X-ray computed tomographic anatomy of the diaphragm

The paper is concerned with retrospective analysis of CT scans of 507 patients without signs of diaphragmatic pathology to investigate normal roentgeno-anatomy of the diaphragm in CT imaging. The four main variants (types) in the structure of the lumbar diaphragm were singled out. CT was shown effective in the determination of pathological changes of the lumbar diaphragm and adjacent zones. It is an informative method among diagnostic procedures used in diaphragmatic diseases.     

Computed tomography in the diagnosis of pathological states of the lumbar diaphragm. 1: general data. Developmental defects and traumatic disorders]

CT was employed for investigation of 94 patients with pathological changes of the diaphragm. Congenital defects and unilateral aplasia of the diaphragm were observed in 5 of them. A new symptom of a pathological line of the diaphragm was recognized, characteristic for this type of patients. Teratodermoid formations with a typical CT picture were found in 3 patients. A tumor growth source was undetectable by CT. The results of investigation of 5 patients with traumatic diaphragmatic hernia have shown no particular advantages of CT over traditional radiation methods. In one case, a traumatic diaphragmatic cyst was correctly diagnosed by CT. CT was shown to be a method of choice in the diagnosis of congenital and traumatic diaphragmatic lesions.     

Muscle fiber architecture of the dog diaphragm

Boriek, Aladin M., Charles C. Miller III, and Joseph R. Rodarte. Muscle fiber architecture of the dog diaphragm.J. Appl. Physiol. 84(1): 318-326, 1998.Previous measurements of muscle thickness and length ratio ofcostal diaphragm insertions in the dog (A. M. Boriek and J. R. Rodarte.J. Appl. Physiol. 77: 2065-2070,1994) suggested, but did not prove, discontinuous muscle fiberarchitecture. We examined diaphragmatic muscle fiber architecture usingmorphological and histochemical methods. In 15 mongrel dogs, transversesections along the length of the muscle fibers were analyzedmorphometrically at ×20, by using the BioQuant System IVsoftware. We measured fiber diameters, cross-sectional fiber shapes,and cross-sectional area distributions of fibers. We also determinednumbers of muscle fibers per cross-sectional area and ratio ofconnective tissue to muscle fibers along a course of the muscle fromnear the chest wall (CW) to near the central tendon (CT) for midcostalleft and right hemidiaphragms, as well as ventral, middle, and dorsalregions of the left costal hemidiaphragm. In six other mongrel dogs,the macroscopic distribution of neuromuscular junctions (NMJ) onthoracic and abdominal diaphragm surfaces was determined by stainingthe intact diaphragmatic muscle for acetylcholinesterase activity. Theaverage major diameter of muscle fibers was significantly smaller, andthe number of fibers was significantly larger midspan between CT and CWthan near the insertions. The ratio of connective tissues to musclefibers was largest at CW compared with other regions along the lengthof the muscle. The diaphragm is transversely crossed by multiplescattered NMJ bands with fairly regular intervals offset in adjacentstrips. Muscle fascicles traverse two to five NMJ, consistent withfibers that do not span the entire fascicle from CT to CW. Theseresults suggest that the diaphragm has a discontinuous fiberarchitecture in which contractile forces may be transmitted among themuscle fibers through the connective tissue adjacent to the fibers.

     

Unilateral agenesis of the diaphragm

Summary A brother and sister with congenital agenesis of the diaphragm are described and the literature reviewed with respect to the familial incidence of congenital diaphragmatic lesions. Although unilateral agenesis of the diaphragm is infrequent, four comparable reports of familial occurrence were found.Based on anatomic and genetic considerations, the hypothesis is advanced that agenesis of the diaphragm may be etiologically different from other lesions of the diaphragm. The possibility exists that a rare recessive gene in some cases might cause this developmental failure of the diaphragm anlage.This investigation was supported in part by USPHS International Postdoctoral Research Fellowship Grant No. FO 5-TW-1129, and by Public Health Service Research Grant No. HD-00635-04, from the National Institute of Child Health and Human Development.     

Diaphragmatic plate electrode stimulation of the hamster diaphragm

We developed a new technique of diaphragmatic stimulation by apposing plate electrodes directly against the diaphragm (DPS) in adult Golden Syrian hamsters. The electrophysiological and the mechanical responses to DPS were compared with those with phrenic nerve stimulation. In four animals, evaluation of the electromyogram before and after curare demonstrated that plate electrode stimulation occurred via the phrenic nerve filaments. In four animals, similar transdiaphragmatic pressure was produced at maximal current with DPS and phrenic nerve stimulation. Using DPS increasing current beyond a certain level resulted in recruitment of muscles besides the diaphragm. In six animals, an external abdominal pressure of 15 cmH2O produced maximal transdiaphragmatic pressure, suggesting that the diaphragm was contracting near optimal position with this external abdominal pressure. In another four animals the twitch and pressure-frequency characteristics with the use of DPS were found to be reproducible over a 2-h period. We conclude that DPS is an effective method of diaphragmatic stimulation and should prove to be a valuable technique to study the diaphragm in long-term studies of small rodents.     

