Search Results (72)

Background: Chronic heart failure (HF) is a systemic condition in which the heart is unable to meet the body’s peripheral demands, leading to both acute and chronic functional decline, accompanied by high morbidity and mortality rates. A non-pharmacological, non-surgical standard approach to managing HF is cardiovascular rehabilitation, which is widely endorsed by international cardiology societies. This typically includes aerobic and anaerobic physical activity involving the peripheral skeletal muscles. However, international guidelines often overlook the clinical significance of the diaphragm and the role of inspiratory muscle training (IMT) in rehabilitation. The diaphragm plays a critical role not only in respiratory and cardiac function but also in supporting limb movements and overall physical performance. In patients with HF, diaphragmatic dysfunction contributes significantly to the symptoms they experience. Conclusions: This review highlights the need for a greater emphasis on incorporating IMT into the standard rehabilitation protocols for patients with HF, given its potential to improve both respiratory function and overall physical capacity. Full article

Background: Even with advanced management involving pharmacologic and ventilatory strategies, respiratory dysfunction increases morbidity and reduces the quality of life. This narrative review examines how craniofacial and cervical manipulative interventions—including nasomaxillary skeletal expansion, breathing re-education, and structural techniques—may holistically optimize airway function by enhancing neurological and lymphatic dynamics, modulating vagal tone, reducing pharyngeal collapsibility, and supporting immune regulation across diverse clinical settings. Objectives: To explore manual techniques that influence respiratory and autonomic function and to evaluate their reported clinical efficacy and supporting evidence, particularly in the context of airway disorders such as asthma and pneumonia. Methods: A narrative review of the literature from PubMed and Google Scholar was conducted using search terms related to airway function and osteopathic manipulative techniques (OMTs). The inclusion criteria spanned 2010–2025 English-language peer-reviewed full-text articles on airway function, OMT, and emergency airway maneuvers. Clinical trials, observational studies, and reviews were included; non-peer-reviewed content and animal studies (unless mechanistically relevant) were excluded. Chapman’s reflexes related to respiratory function were incorporated to highlight somatic–visceral correlations. Key Findings: The techniques reviewed included frontal lift, vomer manipulation, maxillary and zygomatic balancing, and cervical adjustments. Thoracic OMT methods, such as diaphragm doming and lymphatic pump techniques, were also addressed. Emergency techniques, such as the BURP and Larson maneuvers, prone positioning, and high-frequency chest wall oscillation, were presented as comparative strategies to OMTs for acute airway management. Conclusions: Craniofacial and cervical manipulations can be a promising adjunct for enhancing airway function. However, the current literature displays heterogeneity and lack of large-scale randomized trials, which emphasize the necessity for standardized research and the establishment of clinical guidelines with the collected evidence. Full article

Endometriosis, traditionally viewed as a gynecological disorder, is increasingly recognized as a systemic disease with significant cardiovascular implications. Recent studies suggest that women with endometriosis are at higher risk for developing atherosclerosis and other cardiovascular diseases (CVDs), due to chronic systemic inflammation, endothelial dysfunction, oxidative stress, and metabolic disturbances. This review aimed to summarize current evidence on the vascular implications of endometriosis. A literature search was conducted in PubMed and Google Scholar, focusing on studies exploring the relationship between endometriosis and cardiovascular risk. In rare cases, endometriosis can affect extrapelvic locations such as the diaphragm or pericardium, presenting with cyclical chest pain or dyspnea and mimicking cardiopulmonary conditions. These atypical manifestations often delay diagnosis and highlight the need for heightened clinical awareness. Advances in imaging and minimally invasive techniques, including robotic surgery, have improved the detection and management of such presentations. Shared molecular pathways between endometriosis and CVDs, including pro-inflammatory cytokines and metabolic dysregulation, provide a rationale for exploring novel therapeutic approaches. Emerging pharmacologic options such as statins, metformin, or antiplatelet agents may offer dual benefits for both reproductive and cardiovascular health. Given the multifactorial nature of endometriosis, a multidisciplinary approach involving gynecologists, cardiologists, and primary care providers is essential. These findings highlight the need for early cardiovascular risk assessment and tailored preventive strategies in this population. Full article

