Chronic Obstructive Pulmonary Disease (COPD) can cause a diaphragmatic dysfunction (DD), due to the progressive air trapping which leads to muscle fatigue and atrophy, compromising patient?s survival and the duration of mechanical ventilation. Diagnosis and monitoring of DD are possible via diaphragmatic ultrasound (US) by virtue of its non-invasiveness and high availability in the emergency department (ED).

Woman, 77 years old, arrived in ED for a COPD exacerbation. On clinical evaluation, she was awake but confused, with dependent oedemas. The ABG on room air showed a condition of hypoxemia and respiratory and metabolic acidosis; the US evaluation revealed a bilateral B-profile with an irregular pleural line, multiple consolidations and a bilateral pleural effusion; the echocardiogram demonstrated a dilated right ventricle with inefficient contractility and a dilated and hypocollapsing inferior vena cava. Thus, non-invasive ventilation and specific drug therapy were started. Despite the therapy, in less than 24 hours she began drowsy (GCS 8) and the US evaluation showed an almost motionless diaphragm: Levosimendan treatment was started in continuous infusion, to improve the diaphragm contractility and reduce the breathing work. After six hours of treatment, a progressive increase in diaphragmatic excursion (DE) and in right-to-left ratio of maximal excursion were observed with a progressive improvement of ABG parameters and clinical status.

Diaphragmatic US is an essential tool for the evaluation of COPD-induced DD in ED: it allows for close monitoring of DE and the right-to-left ratio of maximum excursion, easily repeatable at patient?s bedside, and evaluation of therapy effectiveness in real time.