• Mark E Haaksma, Jasper M Smit, Alain Boussuges, Alexandre Demoule, Martin Dres, Giovanni Ferrari, Paolo Formenti, Ewan C Goligher, Leo Heunks, Endry H T Lim, Lidwine B Mokkink, Eleni Soilemezi, Zhonghua Shi, Michele Umbrello, Luigi Vetrugno, Emmanuel Vivier, Lei Xu, Massimo Zambon, and Pieter R Tuinman.
• Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands. m.haaksma@amsterdamumc.nl.
• Crit Care. 2022 Apr 8; 26 (1): 99.

BackgroundDiaphragm ultrasonography is rapidly evolving in both critical care and research. Nevertheless, methodologically robust guidelines on its methodology and acquiring expertise do not, or only partially, exist. Therefore, we set out to provide consensus-based statements towards a universal measurement protocol for diaphragm ultrasonography and establish key areas for research.MethodsTo formulate a robust expert consensus statement, between November 2020 and May 2021, a two-round, anonymous and online survey-based Delphi study among experts in the field was performed. Based on the literature review, the following domains were chosen: "Anatomy and physiology", "Transducer Settings", "Ventilator Impact", "Learning and expertise", "Daily practice" and "Future directions". Agreement of ≥ 68% (≥ 10 panelists) was needed to reach consensus on a question.ResultsOf 18 panelists invited, 14 agreed to participate in the survey. After two rounds, the survey included 117 questions of which 42 questions were designed to collect arguments and opinions and 75 questions aimed at reaching consensus. Of these, 46 (61%) consensus was reached. In both rounds, the response rate was 100%. Among others, there was agreement on measuring thickness between the pleura and peritoneum, using > 10% decrease in thickness as cut-off for atrophy and using 40 examinations as minimum training to use diaphragm ultrasonography in clinical practice. In addition, key areas for research were established.ConclusionThis expert consensus statement presents the first set of consensus-based statements on diaphragm ultrasonography methodology. They serve to ensure high-quality and homogenous measurements in daily clinical practice and in research. In addition, important gaps in current knowledge and thereby key areas for research are established. Trial registration The study was pre-registered on the Open Science Framework with registration digital object identifier https://doi.org/10.17605/OSF.IO/HM8UG .© 2022. The Author(s).

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