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López Escárraga, K. Dubos España, R.H. Castillo Bustos, L. Peidró, S. Sastre, X. Sala-Blanch" "autores" => array:6 [ 0 => array:3 [ "nombre" => "V.M." "apellidos" => "López Escárraga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "K." "apellidos" => "Dubos España" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R.H." "apellidos" => "Castillo Bustos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Peidró" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "S." "apellidos" => "Sastre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:4 [ "nombre" => "X." "apellidos" => "Sala-Blanch" "email" => array:2 [ 0 => "xsala@clinic.ub.es" 1 => "xavi.sala.blanch@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Anestesiología, Fellow de Anestesia Regional, Máster en Competencias Médicas Avanzadas, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Ortopedia y Traumatología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Anestesiología, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Anatomía y Embriología Humana, Facultad de Medicina, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La ratio de grosor diafragmático (inspiratorio/espiratorio) como método diagnóstico de parálisis diafragmática asociada al bloqueo interescálenico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1470 "Ancho" => 1589 "Tamanyo" => 65987 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reduction of spirometric parameters observed at 20<span class="elsevierStyleHsp" style=""></span>min after interscalene blockade, with respect to baseline levels.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Phrenic nerve block is a side effect of interscalene block. In the days when neurostimulation was still widely used, incidence was usually estimated at 100% of cases, even when local anaesthetic (LA) volume was reduced to 20<span class="elsevierStyleHsp" style=""></span>ml.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1,2</span></a> The nerve block is caused not only by the spread of LA inside the prevertebral fascia and its effect on the cervical metameres of C3 and C4, but also by the presence, in 60–75% of individuals, of an accessory phrenic nerve, the origin and course of which vary greatly, making it particularly susceptible to inadvertent blockade.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,3</span></a> The use of ultrasound and lower volumes of LA seem to have reduced, though not entirely eradicated, the incidence and intensity of inadvertent phrenic nerve block.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">4–8</span></a> Riazi et al. reported an incidence of 47% of phrenic paralysis using 5<span class="elsevierStyleHsp" style=""></span>ml of anaesthetic injected between the C5 and C6 nerve roots.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> Renes et al., meanwhile, reported an incidence of just 13% using 10<span class="elsevierStyleHsp" style=""></span>ml of ropivacaine 0.75% administered to the C7 nerve root.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> The possibility of reducing the incidence of phrenic paresis associated with interscalene blockade raises the need for a high-sensitivity, high-specificity diagnostic test to identify phrenic nerve involvement.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several such diagnostic tests have been used. The first involved a double-exposure chest X-ray, where the image of the thorax in inspiration (I) was superimposed on the same image in expiration (E), generating a double diaphragmatic line on the untreated hemisphere and a single diaphragmatic line on the blockade hemisphere.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> For many years, forced spirometry was widely used, with an average reduction of 27% (±4.3) of forced vital capacity (FVC) and 26.4% (±6.8) of forced expiratory volume in the first second (FEV1), leading guidelines to recommend avoiding interscalene blockade in patients unable to tolerate a 25% reduction in lung function.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">12–14</span></a> The diagnostic approach changed, however, with the introduction of ultrasound, which can evaluate diaphragmatic movement. Pre- and post-blockade diagnostic ultrasound of the zone of apposition in inspiration, expiration and during the sniff manoeuvre has shown excellent sensitivity and specificity, and has led to a new concept: partial or incomplete blockade. Thus, complete blockade is defined as a post-blockade decrease <75% over baseline, and partial blockade as between 25% and 75%.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2,4</span></a> Recently, diaphragm thickness has been used as a diagnostic tool for phrenic paresis in patients with chronic phrenic neuropathy receiving mechanical ventilation in an ICU,<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">15–19</span></a> and an I/E diaphragm thickening ratio of less that 1.2 has a sensitivity of 93% and a specificity of 100% for diagnosis of diaphragmatic dysfunction.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a> The advantage of this index is that no pre-blockade baseline measurements are needed. To the best of our knowledge, ours is the first study to investigate the use of the diaphragm thickening ratio in the diagnosis of acute phrenic paralysis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our objective was to evaluate the diagnostic capacity of this I/E ratio in phrenic paralysis associated with interscalene blockade, and compare our results with other diagnostic methods that require baseline values.