CHEST Original Research

ULTRASONOGRAPHY

Diaphragmatic Motion Studied by

M-Mode Ultrasonography*
Methods, Reproducibility, and Normal Values
Alain Boussuges, MD, PhD; Yoann Gole, MSc; and Philippe Blanc, MD

Background: Although diaphragmatic motion is readily studied by ultrasonography, the proce-

dure remains poorly codified. The aim of this prospective study was to determine the reference
values for diaphragmatic motion as recorded by M-mode ultrasonography.
Methods: Two hundred ten healthy adult subjects (150 men, 60 women) were investigated. Both
sides of the posterior diaphragm were identified, and M-mode was used to display the movement
of the anatomical structures. Examinations were performed during quiet breathing, voluntary
sniffing, and deep breathing. Diaphragmatic excursions were measured from the M-mode
sonographic images. In addition, the reproducibility (inter- and intra-observer) was assessed.
Results: Right and left diaphragmatic motions were successfully assessed during quiet breathing
in all subjects. During voluntary sniffing, the measurement was always possible on the right side,
and in 208 of 210 volunteers, on the left side. During deep breathing, an obscuration of the
diaphragm by the descending lung was noted in subjects with marked diaphragmatic excursion.
Consequently, right diaphragmatic excursion could be measured in 195 of 210 subjects, and left
diaphragmatic excursion in only 45 subjects. Finally, normal values of both diaphragmatic
excursions were determined. Since the excursions were larger in men than in women, the gender
should be taken into account. The lower limit values were close to 0.9 cm for women and 1 cm for
men during quiet breathing, 1.6 cm for women and 1.8 cm for men during voluntary sniffing, and
3.7 cm for women and 4.7 cm for men during deep breathing.
Conclusions: We demonstrated that M-mode ultrasonography is a reproducible method for
assessing hemidiaphragmatic movement. (CHEST 2009; 135:391– 400)

Key words: diaphragm; gender; sonography; ultrasound

Abbreviations: DB ⫽ deep breathing; LS ⫽ left side; QB ⫽ quiet breathing; RS ⫽ right side; VS ⫽ voluntary sniffing

D iaphragmatic dysfunction is commonly observed

in conditions such as muscular dystrophy or
adjacent thoracic and in abdominal pathologies. Fur-
thermore, nervous system disease and phrenic nerve
injuries may impair diaphragmatic motion. Conse-
*From the UMR MD 2, P2COE, Physiologie et Physiopathologie
en conditions d’oxygénation extrêmes, Université de la Méditer-
ranée et Institut de Médecine Navale du Service de Santé des
Armées, Marseille, France.
The authors have no conflicts of interest to disclose.
Manuscript received June 20, 2008; revision accepted September
9, 2008.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Alain Boussuges, IMNSSA BP 610, 83800
Toulon Armées, France; e-mail: alain.boussuges@univmed.fr
DOI: 10.1378/chest.08-1541
quently, the need for assessment of the diaphrag-
matic function arises in many clinical situations.
Diaphragm function and contractile fatigue are
best assessed with either electrical or magnetic
phrenic nerve stimulation. On the other hand, dia-
phragmatic motion is readily studied by fluoroscopy,
and this technique can be of value in the diagnosis of
diaphragmatic paralysis. Nevertheless, fluoroscopy
requires patient transportation and uses ionizing
radiation. An alternate and interesting method is
sonography.1 Ultrasonography has many advantages
over fluoroscopy, including the lack of ionizing radi-
ation and the possibility of use at the bedside of the
patient. Although the interest of chest ultrasonogra-
phy is recognized, the ultrasonographic evaluation of
the diaphragmatic function remains poorly codified.

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 Figure 1. Ultrasonographic approach of the right and left hemidiaphragms. The liver and spleen were
used as acoustic windows. Left, A: For the right hemidiaphragmatic study, the probe was positioned
below the right costal margin between the midclavicular and anterior axillary lines. The left
diaphragmatic was studied from a low intercostal or subcostal approach. The probe was positioned
between the midaxillary and anterior axillary lines. Right, B: The probe angled cranially so that the
ultrasound beam reached perpendicularly the posterior part of the diaphragm.