A 40-year-old woman with a known diagnosis of Ehlers–Danlos syndrome (EDS) began experiencing progressive shortness of breath and reduced exercise tolerance following her second pregnancy. The patient underwent an unenhanced computed tomography (CT) scan that showed a marked elevation of the left diaphragm. Suspecting diaphragm dysfunction, the patient underwent Dynamic Digital Radiography (DDR) that confirmed a reduction in left diaphragm motility, indicative of impaired diaphragm function. Based on the DDR findings, which demonstrated reduced but preserved diaphragmatic motion without paradoxical movement or complete immobility, the thoracic surgeon decided that surgical intervention, such as plication, was not necessary. Instead, rehabilitation exercises, including breathing techniques and diaphragm strengthening, were recommended. EDS includes connective tissue disorders that vary in severity but are typically characterized by hypermobility of the joints, skin hyper-elasticity, and a predisposition to vascular fragility. One of the complications of EDS is weakened connective tissues, which can affect the diaphragm, impairing the contractility of the muscle and leading to impaired mobility and respiratory symptoms such as shortness of breath. Diaphragm dysfunction can manifest as reduced movement, potentially related to the underlying connective tissue weakness. This case highlights the clinical value of DDR as a non-invasive, low-dose, and dynamic imaging modality in the diagnosis of diaphragmatic dysfunction in EDS patients, enabling individualized treatment planning and potentially avoiding unnecessary surgical interventions. Full article

Congenital diaphragmatic hernia (CDH) is a complex disorder whereby improper formation of the diaphragm allows herniation of the internal organs into the thoracic cavity, resulting in pulmonary hypoplasia among other complications. Although epithelial dysfunction is central to CDH pathology, relatively little attention has been paid to the underlying mechanisms orchestrating epithelial malfunction. Proinflammatory signaling downstream of impaired mechanotransduction due to in utero lung compression has been elucidated to drive epithelial cell phenotypes. This has been illustrated by a reduction in nuclear YAP and the upregulation of NF-kB in CDH models. In this review, we draw from recent findings using emerging technologies to examine epithelial cell mechanisms in CDH and discuss the role of compression as a central and, crucially, sufficient driver of CDH phenotypes. In recognition of the limitations of using genetic knockout models to recapitulate such a heterogenic and etiologically complicated disease, we discuss alternative models such as the established nitrofen rat model, air–liquid interface (ALI) cultures, organoids and ex vivo lung explants. Throughout, we acknowledge the importance of involving mechanical compression in the modeling of CDH in order to faithfully recapitulate the disease. Finally, we explore novel therapeutic strategies from stem cell and regenerative therapies to precision medicine and the importance of defining CDH endotypes in order to guide treatments. Full article

Background/Objective: Gastroesophageal reflux disease (GERD) is multifactorial and affects an increasing number of people. It is a common condition in which the stomach contents move up into the esophagus; thus, its main cause is found in the antireflux valve mechanism of the gastroesophageal junction. This consists of two sphincters, the lower oesophageal and the diaphragmatic. The disease has been related to diaphragm dysfunction, either due to the de-coordination of the diaphragms’ contractility or due to decreased strength. Breathing exercises seem to have a positive effect in this population. The aim of this study was to systematically examine the effects of inspiratory muscle training (IMT) on GERD characteristics. Methods: We conducted a systematic review of research up to April 2024 in Scopus, PubMed, and Science Direct. We included randomized controlled trials (RCTs) and clinical trials assessing the effects of IMT on GERD characteristics. Methodological quality was assessed with the PEDro scale (Physiotherapy Evidence Database) and the Newcastle Ottawa scale (NOC). Results: Among the 1984 studies identified from the search, only three studies (one study with a post-COVID-19 population and two with GERD and healthy subjects) were included in this study, as they presented a fair to high methodological quality. Significant improvements in maximal inspiratory pressure (p < 0.001) and diaphragmatic excursion (p < 0.001) were revealed in one study. No significant differences between groups were mentioned for the reflux symptoms and for LES–EGJ pressure in the studies included. Conclusions: IMT seems to provide promising effects in strengthening the antireflux valve mechanism, as it increases MIP and diaphragmatic excursion. This systematic review established a bibliographic gap for the contribution of IMT in the antireflux valve mechanism. More evidence is needed to support the importance of IMT as a non-pharmacological intervention for GERD patients. Full article