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We designed a descriptive observational study carried out at the Major Outpatient Surgery Unit of the Hospital Universitario Clínic in Barcelona, with the approval of the Institutional Review Board. We included patients aged over 18 years, ASA I<span class="elsevierStyleSmallCaps">–</span>II, scheduled for shoulder surgery. The exclusion criteria were: refusal of or contraindication for regional anaesthesia, presence of clinical signs of infection at the puncture site, moderate to severe chronic pulmonary disease, previous diaphragmatic dysfunction, clotting abnormalities, brachial plexopathy, pregnancy, and allergy to amide-type LAs. All patients willing to participate signed a specific informed consent form.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the block room, the patient was placed in a seated position, non-invasive pulse oximetry and arterial pressure monitoring devices were attached, and the patient was guided through at least 3 forced vital capacity spirometry manoeuvres using the portable spirometer (Datospir-120; Sibel SA, Barcelona, Spain). The best of the 3 scores was recorded as the preblockade baseline FVC and FEV1 values. The patient was then placed in the supine position, with the head raised at an angle of 30°. Both hemithoraces were explored using a portable ultrasound device (EDGE II, Sonosite, Bothell, WA, USA) with a high frequency linear transducer (6–13<span class="elsevierStyleHsp" style=""></span>MHz, HFL 38X, Sonosite, Bothell, Washington, USA) on the anterior axillary line to locate the resting position of the zone of apposition (lung-pleura), which was then followed to its lowest position during deep inspiration. This distance, measured in intercostal spaces, was defined as the diaphragmatic excursion. Finally, on the same anterior axillary line, the zone of apposition was identified in deep inspiration. This point was marked on the surface of the skin, and the diaphragm thickness was measured in inspiration (TI) and in expiration (TE). These measurements were used to calculate the diaphragm thickening ratio (DR: TI/TE) in both hemithoraces.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was then placed in the supine position with the arm to be treated lying next to and slightly bent over the thorax and the head rotated to the contralateral side, and the brachial plexus in the interscalene groove was visualised on ultrasound. We sought to identify the phrenic nerve and measure the distance between this and the midpoint between the ventral branches of C5–C6.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Interscalene blockade was performed as follows: after cleaning the puncture site with 2% chlorhexidine, 2<span class="elsevierStyleHsp" style=""></span>ml of 2% lidocaine without epinephrine was administered at the level of the skin and subcutaneous tissue. Using the in-plane approach, the needle was inserted and advanced from posterior to anterior under real-time ultrasound guidance and positioned at the C5 and C6 nerve roots, downstream of their fusion to form the upper trunk. In all cases, a Stimuplex D, 22<span class="elsevierStyleHsp" style=""></span>G<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2″ needle measuring 0.71<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mm in length connected to a peripheral nerve neurostimulator was used (Stimuplex, HNS 12, B. Braun, Melgunsen, Germany). The neurostimulator was set to an intensity of 0.3<span class="elsevierStyleHsp" style=""></span>mA (2<span class="elsevierStyleHsp" style=""></span>Hz and 100<span class="elsevierStyleHsp" style=""></span>μs), and absence of motor or sensory response confirmed correct location. A total of 20<span class="elsevierStyleHsp" style=""></span>ml ropivacaine 0.5% without epinephrine was administered, aiming to spread the LA between the 2 nerve roots.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After administration of the LA, and during onset of the blockade, sensitivity and muscle strength were evaluated at 10 and 20<span class="elsevierStyleHsp" style=""></span>min. Sensitivity was tested using the pinprick test at the level of the dermatomes of C4 to T1: C4 was tested in the upper part of the acromioclavicular joint, C5 at the insertion of the deltoid muscle tendon, C6 in the dorsal web space between the thumb and first fingers, C7 at the tip of the middle finger, C8 in the little finger and T1 in the medial part of the antecubital fossa. Each pinprick was scored as follows: total loss of sensation (0); decreased sensation, no response to painful stimuli (1); decreased sensation, paraesthesias with response to painful stimuli (2); intact sensation (3). Muscle strength was evaluated by asking the patient to move the body segment in a certain direction against resistance (C5: arm abduction, C6: forearm flexion, C7: forearm extension and C8-T1: finger flexion). Motor blockade level was scored on a scale of 4: 0 (no movement), 1 (limited movement, no response against resistance); 2 (limited movement, response against resistance); and 3 (full range of movement). Successful interscalene block was defined as a score or 1 or less for sensory and motor tests at C4, C5 and C6.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Twenty minutes after completion of the blockade, spirometry and bilateral postblockade measurement of diaphragmatic excursion, TI, TE and DR were re-measured under the conditions previously described. These data were compared with the baseline or pre-blockade measurements.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In spirometry, phrenic paresis was defined as a ≥20% reduction in FVC and FEV1. Regarding diaphragmatic excursion, complete paresis was defined as >75% reduction in diaphragmatic excursion, no movement or paradoxical movement of the diaphragm; partial paresis was defined as between 25% and 75% reduction in movement; and absence of paresis was defined as diaphragmatic movement equal to baseline, or with a reduction of less than 25%. Finally, diaphragmatic paresis was defined as an I/E diaphragm thickening ratio of 1.2 or less.