eMedicine Specialties > Pulmonology > Diaphragmatic Disorders

Diaphragmatic Paralysis

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

Introduction

Background

The respiratory system functions as a vital pump that moves air in and out of the lung gas-exchange units. The respiratory pump consists of central respiratory centers, the spinal cord, peripheral nerves, neuromuscular junctions, and respiratory muscles.

The diaphragm, the most important muscle of ventilation, develops negative intrathoracic pressure to initiate ventilation. Innervated by cervical motor neurons C3-C5 via the phrenic nerves, the cone-shaped muscle by means of contraction decreases intrapleural pressure during inspiration, expands the rib cage, and thereby facilitates movement of gases into the lungs.

Pathophysiology

Diaphragmatic paralyses encompass a spectrum of disease involving a single leaflet, known as unilateral diaphragmatic paralysis (UDP), and that involving both leaflets, known as bilateral diaphragmatic paralysis (BDP).

Although the diaphragm performs most of the work, normal ventilation also requires the simultaneous contraction of respiration accessory muscles (ie, scalene, parasternal portion of the internal and external intercostal muscles, sternocleidomastoid, trapezius). In bilateral diaphragmatic paralysis, respiration accessory muscles assume some or all of the work of breathing by contracting more intensely. An increased effort in the struggle to breathe may fatigue the accessory muscles and lead to ventilatory failure.

Frequency

United States

Incidence is unknown.

Mortality/Morbidity

Unilateral diaphragmatic paralysis

The morbidity of the unilateral paralysis is mainly based on the underlying pulmonary functional status and the etiology of the paralysis. Because most cases of unilateral diaphragmatic paralysis are found incidentally during imaging studies, many patients have no symptoms. The patients that do have symptoms and decreased quality of life are those who have underlying lung disease.

Bilateral diaphragmatic paralysis

Patients with bilateral diaphragmatic paralysis are usually symptomatic and, when symptoms are severe or in the presence of underlying lung pathology, may develop ventilatory failure without medical intervention.

Clinical

History

Bilateral diaphragmatic paralysis is characterized by profound abnormalities of pulmonary and respiratory muscle function. Patients develop severe restrictive ventilatory impairment, and the vital capacity and total lung capacity frequently are below 50% of predicted for that patient. Lung capacity is reduced further when the patient assumes the supine position. Symptoms depend on whether the paralysis is unilateral or bilateral, how rapid the paralysis occurs, and the presence of underlying pulmonary disease.

  • Unilateral diaphragmatic paralysis
    • Unilateral diaphragmatic paralysis is often discovered incidentally in patients undergoing chest radiography for some other reason.
    • Patients usually are asymptomatic at rest but experience dyspnea upon exertion and have a decrease in exercise performance.
    • If the patient has an underlying lung disease, dyspnea may occur at rest.
    • Some patients may develop orthopnea, which is less intense than bilateral diaphragmatic paralysis.
  • Bilateral diaphragmatic paralysis
    • Patients typically present with respiratory failure or dyspnea (may be misinterpreted as a sign of heart failure) that worsens in the supine position.1 Tachypnea and rapid, shallow breathing occur when the patient adopts the recumbent position.
    • Patients also report anxiety, insomnia, morning headache, excessive daytime somnolence and fatigue, and poor sleep habits.

Physical

Physical examination findings depend on whether the paralysis is unilateral or bilateral. Generally, a breathing pattern of paradoxical abdominal wall retraction during inspiration occurs. The physician can evaluate the patient further by palpating under the costal margin and feeling for the descending hemidiaphragms during inspiration.

  • Unilateral diaphragmatic paralysis
    • Patients reveal dullness to percussion and absent breath sounds over the lower chest on the involved side.
    • Excursion on the involved hemithorax is decreased when compared with the healthy side.
  • Bilateral diaphragmatic paralysis
    • Patients report morning headaches, confusion, and signs of cor pulmonale.
    • Chest examination reveals limitation of diaphragmatic excursions and bilateral lower chest dullness with absent breath sounds.
    • Patients are tachypneic and use accessory respiration muscles.
    • The diagnostic finding is a paradoxical inward movement of the abdomen with inspiration.

Causes

  • Unilateral diaphragmatic paralysis
    • The most common diagnosed cause is a malignant (ie, metastatic lung cancer) lesion leading to nerve compression (approximately 30% of patients).
    • If malignancy is not the cause, many times the etiology is not diagnosed.
    • Other causes in the differential include surgical trauma, herpes zoster, cervical spondylosis, trauma, or secondary to surgery (mainly thoracic). 
  • Bilateral diaphragmatic paralysis

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

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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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