eMedicine Specialties > Pulmonology > Diaphragmatic Disorders

Diaphragmatic Paralysis: Differential Diagnoses & Workup

Author: Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Coauthor(s): Shahriar Pirouz, MD, Resident Physician, Department of Internal Medicine, Olive View University of California Los Angeles Medical Center; Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Contributor Information and Disclosures

Updated: Jul 23, 2009

Differential Diagnoses

Other Problems to Be Considered

The following diagnoses may be difficult to differentiate from bilateral diaphragmatic paralysis:

  • Diaphragmatic relaxation can occur in which the muscles are thin but no injury is seen to the nerves.
  • Alveolar hypoventilation is caused by brain stem or high cervical spine disease. Patients have normal respiratory muscle strength and can voluntarily hyperventilate to lower the PaCO2.
  • Anterior horn cells and neuromuscular junction diseases may be difficult to differentiate from phrenic nerve dysfunction.

Workup

Laboratory Studies

Arterial blood gas analysis demonstrates hypoxemia in persons with bilateral diaphragmatic paralysis. Hypoxemia develops from atelectasis and ventilation-perfusion mismatching. Progressive hypercapnia also develops with disease progression.

Imaging Studies

In contrast to bilateral disease, physicians can usually diagnose unilateral paralysis with only radiographic studies.3

  • Chest radiography
    • This study reveals elevated hemidiaphragms, small lung volumes, and atelectasis.
    • In unilateral diaphragmatic paralysis, chest radiographic findings strongly suggest the diagnosis (see Media File 1).


Acute unilateral left diaphragmatic paralysis in ...

Acute unilateral left diaphragmatic paralysis in a patient with moderately severe chronic obstructive pulmonary disease. The patient previously was asymptomatic but developed class III dyspnea following the new event.

[ CLOSE WINDOW ]
Acute unilateral left diaphragmatic paralysis in ...

Acute unilateral left diaphragmatic paralysis in a patient with moderately severe chronic obstructive pulmonary disease. The patient previously was asymptomatic but developed class III dyspnea following the new event.

  • Fluoroscopy
    • Because accessory muscle contraction may create the appearance of diaphragmatic movement, this study may mislead the physician when diagnosing bilateral diaphragmatic paralysis (see Media File 2).
    • Fluoroscopic sniff test (in which paradoxical elevation of the paralyzed diaphragm is observed with inspiration) can confirm chest radiographic findings regarding unilateral diaphragmatic paralysis (see Media File 3).4


Fluoroscopy of elevated left hemidiaphragm in a p...

Fluoroscopy of elevated left hemidiaphragm in a patient with unilateral diaphragmatic paralysis. The diaphragm moves paradoxically upward during inspiration.

[ CLOSE WINDOW ]
Fluoroscopy of elevated left hemidiaphragm in a p...

Fluoroscopy of elevated left hemidiaphragm in a patient with unilateral diaphragmatic paralysis. The diaphragm moves paradoxically upward during inspiration.



Fluoroscopy of elevated left hemidiaphragm in a p...

Fluoroscopy of elevated left hemidiaphragm in a patient with unilateral diaphragmatic paralysis. The diaphragm does not move during expiration. For confirmation, a sniff test is required.

[ CLOSE WINDOW ]
Fluoroscopy of elevated left hemidiaphragm in a p...

Fluoroscopy of elevated left hemidiaphragm in a patient with unilateral diaphragmatic paralysis. The diaphragm does not move during expiration. For confirmation, a sniff test is required.

  • Computed tomography scanning of the chest: This study may be indicated in certain patients to evaluate for potential causes of diaphragmatic paralysis that are due to mediastinal pathology.
  • Magnetic resonance imaging of the neck: This study may be indicated in certain patients to determine the presence of pathologic conditions involving the spinal column or nerve roots that are causing diaphragmatic paralysis.
  • Ultrasonography
    • M-mode ultrasonography is the latest method to evaluate the paralyzed diaphragm. The paralyzed side shows no active caudal movement of the diaphragm with inspiration and abnormal paradoxical movement (ie, cranial movement on inspiration), particularly with the sniff test.
    • M-mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis of the diaphragm in the adult population, and it can be performed at the bedside and can be easily repeated if paralysis is not thought to be permanent.5