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After these measurements and tests, the patient was transferred to the operating room, monitored using standard techniques, placed in the lateral decubitus position and administered balanced general anaesthesia according to the standard protocol. After the intervention, the patient was transferred to the post anaesthesia recovery unit (PACU) until reversal of the motor blockade. On the first postoperative day, patients were asked when they first felt pain in the operated shoulder. This allowed us to measure the effective duration of the blockade.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Demographic variables were recorded (age, weight, height and sex, body mass index, laterality), ASA, quality of ultrasound vision of the interscalene space (very good, good, fair or bad), time to onset of blockade, duration of the blockade, and presence of side effects (Claude Bernard-Horner or dysphonia). Duration of the block was evaluated at 24<span class="elsevierStyleHsp" style=""></span>h. At 7 and 30 days, the surgeon evaluated the appearance of post-blockade neurological dysfunction.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Based on the available data, the foreseen incidence of phrenic paresis was estimated, <span class="elsevierStyleItalic">a priori</span>, to be 100%. An adequate sample size for a descriptive study was considered to be ≥20 individuals. The data were analysed descriptively and expressed as mean and standard deviation, median and range, number of patients and percentages, according to the study variable tested. Nonparametric tests were used for the bivariate statistical analysis. Chi square or Fisher's test was used for qualitative parameters and the Mann Whitney <span class="elsevierStyleItalic">U</span> or Wilcoxon <span class="elsevierStyleItalic">U</span> test for quantitative parameters. Significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Twenty-two patients were included in the study, 12 men and 10 women, average age was 56<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17 years, height 166<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>cm, weight 82<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>kg and BMI 29<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5. Six patients presented an ASA physical status class of I<span class="elsevierStyleSmallCaps">,</span> and 16 were ASA II. The patients underwent major day surgery involving shoulder arthroscopy (9 with rotator cuff repair). The right shoulder was operated in 15 patients, and the left in 7.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Twenty-one (95%) patients presented phrenic nerve blockade according to one or more of the diagnostic methods used in this study. One patient showed no signs or symptoms suggestive of phrenic paralysis and was excluded from further analysis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This was a 26-year-old man, 84<span class="elsevierStyleHsp" style=""></span>kg and 184<span class="elsevierStyleHsp" style=""></span>cm tall, with a long neck, undergoing surgery on his left shoulder. He presented no changes in diaphragmatic excursion (2.5 intercostal spaces before and after blockade), or in the pre- and post-blockade diaphragm thickness index of 1.6 and 1.4, respectively. Decrease in FVC was 6.4% and that of FEV1 was 4.64%.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">All study parameters varied significantly with onset of diaphragmatic blockade (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Spirometric parameters (FVC and FEV1) decreased in all patients (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>), but only 90% (19) presented a reduction greater than or equal to 20% in both parameters. The remaining 2 patients, with a reduction of less than 20% (10% false negatives), did not meet the diagnostic criteria.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">A decrease in diaphragmatic excursion measured at the level of the anterior axillary line was observed in all cases, as shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. However, using our diagnostic criteria, a reduction of ≥75% (complete blockade) was observed in 10 patients (47%) and a reduction of ≥25% and <75% (partial blockade) was observed in the remaining patients (53%); in other words, 100% of patients presented either partial or total phrenic blockade (100% sensitivity) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The pre- and post-blockade diaphragm muscle thickness evaluated in I and E in both the treated and untreated lungs is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The I/E diaphragm thickening ratio on the phrenic blockade hemisphere was below 1.2 (100% sensitivity) in all patients. The pre-blockade ratio of 1.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 changed to 1.05<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.06 after the blockade (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). <a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a> show the boxplot of these measurements.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The ultrasound image of the interscalene space was considered very good in 13 patients (62%) and good in the rest (38%). The phrenic nerve was identified in the anterior belly of the anterior scalene muscle in 10 patients (48%) and at a distance of 1.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.7<span class="elsevierStyleHsp" style=""></span>cm from the puncture site. In all patients, blockade was successful at 20<span class="elsevierStyleHsp" style=""></span>min. The level of sensory and motor blockade observed at 10 and 20<span class="elsevierStyleHsp" style=""></span>min can be seen in <a class="elsevierStyleCrossRefs" href="#fig0035">Figs. 7 and 8</a>, respectively. Twelve patients (57%) presented Claude Bernard-Horner syndrome. No patient presented paralysis of the recurrent laryngeal nerve. The duration of analgesic block was 12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>h. No patient presented post-blockade neurological dysfunction.