Diaphragmatic Paralysis

Diaphragmatic Paralysis : 

Diaphragmatic Paralysis

Slide 2: 

Etiology Clinical features Diagnosis Treatment Prognosis

Etiology : 

Etiology

Etiology-1 : 

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

Etiology-2 : 

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

Etiology-3 : 

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

Clinical Features : 

Clinical Features

Clinical Features- Unilateral paralysis : 

Clinical Features- Unilateral paralysis Elevated hemidiaphragm in CXR Asymptomatic Dyspnea on exertion Decrease in exercise performance Orthopnea (less intense)

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 Clinical Features- Bilateral paralysis

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

PE : 

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

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

CXR : 

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

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

Sniff test : 

Sniff test Ultrasonography/ fluoroscopy “Positive”- paradoxical elevation of the paralyzed diaphragm with inspiration

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

Pulmonary function test : 

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 < 75% of upright

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

EMG : 

EMG One of the most specific tests

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

Transdiaphragmatic pressure : 

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

Diagnosis : 

Diagnosis PE CXR Sniff test PFT EMG Pdi PImax

Maximal inspiratory pressure : 

Maximal inspiratory pressure PImax: ↓in parallel with Pdi Less negative than -60 cm H2O Not as specific as Pdi

Treatment : 

Treatment

Treatment- Unilateral Paralysis : 

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. 459–463)

Treatment- Unilateral Paralysis : 

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. 1265–1267) D.T.M. Lai and H.S. Paterson, Mini-thoracotomy for diaphragmatic plication with thoracoscopic assistance. Ann Thorac Surg 68, 1999, pp. 2364–2365

Treatment-Bilateral Paralysis : 

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

Prognosis : 

Prognosis

Prognosis- Unilateral Paralysis : 

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. 661–666) 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. 248–252)

Prognosis-Bilateral paralysis : 

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 99:1112-1115, 1991)

Thanks for your attention! : 

Thanks for your attention!