Other Tests

  • Pulmonary function testing and arterial blood gas analysis
    • Measuring the vital capacity in the upright and supine positions is the most important pulmonary function test.
    • Normally, vital capacity in recumbency decreases by 10%. In unilateral paralysis, the vital capacity shows a decrease to 70-80% of the predicted level. The decrement is usually slightly more significant in the supine position.
    • In contrast, patients with bilateral diaphragmatic paralysis show a 50% decrease in vital capacity when they are supine. This decrease is from cephalad displacement of abdominal contents.
  • Electromyography
    • Record diaphragmatic electromyography (EMG) findings with other surface or esophageal electrodes; however, EMG has a limited role in unilateral diaphragmatic paralysis.
    • EMG may reveal a neuropathic or myopathic pattern, depending on etiology. Phrenic nerve stimulation at the neck can differentiate between neuropathy and myopathy.
  • Measurement of transdiaphragmatic pressure
    • This is the criterion standard for diagnosis.
    • This test is performed by placing a thin-walled balloon transnasally at the lower end of the esophagus, allowing reflection of the changes in pleural pressure. Then, a second balloon manometer is placed in the stomach to reflect changes in intra-abdominal pressure.
    • The difference between the 2 readings is the transdiaphragmatic pressure. Consult with an expert to perform the test and interpret the results. This measurement can help differentiate diaphragmatic paralysis from other causes of respiratory failure.
  • Maximal inspiratory pressures: Patients with diaphragmatic dysfunction and paralysis have a decrease in maximal inspiratory pressures (PI max). These patients cannot generate high negative inspiratory pressures. Therefore, the Pl max in these patients is less negative than -60 cm water.

More on Diaphragmatic Paralysis

Overview: Diaphragmatic Paralysis
Differential Diagnoses & Workup: Diaphragmatic Paralysis
Treatment & Medication: Diaphragmatic Paralysis
Follow-up: Diaphragmatic Paralysis
Multimedia: Diaphragmatic Paralysis
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Kumar N, Folger WN, Bolton CF. Dyspnea as the predominant manifestation of bilateral phrenic neuropathy. Mayo Clin Proc. Dec 2004;79(12):1563-5. [Medline].

  2. Ulku R, Onat S, Balci A, Eren N. Phrenic nerve injury after blunt trauma. Int Surg. Apr-Jun 2005;90(2):93-5. [Medline].

  3. Gierada DS, Slone RM, Fleishman MJ. Imaging evaluation of the diaphragm. Chest Surg Clin N Am. May 1998;8(2):237-80. [Medline].

  4. Miller JM, Moxham J, Green M. The maximal sniff in the assessment of diaphragm function in man. Clin Sci (Lond). Jul 1985;69(1):91-6. [Medline].

  5. Lloyd T, Tang YM, Benson MD, King S. Diaphragmatic paralysis: the use of M mode ultrasound for diagnosis in adults. Spinal Cord. Aug 2006;44(8):505-8. [Medline].

  6. Ciccolella DE, Daly BD, Celli BR. Improved diaphragmatic function after surgical plication for unilateral diaphragmatic paralysis. Am Rev Respir Dis. Sep 1992;146(3):797-9. [Medline].

  7. Graham DR, Kaplan D, Evans CC, Hind CR, Donnelly RJ. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg. Feb 1990;49(2):248-51; discussion 252. [Medline].

  8. Versteegh MI, Braun J, Voigt PG, et al. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea. Eur J Cardiothorac Surg. Sep 2007;32(3):449-56. [Medline].

  9. Kuniyoshi Y, Yamashiro S, Miyagi K, Uezu T, Arakaki K, Koja K. Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery. Ann Thorac Cardiovasc Surg. Jun 2004;10(3):160-6. [Medline].

  10. Alkofer B, Le Roux Y, Coffin O, Samama G. Thoracoscopic plication of the diaphragm for postoperative phrenic paralysis: a report of two cases. Surg Endosc. May 2004;18(5):868-70. [Medline].

  11. Bach JR, Penek J. Obstructive sleep apnea complicating negative-pressure ventilatory support in patients with chronic paralytic/restrictive ventilatory dysfunction. Chest. Jun 1991;99(6):1386-93. [Medline].

  12. DiMarco AF, Onders RP, Ignagni A, Kowalski KE, Mortimer JT. Phrenic nerve pacing via intramuscular diaphragm electrodes in tetraplegic subjects. Chest. Feb 2005;127(2):671-8. [Medline].