Diaphragm ultrasound makes it possible to diagnose diaphragmatic atrophy and dysfunction. Important indications include unclear dyspnea; diaphragmatic elevation; assessment of diaphragm dysfunction in pulmonary, neuromuscular and neurovascular diseases; and in critically ill patients before noninvasive and mechanical ventilation and follow-up of diaphragm thickness and function during mechanical ventilation with potential prediction of prolonged weaning. In patients with respiratory insufficiency and potential diaphragm dysfunction, it is possible to objectify the contribution of diaphragm dysfunction. In addition, assessment of diaphragmatic hernias, tumors and diaphragmatic dysfunction in COVID-19 and diaphragmatic ultrasound in sports medicine have been described. This narrative review includes the sonomorphology of the diaphragm, standardization of ultrasonographic investigation with transducer positions and ultrasound techniques, normal findings and diagnostic criteria for pathological findings. The correct sonographic measurement, calculation and evaluation can ultimately influence further therapeutic procedures for the patient suffering from diaphragm dysfunction in various diseases. Full article

Background/Objectives: Various conditions contribute to the development of postoperative pulmonary complications (PPCs) following thoracic surgery. In this study, the aim was to investigate whether preoperative diaphragm dysfunction is associated with an increased risk of PPCs after lung cancer resection. Methods: We prospectively examined 45 patients scheduled for video-assisted thoracoscopic surgery (VATS) lobectomy or open thoracotomy. Relevant clinical data were retrieved from hospital database records, while diaphragm muscles were assessed using ultrasound. Results: Our results demonstrated that preoperative diaphragm muscle atrophy was significantly associated with a higher risk of developing PPCs compared to patients with normal diaphragm thickness. Diaphragm atrophy was also linked to prolonged hospital stays. Additionally, we observed a moderate correlation between expiratory diaphragm thickness and the number of PPCs. Conclusions: Low diaphragm expiratory thickness is associated with postoperative pulmonary complications after lobectomy for lung cancer. Importantly, unlike other predictive factors such as age, COPD, or smoking, diaphragmatic atrophy is a modifiable risk factor that can potentially be addressed through early therapeutic intervention. Full article

Background/Objectives: Point-of-care lung ultrasonography (LUS) represents an accurate diagnostic tool in older patients with respiratory failure. The integration of LUS with ultrasonographic assessment of diaphragm thickness and excursion, right vastus lateralis (RVL) muscle thickness and cross-sectional area (CSA) could provide real-time information on frailty and sarcopenia. The primary aim of this proof-of-concept prospective study was to evaluate clinical correlates of thoracic, diaphragmatic, and muscular ultrasound to characterize the associations between frailty, respiratory failure, and sarcopenia in older patients hospitalized for acute respiratory complaints. Methods: Each of 52 participants (age median 84, IQR 80–89 years old) underwent integrated LUS, diaphragm and RVL ultrasound examination upon admission (T0) and after 72 h of hospitalization (T1). LUS score was used to estimate lung interstitial syndrome severity. Diaphragm excursion, thickness, RVL thickness and CSA were measured following a standardized protocol. Frailty was assessed with the PC-FI (Primary Care-Frailty Index). Results: All patients exhibited multifactorial causes of respiratory symptoms. The LUS score on T0 predicted 3-month rehospitalization. Frail patients exhibited higher LUS scores on T1. Diaphragm excursion on T0 was reduced in patients with COPD and heart failure and in those developing delirium during hospitalization. Diaphragm excursion on T1 was negatively associated with PC-FI. Diaphragm thickness, RVL thickness, and CSA exhibited a positive association with obesity. Right vastus lateralis CSA on T1, however, was also negatively associated with PC-FI. Conclusions: Integrated lung, diaphragm, and RVL ultrasound shows clinical correlations with several aspects of frailty that may help to improve the management of geriatric patients with respiratory illness. Full article

Aging disrupts multiple homeostatic processes, including autophagy, a cellular process for the recycling and degradation of defective cytoplasmic structures. Acute treatment with the autophagy inhibitor chloroquine blunts the maximal forces generated by the diaphragm muscle, but the mechanisms underlying neuromuscular dysfunction in old age remain poorly understood. We hypothesized that chloroquine treatment increases the presynaptic retention of the styryl dye FM 4-64 following high-frequency nerve stimulation, consistent with the accumulation of unprocessed bulk endosomes. Diaphragm-phrenic nerve preparations from 24-month-old male and female C57BL/6 × 129 J mice were incubated with FM 4-64 (5 µM) and either chloroquine (50 µM) or vehicle during 80 Hz phrenic nerve stimulation. Acute chloroquine treatment significantly decreased FM 4-64 intensity at diaphragm neuromuscular junctions following 80 Hz phrenic nerve stimulation, consistent with disrupted synaptic vesicle recycling. A similar reduction was evident in regions with the greatest FM 4-64 fluorescence intensity, which most likely surround synaptic vesicle release sites. In the absence of nerve stimulation, chloroquine treatment significantly increased FM 4-64 intensity at diaphragm neuromuscular junctions. These findings highlight the importance of autophagy in regulating presynaptic vesicle retrieval (including vesicle recycling and endosomal processing) and support the role of autophagy impairments in age-related neuromuscular dysfunction. Full article