Various ultrasonographic methods, including changes
in diaphragm thickness during contraction,2,3 dia-
phragmatic motion recorded in two-dimensions4,5 or
M-mode,6,7 and variation in the position of the
diaphragm relative to the kidney, have been pro-
posed.8 Diaphragmatic motion is readily assessed by
M-mode ultrasonography using a commercially avail-
able echocardiograph and has been used to assess
diaphragmatic function in patients after surgery or
high cervical spinal cord injury.9,10 Investigators have
underlined its value. However, although the tech-
nique has been well described in pediatric patients,11
normal values for diaphragmatic excursion during
different respiratory maneuvers and the reproduc-
ibility of the methods remain poorly documented in
adult subjects. This prospective study was designed
to determine the reference values for diaphragmatic
amplitudes recorded by M-mode ultrasonography.
In addition, the intra- and inter-observer reproduc-
ibilities were assessed in a large population of
healthy adult subjects.
echocardiograph (Mylab 30CV; Esaote; Genoa, Italy) connected
to a 2.5 to 3.5 MHz transducer array. Subjects were investigated
in the morning, 2 or 3 hours after a light meal. Ultrasonographic
examinations were performed in the standing position. Two-
dimensional mode was used to find the best approach and to
select the exploration line of each hemidiaphragm (Fig 1). The
liver was used as a window on the right (Fig 2), while the spleen
was used on the left hemidiaphragm (Fig 3). All examinations
were recorded on a personal computer for subsequent blind
analysis.
Right Hemidiaphragm Ultrasonographic Study
The probe was placed between the midclavicular and anterior
axillary lines, in the subcostal area, and directed medially,
cranially, and dorsally, so that the ultrasound beam reached
perpendicularly the posterior third of the right hemidiaphragm.

Materials and Methods

The local ethics committee approved the study protocol, and
written informed consent was obtained from all healthy subjects.
All volunteers were free of any signs of cardio-respiratory and
neurologic diseases, and had normal pulmonary function tests.
Pulmonary function was studied with a spirometer (Ilmeter 1304;
Masterlab Jaeger; Wurzberg, Germany) according to the stan-
dards of the American Thoracic Society. The criteria for classifi-
cation as normal consisted of a FVC ⬎ 80% of predicted, a
FEV1 ⬎ 80% of predicted, and a FEV1/FVC ratio ⬎ 80% of
predicted.
Ultrasonographic examinations were carried out by two expe- Figure 2. Two-dimensional ultrasonographic image of the right
rienced investigators using a commercially available Doppler hemidiaphragm (arrow).

