An ultrasound measurement method for assessing diaphragm mobility during maximal respiration

An ultrasound measurement method for assessing diaphragm mobility during maximal respiration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article An ultrasound measurement method for assessing diaphragm mobility during maximal respiration Xue Shi, Li Zhang, Lan Zeng, Yang Song, Xin Li, Ling Li, Niya Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7226481/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: This study proposes a new method B-mode ultrasound to assess right hemidiaphragm mobility during maximal respiration in healthy adults. Methods: In 29 healthy volunteers, the mean and coefficient of variation of diaphragmatic excursion measured by M-mode and a new B-mode measurements were compared, and their agreement was assessed using the Bland-Altman analysis. Intra-observer and inter-observer agreement were analyzed using intraclass correlation coefficients (ICC) in 15 healthy volunteers. Results: The mean values for diaphragmatic mobility using M-mode and B-mode ultrasound methods were 6.03 ± 1.21 cm and 3.97 ± 0.93 cm, respectively, with coefficients of variation of 0.1103 ± 0.0627 and 0.0772 ± 0.0347. The Bland-Altman plot showed the consistency of the two methods. The ICCs for the first and second M-mode measurements by senior physicians, compared with those by junior physicians, were 0.851 (95% CI: 0.615–0.947), 0.671 (95% CI: 0.177–0.883), and 0.659 (95% CI: 0.168–0.877). For the B-mode ultrasound measurements, the corresponding ICC values were 0.812 (95% CI: 0.533–0.933), 0.832 (95% CI: 0.464–0.945), and 0.701 (95% CI: 0.208–0.896).” Conclusions: The B-mode ultrasound method demonstrated accurate measurement of diaphragmatic mobility, with strong agreement when compared to M-mode ultrasound. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research diaphragmatic ultrasonography displacement of diaphragm maximum respiratory state Figures Figure 1 Figure 2 Figure 3 Introduction Ultrasound has emerged as an important imaging method for assessing diaphragm function, due to its non-invasive nature, real-time capabilities and repeatability 1 , 2 . Diaphragm mobility refers to the displacement amplitude of the diaphragm during contraction and relaxation throughout the respiratory cycle. This measurement primarily reflects pulmonary ventilation capacity 3 , making diaphragm mobility during maximal respiration a crucial indicator for evaluating early diaphragm dysfunction 4 . Currently, M-mode ultrasound is the primary technique used for clinical measurements. However, there is inconsistency in the placement of the ultrasound probe on the abdominal wall, which affects the lower boundary of the measurement. Additionally, factors such as probe angle, the position of the M-mode sampling line, and the specific ultrasound measurement section (upper boundary) are not standardized 4 . These complications hinder the standardization of diaphragm mobility measurements using M-mode ultrasound and make it difficult to cross-reference data across different studies 8 . In order to achieve more accurate measurement of diaphragmatic mobility during maximal respiration, a novel B-mode ultrasound measurement method was devised. This method entailed the placement of the probe in the right midclavicular line and the lowermost intercostal space above the right costal arch, thereby establishing the lower boundary of the measurement. The ultrasound section in which the right hepatic and middle hepatic veins converge into the inferior vena cava concurrently was selected, and the angle of the beam was determined, thus fixing the upper boundary of the measurement. The shortest distance was measured from the probe's centre point to the right side of the inferior vena cava. This distance was found to be approximately 2 cm from the ventral side of the diaphragmatic apex, thus fixing the specific measurement position. The difference between the distance between the end of maximal deep expiration and the end of maximal deep inspiration (DB) was calculated to be the ultrasound diaphragmatic mobility in the maximal respiratory state. The present study proposes to utilise the novel B-mode ultrasound technique in order to compare and contrast it with the conventional M-mode ultrasound measurement technique. The objective of this study is to evaluate the accuracy and repeatability of the novel B-mode ultrasound technique in measuring diaphragm mobility. The study will provide an objective basis for the promotion of the utilisation of the novel technique in measuring diaphragm mobility. Study Subjects 32 healthy adult volunteers (aged>18 years) were recruited for this study, conducted from January 2024 to August 2024 at xx Hospital of xx Medical University. All participants had no previous history of cardiovascular, respiratory, or neurological conditions, no history of thoracic or abdominal surgery, no thoracic deformities, pleural or abdominal effusions, or large tumors, and had not used any medications affecting muscle function. Additionally, none of the participants had a history of respiratory infections in the previous four weeks or a history of smoking. Female participants were not pregnant. Volunteers who did not meet the eligibility criteria or failed to complete two diaphragmatic ultrasound measurements were excluded. General demographic data, including gender, age, weight, height, and body mass index (BMI), were collected before the ultrasound examination. The study was approved by the hospital’s Medical Ethics Committee(2021-Ke-704), and all participants provided written informed consent. Ultrasound Measurements A Mindray Resona R9 color Doppler ultrasound diagnostic system (Shenzhen Myriad Biomedical Electronics Co., Ltd., Shenzhen, Guangdong Province, China) was used for ultrasound evaluation, equipped with the SC6-1U probe. All subjects underwent training on maximal breathing prior to the examination, including instructions on performing maximal inspiration and expiration. During the examination, subjects were placed in a supine position. The traditional method for measuring diaphragmatic mobility was conducted using M-mode ultrasound. The probe was positioned transversely at the intersection of the right midclavicular line and the lower edge of the right costal arch, with the acoustic beam directed toward the diaphragmatic apex. An oblique coronal section of the liver was visualized, and the M-mode sampling line was placed perpendicular to the diaphragm. Subjects were instructed to perform a maximal deep exhalation followed by a maximal deep inhalation to generate a respiratory curve. The vertical distance between the highest point of the curve (end of maximal inspiration) and the lowest point (end of maximal expiration) was measured, representing the degree of movement (DM, Diaphragm mobility using M-mode) of the right diaphragm during maximal respiration (Fig. 1 ). The new method utilized B-mode ultrasound, in which the probe was placed transversely at the intersection of the right midclavicular line and the lowest intercostal space above the right costal arch. The sound beam was directed toward the diaphragm, and subjects were again instructed to perform maximal deep exhalation and inhalation. During respiration, ultrasound images were captured showing the right and middle hepatic veins converging into the inferior vena cava at maximal expiration and inspiration, respectively. Dynamic images were retained, and the shortest distance between the ventral edge of the diaphragm at maximal expiration and the ventral edge at maximal inspiration was measured approximately 2 cm to the right of the inferior vena cava. The difference between these two values (DB, diaphragm mobility using B-mode) was calculated to determine diaphragmatic movement during maximal respiration (Fig. 2 ). Measurements were considered unsuccessful if they failed three times. A senior ultrasound physician with 20 years of experience, who had independently performed more than 40 diaphragm mobility examinations, conducted two diaphragm mobility measurements on all subjects. These two measurements were completed within one week. Additionally, a junior physician with less than 5 years of ultrasound