</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our study confirms that direct measurement of diaphragm thickness, specifically, an I/E diaphragm thickening ratio of less than 1.2, has a very high predictive power for acute diaphragmatic paralysis caused by phrenic nerve blockade. In this regard, our findings are consistent with Boom et al., who showed that diaphragm thickness measurement has a specificity of 100% and a sensitivity of 93% for the diagnosis of chronic diaphragmatic dysfunction due to phrenic neuropathy.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The cut point used in our study is derived from previous studies measuring diaphragm thickness in healthy volunteers, which define normal diaphragm thickness as greater than 0.14<span class="elsevierStyleHsp" style=""></span>cm; a thickness of less than 0.14<span class="elsevierStyleHsp" style=""></span>cm indicates diaphragm atrophy. These studies have also defined the normal diaphragm thickening ratio as over 1.2.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> Considering that the diaphragm thickening ratio is calculated by dividing the maximum or deep inspiratory thickness by the minimum or expiratory thickness (DR: TI/TE), a ratio of 1 indicates less changes in diaphragm thickness during breathing, in other words, less contraction.</p><p id="par0115" class="elsevierStylePara elsevierViewall">It is striking that 2 patients presented a baseline diaphragm thickness of less than 0.14<span class="elsevierStyleHsp" style=""></span>cm (diaphragm atrophy), even though their diaphragm ratio was over 1.2. This can be explained if we consider that, according to the literature, diaphragm thickness ranges from 0.15 to 0.09<span class="elsevierStyleHsp" style=""></span>cm,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> so in these patients, a DR within normal limits suggests that diaphragm contraction was preserved. Nine patients presented a post-blockade diaphragm thickness of less than 0.14-cm, although pre-blockade measurements were normal (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>): we attributed this to total loss of diaphragm muscle tone.</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">This study has some limitations, insofar as the sample size was small and the rater was not blinded, in other words, the same individual performed the spirometric measurements, evaluated diaphragmatic excursion and calculated diaphragm thickness. Moreover, despite many attempts to standardise B-mode ultrasound evaluation of the diaphragm by establishing, for example, patient positioning and the level of the transducer,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> other factors, such as the operator's experience, the presence of abundant panniculus adiposus, short, wide thorax with narrow intercostal spaces, and left-sided measurements, where the window is also reduced, can affect the quality of the measurements. In our case, 2 left diaphragm measurements had to be performed more posterior, between the middle and posterior axillary line, in order to visualise the diaphragm. The quality of this measurement, therefore, is operator-dependent to a certain extent because it requires training.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Ultrasound measurement of diaphragm thickness is a highly useful tool in many situations. Diaphragm thickness has shown a correlation with FVC and muscle action potentials in patients with neuromuscular disorders, such as aminotrophic lateral sclerosis.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> The correlation observed between diaphragm thickness and diaphragm contractility have prompted some researchers evaluate this phenomenon in ventilated patients, and to evaluate the correlation between changes in diaphragm thickness and lung function. This has led to the concept of “muscle-protective” mechanical ventilation, the aim of which is to maintain an adequate level of diaphragmatic activity in order to avoid the reduced diaphragm thickening observed in patients under prolonged mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Ultrasound diaphragm evaluation may also have a place in the field of anaesthesiology as a diagnostic tool for phrenic paralysis in brachial plexus blockade, as a differential diagnostic method for acute dyspnoea, or even to assess diaphragmatic function in patients before extubation due to either the intraoperative use of neuromuscular relaxants, or the presence of an underlying disease that would hamper mechanical ventilation.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The results of our study show that spirometry can indicate significant changes after phrenic paralysis; however, it has little diagnostic capacity. Measuring diaphragmatic excursion by counting the intercostal spaces reached during I and E manoeuvres is an effective technique for diagnosing diaphragmatic paralysis; however, it relies on a baseline excursion measurement, as many patients present partial paralysis (reduction of 25–75% with respect to baseline). In this context, direct measurement of diaphragm muscle thickness should be considered, given the high sensitivity of an I/E diaphragm thickening ratio of less than 1.2 to diagnose phrenic paresis. This ratio, moreover, does not rely on a pre-blockade baseline evaluation, making it a useful tool in the differential diagnosis of diaphragmatic paresis in relation to other processes that could cause post-blockade respiratory failure, such as pneumothorax or recurrent nerve paralysis.