Dynamic digital radiography (DDR) is a recent imaging technique that allows for real-time visualization of thoracic and pulmonary movement in synchronization with the breathing cycle, providing useful clinical information. A 46-year-old male, a former smoker, was evaluated for unexplained dyspnea and reduced exercise tolerance. His medical history included a SARS-CoV-2 infection in 2021. On physical examination, decreased breath sounds were noted at the right-lung base. Spirometry showed results below predicted values. A standard chest radiograph revealed an elevated right hemidiaphragm, a finding not present in a previous CT scan performed during his SARS-CoV-2 infection. To better assess the diaphragmatic function, a posteroanterior DDR study was performed in the standing position with X-ray equipment (AeroDR TX, Konica Minolta Inc., Tokyo, Japan) during forced breath, with the following acquisition parameters: tube voltage, 100 kV; tube current, 50 mA; pulse duration of pulsed X-ray, 1.6 ms; source-to-image distance, 2 m; additional filter, 0.5 mm Al + 0.1 mm Cu. The exposure time was 12 s. The pixel size was 388 × 388 μm, the matrix size was 1024 × 768, and the overall image area was 40 × 30 cm. The dynamic imaging, captured at 15 frames/s, was then assessed on a dedicated workstation (Konica Minolta Inc., Tokyo, Japan). The dynamic acquisition showed a markedly reduced motion of the right diaphragm. The diagnosis of diaphragm dysfunction can be challenging due to its range of symptoms, which can vary from mild to severe dyspnea. The standard chest X-ray is usually the first exam to detect an elevated hemidiaphragm, which may suggest motion impairment or paralysis but fails to predict diaphragm function. Ultrasound (US) allows for the direct visualization of the diaphragm and its motion. Still, its effectiveness depends highly on the operator’s experience and could be limited by gas and abdominal fat. Moreover, ultrasound offers limited information regarding the lung parenchyma. On the other hand, high-resolution CT can be useful in identifying causes of diaphragmatic dysfunction, such as atrophy or eventration. However, it does not allow for the quantitative assessment of diaphragmatic movement and the differentiation between paralysis and dysfunction, especially in bilateral dysfunction, which is often overlooked due to the elevation of both hemidiaphragms. Dynamic Digital Radiography (DDR) has emerged as a valuable and innovative imaging technique due to its unique ability to evaluate diaphragm movement in real time, integrating dynamic functional information with static anatomical data. DDR provides both visual and quantitative analysis of the diaphragm’s motion, including excursion and speed, which leads to a definitive diagnosis. Additionally, DDR offers a range of post-processing techniques that provide information on lung movement and pulmonary ventilation. Based on these findings, the patient was referred to a thoracic surgeon and deemed a candidate for surgical plication of the right diaphragm. Full article

Background: Endometriosis is a systemic, inflammatory, estrogen-dependent condition characterized by endometrial stroma and gland-like lesions outside of the uterus. It causes a range of symptoms, notably chronic pelvic pain, infertility and organ dysfunction. Thoracic endometriosis syndrome (TES) has been described as endometriosis that is found in the lung parenchyma, pleura and diaphragm. It may be asymptomatic or present with symptoms of catamenial pneumothorax, hemothorax, hemoptysis, isolated chest pain, shoulder pain or findings of lung nodules. Aim: The aim of this review is to provide a comprehensive overview of thoracic endometriosis syndrome (TES), including its clinical presentation, diagnostic challenges, and current management strategies. This review aims to highlight the importance of a multidisciplinary approach in the treatment of TES, emphasizing conservative management and the role of minimally invasive surgical techniques for refractory cases. Conclusions: Thoracic endometriosis syndrome appears to be a marker of severe endometriosis. As much as possible, the patient with TES is managed conservatively, with surgery reserved for refractory cases. When surgery is recommended, the procedure is conducted through a multidisciplinary minimally invasive approach, with video-assisted thoracoscopic surgery (VATS) and video-assisted laparoscopy. Meticulous intraoperative survey, the removal of endometriosis implants with and without robotic assistance and post-operative hormonal therapy may be recommended to prevent recurrence. Full article

