragms,
excursion is reduced (less than 20% of con-
traction fraction) or delayed in spontaneous
or deep inspiration 10. Also, there may be ex-
cursion limitation and greater thickness may
be associated; contrary to chronically para-
lyzed diaphragms, where thickness tends to
be less than 2 mm4.
It is important to repeat measurements, since
single measurements may lead to a false neg-
ative in acute paralysis cases where atrophy
has not yet occurred or false positive in small
individuals4.
The patients with bilateral diaphragmatic pa-
ralysis (Fig.  6A) may also have a normal
assessment. This is attributed to the active
contraction of the abdominal muscles during
expiration, followed by a sudden relaxation of
the abdominal muscles at the beginning of
inspiration resulting in a descending move-
ment of the paralyzed diaphragm. Potentially,
this may be misinterpreted as an active dia-
phragmatic contraction4. This finding, fol-
lowed by the absence of increased thickness
with inspiration, is suggestive of diaphrag-
matic paralysis.
The snif test is conducted with short inspi-
ratory efforts only through the nares. In a
paralyzed diaphragm no motion is docu-
mented, or the diaphragm moves in cephalad
direction instead of towards the transducer.
This cephalad motion of the dome is exag-
gerated by a snif test. The paradoxical dome
motion is an indication of unilateral dia-
phragmatic paralysis. The snif test is positive
in more than 90% of patients with unilateral
paralysis (Fig.  6B). However, bilateral dia-
phragmatic paralysis cannot be confirmed
with the assessment of the diaphragmatic
dome motion.
With bilateral paralysis, the diaphragm moves
caudally during inspiration. This caudal mo-
tion is associated with two compensatory
strategies that individuals use to breathe: the
external intercostal muscles to actively inhale
or the abdominal muscles to passively inhale.
The diaphragm can move caudally because
the subdiaphragmatic pressure becomes more
negative.
If the bilateral diaphragmatic paralysis is con-
firmed, nocturnal hypoventilation evaluation
should be considered1.
7
 Anales de Radiología México. 2023;22

A B

F igure   6. A: Diaphragmatic paralysis. Note the absence of respiratory movement of the right hemidiaphragm. B: the paradoxical
movement is associated to the use of accessory muscles and can be seen as an inversion of the respiratory cycle (yellow arrow).

Ventilator-induced diaphragmatic need to be reintubated within the next 48

dysfunction hours7.

It is considered crucially important for clini- Mechanical ventilation contributes to the

cians to be familiar with imaging strategies
that may allow them to quickly and timely
change the treatment and prognosis of the
patient, previously familiar with ventilator-in-
duced diaphragmatic dysfunction and diag-
nostic imaging.
About 13% to 26% of patients that are extu-
bated after a spontaneous respiration trial
onset of diaphragmatic myopathy and
dysfunction due to diaphragm disuse.
Ventilator-induced diaphragmatic dysfunc-
tion is defined as a reduction in forced capac-
ity of the diaphragm and it is associated with
a significant mortality increase, as well as
with the time that mechanical ventilation is
used, so it is important to identify the dys-
function and establish early management.

8
 A.P. Hernández-Morales et al.  Diaphragm. Anatomy and evaluation by ultrasound
Diaphragmatic dysfunction is associated to
fat atrophy and loss of myofibrils, and may
be evident after 24 to 26 hours after the initi-
ation of mechanical ventilation. The mecha-
nisms that contribute to ventilator-induced
diaphragmatic dysfunction include activation
of proteolytic pathways, caspases and proteo-
somes, as well as disturbances in mitochon-
drial transport, resulting in an increase of
reactive oxygen species and oxidative stress1.
The assessment of diaphragmatic function
with fluoroscopy, stimulation of the phrenic
nerve, magnetic resonance imaging and
transdiaphragmatic pressure measurement
has certain limitations, such as exposure to
ionizing radiation, low availability, invasive-
ness and the need to transport the patient.10
There are two ultrasound diaphragmatic
predictors to successfully extubate a pa-
tient: diaphragmatic excursion, measuring
the distance of the diaphragm during the re-
spiratory cycle and the fraction of diaphrag-
matic contraction, that reflects the thickness
variability during respiratory effort, as previ-
ously mentioned.
The definition of «weaning failure» (extuba-
tion failure) is not standard, but it covers one
or more of the following points in the first
48-72 hours: need to reintubate, unscheduled
non-invasive mechanical ventilation, death,
tracheostomy, terminal extubation, extuba-
tion delay or spontaneous respiration test fail-
ure7.
Contraction fraction has proved to be the
best estimator of muscular effort during
non-invasive mechanical ventilation, and pre-
dicts extubation failure during a spontaneous
respiration test with the ventilator. The cutoff
value reported for extubation or failure is in
the range of 30% to 36% during a sponta-
neous respiration trial11.
The cutoff value for diaphragmatic dysfunc-
tion diagnosis using M mode, through
excursion, is 10-14 mm during a spontaneous
respiration with mechanical ventilation11.
CONCLUSIONS
The key ultrasound findings for the diagnosis
of diaphragmatic disease are morphologic
and functional.
Limitations for assessment are:
– Poor acoustic window.
– Obesity.
– False negative findings in acute diaphrag-
matic paralysis and false positive findings
in small individuals.
Experience is required for measurement of
functional parameters of the diaphragm to be
able to help the clinician with certainty. When
excursion of the diaphragm is measured, the
radiologist must place the measuring line as
perpendicular as possible to the diaphragm,
since the accuracy and repetitivity of excur-
sion may be affected.
It must be taken into consideration that if the
point is measured in excursion, and the patient
is in mechanical assist ventilation, the excur-
sion may represent the two forces exerted in
the same direction: first, the contraction force
itself, and secondly, the displacement of the
diaphragm due to the pressure applied with
the ventilator. In this case, there is no way to
9
 Anales de Radiología México. 2023;22
tell what part of diaphragmatic displacement
is passive, due to the external force applied by
the ventilator, or active from the contraction
action as negative pressure is generated. If the
goal is to assess diaphragmatic excursion
without the assistance of the ventilator, a brief
recording is necessary during spontaneous
respiration. Otherwise, the contraction and the
motion of the diaphragm must be detected
during the patient-ventilator interaction.
FUNDING
The authors declare they received no finan-
cial support.
CONFLICTS OF INTEREST
The authors declare they have no conflicts of
interest.
ETHICAL DISCLOSURES
Protection of persons and animals. The au-
thors declare that no experiments in humans
or animals were conducted for this research.
Confidentiality of data. The authors de-
clare that they have followed the protocols
10
of their work site on the publication of pa-
tient data.
Right to privacy and informed consent. The
authors have obtained informed consent from
patients and/or subjects referred to in this
paper. This document is held by the corre-
sponding author.
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