Endurance exercise attenuates ventilator-induced diaphragm dysfunction

Controlled mechanical ventilation (MV) is a life-saving measure for patients in respiratory failure. However, MV renders the diaphragm inactive leading to diaphragm weakness due to both atrophy and contractile dysfunction. It is now established that oxidative stress is a requirement for MV-induced diaphragmatic proteolysis, atrophy, and contractile dysfunction to occur. Given that endurance exercise can elevate diaphragmatic antioxidant capacity and the levels of the cellular stress protein heat shock protein 72 (HSP72), we hypothesized that endurance exercise training before MV would protect the diaphragm against MV-induced oxidative stress, atrophy, and contractile dysfunction in female Sprague-Dawley rats. Our results confirm that endurance exercise training before MV increased both HSP72 and the antioxidant capacity in the diaphragm. Importantly, compared with sedentary animals, exercise training before MV protected the diaphragm against MV-induced oxidative damage, protease activation, myofiber atrophy, and contractile dysfunction. Further, exercise protected diaphragm mitochondria against MV-induced oxidative damage and uncoupling of oxidative phosphorylation. These results provide the first evidence that exercise can provide protection against MV-induced diaphragm weakness. These findings are important and establish the need for future experiments to determine the mechanism(s) responsible for exercise-induced diaphragm protection.     

In vivo length-force relationship of canine diaphragm

Diaphragmatic length was measured by sonomicrometry and transdiaphragmatic pressure (Pdi) by conventional latex balloons in eight dogs anesthetized with pentobarbital sodium under passive conditions and during supramaximal phrenic stimulation. The passive length-pressure relationship indicates that the crural part of the diaphragm is more compliant than the costal part. With supramaximal stimulation the costal diaphragm showed a length-pressure relationship similar in shape to in vitro length-tension curves previously described for the canine diaphragm. The crural part has a smaller pressure-length slope than the costal part in the length range from 80% of optimum muscle length (Lo) to Lo. At supine functional residual capacity (FRC) the resting length (LFRC) of the costal and crural diaphragms are not at Lo. The costal part is distended to 105% of Lo, and crural is shortened to 92% of Lo. Tidal shortening will increase the force output of costal while decreasing that of the crural diaphragm. The major forces setting the passive supine LFRC are the abdominal weight (pressure) and the elastic recoil of the lungs. The equilibrium length (resting length of excised diaphragmatic strips) was 79 +/- 3.6% LFRC for the costal diaphragm and 87 +/- 3.9% LFRC for the crural diaphragm. Similar shortening was obtained in the upright position, indicating passive diaphragmatic stretch at supine LFRC.     

Metabolite changes in the loaded hypoperfused and failing diaphragm

Metabolite changes in the costal diaphragm were determined in anesthetized dogs subjected to a moderate inspiratory elastic load and to reduced blood flow. Diaphragmatic blood flow was reduced by occlusion of the descending aorta and internal mammary arteries. The goal of this study was to demonstrate that the failing diaphragm under these conditions shows biochemical changes similar to that of skeletal muscle fatigue. Selected metabolite concentrations were determined 1) during mechanical ventilation and normal blood flow, 2) during blood flow reduction and inspiratory loading when the ratio of airway pressure to diaphragmatic electromyogram (Paw/Edi) had decreased by 50% (fatigue), and 3) at 1 h after restoration of blood flow and mechanical ventilation (recovery). During fatigue, glycogen, ATP, and phosphocreatine were 30, 50, and 50% of control levels, respectively. Glucose 6-phosphate and lactate were two- and fivefold higher, respectively, than control concentrations. During recovery, all metabolites, except ATP and lactate, returned to control concentrations. These changes were not seen in resting ischemic skeletal muscles or in the diaphragmatic samples of the mechanically ventilated animals with diaphragmatic blood flow limitation. We conclude that when the loaded and hypoperfused diaphragm fails, as indicated by lower than control Paw/Edi, metabolite changes similar to that observed in fatigued skeletal muscle occur.     

Peroxynitrite induces contractile dysfunction and lipid peroxidation in the diaphragm.