The COVID-19 pandemic has brought significant attention to the respiratory system, with much focus on lung-related disorders. However, the diaphragm, a crucial component of respiratory physiology, has not been adequately studied, especially in the context of long COVID. This review explores the multipotential role of the diaphragm in both respiratory health and disease, emphasizing its involvement in long-term complications following SARS-CoV-2 infection. The diaphragm’s fundamental role in respiratory physiology and its impact on balance and posture control, breathing patterns, and autonomic nervous system regulation are discussed. This review examines complications arising from COVID-19, highlighting the diaphragm’s involvement in neurological, musculoskeletal, and inflammatory responses. Particular attention is given to the neuroinvasive impact of SARS-CoV-2, the inflammatory response, and the direct viral effects on the diaphragm. The diaphragm’s role in long COVID is explored, with a focus on specific symptoms such as voice disorders, pelvic floor dysfunction, and sleep disturbances. Diagnostic challenges, current methods for assessing diaphragmatic dysfunction, and the complexities of differentiating it from other conditions are also explored. This article is the first to comprehensively address diaphragmatic dysfunction resulting from COVID-19 and long COVID across various physiological and pathological aspects, offering a new perspective on its diagnosis and treatment within a multisystem context. Full article

Background: This study analyzed weaning characteristics and assessed the association of clinical and ultrasonographic indices—maximum inspiratory pressure (MIP), rapid shallow breathing index (RSBI), peak flow expiratory (PFE), diaphragm-thickening fraction (DTF), diaphragm thickness (DT), diaphragm excursion (DE), diaphragm-RSBI (D-RSBI), and lung ultrasound (LUS) patterns—with weaning failure. Methods: This retrospective cohort study included critically ill COVID-19 patients aged 18 and older who had been on invasive mechanical ventilation for at least 48 h and undergoing weaning. Exclusion criteria included absence of ultrasound assessments, neuromuscular diseases, and chronic cardio-respiratory dysfunction. Results: Among 61 patients, 44.3% experienced weaning failure, 27.9% failed the spontaneous breathing trial (SBT), 16.4% were re-intubated within 48 h, and 28% required tracheostomy. Weaning failure was associated with prolonged ventilation (29 vs. 7 days, p < 0.001), extended oxygen therapy, longer ICU stays, and higher ICU mortality. These patients had higher pressure support, lower oxygenation levels, a higher RSBI, and a lower MIP. While PEF, DTF, DE, and D-RSBI showed no significant differences, both right and left diaphragm thicknesses and the inspiratory thickness of the left diaphragm were reduced in failure cases. LUS scores were significantly higher before and after SBT in the failure group. Bivariate analysis identified RSBI [OR = 1.04 (95% CI = 1.01–1.07), p = 0.010], MIP [OR = 0.92 (95% CI = 0.86–0.99), p = 0.018], and LUS [OR = 1.15 (95% CI = 0.98–1.35), p = 0.025] as predictors of weaning failure; however, these associations were not confirmed in multivariate analysis. Conclusions: Ultrasound provides supplementary information during weaning, but no definitive association between ultrasound indices and weaning failure was confirmed in this study. Full article

Fatigue and dyspnea are the most commonly reported long-term complaints in individuals previously infected with SARS-CoV-2. This study aimed to comprehensively evaluate diaphragm muscle function in post-COVID-19 patients and investigate whether potential diaphragm dysfunction contributes to physical functioning impairment. A total of 46 patients who qualified for pulmonary rehabilitation were examined. Diaphragm muscle function parameters were evaluated using ultrasonography, while the severity of dyspnea, aerobic capacity, and the amount of energy used by the body during physical activity were assessed using the six-minute walk test, mMRC scale, and Metabolic Equivalent Task (MET), respectively. We identified that 69.5% of patients had diaphragm atrophy and 6.5% had diaphragm paralysis. The percentage of atrophy was not related to age, gender, BMI, oxygen therapy usage during the COVID-19 infection course, and disease severity. Patients who experienced cough, fever, and no loss of smell during the COVID-19 course had significantly greater diaphragm inspiratory thickness values, while patients with cough and no smell disorders had a significantly lower percentage of diaphragm atrophy. Diaphragm functional parameters were strongly associated with selected variables of exercise tolerance, such as distance in the six-minute walk test, oxygen saturation levels, fatigue, and exertion on the Borg scale. In conclusion, diaphragm muscle dysfunction is a serious long-term post-COVID-19 consequence and can be viewed as a major contributing factor to prolonged functional impairments. Full article