Diaphragmatic Paralysis

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Diaphragmatic Paralysis

• 4B Intern ???
• 2004/11/8

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• Etiology
• Clinical features
• Diagnosis
• Treatment
• Prognosis

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Etiology
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Etiology-1

• Open heart surgery
• leading cause of unilateral phrenic palsy
  (2-20)
• left-sided most frequently
• harvest of internal mammary artery
• cold cardioplegia solution
• mechanical stretching

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Etiology-2

• (2) Thoracotomy, pleurectomy, pneumonectomy
  generally not accompanied by the risk
• (3) Mediastinal and esophageal procedures
• (4) Trauma manipulation of the cervical spine,
  penetrating injuries or surgery of the neck or
  thorax, jugular or subclavian venous
  catheterization, birth trauma
• (5) Space-occupying lesions cervical
  osteoarthritis, aortic aneurysm, substernal
  thyroid, bronchogenic or mediastinal tumors

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Etiology-3

• (6) Local inflammation pleurisy and pneumonia,
  specific inflammations of the phrenic nerves
  (herpes zoster infection or vasculitis)
• (7) Mediastinal radiotherapy
• (8) Peripheral neuropathy diabetes
• (9) Neuralgic amyotrophy
• (10) Neuromuscular diseases multiple sclerosis,
  anterior horn cell disease, acid maltase
  deficiency

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Clinical Features
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Clinical Features- Unilateral paralysis

• Elevated hemidiaphragm in CXR
• Asymptomatic
• Dyspnea on exertion
• Decrease in exercise performance
• Orthopnea (less intense)

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Clinical Features- Bilateral paralysis

• Severe exertional dyspnea, marked orthopnea
• Much worse supine
• Prolonged mechanical ventilation, tracheostomy
• Hypoxemia, atelectasis, chronic respiratory
  failure, pneumonia, morbidity
• Sleep disturbances
• Nocturnal hypoxia, worsening hypercapnia,
  anxiety, daytime somnolence, morning headaches

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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PE

• Unilateral
• Dullness to percussion, breath sounds (-) over
  the lower chest
• Decreased excursion
• Bilateral
• Dullness with absent breath sounds, limitation of
  diaphragmatic excursions
• Tachypnea, accessory respiratory muscle use
• Diagnostic finding
• paradoxical inward movement of the abdomen with
  inspiration

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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CXR

• Elevated hemidiaphragms
• Small lung volumes
• Atelectasis
• Strongly suggest the diagnosis of unilateral
  diaphragmatic
• paralysis

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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Sniff test

• Ultrasonography/ fluoroscopy
• Positive-
• paradoxical elevation of the paralyzed diaphragm
  with inspiration

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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Pulmonary function test

• Unilateral paralysis mild restriction
• Bilateral paralysis severe restriction
• ?VC, MVV 55, 45 (inspiratory muscle weakness)
• ? FRC, RV 35-40 (pulmonary atelectasis)
• Supine VC lt 75 of upright

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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EMG

• One of the most specific tests

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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Transdiaphragmatic pressure

• Criterion standard for diagnosis
• (A) a thin-walled balloon at the lower end of the
  esophagus (pleural pressure)
• (B) a second balloon manometer in the stomach
• (intra-abdominal pressure)
• Pdi difference between A and B

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Diagnosis

• PE
• CXR
• Sniff test
• PFT
• EMG
• Pdi
• PImax

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Maximal inspiratory pressure

• PImax ?in parallel with Pdi
• Less negative than -60 cm H2O
• Not as specific as Pdi

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(No Transcript)
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Treatment
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Treatment- Unilateral Paralysis

• Usually asymptomatic, rarely requires treatment
• Wait 3 months postoperatively for signs of
  recovery
• (Y. Deng, K. Byth and H.S. Paterson, Phrenic
  nerve injury associated with high free right
  internal mammary artery harvesting. Ann Thorac
  Surg 76, 2003, pp. 459463)

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Treatment- Unilateral Paralysis

• Diaphragmatic plication
• often necessary in infants
• (M. Tönz, L.K. von Segesser, T. Mihaljevic, U.
  Arbenz, U.G. Stauffer and M.I. Turina , Clinical
  implications of phrenic nerve injury after
  pediatric cardiac surgery. J Pediatr Surg 31,
  1996, pp. 12651267)
• D.T.M. Lai and H.S. Paterson, Mini-thoracotomy
  for diaphragmatic plication with thoracoscopic
  assistance. Ann Thorac Surg 68, 1999, pp.
  23642365

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Treatment-Bilateral Paralysis

• Plication
• Bilateral plication reserved for irreversible
  denervation with substantial paradoxical motion
  documented by fluoroscopy
• Mechanical ventilation nasal CPAP, intermittent
  positive-pressure ventilation by nasal or oral
  mask

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Prognosis
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Prognosis- Unilateral Paralysis

• Excellent, 1-18 months
• (P.G. Wilcox, P.D. Pare and R.L. Pardy, Recovery
  after unilateral phrenic injury associated with
  coronary artery revascularization. Chest 98,
  1990, pp. 661666)
• unless significant underlying pulmonary disease
• Return of diaphragmatic function
• Recruitment of other inspiratory muscles
  (compensation)
• Symptomatic patient s/p plication
• subjective and objective improvement
• (D.R. Graham, D. Kaplan, C.C. Evans, C.R.K. Hind
  and R.J. Donnelly, Diaphragmatic plication for
  unilateral diaphragmatic paralysis a 10-year
  experience. Ann Thorac Surg 49, 1990, pp.
  248252)

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Prognosis-Bilateral paralysis

• Enhanced use of neck and rib cage inspiratory
  muscles
• Better pulmonary function in upright position
• Severe symptoms when lying down
• Often recover, 2 years
• (Olopade CO, Staats BA Time course of recovery
  from frostbitten phrenics after coronary artery
  bypass graft surgery. Chest 991112-1115, 1991)

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