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion, the <1.2 I/E diaphragm thickening ratio appears to be useful in the diagnosis of phrenic paresis associated with interscalene block, and does not rely on pre-blockade baseline evaluation. This makes it a valuable tool in the differential diagnosis of post-brachial plexus blockade dyspnoea.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed adhere to the ethical guidelines of the responsible committee on human experimentation and comply with the Declaration of Helsinki of the World Medical Association.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols implemented in their place of work regarding the use of patient data in publications.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of all patients and/or subjects included in this manuscript. The informed consent forms can be obtained from the author for correspondence.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres982062" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec949638" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres982063" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec949639" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-08" "fechaAceptado" => "2017-09-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec949638" "palabras" => array:4 [ 0 => "Interscalene block" 1 => "Phrenic palsy" 2 => "Ultrasound" 3 => "Diaphragmatic thickness index" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec949639" "palabras" => array:4 [ 0 => "Bloqueo interescalénico" 1 => "Paresia frénica" 2 => "Ecografía" 3 => "Índice de grosor diafragmático" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diaphragmatic paralysis is a side-effect associated with interscalene block. Thickness index of the diaphragm muscle (inspiratory thickness/expiratory thickness) obtained by ultrasound has recently been introduced in clinical practice for diagnosis of diaphragm muscle atrophy. Our objective was to evaluate this index for the diagnosis of acute phrenic paresis associated with interscalene block.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We designed an observational study in 22 patients scheduled for shoulder arthroscopy. Spirometry was performed (criteria of phrenic paresis was a decrease in FVC and FEV1 ≥20%). Ultrasound apposition zone was assessed in anterior axillary line and diaphragmatic displacement was evaluated on inspiration and expiration (number of intercostal spaces; phrenic paresis considered a reduction ≥25%) and thickness of the diaphragm muscle (a phrenic paresis was considered an index <1.2). These determinations were performed before and at 20<span class="elsevierStyleHsp" style=""></span>min after interscalene block at C5–C6 with 20<span class="elsevierStyleHsp" style=""></span>ml of 0.5% ropivacaine.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty-one patients (95%) presented phrenic nerve block according to one or more of the methods used. One patient did not show any symptoms or signs suggestive of phrenic paralysis and was excluded. All the patients presented phrenic paresis based on the diaphragmatic thickness index, with the pre-block index being 1.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 and post-block of 1.05<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.06 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). Ninety percent of the patients (19) presented phrenic paresis according to spirometry and all the patients had a reduction in diaphragmatic movement after the block (from 1.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 intercostal spaces to 0.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.3; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The index of inspiratory/expiratory diaphragmatic thickness at cut-off <1.2 seems to be useful in the diagnosis of phrenic paresis associated with interscalene block. This index does not require a baseline pre-assessment.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La parálisis diafragmática es un efecto indeseable clásicamente asociado al bloqueo interescalénico. De forma reciente ha sido introducido en clínica el índice del grosor del músculo diafragma (grosor inspiratorio/grosor espiratorio) obtenido mediante ecografía como herramienta diagnóstica en la parálisis crónica y atrofia del músculo diafragma. Nuestro objetivo fue evaluar este índice para el diagnóstico de paresia frénica aguda asociada al bloqueo interescalénico.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Diseñamos un estudio observacional descriptivo en 22 pacientes programados para artroscopia de hombro. Se les realizó una espirometría forzada (se consideró paresia frénica un descenso del FVC y FEV1 ≥20%), se identificó la zona de aposición en la línea axilar anterior y se evaluó el desplazamiento diafragmático en inspiración y espiración máximas (n.° de espacios intercostales; se consideró paresia frénica una reducción ≥25%) y el grosor del músculo diafragma (se consideró paresia frénica un índice <1,2). Estas determinaciones se realizaron antes y a los 20 min de realizar el bloqueo interescalénico entre C5 y C6 con 20 ml de ropivacaína 0,5%.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Veintiún pacientes (95%) presentaron bloqueo del nervio frénico según alguno o varios de los métodos empleados. Un paciente no manifestó ningún síntoma ni signo sugestivo de parálisis frénica y fue excluido del análisis posterior. Todos los pacientes presentaron paresia frénica con base en el índice del grosor diafragmático, con un índice prebloqueo de 1,8 ± 0,5 y posbloqueo de 1,05 ± 0,06 (p < 0,001). El 90% de los pacientes (19) presentó paresia frénica según la espirometría y todos los pacientes presentaron un descenso diafragmático reducido tras el bloqueo (de 1,9 ± 0,5 espacios intercostales a 0,5 ± 0,3; p < 0,001).