PMC4309166_01
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a) Frontal chest radiograph during initial presentation. (
b) Lateral chest radiograph during initial presentation.
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The chest radiographs ( Figure 1a and 1b) demonstrated an elevated left hemi-diaphragm.
Fluoroscopy with sniff test.
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Screening of diaphragmatic movement during fluoroscopy with sniff manoeuvres revealed a paradoxical movement of both hemi-diaphragms ( Figure 2). The diagnosis of bilateral diaphragmatic weakness was made on the basis of fluoroscopy with a sniff test ( Figure 2) and ultrasonography of the diaphragm.
Polysomnographic tracing without ventilatory support showing paradoxical movements of thorax and abdomen (traces 3 and 4, respiratory inductive plethysmography).. From the nasal pressure signal (trace 5) it can be seen that breathing movements follow the inspiration.
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Polysomnography without ventilatory support showed periods of nocturnal desaturations together with out-of-phase thoracic and abdominal movement ( Figure 3 and Figure 4).
Polysomnography with ventilatory support (Bilevel PAP, IPAP=14, EPAP=6, see trace 5).. Abdominal and thoracic movements are not completely in-phase because the ventilatory support is not triggered before there is inspiratory flow.
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Polysomnography without ventilatory support showed periods of nocturnal desaturations together with out-of-phase thoracic and abdominal movement ( Figure 3 and Figure 4).