experience conducted diaphragm mobility measurement within one week on 15 selected subjects. Each measurement was performed five times, with the highest and lowest values discarded, and the remaining three values were averaged. The coefficient of variation was calculated using the five measurements obtained during the first examination by the senior physician. Statistical Analysis Data conforming to normal distribution were expressed as mean ± standard deviation, and data not normally distributed were expressed as the median and interquartile range. The coefficient of variation (CV) for the measurements was compared using a paired t-test. The Bland-Altman plotting was utilized to assess the consistency between the first and second measurements by senior physicians and between the measurements by junior physicians. Intraclass correlation coefficients (ICC) were calculated to evaluate the consistency of repeated measurements by senior physicians and junior physicians. Consistency was categorized as poor (ICC 0.80). All statistical analyses were conducted using SPSS (PASW Statistics 27.0, Chicago, IL, USA) and MedCalc (MedCalc 22.0, Mariakerke, Belgium). P<0.05 was considered statistically significant. Results General Information Initially, a total of 32 healthy volunteers were recruited for this study, and all participants successfully underwent B-mode ultrasound measurements. However, three of them were excluded because M-mode ultrasound measurements of the diaphragm were obstructed by lung tissue during maximal exhalation or inhalation. As a result, 29 healthy volunteers were included in the final analysis, comprising 9 males and 20 females, with an average age of 24.6 ± 3.3 years and a BMI of 21.6 ± 2.9. (location for table 1 ) Comparison of M-mode and B-mode ultrasound diaphragmatic mobility measurements The mean diaphragmatic mobility measured using traditional M-mode ultrasound in all 29 subjects was 6.03±1.21 cm, while the mean value obtained using the B-mode method was 3.97±0.93 cm, with a statistically significant difference between the two groups (P < 0.05). Notably, the mean value measured by M-mode ultrasound was not only significantly higher than that of B-mode ultrasound, but the vast majority of individual measurements were also greater (out of 145 measurements, only two were less than or equal to the B-mode values). For each subject, the standard deviation of five measurements using both M-mode and B-mode ultrasound was calculated. The mean standard deviation for M-mode ultrasound was 0.65±0.38 cm, whereas for B-mode ultrasound it was 0.29±0.10 cm (P < 0.05). This study also calculated the coefficient of variation for diaphragm mobility measurements using M-mode and B-mode ultrasound. The coefficient of variation for M-mode measurements was 0.1103 ± 0.0627, while for B-mode measurements it was 0.0772 ± 0.0347 (P < 0.05) .(Table 2) (location for table 2) Evaluation of the agreement between the two measurements of M-mode ultrasound and B-mode ultrasound The Bland-Altman plots illustrate the agreement between M-mode and B-mode ultrasound measurements of diaphragm mobility taken by senior physicians (first and second measurements) and junior physicians (Fig.3). The results indicate that the mean differences between M-mode and B-mode measurements in the three sets of measurements were 2.10 cm, 2.40 cm, and 2.20 cm, respectively, with 95% limits of agreement of (0.10, 4.20), (0.30, 4.60), and (0.50, 3.90), respectively. These findings demonstrate good consistency between the two ultrasound measurement methods (Table 3). A paired samples t-test revealed that the M-mode measurements were significantly higher than the B-mode measurements(t = 11.08, P < 0.05). (location for figure 3 and table 3) Intra- and Inter-Observer Consistency Evaluation of M-mode Ultrasound Measurements The reproducibility of diaphragm mobility measurements using M-mode ultrasound during maximum respiratory was analyzed between the first and second measurements conducted by the senior physician. The results demonstrated an intraclass correlation coefficient (ICC) of 0.851(95% CI:0.615–0.947) , indicating a high degree of intra-observer consistency within the same senior physician. The reproducibility of diaphragm mobility measurements using M-mode ultrasound was analyzed between the first measurement by the senior physician and the measurements by the junior physician. The ICC was 0.671 (95% CI:0.177, 0.883).Similarly, for the second measurement conducted by the senior physician, the ICC was 0.659 (95% CI :0.168, 0.877), also indicating moderate inter-observer consistency between the senior and junior physicians. Intra- and Inter-Observer Consistency Evaluation of B-mode Ultrasound Measurements The reproducibility of diaphragm mobility measurements using B-mode ultrasound during maximum respiratory effort was analyzed between the first and second measurements conducted by the senior physician. The results showed an ICC of 0.812 (95% CI :0.533, 0.933) indicating a high level of intra-observer consistency for the senior physician. The reproducibility of diaphragm mobility measurements using B-mode ultrasound was analyzed between the first measurement conducted by the senior physician and those conducted by the junior physician. The ICC was 0.832 (95% CI :0.464, 0.945).Similarly, a comparison of the second B-mode ultrasound measurements between senior and junior physicians resulted in an ICC of 0.701 (95% CI: 0.208,0.896), indicating a high level of agreement between the two groups (Table 4). (location for table 4) Discussion In the context of evaluating early diaphragmatic dysfunction, the maximal respiratory state assumes greater significance in comparison to the calm respiratory state. In general terms, the tidal volume in a calm respiratory state reflects the minimum diaphragmatic function required to maintain normal gas exchange. The degree of diaphragmatic use is minimal, which makes it difficult to detect potential diaphragmatic dysfunction at an early stage. The maximum respiratory state of the human body is typically defined as the maximal inspiratory and expiratory movements, both of which must be achieved during periods of maximal active work. This enables the diaphragm to reach its full elevation and descent, thereby achieving the maximum degree of diaphragm movement. Consequently, the human body requires a greater degree of diaphragmatic function in the maximal respiratory state than in the calm respiratory state. In the presence of underlying diaphragmatic dysfunction, the ability to meet the demand for diaphragmatic function in the maximal respiratory state is compromised, which can result in a decrease in the maximum movement of the diaphragm. In conclusion, potential or mild diaphragmatic dysfunction can be detected earlier and more easily in the maximal respiratory state of the human body. Bousseges et al. demonstrated that during maximal respiration, the mean diaphragm movement was 7 ± 1.1 cm in healthy males and 5.7 ± 1.1 cm in healthy females 9 . In another study comparing diaphragmatic function between healthy individuals and sepsis patients, the average diaphragmatic mobility during deep breathing was 42.26 ± 8.21 mm in healthy individuals, 27.46 ± 6.03 mm in sepsis patients with SOFA scores of 2 to 5, and 16.27 ± 4.76 mm in those with SOFA scores greater than 5 10 . These findings demonstrate that diaphragmatic mobility not only differentiates between healthy individuals and patients with diaphragmatic dysfunction, but also allows for the evaluation of diaphragmatic dysfunction severity across different diseases. Moreover, it is particularly suited for early detection of diaphragmatic dysfunction. M-mode ultrasound has been widely used to evaluate diaphragmatic movement during maximal respiration due to its simplicity and clinical value. However, there is a lack of consensus regarding the positioning of the probe, the angle of probe orientation, the angle of the sampling line, and the measurement cut-off plane, among other parameters 14 – 17 . Some studies suggests that the probe should be placed in the intercostal for measurement when the subcostal measurement cannot be made, indicating a notable failure rate for subcostal measurements. This suggests that there