Peroxynitrite may be generated in and around muscles in several pathophysiological conditions (e.g., sepsis) and may induce muscle dysfunction in these disease states. The effect of peroxynitrite on muscle force generation has not been directly assessed. The purpose of the present study was to assess the effects of peroxynitrite administration on diaphragmatic force-generating capacity in 1) intact diaphragm muscle fiber bundles (to model the effects produced by exposure of muscles to extracellular peroxynitrite) and 2) single skinned diaphragm muscle fibers (to model the effects of intracellular peroxynitrite on contractile protein function) by examining the effects of both peroxynitrite and a peroxynitrite-generating solution, 3-morpholinosydnonimine, on force vs. pCa characteristics. In intact diaphragm preparations, peroxynitrite reduced diaphragm force generation and increased muscle levels of 4-hydroxynonenal (an index of lipid peroxidation). In skinned fibers, both peroxynitrite and 3-morpholinosydnonimine reduced maximum calcium-activated force. These data indicate that peroxynitrite is capable of producing significant diaphragmatic contractile dysfunction. We speculate that peroxynitrite-mediated alterations may be responsible for much of the muscle dysfunction seen in pathophysiological conditions such as sepsis.     

Relationship between axial motion and volume displacement of the diaphragm during VC maneuvers.

During semistatic inspiratory and expiratory vital capacity (VC) maneuvers, axial motion of the diaphragm was measured by lateral fluoroscopy and was compared with diaphragmatic volume displacement. Axial motion was measured at the anterior, middle, and posterior parts of the diaphragm, and the mean of these measurements was used. The volume displacement was calculated in two ways: first, from respiratory inductive plethysmograph-(Respitrace) derived cross-sectional area changes of rib cage and abdomen (Vdi,RIP) by means of a theoretical analysis described by Mead and Loring (J. Appl. Physiol. 53: 750-755, 1982) and, second, from fluoroscopically measured changes in position and anteroposterior surface of the diaphragm (Vdi,F). A very good linear relationship was found between Vdi,RIP and Vdi,F during inspiration as well as expiration (r greater than 0.95), indicating that the analysis of Mead and Loring was valid in the conditions of the present study. The diaphragmatic volume displacement (active or passive) accounted for 50-60% of VC. A very good linear relationship was also found between mean axial motion and volume displacement of the diaphragm measured with both methods during inspiration and expiration (r greater than 0.98). Our data suggest that, over the VC range, diaphragmatic displacement functionally can be represented by a pistonlike model, although topographically and anatomically it does not behave as a piston.     

Differential activation within costal diaphragm during rapid-eye-movement sleep in cats

Simultaneous recordings of the diaphragmatic electromyogram (EMG) were made from two separate regions of the costal diaphragm in six normal cats. The diaphragmatic activities were always synchronous and the amplitudes and rates of rise were similar during slow-wave sleep. In contrast, during natural rapid-eye-movement (REM) sleep, different activity was often present in the two leads. These differences were in the time of onset and offset, as well as in the amplitude and spike patterns, and occurred in approximately 5-20% of the diaphragmatic bursts averaged over the entire REM sleep period. With respect to eye movement density, the rate of differential activation was higher during periods of high density (26%) than in the absence of eye movements (1%) in the four animals for which these data were available. Differential activation of portions of the costal diaphragm is apparently a normal event of REM sleep. This could result from descending state-specific phasic neuronal activity that bypasses the medullary respiratory generator. Differential activation of portions of the diaphragm could contribute to disordered ventilation during REM sleep.     

The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury

Nerve transfers have been well described for the treatment of congenital and traumatic injuries in the brachial plexus and extremities. This series is the first to describe nerve transfers to reanimate the diaphragm in patients confined to long-term positive pressure ventilation because of high cervical spine injury. Patients who have sustained injury to the spinal cord at the C3 to C5 level suffer axonal loss in the phrenic nerve. They can neither propagate a nerve stimulus nor respond to implanted diaphragmatic pacing devices (electrophrenic respiration). Ten nerve transfers were performed in six patients who met these conditions. The procedures used end-to-end anastomoses from the fourth intercostal to the phrenic nerve approximately 5 cm above the diaphragm. A phrenic nerve pacemaker was implanted as part of the procedure and was placed distal to the anastomosis. Each week, the pacemaker was activated to test for diaphragmatic response. Once diaphragm movement was documented, diaphragmatic pacing was instituted. Eight of the 10 transfers have had more than 3 months to allow for axonal regeneration. Of these, all eight achieved successful diaphragmatic pacing (100 percent). The average interval from surgery to diaphragm response to electrical stimulation was 9 months. All patients were able to tolerate diaphragmatic pacing as an alternative to positive pressure ventilation, as judged by end tidal CO2 values, tidal volumes, and patient comfort. Intercostal to phrenic nerve transfer with diaphragmatic pacing is a viable means of liberating patients with high cervical spine injury from long-term mechanical ventilation.     