  13. Easton PA, Fleetham JA, de la Rocha A, Anthonisen NR. Respiratory function after paralysis of the right hemidiaphragm. Am Rev Respir Dis. Jan 1983;127(1):125-8. [Medline].

  14. Xu WD, Gu YD, Lu JB, Yu C, Zhang CG, Xu JG. Pulmonary function after complete unilateral phrenic nerve transection. J Neurosurg. Sep 2005;103(3):464-7. [Medline].

  15. [Guideline] Consortium for Spinal Cord Medicine, Paralyzed Veterans of America. Respiratory management following spinal cord injury: a clinical practice guideline for health-care professionals. National Guideline Clearinghouse. Jan 2005.

  16. Celli BR. Respiratory management of diaphragm paralysis. Semin Respir Crit Care Med. Jun 2002;23(3):275-81. [Medline].

  17. Chuang ML, Chuang DC, Lin IF, Vintch JR, Ker JJ, Tsao TC. Ventilation and exercise performance after phrenic nerve and multiple intercostal nerve transfers for avulsed brachial plexus injury. Chest. Nov 2005;128(5):3434-9. [Medline].

  18. Gibson GJ. Diaphragmatic paresis: pathophysiology, clinical features, and investigation. Thorax. Nov 1989;44(11):960-70. [Medline].

  19. Glenn WW. The treatment of respiratory paralysis by diaphragm pacing. Ann Thorac Surg. Aug 1980;30(2):106-9. [Medline].

  20. Glenn WW, Hogan JF, Loke JS, Ciesielski TE, Phelps ML, Rowedder R. Ventilatory support by pacing of the conditioned diaphragm in quadriplegia. N Engl J Med. May 3 1984;310(18):1150-5. [Medline].

  21. Kreitzer SM, Feldman NT, Saunders NA, Ingram RH Jr. Bilateral diaphragmatic paralysis with hypercapnic respiratory failure. A physiologic assessment. Am J Med. Jul 1978;65(1):89-95. [Medline].

  22. Lisboa C, Pare PD, Pertuze J, et al. Inspiratory muscle function in unilateral diaphragmatic paralysis. Am Rev Respir Dis. Sep 1986;134(3):488-92. [Medline].

  23. Moxham J, Shneerson JM. Diaphragmatic pacing. Am Rev Respir Dis. Aug 1993;148(2):533-6. [Medline].

  24. Piehler JM, Pairolero PC, Gracey DR, Bernatz PE. Unexplained diaphragmatic paralysis: a harbinger of malignant disease?. J Thorac Cardiovasc Surg. Dec 1982;84(6):861-4. [Medline].

  25. Sandham JD, Shaw DT, Guenter CA. Acute supine respiratory failure due to bilateral diaphragmatic paralysis. Chest. Jul 1977;72(1):96-8. [Medline].

  26. Smith PE, Edwards RH, Calverley PM. Mechanisms of sleep-disordered breathing in chronic neuromuscular disease: implications for management. Q J Med. Dec 1991;81(296):961-73. [Medline].

[ CLOSE WINDOW ]

Keywords

diaphragmatic paralysis, diaphragm paralysis, diaphragm paresis, paralyzed diaphragm, diaphragmatic disorder, diaphragmatic dysfunction, diaphragm dysfunction, respiratory pump, central respiratory centers, spinal cord, peripheral nerves, neuromuscular junctions, respiratory muscles, diaphragm, bilateral diaphragmatic paralysis, unilateral diaphragmatic paralysis, ventilatory support, diaphragm tumor, diaphragm mass, breathing disorder, diaphragm, diaphragm pacing, diaphragmatic pacing, diaphragm plication, diaphragmatic plication

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Nader Kamangar, MD, FACP, FCCP, FAASM,, Associate Professor of Clinical Medicine, Director of Hospitalist/Intensivist Program, Division of Pulmonary, Critical Care and Sleep Medicine, David Geffen School of Medicine at University of California Los Angeles; Associate Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA/West Los Angeles Veterans Affairs Medical Center
Nader Kamangar, MD, FACP, FCCP, FAASM, is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Shahriar Pirouz, MD, Resident Physician, Department of Internal Medicine, Olive View University of California Los Angeles Medical Center
Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World 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: eMedicine Salary Employment

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.