is a certain degree of failure rate in measuring diaphragmatic mobility by performing subcostal M-mode ultrasound. This variability in measurement positions can lead to inaccurate data, making it difficult to compare results across studies. Furthermore, the limitations of M-mode ultrasound measurements of diaphragm mobility during maximal respiration are more importantly due to the presence of “drift” and “off-target” phenomena. “Drift” refers to the situation where the intersection of the M-mode ultrasound sampling line and the diaphragm (the measurement point) does not remain consistent during respiratory motion, while “off-target” means that the sampling line completely detaches from the diaphragm. For instance, during periods of calm breathing, characterised by minimal diaphragm movement, the measurement point on the M-mode ultrasound sampling line, even with drift, can be consistently located within the target zone of the diaphragm’s range of motion. Consequently, the measurement value remains relatively stable. However, in the maximum respiratory state, i.e. when the diaphragm moves the most, the movement of the diaphragm is up and down, anterior and posterior, and left and right in three dimensions. This makes it difficult to measure the same diaphragm point on the M-mode ultrasound sampling line in the deep expiratory and deep inhalation states. In fact, the point may even be far away from the diaphragm. This may lead to the phenomenon of running away from the target. This, in turn, may lead to the failure of the measurement 19 . Consequently, conventional M-mode ultrasound is not an appropriate modality for measuring diaphragmatic mobility in the maximal respiratory state. In this study, the values of M-mode ultrasound were found to be significantly larger than those of B-mode ultrasound. This can be attributed to the obvious “drift” and “off-target” phenomenon of M-mode ultrasound measurement, which is caused by the significant deviation of the sampling line of M-mode ultrasound from the vertical movement of the diaphragm. Secondly, the mean standard deviation and coefficient of variation of the M-mode measurement results were significantly larger than those of the B-mode ultrasound, mainly because the traditional M-mode ultrasound measurement method did not agree on the location of the probe, i.e., It was not possible to fix the lower boundary of the measurement, and the specific section of the measurement did not unify. In other words, it was not possible to fix the upper boundary of the measurement. This resulted in a significant degree of dispersion of the measured data, and the stability of the measured data was significantly lower than that of the B-mode ultrasound measurement method. Despite the specification of probe position and measurement direction during M-mode ultrasound, frequent “drift” and “off-target” phenomena may lead to inaccurate or incomplete measurements. In this study, a novel B-mode ultrasound measurement method was employed, with the advantage that the probe was placed in the right midclavicular line at the endmost intercostal space, and the probe was clamped by two ribs, thus fixing the position of the probe and maintaining the consistency of the lower boundary of the measurement. Secondly, irrespective of whether the measurement was taken at the conclusion of deep inhalation or exhalation, the measurement section in question corresponded to the section in which the right hepatic vein and the middle hepatic vein converge into the inferior vena cava. The measurement position was fixed; that is to say, the centre of the probe was positioned 2 cm to the right of the inferior vena cava. This ensured the consistency of the upper boundary of the measurement and, by extension, the stability of the measured values. In this study, a high degree of consistency was obtained in the evaluation of the reproducibility of the first and second measurements of the senior physicians, as well as in the evaluation of the consistency between the groups of senior and junior physician. These measurements were found to be significantly correlated with the true vertical movement radials of the diaphragm during maximal respiration (p < 0.05).Moreover, the Bland-Altman plots demonstrated that there was a strong correlation between the B-mode and M-mode methods for measuring diaphragm mobility. Furthermore, the coefficient of variation and the standard deviation of the B-mode ultrasound were found to be considerably smaller than those of the M-mode ultrasound (0.1103 ± 0.0627 VS 0.0772 ± 0.0347,P < 0.05). This finding indicates that B-mode ultrasound is a more appropriate method for measuring diaphragm mobility in the maximal respiratory state than M-mode ultrasound. The limitations of this study are as follows: First, the sample size was inadequate. Second, the methodology lacked a gold standard for measuring diaphragm mobility. Consequently, the study primarily served as a methodological investigation of diaphragm mobility. Additionally, the study population consisted exclusively of healthy individuals without the evaluation of diaphragm function in disease states. However, B-mode ultrasound shows promise as a tool for the early assessment of diaphragm function in a wide range of respiratory diseases. The value of difference in probe-to-diaphragm distance during inhalation and exhalation is used as an indicator of diaphragm mobility in B-mode ultrasound. However, it should be noted that this measurement does not accurately reflect the true vertical movement of the diaphragm. In future studies, we aim to develop an accurate methodology for estimating the true vertical movement of the diaphragm based on B-mode ultrasound measurements. The right diaphragm is distinguished by the convergence of the right hepatic vein and the middle hepatic vein into the inferior vena cava, whereas the left diaphragm lacks such distinctive markings. Therefore, only the right diaphragm was measured in this study. It should be acknowledged that optimal respiratory cooperation from patients is essential for achieving maximal respiratory state measurements. Thus, the scope of future applications should be judiciously confined to patients with diverse respiratory ailments who retain sufficient consciousness and demonstrate the capacity for respiratory coordination. Such as patients with chronic obstructive pulmonary disease and interstitial pneumonia. In summary, although M-mode ultrasound is the conventional modality for measuring diaphragmatic mobility in the maximal respiratory state, it is subject to significant “drift” and “off-target” phenomena. These phenomena result in the measurement position and angle being non-uniform, consequently leading to substantially larger and erroneous measurement values. This new B-mode ultrasound measurement method, however, is significantly more accurate than M-mode ultrasound and closer to the real situation of diaphragm mobility because it specifies the position of the probe and the measurement plane, fixes the lower boundary of the measurement, and establishes the standard upper line of the measurement. It can be used as the first choice for diaphragm mobility measurement in the maximal respiratory state. Declarations Author Contributions: H.G. conceived and designed the work. X.S. made substantial contributions to data acquisition, analysis, and interpretation for the work. L.Zhang., L. Zeng. and N.Zhang made substantial contributions to data analysis and interpretation. Y.S., X.L. and L.L. revised the manuscript critically for important intellectual content. X.S., H.G. drafted the work and revised it critically for important intellectual content. X.S., L. Zhang., L.Zeng, Y.S., X.L., L.L., N.Zhang and H.G. gave final approval of the version submitted for publication. X.S., L.Zhang., L.Zeng, Y.S., X.L., L.L., N.Zhang and H.G. agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding: This study was supported by the Research Start-up Fund，Beijing Chaoyang Hospital， Capital Medical University（2022）. Acknowledgements : The authors acknowledge all the staff in the Ultrasound Department of Beijing Chaoyang Hospital of Capital Medical University. Disclosures: All the authors have no conflicts of interest. References Suttapanit, K., Lerdpaisarn, P., Charoensuksombun, C., Sanguanwit, P. & Supatanakij, P. 