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El índice del grosor diafragmático en inspiración/espiración < 1,2 parece ser de utilidad en el diagnóstico de paresia frénica asociada al bloqueo interescalénico, sin que sea necesaria una evaluación basal prebloqueo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López Escárraga VM, Dubos España K, Castillo Bustos RH, Peidró L, Sastre S, Sala-Blanch X. La ratio de grosor diafragmático (inspiratorio/espiratorio) como método diagnóstico de parálisis diafragmática asociada al bloqueo interescálenico. Rev Esp Anestesiol Reanim. 2018;65:81–89.</p>" ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 971 "Ancho" => 1580 "Tamanyo" => 105681 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patients undergoing phrenic blockade and performance of the 3 diagnostic methods: spirometry, diaphragmatic excursion and diaphragm ratio.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1470 "Ancho" => 1589 "Tamanyo" => 65987 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reduction of spirometric parameters observed at 20<span class="elsevierStyleHsp" style=""></span>min after interscalene blockade, with respect to baseline levels.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 854 "Ancho" => 1598 "Tamanyo" => 44094 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percentage reduction of FVC and FEV1 in the group of 21 patients.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1236 "Ancho" => 2356 "Tamanyo" => 119255 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Descent of the blockade and untreated diaphragm hemispheres within the zone of apposition during normal inspiration and deep expiration, measured in number of intercostal spaces.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1009 "Ancho" => 2374 "Tamanyo" => 83309 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Boxplot showing the thickness (in cm) of the blockade and untreated diaphragm hemispheres in inspiration and expiration at baseline and at 20<span class="elsevierStyleHsp" style=""></span>min.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 986 "Ancho" => 2335 "Tamanyo" => 79793 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Boxplot showing the diaphragm thickening ratio of both the blockade and untreated hemispheres at baseline and at 20<span class="elsevierStyleHsp" style=""></span>min.</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1650 "Ancho" => 2333 "Tamanyo" => 97755 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Sensory blockade of the corresponding C4 to C8-T1 metameres at study time points.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1769 "Ancho" => 2314 "Tamanyo" => 107035 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Motor blockade of the corresponding C5 to C8-T1 metameres at study time points.</p>" ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1360 "Ancho" => 2504 "Tamanyo" => 274162 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">(1) Location of the zone of apposition in maximum inspiration on the anterior axillary line for measuring diaphragm thickness in inspiration and in maximum expiration. (2) Example of diaphragm thickness analysis obtained for one of the study patients, including: (A) Preblockade inspiratory diaphragm thickness: 0.21<span class="elsevierStyleHsp" style=""></span>A) Preblockade expiratory diaphragm thickness: 0.17 Preblockade diaphragm ratio: TI/TE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.21/0.17<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.23. (C) Postblockade inspiratory diaphragm thickness: 0.07. (D) Postblockade expiratory diaphragm thickness: 0.07 Postblockade diaphragm ratio: TI/TE<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.07/0.07<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.</p>" ] ] 9 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">20<span class="elsevierStyleHsp" style=""></span>min postblockade (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Spirometry</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FVC (ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3290<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1499 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1997<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1076 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FEV1 (ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2831<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1186 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1790<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>912 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">No of intercostal spaces</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Blockade hemisphere \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Untreated hemisphere \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Diaphragm thickness on the blockade hemisphere</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.35<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Expiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.05<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Untreated hemisphere</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inspiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.31<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.635 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Expiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.124 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.66<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.231 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1662971.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Parameters studied for the diagnosis of phrenic paresis associated with interscalene block.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "W.F. 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