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Figure 3. Two-dimensional ultrasonographic image of the left
hemidiaphragm (arrow).
Diaphragm movements were recorded in M-mode. Ultrasono-
graphic measurements were performed during quiet breathing
(QB), voluntary sniffing (VS), and deep breathing (DB) 关Fig 4兴.
This maneuver began at the end of normal expiration, and the
volunteers were asked to breathe in as deeply as they possibly
could.
Figure 4. Measurements were performed during QB (top, 1),
VS (center, 2), and DB (bottom, 3).
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Left Hemidiaphragm Ultrasonographic Study
A subcostal or low intercostal probe position was chosen
between the anterior and mid axillary lines to obtain the best
imaging of the left hemidiaphragmatic dome. The motion was
recorded during the same respiratory maneuvers as for the right
hemidiaphragm.
Variables Measured
The diaphragm inspiratory amplitudes (excursions) were mea-
sured from the M-mode sonography. For the QB and DB
measurements, the first caliper was placed at the foot of the
inspiration slope on the diaphragm echoic line and the second
caliper was placed at the apex of this slope. For VS measurement,
the amplitude of excursion was measured on the vertical axis of
the tracing from the baseline to the point of maximum height of
inspiration on the graph. Several respiratory cycles were re-
corded, and measurements were averaged from at least three
different cycles.
Upper and lower limits of normal (ie, ninety-fifth and fifth
percentiles) were calculated as mean ⫾ 1.65 ⫻ SD. The right-to-
left ratio of hemidiaphragmatic excursion was calculated for the
different maneuvers.5
Statistical Analysis
Continuous variables were expressed as mean ⫾ SD. Statistical
tests were run on statistics software (Sigmastat; SPSS; Chicago,
IL). The data distribution was analyzed with a Kolmogorov-
Smirnov test. For a normal distribution, differences among men
and women were compared using an unpaired Student t test. In
the case of cohorts of variables not having a normal distribution,
comparisons were made with the Mann-Whitney test. Relation-
ships between ultrasonographic measurements and anthropomet-
ric data or pulmonary function tests were made by linear
regression analysis to produce a correlation coefficient. Differ-
ences were considered significant at p ⬍ 0.05.
Assessment of Reproducibility
To assess intra-observer variability, 180 volunteers (131 men,
49 women) were examined twice by the same operator, with an
interval of at least one day between the two measurements.
Furthermore, 170 subjects (123 men, 47 women) were examined
by two different observers to assess inter-observer variability.
Pearson correlation analysis and Bland-Altman plotting were
performed for the assessment of reproducibility.12
Results
Initially, 236 healthy subjects were screened.
However, 26 subjects had lower spirometric param-
eters than normal and were excluded. In total, 210
subjects (150 men, 60 women, 50 ⫾ 14 years) were
investigated (Table 1). Their pulmonary function
tests were normal 关FVC ⫽ 3.6 ⫾ 1 (100 ⫾ 13% of
predicted), FEV1 ⫽ 3.1 ⫾ 0.9 L (95 ⫾ 11% of pre-
dicted), FEV1/FVC ⫽ 87 ⫾ 7%兴.
Right and left diaphragmatic motions were suc-
cessfully accomplished during QB in the whole
population. Mean excursions were measured to
1.8 ⫾ 0.3 cm on the right side (RS) and 1.8 ⫾ 0.4 cm
CHEST / 135 / 2 / FEBRUARY, 2009 393
 Table 1—Anthropometric Data of the 210 Healthy
Volunteers*
Variables Men Women p Value
Age, yr 50 ⫾ 14 (20–77) 49 ⫾ 16 (21–77) 0.7
Height, cm 171 ⫾ 6 (154–190) 159 ⫾ 8 (143–177) ⬍ 0.001
Weight, kg 75 ⫾ 11 (50–108) 62 ⫾ 13 (42–100) ⬍ 0.001
BMI, kg/m2 23 ⫾ 4 (18–35) 25 ⫾ 5 (16–45) 0.01
*Data are presented as mean ⫾ SD (minimum-maximum).
on the left side (LS). During VS, measurement was
always possible on RS, and in 208 of 210 volunteers,
on the LS. Excursions on RS and LS were
2.8 ⫾ 0.6 cm and 3 ⫾ 0.6 cm, respectively. In sub-
jects with marked diaphragmatic excursion, the dia-
phragm was obscured by the descending lung during
DB. Consequently, right diaphragmatic motion
could be measured in 195 subjects (140 men, 55
women). Mean excursion was 6.6 ⫾ 1.3 cm. Left
diaphragmatic excursion was obtained in only 45