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Boccatonda, A., Decorato, V., Cocco, G., Marinari, S. & Schiavone, C. Ultrasound evaluation of diaphragmatic mobility in patients with idiopathic lung fibrosis: A pilot study. Multidiscip. Respir. Med. 14 , 1 (2019). Gethin-Jones, T. L., Noble, V. E. & Morse, C. R. Quantification of diaphragm function using ultrasound: Evaluation of a novel technique. Ultrasound Med. Biol. 36 (11), 1965-1969 (2010). Voyvoda, N., Yucel, C., Karatas, G., Oguzulgen, I. & Oktar, S. An evaluation of diaphragmatic movements in hemiplegic patients. Br. J. Radiol. 85 (1012), 411-414 (2012). Toledo, N. S. et al. Left hemidiaphragmatic mobility: Assessment with ultrasonographic measurement of the craniocaudal displacement of the splenic hilum and the inferior pole of the spleen. J. Ultrasound. Med. 25 (1), 41-49 (2006). Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 31 Oct, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 11 Sep, 2025 Reviewers agreed at journal 18 Aug, 2025 Reviews received at journal 18 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers invited by journal 14 Aug, 2025 Editor assigned by journal 14 Aug, 2025 Editor invited by journal 11 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 07 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7226481","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":502234642,"identity":"fcd66b3f-e684-44ef-9fdc-2711f1ebc7a0","order_by":0,"name":"Xue Shi","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xue","middleName":"","lastName":"Shi","suffix":""},{"id":502234643,"identity":"942c9eeb-15ed-4432-a5d4-336e53de2c66","order_by":1,"name":"Li Zhang","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Zhang","suffix":""},{"id":502234644,"identity":"7c70af99-b3ed-4f0c-912f-1c4ad883dced","order_by":2,"name":"Lan Zeng","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lan","middleName":"","lastName":"Zeng","suffix":""},{"id":502234645,"identity":"a2f07171-1aa6-4a94-86b5-c2c4fd3bcb95","order_by":3,"name":"Yang Song","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Song","suffix":""},{"id":502234646,"identity":"4ebd865f-d7d2-438c-8121-240aecc6eb55","order_by":4,"name":"Xin Li","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Li","suffix":""},{"id":502234647,"identity":"8ccce909-80f7-4b2b-8509-9469ae41ab34","order_by":5,"name":"Ling Li","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ling","middleName":"","lastName":"Li","suffix":""},{"id":502234649,"identity":"b3795aa0-bbac-44d4-8aae-5b23771c83cc","order_by":6,"name":"Niya Zhang","email":"","orcid":"","institution":"Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Niya","middleName":"","lastName":"Zhang","suffix":""},{"id":502234652,"identity":"74a0c700-897a-49e7-9b79-a629045168f5","order_by":7,"name":"Huiyu Ge","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYDACCTBpw8PP30CaljQZyRkHSNNy2MagIYFIHfLRPcafbrad5zFgOMD44WMOEVoM75wxMM5tu81jztzALDlzGzFaZuQYJOduu81j2XCAjZmXWC2Hc7ed4zE4kECkFnmJHMPm3G0HSNBiIJFWzJz7L5lHcsbBZuL8Ij8jefPnnDN29vz8zQc/fCTKlgMcBlAmYwMR6kG2NLA/IE7lKBgFo2AUjFwAAOqMNsHqXR8fAAAAAElFTkSuQmCC","orcid":"","institution":"Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Huiyu","middleName":"","lastName":"Ge","suffix":""}],"badges":[],"createdAt":"2025-07-27 13:38:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7226481/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7226481/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-22045-8","type":"published","date":"2025-10-31T15:57:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89691793,"identity":"b35f2a7b-6849-44cb-b2d3-6298b746041c","added_by":"auto","created_at":"2025-08-22 16:55:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":170640,"visible":true,"origin":"","legend":"\u003cp\u003eM-mode ultrasound measurements of diaphragmatic mobility. (A) Pattern diagram of the M-mode ultrasound measurement. (B) Diaphragmatic mobility is represented by the vertical distance (a) between the point of maximal inspiration and maximal expiration. In this image, the measured diaphragmatic mobility is 7.33 cm. IVC: Inferior vena cava. RHV: Right hepatic veins. MHV: Middle hepatic veins.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7226481/v1/8f329493659506e5dccba337.png"},{"id":89691116,"identity":"3741af5e-06c0-484e-97a3-e0362cce8f65","added_by":"auto","created_at":"2025-08-22 16:47:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":205520,"visible":true,"origin":"","legend":"\u003cp\u003eNew B-mode ultrasound measurement of diaphragm mobility. (A) Pattern diagram of the M-mode ultrasound measurement. (B) Shows the ultrasound image of the right hepatic vein and the middle hepatic vein entering the inferior vena cava at the point of maximal expiration. The distance of the probe from the diaphragm is 14.16 cm (a). (C) Shows the ultrasound image at maximal inspiration. The distance of the probe from the diaphragm is 9.62 cm(b). The diaphragmatic mobility was calculated as the difference between these two measurements: a - b = 14.16 cm - 9.62 cm = 4.54 cm. IVC: Inferior vena cava. RHV: Right hepatic veins. MHV: Middle hepatic veins.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7226481/v1/077c0dc4127fc08db16de4a5.png"},{"id":89691119,"identity":"542f1220-156e-4fe9-b600-690e6d7197cb","added_by":"auto","created_at":"2025-08-22 16:48:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":130615,"visible":true,"origin":"","legend":"\u003cp\u003eBland-Altman plots of the agreement between the measurements of right hemidiaphragm mobility obtained by M-mode and B-mode ultrasound measurements. X axis: Mean of diaphragm mobility measurements by M-mode and B-mode ultrasound. Y axis: Difference between diaphragm mobility measurements by M-mode and B-mode ultrasound. (A) First time M-mode and B-mode ultrasound measurements by senior physicians. (B) Second time M-mode and B-mode ultrasound measurements by senior physicians. (C) Once time M-mode and B-mode ultrasound measurements by junior physicians.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7226481/v1/61bcc32f8f95de708ebd4b26.png"},{"id":95039907,"identity":"119275db-d9ad-4148-b4d9-997ef82356ea","added_by":"auto","created_at":"2025-11-03 16:05:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1050381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7226481/v1/49d82b8c-ac31-4b26-98f8-f300333e1640.pdf"},{"id":89691117,"identity":"5b2ee439-6d36-426d-a098-e4a84b151e55","added_by":"auto","created_at":"2025-08-22 16:47:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":29096,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7226481/v1/8ab1827e49d96aaabbb19f30.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"An ultrasound measurement method for assessing diaphragm mobility during maximal respiration","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUltrasound has emerged as an important imaging method for assessing diaphragm function, due to its non-invasive nature, real-time capabilities and repeatability\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Diaphragm mobility refers to the displacement amplitude of the diaphragm during contraction and relaxation throughout the respiratory cycle. This measurement primarily reflects pulmonary ventilation capacity\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, making diaphragm mobility during maximal respiration a crucial indicator for evaluating early diaphragm dysfunction\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Currently, M-mode ultrasound is the primary technique used for clinical measurements. However, there is inconsistency in the placement of the ultrasound probe on the abdominal wall, which affects the lower boundary of the measurement. Additionally, factors such as probe angle, the position of the M-mode sampling line, and the specific ultrasound measurement section (upper boundary) are not standardized\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. These complications hinder the standardization of diaphragm mobility measurements using M-mode ultrasound and make it difficult to cross-reference data across different studies\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn order to achieve more accurate measurement of diaphragmatic mobility during maximal respiration, a novel B-mode ultrasound measurement method was devised. This method entailed the placement of the probe in the right midclavicular line and the lowermost intercostal space above the right costal arch, thereby establishing the lower boundary of the measurement. The ultrasound section in which the right hepatic and middle hepatic veins converge into the inferior vena cava concurrently was selected, and the angle of the beam was determined, thus fixing the upper boundary of the measurement. The shortest distance was measured from the probe's centre point to the right side of the inferior vena cava. This distance was found to be approximately 2 cm from the ventral side of the diaphragmatic apex, thus fixing the specific measurement position. The difference between the distance between the end of maximal deep expiration and the end of maximal deep inspiration (DB) was calculated to be the ultrasound diaphragmatic mobility in the maximal respiratory state. The present study proposes to utilise the novel B-mode ultrasound technique in order to compare and contrast it with the conventional M-mode ultrasound measurement technique. The objective of this study is to evaluate the accuracy and repeatability of the novel B-mode ultrasound technique in measuring diaphragm mobility. The study will provide an objective basis for the promotion of the utilisation of the novel technique in measuring diaphragm mobility.\u003c/p\u003e\n\u003ch3\u003eStudy Subjects\u003c/h3\u003e\n\u003cp\u003e32 healthy adult volunteers (aged\u0026gt;18 years) were recruited for this study, conducted from January 2024 to August 2024 at xx Hospital of xx Medical University. All participants had no previous history of cardiovascular, respiratory, or neurological conditions, no history of thoracic or abdominal surgery, no thoracic deformities, pleural or abdominal effusions, or large tumors, and had not used any medications affecting muscle function. Additionally, none of the participants had a history of respiratory infections in the previous four weeks or a history of smoking. Female participants were not pregnant. Volunteers who did not meet the eligibility criteria or failed to complete two diaphragmatic ultrasound measurements were excluded. General demographic data, including gender, age, weight, height, and body mass index (BMI), were collected before the ultrasound examination. The study was approved by the hospital\u0026rsquo;s Medical Ethics Committee(2021-Ke-704), and all participants provided written informed consent.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eUltrasound Measurements\u003c/h2\u003e\u003cp\u003eA Mindray Resona R9 color Doppler ultrasound diagnostic system (Shenzhen Myriad Biomedical Electronics Co., Ltd., Shenzhen, Guangdong Province, China) was used for ultrasound evaluation, equipped with the SC6-1U probe. All subjects underwent training on maximal breathing prior to the examination, including instructions on performing maximal inspiration and expiration. During the examination, subjects were placed in a supine position.\u003c/p\u003e\u003cp\u003eThe traditional method for measuring diaphragmatic mobility was conducted using M-mode ultrasound. The probe was positioned transversely at the intersection of the right midclavicular line and the lower edge of the right costal arch, with the acoustic beam directed toward the diaphragmatic apex. An oblique coronal section of the liver was visualized, and the M-mode sampling line was placed perpendicular to the diaphragm. Subjects were instructed to perform a maximal deep exhalation followed by a maximal deep inhalation to generate a respiratory curve. The vertical distance between the highest point of the curve (end of maximal inspiration) and the lowest point (end of maximal expiration) was measured, representing the degree of movement (DM, Diaphragm mobility using M-mode) of the right diaphragm during maximal respiration (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The new method utilized B-mode ultrasound, in which the probe was placed transversely at the intersection of the right midclavicular line and the lowest intercostal space above the right costal arch. The sound beam was directed toward the diaphragm, and subjects were again instructed to perform maximal deep exhalation and inhalation. During respiration, ultrasound images were captured showing the right and middle hepatic veins converging into the inferior vena cava at maximal expiration and inspiration, respectively. Dynamic images were retained, and the shortest distance between the ventral edge of the diaphragm at maximal expiration and the ventral edge at maximal inspiration was measured approximately 2 cm to the right of the inferior vena cava. The difference between these two values (DB, diaphragm mobility using B-mode) was calculated to determine diaphragmatic movement during maximal respiration (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Measurements were considered unsuccessful if they failed three times. A senior ultrasound physician with 20 years of experience, who had independently performed more than 40 diaphragm mobility examinations, conducted two diaphragm mobility measurements on all subjects. These two measurements were completed within one week. Additionally, a junior physician with less than 5 years of ultrasound experience conducted diaphragm mobility measurement within one week on 15 selected subjects. Each measurement was performed five times, with the highest and lowest values discarded, and the remaining three values were averaged. The coefficient of variation was calculated using the five measurements obtained during the first examination by the senior physician.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData conforming to normal distribution were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and data not normally distributed were expressed as the median and interquartile range. The coefficient of variation (CV) for the measurements was compared using a paired t-test. The Bland-Altman plotting was utilized to assess the consistency between the first and second measurements by senior physicians and between the measurements by junior physicians. Intraclass correlation coefficients (ICC) were calculated to evaluate the consistency of repeated measurements by senior physicians and junior physicians. Consistency was categorized as poor (ICC\u0026thinsp;\u0026lt;\u0026thinsp;0.40), moderate (ICC 0.41\u0026ndash;0.60), good (ICC 0.61\u0026ndash;0.80), or excellent (ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.80). All statistical analyses were conducted using SPSS (PASW Statistics 27.0, Chicago, IL, USA) and MedCalc (MedCalc 22.0, Mariakerke, Belgium). P\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eGeneral Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitially, a total of 32 healthy volunteers were recruited for this study, and all participants successfully underwent B-mode ultrasound measurements. However, three of them were excluded because M-mode ultrasound measurements of the diaphragm were obstructed by lung tissue during maximal exhalation or inhalation. As a result, 29 healthy volunteers were included in the final analysis, comprising 9 males and 20 females, with an average age of 24.6\u0026nbsp;±\u0026nbsp;3.3 years and a BMI of 21.6\u0026nbsp;±\u0026nbsp;2.9.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(location for table 1 )\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of M-mode and B-mode ultrasound diaphragmatic mobility measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean diaphragmatic mobility measured using traditional M-mode ultrasound in all 29 subjects was 6.03±1.21 cm, while the mean value obtained using the B-mode method was 3.97±0.93 cm, with a statistically significant difference between the two groups (P \u0026lt; 0.05). Notably, the mean value measured by M-mode ultrasound was not only significantly higher than that of B-mode ultrasound, but the vast majority of individual measurements were also greater (out of 145 measurements, only two were less than or equal to the B-mode values).