Distortion of chest wall and work of diaphragm in preterm infants

Chest wall distortion is common in infants and is especially visible in preterm infants. It has been suggested that this distortion increases the volume displacement of the diaphragm during inspiration, which may be associated with muscular fatigue and apnea. We studied 10 preterm infants who had no evidence of lung disease, investigating the effect of chest wall distortion on the volume displacement and work of the diaphragm. The volume changes of the respiratory system were partitioned using an inductance plethysmograph. The minute volume displacement and the work of the diaphragm were calculated using the partitioned abdominal volume change and the gastric and esophageal pressures. The paradoxical movement of the chest wall lasted an average of 36% of inspiration. The minute volume displacement of the diaphragm ranged from 72 to 176% of the minute pulmonary ventilation, and diaphragmatic work ranged from 94 to 793% of that performed on the lungs. The amount of chest wall distortion, as reflected by the duration of the paradoxical chest wall movement, the minute volume excursion, or work of the diaphragm, was not related to the mechanical properties of the lungs. This estimated work load may represent a significant expenditure of calories in these infants and may contribute to the development of diaphragmatic fatigue, apnea, and a prolonged need for mechanical ventilation.     

Relationship between diaphragm length and abdominal dimensions

We examined the relationship between changes in abdominal cross-sectional area, measured by respiratory inductive plethysmography, and changes in length in the costal and crural parts of the diaphragm, measured by sonomicrometry, in nine supine, anesthetized dogs. During passive inflation, both parts of the diaphragm shortened and abdominal cross-sectional area increased. During passive deflation, both parts of the diaphragm lengthened and abdominal cross-sectional area decreased. We subsequently used the relationship between costal and crural diaphragmatic length, respectively, and abdominal cross-sectional area during passive inflation-deflation to predict the length changes in the costal and crural diaphragm during quiet breathing before and after bilateral phrenicotomy. In the intact animal the inspiratory shortening in the crural diaphragm was almost invariably greater than predicted from the relationship during passive inflation. During inspiration after phrenicotomy the crural diaphragm invariably lengthened, whereas the costal diaphragm often shortened. In general there was a good correlation between the measured and predicted length change for the crural diaphragm (r = 0.72 before and 0.79 after phrenicotomy) and a poor one for the costal diaphragm (r = 0.05 before and 0.19 after phrenicotomy).     

Computer simulation analysis of normal and abnormal development of the mammalian diaphragm

Background  

Congenital diaphragmatic hernia (CDH) is a birth defect with significant morbidity and mortality. Knowledge of diaphragm morphogenesis and the aberrations leading to CDH is limited. Although classical embryologists described the diaphragm as arising from the septum transversum, pleuroperitoneal folds (PPF), esophageal mesentery and body wall, animal studies suggest that the PPF is the major, if not sole, contributor to the muscular diaphragm. Recently, a posterior defect in the PPF has been identified when the teratogen nitrofen is used to induce CDH in fetal rodents. We describe use of a cell-based computer modeling system (Nudge++™) to study diaphragm morphogenesis.     

Pressure-flow relations of diaphragm and vital organs with nitroprusside-induced vasodilatation

We determined maximal conductance in the diaphragm and other vital organs in 14 anesthetized dogs, weighing 22.8 +/- 4.2 kg, which were given maximal vasodilating doses of nitroprusside (mean dose 13.9 +/- 4.3 micrograms X kg-1 X min-1) and the blood pressure was lowered in stages by hemorrhage. Blood flow in the diaphragm, brain, heart, kidney, gut, and quadriceps was measured with radiolabeled microspheres. To ensure maximal vasodilatation of diaphragmatic vessels, we stimulated the phrenic nerves to produce diaphragmatic contractions at 0.3 Hz. The mean cardiac output was 2.13 +/- 0.42 l/min (thermodilution) before nitroprusside and 4.68 +/- 1.45 after (P less than 0.001). Nitroprusside failed to break the autoregulation of the brain. Pressure-flow relations (P-F) in other regions were linear (r = 0.70 +/- 0.03, P less than 0.001) and blood pressure at zero flow (X-intercept) was always greater than venous pressure (diaphragm = 11, kidney = 19, heart = 8, gut = 8, quadriceps = 32 mmHg). The flow to the diaphragm (Qdi) could be predicted by Qdi (ml X min-1 X g-1) = [(3.13 +/- 0.56) X Pa X 10(-2)] -0.52 (r = 0.71), where Pa is mean arterial pressure. The maximal vascular conductance (i.e., slope of the P-F relation) of the diaphragm was 27% of the conductance in the kidney, 87% of the value in the gut, and 42% of that in the heart. In conclusion the maximal diaphragmatic blood flow at a given blood pressure is much larger when the muscle is stimulated than is observed in spontaneously breathing animals.     