volunteers (38 men, 7 women) during DB (mean,
7.3 ⫾ 1 cm).
For all the maneuvers studied, the diaphragmatic
excursion was greater in men than in women. Con-
sequently, limit values differed according to gender
(Tables 2, 3).The mean ratios between the right and
left hemidiaphragmatic motion were 1 ⫾ 0.2 for QB,
1 ⫾ 0.2 for VS and 1.1 ⫾ 0.2 for DB.
One volunteer (1 man) out of 210 presented a ratio
outside the normal range (⬎ 0.5 and ⬍ 1.6) during
QB. Two other subjects (2 women) presented a ratio
outside the normal range during VS. None of the
subjects presented a ratio outside the limits for
either QB or VS. Among the 45 subjects in whom the
two diaphragmatic excursions could be recorded
during DB, the ratio was within the normal range in
all cases. No significant correlation was found be-
tween age and diaphragmatic excursion.
A weak correlation was observed between height
and diaphragmatic excursion during QB on the RS
(r ⫽ 0.2, p ⬍ 0.05) and the LS (r ⫽ 0.2, p ⬍ 0.01).
This correlation was also found with right hemidia-
phragmatic excursion during DB (r ⫽ 0.4, p ⬍ 0.0001).
A correlation was found between weight and dia-
phragmatic excursion during QB on the RS (r ⫽ 0.3,
p ⬍ 0.0001) and the LS (r ⫽ 0.2, p ⬍ 0.01). The cor-
Table 2—Right Diaphragmatic Excursions and Limit Values in Men and Women*
Variables Men, cm
Quiet breathing 1.8 ⫾ 0.3 (1.1–2.5)
Voluntary sniffing 2.9 ⫾ 0.6 (1.8–4.4)
Deep breathing 7 ⫾ 1.1 (4.7–9.2)
*Data are presented as mean ⫾ SD (5th to 95th percentile).
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relation between weight and right hemidiaphragmatic
excursion during DB was also significant (r ⫽ 0.3,
p ⬍ 0.0001).
Right diaphragmatic excursion during DB and
during VS was correlated with FVC (r ⫽ 0.3,
p ⬍ 0.0001; r ⫽ 0.2, p ⬍ 0.05, respectively) and
FEV1 (r ⫽ 0.3, p ⬍ 0.001; r ⫽ 0.2, p ⬍ 0.05, respec-
tively). A weak correlation was also found between
left diaphragmatic excursion during QB and FVC
(r ⫽ 0.2, p ⬍ 0.05) and FEV1 (r ⫽ 0.2, p ⬍ 0.05).
Reproducibility
The reproducibility of left diaphragmatic excur-
sion during DB (successfully recorded in only 45
subjects) was not assessed.
Intraobserver Variability
The correlation between the two measurements
was highly significant for right diaphragmatic motion
during QB (r ⫽ 0.96, p ⬍ 0.001), VS (r ⫽ 0.96,
p ⬍ 0.001), and DB (r ⫽ 0.96, p ⬍ 0.001), and for left
diaphragmatic motion during QB (r ⫽ 0.94,
p ⬍ 0.001) and VS (r ⫽ 0.97, p ⬍ 0.001).
Interobserver Variability
The correlation between the two measurements
was highly significant for right diaphragmatic excur-
sions measured during QB (r ⫽ 0.95, p ⬍ 0.001), VS
(r ⫽ 0.96, p ⬍ 0.001), and DB (r ⫽ 0.94, p ⬍ 0.001),
and for left diaphragmatic motion during QB (r ⫽ 0.91,
p ⬍ 0.001) and VS (r ⫽ 0.93, p ⬍ 0.001). The differ-
ences between the two different measurements
plotted against their mean value are presented in
Figures 5– 8.
Discussion
In the present study, the ultrasonographic record-
ing of the right hemidiaphragmatic movement was
found to be straightforward. Indeed, the liver win-
dow was large and allowed a good visualization of the
right diaphragmatic dome. Consequently, the dia-
phragmatic motion of the right hemidiaphragm
could be obtained during QB and VS in the whole
Women, cm p Value
1.6 ⫾ 0.3 (1–2.2) ⬍ 0.001
2.6 ⫾ 0.5 (1.6–3.6) ⬍ 0.001
5.7 ⫾ 1 (3.6–7.7) ⬍ 0.001
Original Research
 Table 3—Left Diaphragmatic Excursions and Limit Values in Men and Women*
Variables Men, cm
Quiet breathing 1.8 ⫾ 0.4 (1–2.6)
Voluntary sniffing 3.1 ⫾ 0.6 (1.9–4.3)
Deep breathing 7.5 ⫾ 0.9 (5.6–9.3)
*Data are presented as mean ⫾ SD (5th to 95th percentile).
population. Although complete motion could be
assessed in most cases during DB, the descending
lung masked the ultrasonographic images and im-
peded the measurement of the total diaphragmatic
excursion in some subjects. In these circumstances,
the probe could be displaced caudally with an angle
adjustment to maintain a perpendicular approach of
the right hemidiaphragmatic motion. This some-
times improved the recording of the complete ex-
cursion. Overall, the right diaphragmatic motion
during DB could be measured in 93% of cases. This
high rate of success would be reduced if the study
had included patients with respiratory disease. In-
