83 year old female presents to the ED with left hip fracture' She has no significant PMHx' takes an

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• 83 year old female presents to the ED with left
  hip fracture. She has no significant PMHx.
  takes an aspirin daily, EKG is normal. Chest
  Xray reveals an elevated right hemidiaphragm.
  What do I tell the ortho resident consulting me
  about this isolated finding?

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Diaprhagmatic Paralysis

• The Significance to the Medicine
• Consultant

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Normal Diaphragm Function

• Ventilation depends on the ability of the
  respiratory pump to move air in and out of the
  gas exchange portion of the lungs. The
  respiratory muscles serve as the link between the
  different components of the pump the
  respiratory centers, the conducting nerves and
  the rib cage and abdomen.

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The Diaphragm

• The most important of the respiratory muscles is
  the diaphragm. Contraction of the diaphragm has
  the following effects that promote air movement
  into the lungs
• It decreases intrapleural pressure
• It raises or inflates the rib cage using the
  abdomen as a fulcrum on which to lean.
• It expands the rib cage through its zone of
  apposition by generating positive intraabdominal
  pressure.

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Alterations with diaphragmatic paralysis

• Diaphragmatic paralysis can involve either the
  whole diaphragm(bilateral) or only one
  leaflet(unilateral). In this setting, the
  accessory muscles of respiration assume some or
  all the work of breathing, depending upon the
  degree of diaphragmatic compromise.

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Unilateral Diaphragmatic Paralysis

• Unilateral diaphragmatic paralysis is seen as the
  elevated hemidiaphragm so commonly noted on
  chest radiograph. This brings to mind the
  clinical question, what is the significance?

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• Pulmonary function tests in unilateral diaphragm
  paralysis show moderate to no reductions in vital
  capacity while upright but usually some decrease
  when supine. Studies have shown that total lung
  capacity is reduced about 20 percent.

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Differential diagnosis of elevated hemidiaphragm

• Most common cause is phrenic nerve invasion from
  bronchogenic CA
• Idiopathic
• Trauma
• Surgery
• Phrenic nerve cooling seen after cardiac surgery
• Cervicle spondylosis
• Poliomyelitis
• Intubation for surgery probably from neck
  hyperextension

• Other causes are very rare and more common in
  Bilateral diaphragmatic paralysis, these inclued
  spinal cord transection, Multiple
  sclerosis,Guillain-Barre Syndrom,Phrenic nerve
  dysfunction,throid dysfunction,Malnutrion, Acid
  maltase deficiency, CTD, Amyloidosis

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Clinical manifestations

• Patients without underlying lung disease are
  usually asymptomatic at rest, but may have
  dyspnea with exertion.
• Orthopnea may also occur but is not as intense
  as with bilateral diaphragmatic paralysis.
• Patients with PFO are found to have increased
  incidence of R to L shunts.

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So what do we do with the radiographic finding

• The prognosis of unilateral diaphragmatic
  paralysis is determined by the cause. If it is
  idiopathic, some cases recover spontaneously.
  For those that do not, patients are still usually
  able to lead a normal life.

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Treatment options

• For those patients with significant exercise
  intolerance or morbidity, surgical plication will
  improve both the physiology and symptoms in
  patients with significant symptoms.

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Surgical Plication

• Before plication, the healthy hemidiaphragm
  generates pressure to the affected side. This
  pressure pulls up the paralyzed leaflet. This
  ineffective motion does not allow appropriate
  expansion of the ipsilateral lung.

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• Plication repairs the flail segment by stretching
  the paralyzed diaphragm as a semi-taught sheet
  between the lower borders of the rigid chest wall.

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• After plication there is improvement in static
  lung mechanics, exercise performance, blood gas
  exchange and respiratory muscle function.

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Evidence for Plication

• One study showed at fourteen year follow up,
  improvement of patient spirometry in all lung
  function tests.

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In conclusion...

• An isolated finding of elevated hemidiaphragm
  should prompt the consultant to consider the
  differential diagnosis. If determined to be
  idiopathic or from non malignant causes then the
  patients symptoms should be reviewed. If the
  patient is

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• symptomatic then surgical plication should be
  considered, otherwise the prognosis is good and
  no additional therapy is necessary.

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Back to original case

• Review of systems revealed no significant
  orthopnea or dyspnea on exertion. Old radiograph
  from two years previous showed no change. Most
  importantly no mass was seen on chest radiograph.
  It was concluded that this was idiopathic and no
  further work up needed.