Anatomic landmarks to estimate the length of the diaphragm from chest radiographs - Effects of emphysema and lung volume reduction surgery

Study objectives: To define anatomic landmarks that can be used to predict insertions of the diaphragm on chest radiographs and to estimate diaphragm length. Design: Prospective clinical trial with a parallel group design. Setting. Laboratory investigations in normal volunteers recruited by advertisement and in emphysema outpatients being evaluated for elective bilateral lung volume reduction surgery (LVRS). Patients: Twenty-six normal subjects classified into young and older age groups, with a third group of 13 emphysema patients matched for age and sex with the older group. Measurements: Identification and between-group comparisons were made of anatomic landmarks on anteroposterior and and lateral chest radiographs obtained at total lung capacity. Predicted landmarks were generated from normal subjects. Within-subject and between-group comparisons were made of diaphragm length index (DLI) based on observed anatomic landmarks (DLIobs) and diaphragm length index based on predicted anatomic landmarks (DLIpred) at functional residual capacity. Results: Anatomic landmarks were not different between the three groups or between male and female subjects, and were not different before and after LAIRS in emphysema patients. No difference was found between DLIobs and DLIpred in normal subjects and emphysema patients, but both were smaller in emphysema patients than in normal subjects and increased after LAIRS' in emphysema patients. Conclusion: This study validates the use of anatomic landmarks to estimate DLL Using these landmarks simplifies the determination of diaphragmatic lengths and could be a useful tool for the evaluation of the functional capacity of the diaphragm, and possibly as a prognostic indicator of patients who are candidates for LVRS.