deed, increased respiratory effort can result in
greater chest wall movement and cause the ribs and
lung to obscure the images in patients with dyspnea.
In patients referred for pulmonary function test-
ing, Scott et al8 showed a 28% failure rate in
attempting an ultrasonographic scan of the right
hemidiaphragm.
Visualization of the left hemidiaphragm is recog-
nized as more difficult due to the smaller window of
the spleen as compared with the liver window.
However, in our healthy subject population, the left
hemidiaphragm was always seen and the motion
during QB could be measured systematically. During
VS, motion could be measured in most cases. On the
other hand, the left hemidiaphragm was frequently
obscured by the expanding lung during DB. The
position of the probe could not be readily adjusted as
the spleen window is small. In total, the diaphrag-
matic motion of the left hemidiaphragm was only
recorded in 45 of 210 subjects (21%). Gersovich13
failed to record left hemidiaphragm excursion in 15
of their 23 volunteers (65%). In this study, the lack of
visualization of the excursion was observed in sub-
jects with the greater range of excursion (⬎ 5 cm). In
our experience, during DB, part of the left hemidia-
phragmatic excursion could be visualized, but the
lung frequently masked the dome. In the event of
hemidiaphragmatic paresis, recording of weak excur-
sion should not be impeded by this phenomenon.
The present study demonstrated that both left and
right diaphragmatic excursion measurements per-
formed by M-mode ultrasonography were reproduc-
ible. High correlation coefficients and small mean
differences were observed in the Bland-Altman
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Women, cm p Value
1.6 ⫾ 0.4 (0.9–2.4) 0.002
2.7 ⫾ 0.5 (1.7–3.7) ⬍ 0.001
6.4 ⫾ 1 (4.3–8.4) ⬍ 0.01
plots12 both between and within observers. Normal
limit values were, therefore, established from these
measurements. To our knowledge, this is the largest
study concerning reference values of diaphragmatic
motion recorded by M-mode ultrasonography. To
define the normal value in a subject, gender should
be taken into account. Indeed, in our study, men
exhibited larger excursion than women in all the
maneuvers studied.
From our results, the lower limit of diaphragmatic
excursion during QB was estimated to be 0.9 cm in
women and 1 cm in men. These values were com-
parable to those of studies using fluoroscopy14 or
ultrasonographic methods.5,15
VS has been described to be of value for the
diagnosis of diaphragmatic paralysis. A paradoxical
movement has been observed on the paralyzed side
using fluoroscopy or ultrasonography.10 In our sub-
jects, sniffing led to a sharp downstroke of the
hemidiaphragm. Mean excursion was measured
around 2.5 to 3 cm on both sides and lower limit
values to 1.6 cm in women and 1.8 cm in men. To
our knowledge, these values have not been assessed
previously and may be of use in the diagnosis of
diaphragmatic paresis.
A wide range of excursion was recorded during
DB. In a previous study of 64 healthy subjects,
Kantarci et al7 assessed the diaphragmatic motion on
both sides during deep DB and measured an excur-
sion ranging from 2.5 to 8.4 cm on the RS and from
2.4 to 8.1 cm on the LS. In our study, the mean
diaphragmatic excursion was 6 to 7 cm, close to the
values measured by Cohen et al16 (6 ⫾ 0.7 cm) and
Targhetta et al6 (6.8 ⫾ 0.8 cm). Finally, the lower
limit values were estimated to be 4.7 and 3.6 cm on
the RS and 5.6 and 4.3 cm on the LS for men and
women, respectively.
A sex-difference has been noted in several studies.
It was linked to the relation between diaphragmatic
excursion and weight and height.7,17 These observa-
tions were confirmed in our study; indeed height and
weight were found to affect the diaphragmatic mo-
tion. A weak correlation between diaphragmatic excur-
sion and inspiratory or expiratory volumes was also
observed. Cohen et al16 and Houston et al18 noted a
linear relationship between diaphragmatic excursion
CHEST / 135 / 2 / FEBRUARY, 2009 395
 Figure 5. Intraobserver reproducibility of the RS diaphragmatic motion. The intraobserver
differences were 0.3 ⫾ 7% during QB (top, A), 0.3 ⫾ 6% during VS (center, B), and 0 ⫾ 6.2%
during DB (bottom, C).