Effect of digitalis on the diaphragm in anesthetized dogs

We examined the effect of digitalis on diaphragmatic contractility and fatigability in 19 anesthetized mechanically ventilated dogs. The diaphragmatic force was assessed from transdiaphragmatic pressure (Pdi) developed at functional residual capacity against an occluded airway during cervical phrenic nerve stimulation. In a first group of five dogs, Pdi-stimulus frequency relationships were compared before and after administration of ouabain in doses of 0.01, 0.02, and 0.04 mg/kg. In a second group, diaphragmatic fatigue was produced by bilateral phrenic nerve stimulation at 30 Hz. Ten seconds of stimulation and 15 s of mechanical ventilation were repeated for 30 min. The rates of decrease in Pdi were compared between two groups, one of 0.05 mg/kg deslanoside-treated dogs (n = 7) and one of nontreated dogs (n = 7). After ouabain administration Pdi was significantly greater at each frequency in a dose-dependent manner. On the other hand, the rate of decrease in Pdi in the deslanoside group was significantly smaller than that in the nontreated group, whereas deslanoside did not greatly change the Pdi-frequency curves in fresh diaphragm. We conclude that ouabain improves contractility of the fresh diaphragm and that deslanoside has a protective effect against fatigability.     

Functional importance of a highly elastic ligament on the mammalian diaphragm.

The diaphragm of mammals is a musculotendinous dome separating the thoracic and abdominal cavities. With no skeletal elements to stretch it, the diaphragm has the problem of positioning its muscle fibres at a length appropriate for the onset of an inspiratory contraction. This is achieved through a negative intrapleural pressure, resulting from the opposing elastic recoil of the ribcage and lungs, which sucks the diaphragm into the thorax and extends the muscle fibres. A consequence of this negative pressure is that the diaphragm muscle is under tension when inactive during expiration. This is an unusual condition for skeletal muscles, which can suffer irreversible changes when stretched to long length, or they may respond by growing longer. We now describe a highly elastic and resilient diaphragmatic ligament which sets a sarcomere length enabling the muscle to use its full operating range, reduces stress on the diaphragm muscle fibres, and assists shortening of the diaphragm muscle at the onset of inspiration by means of elastic recoil.     

An overview of phrenic nerve and diaphragm muscle development in the perinatal rat.

In this overview, we outline what is known regarding the key developmental stages of phrenic nerve and diaphragm formation in perinatal rats. These developmental events include the following. Cervical axons emerge from the spinal cord during embryonic (E) day 11. At approximately E12.5, phrenic and brachial axons from the cervical segments merge at the brachial plexi. Subsequently, the two populations diverge as phrenic axons continue to grow ventrally toward the diaphragmatic primordium and brachial axons turn laterally to grow into the limb bud. A few pioneer axons extend ahead of the majority of the phrenic axonal population and migrate along a well-defined track toward the primordial diaphragm, which they reach by E13.5. The primordial diaphragmatic muscle arises from the pleuroperitoneal fold, a triangular protrusion of the body wall composed of the fusion of the primordial pleuroperitoneal and pleuropericardial tissues. The phrenic nerve initiates branching within the diaphragm at approximately E14, when myoblasts in the region of contact with the phrenic nerve begin to fuse and form distinct primary myotubes. As the nerve migrates through the various sectors of the diaphragm, myoblasts along the nerve's path begin to fuse and form additional myotubes. The phrenic nerve intramuscular branching and concomitant diaphragmatic myotube formation continue to progress up until E17, at which time the mature pattern of innervation and muscle architecture are approximated. E17 is also the time of the commencement of inspiratory drive transmission to phrenic motoneurons (PMNs) and the arrival of phrenic afferents to the motoneuron pool. During the period spanning from E17 to birth (gestation period of approximately 21 days), there is dramatic change in PMN morphology as the dendritic branching is rearranged into the rostrocaudal bundling characteristic of mature PMNs. This period is also a time of significant changes in PMN passive membrane properties, action-potential characteristics, and firing properties.