eMedicine Specialties > Pulmonology > Diaphragmatic Disorders

Diaphragm Disorders: Differential Diagnoses & Workup

Author: Abhijit A Raval, MD, Pulmonary Diseases and Critical Care Fellow, James H Quillen College of Medicine
Coauthor(s): Ryland P Byrd Jr, MD, Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University; Chief of Pulmonary Medicine, Medical Director of Respiratory Therapy, Intensive Care Unit, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, James H Quillen Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Apr 16, 2009

Differential Diagnoses

Decreased pulmonary or abdominal compliance
Pleural adhesions

Other Problems to Be Considered

  • Fractures, Cervical Spine
  • Guillain-Barré Syndrome
  • Myasthenia Gravis
  • Cervical fracture
  • Cerebral hemorrhage or ischemia
  • Numerous neuropathies
  • Injury to phrenic nerve from trauma
  • Injury to phrenic nerve from neoplasm
  • Injury to phrenic nerve from surgery (most commonly from cardiac surgery due to cold cardioplegia)
  • Alveolar hypoventilation caused by brainstem or higher cervical spinal injury17
  • Anterior horn cell or neuromuscular junction disease to differentiate from phrenic nerve dysfunction

Workup

Laboratory Studies

  • Laboratory studies are limited to discovery of neuropathic causes of diaphragmatic dysfunction.
  • Arterial blood gas determinations may show hypoxemia with underlying V/Q mismatch and progressive hypercapnia as respiratory failure develops.

Imaging Studies

  • Chest radiography18
    • Neurologic impairment manifests radiographically with elevation of the diaphragm (unilateral or bilateral), mediastinal shift upon inspiration, and diminished, absent, or paradoxic movements upon inspiration. Chest radiographs may exhibit a cervical or thoracic mass that encompasses the phrenic nerve. Small lung volume and atelectasis are also common features.
    • Congenital defect or traumatic rupture is demonstrated roentgenographically with abdominal contents in the thorax on the affected side. A nasogastric tube that radiographically appears to be in the thorax may be misinterpreted as a massive hemothorax. Thus, palpation of lung parenchyma and/or abdominal viscus within the thorax before inserting a chest tube into a patient with trauma is always important.
Radiograph of a man who fell 45 ft from scaffoldi...

Radiograph of a man who fell 45 ft from scaffolding, through plate glass windows, and onto the ground. Intraoperatively, he had a completely avulsed diaphragm on the left side. The patient subsequently recovered after a 45-day hospital course of treatment.

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Radiograph of a man who fell 45 ft from scaffoldi...

Radiograph of a man who fell 45 ft from scaffolding, through plate glass windows, and onto the ground. Intraoperatively, he had a completely avulsed diaphragm on the left side. The patient subsequently recovered after a 45-day hospital course of treatment.


  • Fluoroscopy18
    • Up to 6% of the healthy population has paradoxic movement of a hemidiaphragm on a deep inspiratory effort against a closed airway (sniff test) as a normal finding.
    • The sniff test result is considered positive if a 2-cm or greater excursion is present and the whole leaf of the hemidiaphragm, in the oblique view, is involved.
    • Fluoroscopy is positive in 90% of cases of unilateral diaphragmatic paralysis. In bilateral paralysis, the sniff test result may be misleading because the cephalad movement of the ribs and accessory muscle contraction gives the false appearance of caudal displacement of the diaphragm.
    • Measurement of diaphragmatic thickness by ultrasonography has been used in a small series to confirm and assess recovery of diaphragmatic paralysis.19
    • CT scanning is usually not very helpful in bilateral paralysis. Dynamic MRI, however, may prove to be useful.