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 Figure 6. Intraobserver reproducibility of the left diaphragmatic motion. The intraobserver differences were 0.6 ⫾ 7.5% during QB (top,
A) and 0.2 ⫾ 6% during VS (bottom, B).

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 Figure 7. Interobserver reproducibility of the right diaphragmatic motion. The interobserver differences were 0.5 ⫾ 7% during QB (top
left, A), 0.4 ⫾ % during VS (top right, B), and 1 ⫾ 7% during DB (bottom, C).
and inspired volumes. In contrast, Scott et al8 stated
that measuring diaphragm movement by ultrasonog-
raphy during QB and forceful maneuvers provided a
poor reflection of static and dynamic measures of
pulmonary function. Several factors could explain
these discrepancies. Diaphragmatic motion contrib-
utes to three fourths and thoracic expansion to one
fourth of the inspiratory volumes at the vital capacity.
Consequently, various inspiratory volumes may have
been measured for the same diaphragmatic excur-
sion. Furthermore, diaphragmatic motion could be
affected by the examination position of the subjects.
In the study by Houston et al,18 the relation between
inspired volume and hemidiaphragmatic movement
was better in the supine than in the sitting position.
In total, the weak correlation between diaphragmatic
excursion and inspiratory volumes in our subjects
was not unexpected, as the inspiratory volumes
depended on several parameters including diaphrag-
matic motion and also rib thoracic expansion and
abdominal and thoracic compliance.
The relevance of the side-to-side diaphragmatic
motion comparison has been noted in fluoroscopy
studies.19 Using real time ultrasonography, Houston
et al5 determined a normal range of side-to-side
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variability as defined by the right-to-left ratio of
maximal excursion on DB. They considered that a
measurement lying outside the range of 0.5 to 1.6
should be considered to be abnormal. In our study,
the mean ratio was near unity for QB, VS, and DB.
A ratio outside these limits was observed in some
subjects during QB or VS. However, no healthy
volunteer presented an abnormal ratio for both
maneuvers. The ratio always fell between normal
limits when right and left diaphragmatic excursions
were compared during DB. In line with studies using
fluoroscopy or two-dimensional ultrasonography, our
observations confirm the interest of the comparison
between the two sides and the strong suspicion of
abnormal motion in the event of a right-to-left ratio
of hemidiaphragmatic excursion outside these limits.
Studies using fluoroscopy or MRI have shown that
diaphragmatic motion depends somewhat on the
position of the subject. Our results concern the
diaphragmatic motion of healthy subjects solely in
the erect position. Despite this limitation, it has
been demonstrated that diaphragmatic excursion is
greater in the supine position than in the sitting or
the standing positions.20 Consequently, in the event
of a recording of an excursion lower than our limit
Original Research
 Figure 8. Interobserver reproducibility of the left diaphragmatic motion. The interobserver differ-
ences were 1.1 ⫾ 8.6% during QB (top, A) and 1.4 ⫾ 6% during VS (bottom, B).

values, an impairment of diaphragmatic motion
should be suspected, irrespective of position.
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Original Research