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;For each subject, the standard deviation of five measurements using both M-mode and B-mode ultrasound was calculated. The mean standard deviation for M-mode ultrasound was 0.65±0.38 cm, whereas for B-mode ultrasound it was 0.29±0.10 cm (P \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study also calculated the coefficient of variation for diaphragm mobility measurements using M-mode and B-mode ultrasound. The coefficient of variation for M-mode measurements was 0.1103\u0026nbsp;±\u0026nbsp;0.0627, while for B-mode measurements it was 0.0772\u0026nbsp;±\u0026nbsp;0.0347 (P \u0026lt; 0.05) .(Table 2)\u003c/p\u003e\n\u003cp\u003e(location for table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvaluation of the agreement between the two measurements of M-mode ultrasound and B-mode ultrasound\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Bland-Altman plots illustrate the agreement between M-mode and B-mode ultrasound measurements of diaphragm mobility taken by senior physicians (first and second measurements) and junior physicians (Fig.3). The results indicate that the mean differences between M-mode and B-mode measurements in the three sets of measurements were 2.10 cm, 2.40 cm, and 2.20 cm, respectively, with 95% limits of agreement of (0.10, 4.20), (0.30, 4.60), and (0.50, 3.90), respectively. These findings demonstrate good consistency between the two ultrasound measurement methods (Table 3). A paired samples t-test revealed that the M-mode measurements were significantly higher than the B-mode measurements(t = 11.08, P \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e(location for figure 3 and table 3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntra- and Inter-Observer Consistency Evaluation of M-mode Ultrasound Measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reproducibility of diaphragm mobility measurements using M-mode ultrasound during maximum respiratory was analyzed between the first and second measurements conducted by the senior physician. The results demonstrated an intraclass correlation coefficient (ICC) of 0.851(95% CI:0.615–0.947) , indicating a high degree of intra-observer consistency within the same senior physician.\u003c/p\u003e\n\u003cp\u003eThe reproducibility of diaphragm mobility measurements using M-mode ultrasound was analyzed between the first measurement by the senior physician and the measurements by the junior physician. The ICC was 0.671 (95% CI:0.177, 0.883).Similarly, for the second measurement conducted by the senior physician, the ICC was 0.659 (95% CI :0.168, 0.877), also indicating moderate inter-observer consistency between the senior and junior physicians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntra- and Inter-Observer Consistency Evaluation of B-mode Ultrasound Measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reproducibility of diaphragm mobility measurements using B-mode ultrasound during maximum respiratory effort was analyzed between the first and second measurements conducted by the senior physician. The results showed an ICC of 0.812 (95% CI :0.533, 0.933) indicating a high level of intra-observer consistency for the senior physician.\u003c/p\u003e\n\u003cp\u003eThe reproducibility of diaphragm mobility measurements using B-mode ultrasound was analyzed between the first measurement conducted by the senior physician and those conducted by the junior physician. The ICC was 0.832 (95% CI :0.464, 0.945).Similarly, a comparison of the second B-mode ultrasound measurements between senior and junior physicians resulted in an ICC of 0.701 (95% CI: 0.208,0.896), indicating a high level of agreement between the two groups (Table 4).\u003c/p\u003e\n\u003cp\u003e(location for table 4)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the context of evaluating early diaphragmatic dysfunction, the maximal respiratory state assumes greater significance in comparison to the calm respiratory state. In general terms, the tidal volume in a calm respiratory state reflects the minimum diaphragmatic function required to maintain normal gas exchange. The degree of diaphragmatic use is minimal, which makes it difficult to detect potential diaphragmatic dysfunction at an early stage. The maximum respiratory state of the human body is typically defined as the maximal inspiratory and expiratory movements, both of which must be achieved during periods of maximal active work. This enables the diaphragm to reach its full elevation and descent, thereby achieving the maximum degree of diaphragm movement. Consequently, the human body requires a greater degree of diaphragmatic function in the maximal respiratory state than in the calm respiratory state. In the presence of underlying diaphragmatic dysfunction, the ability to meet the demand for diaphragmatic function in the maximal respiratory state is compromised, which can result in a decrease in the maximum movement of the diaphragm. In conclusion, potential or mild diaphragmatic dysfunction can be detected earlier and more easily in the maximal respiratory state of the human body.\u003c/p\u003e\u003cp\u003eBousseges et al. demonstrated that during maximal respiration, the mean diaphragm movement was 7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 cm in healthy males and 5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 cm in healthy females\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. In another study comparing diaphragmatic function between healthy individuals and sepsis patients, the average diaphragmatic mobility during deep breathing was 42.26\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21 mm in healthy individuals, 27.46\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03 mm in sepsis patients with SOFA scores of 2 to 5, and 16.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.76 mm in those with SOFA scores greater than 5\u003csup\u003e10\u003c/sup\u003e. These findings demonstrate that diaphragmatic mobility not only differentiates between healthy individuals and patients with diaphragmatic dysfunction, but also allows for the evaluation of diaphragmatic dysfunction severity across different diseases. Moreover, it is particularly suited for early detection of diaphragmatic dysfunction.\u003c/p\u003e\u003cp\u003eM-mode ultrasound has been widely used to evaluate diaphragmatic movement during maximal respiration due to its simplicity and clinical value. However, there is a lack of consensus regarding the positioning of the probe, the angle of probe orientation, the angle of the sampling line, and the measurement cut-off plane, among other parameters\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Some studies suggests that the probe should be placed in the intercostal for measurement when the subcostal measurement cannot be made, indicating a notable failure rate for subcostal measurements. This suggests that there is a certain degree of failure rate in measuring diaphragmatic mobility by performing subcostal M-mode ultrasound. This variability in measurement positions can lead to inaccurate data, making it difficult to compare results across studies.