Other Tests

  • Pulmonary function tests, including maximum inspiratory pressures, transdiaphragmatic pressure measurement, and vital capacity (VC), in both upright and supine positions, help the clinician determine whether diaphragmatic dysfunction is present and/or the degree of respiratory compromise experienced by the patient in different positions. Significant restrictive physiology is noted in patients with diaphragmatic paralysis.
  • In healthy individuals, a 10% decrease in VC in the supine position typically is present. This decrease in VC may increase to as much as 50% in patients with bilateral diaphragmatic paralysis. In unilateral paralysis, VC decreases by 15-20% in the supine position, but still ranges from 70-80% of predicted.
  • Maximal inspiratory pressure (PI-max) is also a useful test. In patients with systemic or generalized neuromuscular disease and bilateral diaphragmatic paralysis, the PI-max is less than - 60 cm water. In patients with unilateral diaphragmatic paralysis, the PI-max is less useful because it decreases to a value of 60% predicted.
  • Phrenic nerve conduction studies are used to assess the latency of conducting nervous impulses along the course of the nerve. This helps localize lesions to one side or the other and helps the clinician to decipher whether the condition is a bilateral phenomenon. This test is not generally available and may require referral to a center that is able to provide this service.
  • An electromyogram is useful to show neuropathic or myopathic patterns, and the test can be complemented by phrenic nerve stimulation at the neck.20
  • Magnetometers or inductance plethysmographic coils placed around the abdomen and chest may also provide diagnostic clues by revealing paradoxical chest wall motion.
  • Measurement of transdiaphragmatic pressure is the criterion standard in the diagnosis of diaphragmatic dysfunction and paralysis. It reflects the difference between intragastric pressure versus intrapleural pressure. Although this test is effort dependent, the sensitivity can be increased my measuring pressure by electrically stimulating the phrenic nerve and measuring twitch or tetanic transdiaphragmatic pressure.
  • Electromyography has a limited role in unilateral diaphragmatic paralysis.
  • The maximum transdiaphragmatic pressure during static effort is also decreased.
  • M-mode ultrasonography is the latest method to evaluate a paralyzed diaphragm, from which the paralyzed hemidiaphragm shows no active caudal movement with inspiration.
  • MRI of the neck may be useful to determine if the presence of pathologic conditions involving the spinal column and nerve roots are causing diaphragmatic paralysis.

More on Diaphragm Disorders

Overview: Diaphragm Disorders
Differential Diagnoses & Workup: Diaphragm Disorders
Treatment & Medication: Diaphragm Disorders
Follow-up: Diaphragm Disorders
Multimedia: Diaphragm Disorders
References
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References

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Further Reading

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Keywords

diaphragm disorders, diaphragm dysfunction, phrenic nerve injury, diaphragm, respiratory dysfunction, Bochdalek hernias, congenital diaphragmatic hernia, Guillain-Barré syndrome, lead neuropathy, postinfectious neuropathies, chiropractic cervical spine manipulation, uremia, diaphragmatic rupture, Morgagni hernia, eventration of the diaphragm, diaphragmatic agenesis, syringomyelia, poliomyelitis, motor neuron disease, brachial plexus neuritis, diabetic neuropathy, nutritional neuropathy, alcoholic neuropathy, vasculitic neuropathy, infection-related nerve injury, myasthenia gravis, myotonic dystrophies, Duchenne muscular dystrophy, metabolic myopathies, polymyositis, acquired diaphragmatic disorders, innervation defects, cerebral stroke, spinal cord disorders, phrenic nerve neuropathy

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Contributor Information and Disclosures

Author

Abhijit A Raval, MD, Pulmonary Diseases and Critical Care Fellow, James H Quillen College of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ryland P Byrd Jr, MD, Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University; Chief of Pulmonary Medicine, Medical Director of Respiratory Therapy, Intensive Care Unit, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, James H Quillen Veterans Affairs Medical Center
Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ryland P Byrd Jr, MD, Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University; Chief of Pulmonary Medicine, Medical Director of Respiratory Therapy, Intensive Care Unit, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, James H Quillen Veterans Affairs Medical Center
Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H, Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine
Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine
Disclosure: Keck School of Medicine, USC None None

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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