eMedicine Specialties > Pulmonology > Diaphragmatic Disorders

Diaphragmatic Paralysis: Follow-up

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

Follow-up

Complications

Phrenic nerve injury commonly occurs from cold cardioplegia or mechanical stretching during open-heart surgery.

Prognosis

  • Unilateral diaphragmatic paralysis
    • Depending on the etiology of the diaphragmatic paralysis, the prognosis of unilateral disease usually is excellent unless the patient has significant underlying pulmonary disease.
    • Patients develop compensatory mechanisms, and patients with phrenic injuries may recover fully or partially.13
    • At times, patients may spontaneously recover from idiopathic disease. Patients who do not recover from unilateral diaphragmatic dysfunction generally lead relatively normal lives.
    • Patients generally are asymptomatic.
    • Dyspnea may develop during exercise or in other situations, leading to increased ventilatory demands.
  • Bilateral diaphragmatic paralysis14
    • The prognosis depends on the nature of the underlying disease.
    • Patient diaphragm function may recover if nerve injury is not permanent, while other patients may require long-term ventilatory support.
  • Surgical considerations: Although not proven in randomized trials, patients who continue to be dyspneic or continue to lead a poor quality of life can be considered for surgical plication.

Miscellaneous

Medicolegal Pitfalls

In patients with nontraumatic bilateral diaphragmatic paralysis, the diagnosis often goes unrecognized until the patient presents with cor pulmonale or cardiorespiratory failure.

Unilateral diaphragmatic paralysis often is asymptomatic and is recognized as unilateral elevation of the diaphragm on a chest radiograph.

Special Concerns

  • Diaphragmatic dysfunction following cardiac surgery
    • Diaphragmatic dysfunction often occurs postoperatively in patients undergoing cardiac surgery. This has been attributed to pleurotomy in order to harvest internal mammary artery (IMA) grafts, which results in greater chest wall and parenchymal trauma, greater pain, and impairment of cough and deep breathing. In addition, IMA dissection may reduce blood supply to ipsilateral intercostal muscles and cause mechanical injury to the phrenic nerve.
    • In the past, studies have confirmed phrenic nerve injury from cold-induced injury during myocardial protection, although in current practice most centers use warm cardioplegia.
    • The consequences of post–cardiac surgery diaphragm dysfunction vary from asymptomatic radiographic abnormalities to severe pulmonary dysfunction requiring prolonged mechanical ventilation and increased morbidity and mortality.
    • In one study, the incidence of diaphragmatic dysfunction was 11% (5 of 44 patients), and only 1 patient had phrenic nerve palsy.
    • Most patients with post–cardiac surgery diaphragmatic dysfunction improve with conservative measures such as chest physiotherapy, prevention and treatment of pneumonia, treatment of underlying chronic obstructive pulmonary disease (if present), and overall care. Rarely, diaphragmatic plication may also be required in such patients.
 


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
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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].

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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

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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.

 
 
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