\u003c/p\u003e\u003cp\u003eFurthermore, the limitations of M-mode ultrasound measurements of diaphragm mobility during maximal respiration are more importantly due to the presence of \u0026ldquo;drift\u0026rdquo; and \u0026ldquo;off-target\u0026rdquo; phenomena. \u0026ldquo;Drift\u0026rdquo; refers to the situation where the intersection of the M-mode ultrasound sampling line and the diaphragm (the measurement point) does not remain consistent during respiratory motion, while \u0026ldquo;off-target\u0026rdquo; means that the sampling line completely detaches from the diaphragm. For instance, during periods of calm breathing, characterised by minimal diaphragm movement, the measurement point on the M-mode ultrasound sampling line, even with drift, can be consistently located within the target zone of the diaphragm\u0026rsquo;s range of motion. Consequently, the measurement value remains relatively stable. However, in the maximum respiratory state, i.e. when the diaphragm moves the most, the movement of the diaphragm is up and down, anterior and posterior, and left and right in three dimensions. This makes it difficult to measure the same diaphragm point on the M-mode ultrasound sampling line in the deep expiratory and deep inhalation states. In fact, the point may even be far away from the diaphragm. This may lead to the phenomenon of running away from the target. This, in turn, may lead to the failure of the measurement \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Consequently, conventional M-mode ultrasound is not an appropriate modality for measuring diaphragmatic mobility in the maximal respiratory state. In this study, the values of M-mode ultrasound were found to be significantly larger than those of B-mode ultrasound. This can be attributed to the obvious \u0026ldquo;drift\u0026rdquo; and \u0026ldquo;off-target\u0026rdquo; phenomenon of M-mode ultrasound measurement, which is caused by the significant deviation of the sampling line of M-mode ultrasound from the vertical movement of the diaphragm. Secondly, the mean standard deviation and coefficient of variation of the M-mode measurement results were significantly larger than those of the B-mode ultrasound, mainly because the traditional M-mode ultrasound measurement method did not agree on the location of the probe, i.e., It was not possible to fix the lower boundary of the measurement, and the specific section of the measurement did not unify. In other words, it was not possible to fix the upper boundary of the measurement. This resulted in a significant degree of dispersion of the measured data, and the stability of the measured data was significantly lower than that of the B-mode ultrasound measurement method. Despite the specification of probe position and measurement direction during M-mode ultrasound, frequent \u0026ldquo;drift\u0026rdquo; and \u0026ldquo;off-target\u0026rdquo; phenomena may lead to inaccurate or incomplete measurements.\u003c/p\u003e\u003cp\u003eIn this study, a novel B-mode ultrasound measurement method was employed, with the advantage that the probe was placed in the right midclavicular line at the endmost intercostal space, and the probe was clamped by two ribs, thus fixing the position of the probe and maintaining the consistency of the lower boundary of the measurement. Secondly, irrespective of whether the measurement was taken at the conclusion of deep inhalation or exhalation, the measurement section in question corresponded to the section in which the right hepatic vein and the middle hepatic vein converge into the inferior vena cava. The measurement position was fixed; that is to say, the centre of the probe was positioned 2 cm to the right of the inferior vena cava. This ensured the consistency of the upper boundary of the measurement and, by extension, the stability of the measured values. In this study, a high degree of consistency was obtained in the evaluation of the reproducibility of the first and second measurements of the senior physicians, as well as in the evaluation of the consistency between the groups of senior and junior physician. These measurements were found to be significantly correlated with the true vertical movement radials of the diaphragm during maximal respiration (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).Moreover, the Bland-Altman plots demonstrated that there was a strong correlation between the B-mode and M-mode methods for measuring diaphragm mobility. Furthermore, the coefficient of variation and the standard deviation of the B-mode ultrasound were found to be considerably smaller than those of the M-mode ultrasound (0.1103\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0627 VS\u003c/p\u003e\u003cp\u003e0.0772\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0347,P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This finding indicates that B-mode ultrasound is a more appropriate method for measuring diaphragm mobility in the maximal respiratory state than M-mode ultrasound.\u003c/p\u003e\u003cp\u003eThe limitations of this study are as follows: First, the sample size was inadequate. Second, the methodology lacked a gold standard for measuring diaphragm mobility. Consequently, the study primarily served as a methodological investigation of diaphragm mobility. Additionally, the study population consisted exclusively of healthy individuals without the evaluation of diaphragm function in disease states. However, B-mode ultrasound shows promise as a tool for the early assessment of diaphragm function in a wide range of respiratory diseases. The value of difference in probe-to-diaphragm distance during inhalation and exhalation is used as an indicator of diaphragm mobility in B-mode ultrasound. However, it should be noted that this measurement does not accurately reflect the true vertical movement of the diaphragm. In future studies, we aim to develop an accurate methodology for estimating the true vertical movement of the diaphragm based on B-mode ultrasound measurements. The right diaphragm is distinguished by the convergence of the right hepatic vein and the middle hepatic vein into the inferior vena cava, whereas the left diaphragm lacks such distinctive markings. Therefore, only the right diaphragm was measured in this study. It should be acknowledged that optimal respiratory cooperation from patients is essential for achieving maximal respiratory state measurements. Thus, the scope of future applications should be judiciously confined to patients with diverse respiratory ailments who retain sufficient consciousness and demonstrate the capacity for respiratory coordination. Such as patients with chronic obstructive pulmonary disease and interstitial pneumonia.\u003c/p\u003e\u003cp\u003eIn summary, although M-mode ultrasound is the conventional modality for measuring diaphragmatic mobility in the maximal respiratory state, it is subject to significant \u0026ldquo;drift\u0026rdquo; and \u0026ldquo;off-target\u0026rdquo; phenomena. These phenomena result in the measurement position and angle being non-uniform, consequently leading to substantially larger and erroneous measurement values. This new B-mode ultrasound measurement method, however, is significantly more accurate than M-mode ultrasound and closer to the real situation of diaphragm mobility because it specifies the position of the probe and the measurement plane, fixes the lower boundary of the measurement, and establishes the standard upper line of the measurement. It can be used as the first choice for diaphragm mobility measurement in the maximal respiratory state.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH.G. conceived and designed the work. X.S. made substantial contributions to data acquisition, analysis, and interpretation for the work. L.Zhang., L. Zeng. and N.Zhang made substantial contributions to data analysis and interpretation. Y.S., X.L. and L.L. revised the manuscript critically for important intellectual content. X.S., H.G. drafted the work and revised it critically for important intellectual content. X.S., L. Zhang., L.Zeng, Y.S., X.L., L.L., N.Zhang and H.G. gave final approval of the version submitted for publication. X.S., L.Zhang., L.Zeng, Y.S., X.L., L.L., N.Zhang and H.G. agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Research Start-up Fund，Beijing Chaoyang Hospital， Capital Medical University（2022）.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge all the staff in the Ultrasound Department of Beijing Chaoyang Hospital of Capital Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosures:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSuttapanit, K., Lerdpaisarn, P., Charoensuksombun, C., Sanguanwit, P. \u0026amp; Supatanakij, P. Diaphragmatic ultrasonographic evaluation as an assessment guide for predicting noninvasive ventilation failure in acute exacerbation of chronic obstructive pulmonary disease. \u003cem\u003eAm. J. Emerg. Med.\u003c/em\u003e\u003cstrong\u003e93\u003c/strong\u003e, 13-20 (2025).\u003c/li\u003e\n \u003cli\u003eFormenti, P. et al. Exploring ultrasonographic diaphragmatic function in perioperative anesthesia setting: A comprehensive narrative review. \u003cem\u003eJ. Clin. Anesth.\u003c/em\u003e\u003cstrong\u003e97\u003c/strong\u003e, 111530 (2024).\u003c/li\u003e\n \u003cli\u003eSchulz, A. et al. Comparison of ultrasound measurements for diaphragmatic mobility, diaphragmatic thickness, and diaphragm thickening fraction with each other and with lung function in patients with chronic obstructive pulmonary disease. \u003cem\u003eInt. J. Chronic Obstr. Pulm. Dis.