Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR

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© Government of Western Australia

Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR

Population Covered By The Guidance

This pathway provides guidance on the imaging investigation of adult patients with a raised hemi-
diaphragm on previous chest radiographs.

Date reviewed: January 2012

Date of next review: 2017/2018
Published: January 2012
Quick User Guide

Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient
points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE

None 0

Minimal < 1 millisieverts

Low 1-5 mSv

Medium 5-10 mSv

High >10 mSv

Pathway Diagram

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Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR
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Image Gallery
Note: These images open in a new page

1 Raised Hemidiaphragm

Image 1 (Plain Radiograph, PA): Raised right hemidiaphragm secondary to

phrenic nelve palsy during resection of thymoma. Note sternotomy wires in-
situ.

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Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR
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© Government of Western Australia

2a Apparent Raised Hemidiaphragm due to Subpulmonic Effusion

Image 2a and 2b (Plain Radiographs, PA and Lateral Decubitus): The left

hemidiaphragm is apparently raised on the PA film. The lateral decubitus
film reveals a subpulmonic pleural effusion with fluid tracking along the left
lateral chest wall.

2b

Teaching Points
Common causes of elevation of a hemidiaphragm include
Lung volume loss
Eventration
Abdominal disease
Phrenic nerve palsy
Splinting
Mimics
Comparison with previous films of the chest is the initial assessment
Further investigations may include fluoroscopy, ultrasound and CT of the chest based on the
suspicion of an underlying clinical diagnosis

Computed Tomography (CT)

Useful for excluding mediastinal lesions causing phrenic nerve palsy and to evaluate a possible
subdiaphragmatic cause for elevation of a hemidiaphragm 6

Fluoroscopy
Simplest, quickest, and most practical method of assessing diaphragm movement 1
Primarily a qualitative method, quantitative information being indirectly obtained and limited
geometrically by the divergent beam and object to film distance 2
Reduced, absent or paradoxical movement of the hemidiaphragm, especially during sniffing infers
hemidiaphragmatic paresis or paralysis 1,2,3
Limitations - diaphragm motion may be diminished due to inflammatory processes such as
pneumonia, pleuritis, pleural effusion, peritonitis, and subphrenic abscess, so fluoroscopic
assessment is best delayed until reversible conditions that may affect the diaphragm have been
treated to resolution 1

Raised Hemidiaphragm

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Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR
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© Government of Western Australia

Common causes of unilateral hemidiaphragm elevation include 1

Lung volume loss (atelectasis, lobar collapse, partial lung resection, radiation fibrosis,
congenital hypoplasia)
Eventration
Abdominal disease (dilated stomach or colon, hepatomegaly, splenomegaly, subphrenic
abscess)
Phrenic nerve paralysis
Splinting
Mimics (subpulmonic pleural effusion, large pleural mass, diaphragmatic hernia)
Diaphragmatic paralysis is most frequently caused by interruption of the phrenic nerve, and may
be unilateral or bilateral. Phrenic nerve invasion by a malignant neoplasm and trauma related to
cardiothoracic surgery (stretch, crush, or transection) are the most common causes, although many
cases are idiopathic 1

Ultrasound
Useful in the evaluation of patients with suspected abnormalities of diaphragmatic movement 3,4,5
Equivalent to fluoroscopy in diagnosing diaphragm dysfunction 3
Superior to plain radiographs in the assessment of some supradiaphragmatic causes (e.g. pleural
effusion, pleural masses) and most subdiaphragmatic causes (hepatomegaly, subphrenic
collections, etc) of elevated hemidiaphragm 2
Advantages- direct quantitative, quick and portable method of assessing hemidiaphragmatic
movement

References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine,
Levels of Evidence. Download the document

1. Gierada DS, Slone RM, Fleishman MJ. Imaging evaluation of the diaphragm. Chest Surg Clin N
Am. 1998;8:237-80. (Review article)
2. Tarver RD, Conces DJ Jr, Cory DA, et al. Imaging of the diaphragm and its disorders. J Thorac
Imag. 1989;4:1-18. (Review article)
3. Houston JG, Fleet M, Cowan MD, et al. Comparison of ultrasound with fluoroscopy in the
assessment of suspected hemidiaphragmatic movement abnormality. Clin Radiol.
1995;50:95-8. (Level III evidence)
4. Gottesman E, McCool D. Ultrasound evaluation of the paralysed diaphragm. Am J Respir Crit
Care Med. 1997;155:1570-4. (Level III evidence)
5. Cohen E, Mier A, Heywood P, et al. Excursion-volume relation of the right hemidiaphragm
measured by ultrasonography and respiratory airflow measurements. Thorax. 1994;49:885-9.
(Level III evidence)
6. Brink JA, Heiken JP, Semenkovich J, et al. Abnormalities of the diaphragm and adjacent
structures: findings on multiplanar spiral CT scans. AJR Am J Roentgenol. 1994;163:307-10.
(Pictorial essay)

Information for Consumers

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 Diagnostic Imaging Pathways - Raised Hemidiaphragm on CXR
Printed from Diagnostic Imaging Pathways
www.imagingpathways.health.wa.gov.au
© Government of Western Australia

Information from this website Information from the Royal

Australian and New Zealand
College of Radiologists’ website

Consent to Procedure or Treatment Computed Tomography (CT)

Radiation Risks of X-rays and Scans Iodine-Containing Contrast Medium

Computed Tomography (CT) Plain Radiography/X-rays

Ultrasound Radiation Risk of Medical Imaging During

Pregnancy
Chest Radiograph (X-ray)
Radiation Risk of Medical Imaging for
Adults and Children

Ultrasound

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