title: Reliability of two-dimensional echocardiography in the assessment of clinically significant abnormal hemidiaphragm motion in pediatric cardiothoracic patients: Comparison with fluoroscopy.
abstract: OBJECTIVE
  To assess the utility and reliability of echocardiographic assessment of hemidiaphragm motion abnormalities in pediatric cardiothoracic patients.
  
  
  METHODS
  Retrospective observational study, with post hoc blinded assessment of echocardiographic and fluoroscopic results.
  
  
  METHODS
  Tertiary care center.
  
  
  METHODS
  Thirty-six consecutive pediatric cardiothoracic patients with suspected hemidiaphragm paralysis were identified and included in the study.
  
  
  METHODS
  None.
  
  
  RESULTS
  The results of both echocardiographic and fluoroscopic studies on all patients were included. In addition, blinded review of study results were performed. The sensitivity and specificity of fluoroscopy in identifying hemidiaphragms that needed plication were 100% and 74%, respectively. The positive predictive value was 55%; negative predictive value was 100%. Comparing reported diagnoses with blinded review of the studies showed poor agreement; reviewers agreed with 89% diagnosed as normal, 44% of paralyzed, and 76% of paradoxical hemidiaphragms. The sensitivity and specificity of echo in identifying hemidiaphragms that needed plication were 100% and 81%, respectively. The positive predictive value and negative predictive value were 66% and 100%. Comparing reported diagnoses with blinded review, reviewers agreed with 97% diagnosed as normal, 81% of paralyzed, and 100% of paradoxical hemidiaphragms. Echocardiography was less accurate in discriminating between paralyzed and paradoxical diaphragm motion. Echocardiography was specific for paradoxical motion, since both patients identified by echocardiography were confirmed by fluoroscopy, but it was not sensitive. In nine patients, echo showed paralyzed motion that was identified by fluoroscopy as paradoxical.
  
  
  CONCLUSIONS
  This study supports the use of echocardiography in the assessment of diaphragm function. When the diaphragms are clearly visualized by echo, as they are in the majority of cases, the addition of an additional fluoroscopic study adds no clinical value. The differentiation between paralyzed and paradoxical motion is unreliable by both imaging modalities.
authors.affiliation: Division of Pediatric Cardiology, University of California at San Francisco, USA.
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Miller
authors.forename: Michael M
authors.initials: MM
authors.lastname: Brook
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Tacy
mesh_terms: D000293:Adolescent; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010791:Phrenic Nerve / Q000293:injuries; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012133:Respiratory Paralysis / Q000175:diagnosis* / Q000209:etiology; D012189:Retrospective Studies