\u003c/em\u003e\u003cstrong\u003e17\u003c/strong\u003e, 2217-2227 (2022).\u003c/li\u003e\n \u003cli\u003eMorishima, R. et al. The difference in the diaphragmatic physiological measures between inspiratory and expiratory phases in ALS. \u003cem\u003eNeurol. Sci.\u003c/em\u003e\u003cstrong\u003e43\u003c/strong\u003e(12), 6821-6830 (2022).\u003c/li\u003e\n \u003cli\u003eHaaksma, M. E. et al. EXpert consensus On Diaphragm UltraSonography in the critically ill (EXODUS): A Delphi consensus statement on the measurement of diaphragm ultrasound-derived parameters in a critical care setting. \u003cem\u003eCrit. Care\u003c/em\u003e\u003cstrong\u003e26\u003c/strong\u003e(1), 99 (2022).\u003c/li\u003e\n \u003cli\u003eTralhao, A. et al. Early changes in diaphragmatic function evaluated using ultrasound in cardiac surgery patients: A cohort study. \u003cem\u003eJ. Clin. Monitor. Comp.\u003c/em\u003e\u003cstrong\u003e34\u003c/strong\u003e(3), 559-566 (2020).\u003c/li\u003e\n \u003cli\u003ePetrar, S. D., Seltenrich, M. E., Head, S. J. \u0026amp; Schwarz, S. K. W. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: A randomized clinical trial. \u003cem\u003eRegion. Anesth. Pain Med.\u003c/em\u003e\u003cstrong\u003e40\u003c/strong\u003e(2), 133-138 (2015).\u003c/li\u003e\n \u003cli\u003eYao, X. et al. Ultrasound assessment of diaphragmatic dysfunction in non-critically ill patients: Relevant indicators and update. \u003cem\u003eFront. Med.\u003c/em\u003e\u003cstrong\u003e11\u003c/strong\u003e, 1389040 (2024).\u003c/li\u003e\n \u003cli\u003eBoussuges, A., Gole, Y. \u0026amp; Blanc, P. Diaphragmatic motion studied by m-mode ultrasonography: Methods, reproducibility, and normal values. \u003cem\u003eChest\u003c/em\u003e\u003cstrong\u003e135\u003c/strong\u003e(2), 391-400 (2009).\u003c/li\u003e\n \u003cli\u003eChen, Y. et al. Quantification of diaphragmatic dynamic dysfunction in septic patients by bedside ultrasound. \u003cem\u003eSci. Rep.\u003c/em\u003e\u003cstrong\u003e12\u003c/strong\u003e(1), 17336 (2022).\u003c/li\u003e\n \u003cli\u003eZhang, T., Liu, Y., Xu, D., Dong, R. \u0026amp; Song, Y. Diaphragmatic dynamics assessed by bedside ultrasound predict extubation in the intensive care unit: A prospective observational study. \u003cem\u003eInt. J. Gen. Med.\u003c/em\u003e\u003cstrong\u003e17\u003c/strong\u003e, 5373-5380 (2024).\u003c/li\u003e\n \u003cli\u003eLjilja Posavec, A. et al. Ultrasonic evaluation of diaphragm in patients with systemic sclerosis. \u003cem\u003eJ. Pers. Med.\u003c/em\u003e\u003cstrong\u003e13\u003c/strong\u003e(10) (2023).\u003c/li\u003e\n \u003cli\u003eHamadah, H. K. et al. Ultrasound for diaphragmatic dysfunction in postoperative cardiac children. \u003cem\u003eCardiol. Young\u003c/em\u003e\u003cstrong\u003e27\u003c/strong\u003e(3), 452-458 (2017).\u003c/li\u003e\n \u003cli\u003eGottesman, E. \u0026amp; McCool, F. D. Ultrasound evaluation of the paralyzed diaphragm. \u003cem\u003eAm. J. Respir. Crit. Care Med.\u003c/em\u003e\u003cstrong\u003e155\u003c/strong\u003e(5), 1570-1574 (1997).\u003c/li\u003e\n \u003cli\u003eVivier, E. et al. Diaphragm ultrasonography to estimate the work of breathing during non-invasive ventilation. \u003cem\u003eIntensive Care Med.\u003c/em\u003e\u003cstrong\u003e38\u003c/strong\u003e(5), 796-803 (2012).\u003c/li\u003e\n \u003cli\u003eBoccatonda, A., Decorato, V., Cocco, G., Marinari, S. \u0026amp; Schiavone, C. Ultrasound evaluation of diaphragmatic mobility in patients with idiopathic lung fibrosis: A pilot study. \u003cem\u003eMultidiscip. Respir. Med.\u003c/em\u003e\u003cstrong\u003e14\u003c/strong\u003e, 1 (2019).\u003c/li\u003e\n \u003cli\u003eGethin-Jones, T. L., Noble, V. E. \u0026amp; Morse, C. R. Quantification of diaphragm function using ultrasound: Evaluation of a novel technique. \u003cem\u003eUltrasound Med. Biol.\u003c/em\u003e\u003cstrong\u003e36\u003c/strong\u003e(11), 1965-1969 (2010).\u003c/li\u003e\n \u003cli\u003eVoyvoda, N., Yucel, C., Karatas, G., Oguzulgen, I. \u0026amp; Oktar, S. An evaluation of diaphragmatic movements in hemiplegic patients. \u003cem\u003eBr. J. Radiol.\u003c/em\u003e\u003cstrong\u003e85\u003c/strong\u003e(1012), 411-414 (2012).\u003c/li\u003e\n \u003cli\u003eToledo, N. S. et al. Left hemidiaphragmatic mobility: Assessment with ultrasonographic measurement of the craniocaudal displacement of the splenic hilum and the inferior pole of the spleen. \u003cem\u003eJ. Ultrasound. Med.\u003c/em\u003e\u003cstrong\u003e25\u003c/strong\u003e(1), 41-49 (2006).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"diaphragmatic ultrasonography, displacement of diaphragm, maximum respiratory state","lastPublishedDoi":"10.21203/rs.3.rs-7226481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7226481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study proposes a new method B-mode ultrasound to assess right hemidiaphragm mobility during maximal respiration in healthy adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 29 healthy volunteers, the mean and coefficient of variation of diaphragmatic excursion measured by M-mode and a new B-mode measurements were compared, and their agreement was assessed using the Bland-Altman analysis. Intra-observer and inter-observer agreement were analyzed using intraclass correlation coefficients (ICC) in 15 healthy volunteers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean values for diaphragmatic mobility using M-mode and B-mode ultrasound methods were 6.03 ± 1.21 cm and 3.97 ± 0.93 cm, respectively, with coefficients of variation of 0.1103 ± 0.0627 and 0.0772 ± 0.0347. The Bland-Altman plot showed the consistency of the two methods. The ICCs for the first and second M-mode measurements by senior physicians, compared with those by junior physicians, were 0.851 (95% CI: 0.615–0.947), 0.671 (95% CI: 0.177–0.883), and 0.659 (95% CI: 0.168–0.877). For the B-mode ultrasound measurements, the corresponding ICC values were 0.812 (95% CI: 0.533–0.933), 0.832 (95% CI: 0.464–0.945), and 0.701 (95% CI: 0.208–0.896).”\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe B-mode ultrasound method demonstrated accurate measurement of diaphragmatic mobility, with strong agreement when compared to M-mode ultrasound.\u003c/p\u003e","manuscriptTitle":"An ultrasound measurement method for assessing diaphragm mobility during maximal respiration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 16:47:55","doi":"10.21203/rs.3.rs-7226481/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-11T15:08:39+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"194210467965583769505110363385652916644","date":"2025-08-18T14:33:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T10:36:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69438159634264589540379113100898703158","date":"2025-08-16T21:03:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264515086652197738174876725400677033728","date":"2025-08-14T09:59:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T09:53:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T09:50:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-11T14:00:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T15:02:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-08-07T14:59:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4e1baa6d-3308-4356-a51c-7201dab81078","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":53343774,"name":"Health sciences/Diseases"},{"id":53343775,"name":"Health sciences/Health care"},{"id":53343776,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-11-03T16:00:14+00:00","versionOfRecord":{"articleIdentity":"rs-7226481","link":"https://doi.org/10.1038/s41598-025-22045-8","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-10-31 15:57:12","publishedOnDateReadable":"October 31st, 2025"},"versionCreatedAt":"2025-08-22 16:47:55","video":"","vorDoi":"10.1038/s41598-025-22045-8","vorDoiUrl":"https://doi.org/10.1038/s41598-025-22045-8","workflowStages":[]},"version":"v1","identity":"rs-7226481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7226481","identity":"rs-7226481","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}