Open Journal http://dx.doi.org/10.17140/PRRMOJ-SE-1-105 pulmonary Research and respiratory medicinE Pulm Res Respir Med Open J ISSN 2377-1658 Diaphragm Ultrasonography as a Tool to Assess Paradoxical Breathing in a Patient With Asthma Attack Sunao Mikura, MD 1 ; Takeshi Saraya, MD, PhD 1* ; Taro Minami, MD 2* ; Toru Satoh, MD, PhD 3 ; Keisuke Oda, PhD 4 ; Hisako Shinbara, PhD 5 ; Sadatomo Tasaka, MD, PhD 6 ; Hiroshi Kuraishi, MD, PhD 7 ; Hajime Takizawa, MD, PhD 1 1 Department of Respiratory Medicine, Kyorin University School of Medicine, Miatka City, Tokyo, Japan 2 Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA 3 Department of Cardiology, Kyorin University School of Medicine, Miatka City, Tokyo, Japan 4 Departments of Component Technology, Engineering Operation, Automotive OEM Business Division, JVC Kenwood Corporation, Tokyo 192-8525, Japan 5 Departments of Development, Engineering Operation, Media Business Division, JVC Kenwood Corporation, Tokyo 192-8525, Japan 6 Department of Respiratory Medicine, Hirosaki University School of Medicine, Hirosaki 036- 8562, Japan 7 Department of Pulmonology, Nagano Red Cross Hospital, Nagano 380-8582, Japan * Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 Fax: +81 (0)422 44 0671 E-mail: sara@yd5.so-net.ne.jp Taro Minami, MD Assistant Professor of Medicine Divisions of Pulmonary Critical Care and Sleep Medicine Memorial Hospital of Rhode Island The Warren Alpert Medical School of Brown University Pawtucket, RI, USA Tel. +1-401-729-2635 E-mail: nantaro@gmail.com Article History Received: June 30 th , 2016 Accepted: July 25 th , 2016 Published: July 25 th , 2016 Copyright ©2016 Saraya T and Minami T. This is an open access article distrib- uted under the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unre- stricted use, distribution, and repro- duction in any medium, provided the original work is properly cited. Special Edition 1 Article Ref. #: 1000PRRMOJSE1105 Case Report Page S14 Citation Mikura S, Saraya T, Minami T, et al. Diaphragm ultrasonography as a tool to assess paradoxical breath- ing in a patient with asthma attack [Videos]. Pulm Res Respir Med Open J. 2016; SE(1): S14-S16. doi: 10.17140/PRRMOJ-SE-1-105 Special Edition “Revisiting Physical Diagnosis in Respiratory Medicine” KEYWORDS: Diaphragm ultrasonography; Paradoxical breathing; Respiratory distress; Asth- ma attack. CASE REPORT A 67-year-old woman experienced chronic dyspnea, wheezes, and dry cough for 1 year and was admitted to our hospital. She had no remarkable medical history. Her dyspnea worsened over 2 months and was admitted to the hospital for further diagnostic and therapeutic interventions. On examination, the patient was in respiratory distress. The blood pressure, pulse rate, respiratory rate, temperature, and oxygen saturation were 158/108 mmHg, 108 beats per min- ute, 30 breaths per minute, 36.4 °C, and 92%, respectively while she was breathing ambient air. Physical examination revealed paradoxical breathing with the chest wall moving inwards dur- ing inspiration and outwards during expiration (Video 1) together with diffuse inspiratory and expiratory wheezes of Jonson Grade 3 (Video 2). Diaphragm ultrasonography was performed to assess her respiratory failure, which revealed a normally functioning diaphragm, i.e. it de- scended during the inspiratory phase and ascended during the expiratory phase (Video 3) with a normal contraction (thickness of the diaphragm (tdi); Figure 1A: tdi at end-inspiration, 4.9 mm; Figure 1B: tdi at end-expiration, 2.6 mm; ∆tdi% of 88.4%). Thus, paradoxical breathing was assumed to be due to high respiratory load that was triggered by severe asthma attack. Figure 1: Diaphragm ultrasonography reveals that right diaphragm contracts normally (thick- ness of diaphragm [tdi]; Figure 1A: tdi at end-inspiration, 4.9 mm; Figure 1B: tdi at end- expiration, 2.6 mm; ∆tdi% of 88.4%).