The American College of Radiology has published Appropriateness Criteria on the initial imaging of suspected diaphragm dysfunction, covering eventration, weakness and paralysis. These conditions are hard to diagnose clinically because their symptoms vary: breathlessness, orthopnoea when lying flat, cough and sometimes chest pain.
The criteria note that diaphragm dysfunction is often first suggested incidentally, when imaging is done for these symptoms. Imaging then has two jobs: to confirm the diagnosis by watching the diaphragm move in real time, and to look for an underlying cause along the course of the phrenic nerve and elsewhere.
Like other Appropriateness Criteria, the document rates imaging procedures for defined clinical scenarios using a systematic literature review and a formal expert rating method. Where evidence is thin, which is common in this area, expert opinion carries more weight.
For radiologists, the practical point is that a static image raises the question and a dynamic study answers it. Readers should consult the full document for the ratings for each scenario.
- Consider diaphragm dysfunction in unexplained breathlessness or orthopnoea, especially when lying flat worsens it.
- Confirm suspected dysfunction with a real-time study of diaphragm motion rather than a static image alone.
- Look for a cause along the phrenic nerve course when paralysis is confirmed.
- Check the full ACR document for the procedure ratings in each clinical scenario.
Why it matters
Diaphragm paralysis is often missed because a raised hemidiaphragm is reported but never followed by a study that shows how it moves.
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