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Diaphragmatic Paralysis Treatment & Management

  • Author: Nader Kamangar, MD, FACP, FCCP, FCCM; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Apr 09, 2015
 

Medical Care

Unilateral diaphragmatic paralysis

Most patients with unilateral diaphragmatic paralysis are asymptomatic and do not require treatment. If the underlying causes are discivered, they can be treated. Even when the etiology is not known, many times paralysis resolves on its own, albeit slowly over a period of months to more than a year. In a select group of patients with unilateral diaphragmatic paralysis who have severe dyspnea upon excursion, surgical treatment has been shown to be beneficial.

Diaphragmatic plication

Stabilization from surgical plication of the paralyzed diaphragm provides good results in selected patients. Following plication, the paralyzed diaphragm does not paradoxically move cephalad into the thorax during inspiration and, therefore, improves ventilation to the affected site. Furthermore, the procedure also favors the healthy diaphragm, which now performs less work.

In a select group of patients, diaphragmatic plication decreased breathlessness, improved vital capacity by 10-20%, and improved PaO2 by 10%. In one surgical series, the mean forced tidal volume improved dramatically from 216 mL to 415 mL after plication and it was possible to discontinue mechanical ventilation within 2-12 days of plication.[12] Functional and physiologic results of diaphragm plication have been shown to endure over long-term follow-up. In another study, 41 patients underwent plication of the hemidiaphragm. Patients were followed up for at least 48 months. Mean forced vital capacity, forced expiratory volume at 1 second, functional residual capacity, and total lung capacity all improved by 17%, 21%, 20%, and 20% (P < .005), respectively, at 48 months. These mean values had remained constant when compared with the 6-month follow-up.[13]

Plication of the diaphragm can be performed using a number of techniques through a thoracotomy, video-assisted thoracoscopic surgery (VATS), or laparoscopy. The VATS approach can have similar results as the thoracotomy series, with fewer complications.[14]

A common relative contraindication to plication is morbid obesity, as surgical plication is technically more difficult in these patients. This group of patients should be evaluated for bariatric surgery and may be able to avoid plication with improvement of pulmonary function after significant weight loss.[4] Patients with certain neuromuscular disorders (ie, amyotrophic lateral sclerosis and muscular dystrophy) should be approached with caution as plication provides only modest benefit with more complications.[4]

Bilateral diaphragmatic paralysis

The treatment of bilateral diaphragmatic paralysis mainly depends on the etiology and severity of the paralysis. Invasive ventilation was historically the main treatment for patients who developed respiratory failure as a result of bilateral diaphragmatic paralysis. Later, a subset of these patients who did not have intrinsic lung pathology became candidates for noninvasive ventilation.

Currently phrenic pacing is increasingly being employed in patients with central respiratory paralysis and upper cervical spinal cord injury (lesions above C3) to wean them off the ventilators.[15] These patients ideally should not have any intrinsic lung disease. Electrodes can be implanted intrathoracically via thoracotomy and, more recently, with VATS. Alternatively, electrodes can be placed intramuscularly via a laparoscopic approach.[16] In this approach, intramuscular electrodes are placed near the entrance points of the phrenic nerves using motor-point mapping techniques.

Diaphragm pacing allows patients to speak again and use their olfaction system. It reduces the occurrence of respiratory infections, provides more natural breathing, and avoids dependency on a mechanical ventilator.[15] The phrenic nerve should be tested with a phrenic nerve conduction study before planning for diaphragmatic pacing. Deconditioning and atrophy of the diaphragm prior to pacing is the main limiting factor in weaning patients off the ventilators.

Negative-pressure systems may induce obstruction of the upper airway, particularly if the upper airway dilators are weak and unable to counteract the negative pressure generated by the ventilator. Therefore, sleep studies are required for patients who are being considered for negative-pressure ventilation.[17] Consideration of positive-pressure ventilation lessens the need for screening sleep studies.

Most patients with mild-to-moderate diaphragmatic weakness maintain daytime gas exchange but worsen during sleep. Sleep studies and ventilatory-assist device treatments may identify this condition. Nighttime noninvasive ventilation could be used in this group of patients.

Patients in whom nasal or oral positive-pressure ventilation is unsuccessful may need other forms of noninvasive ventilation (eg, negative-pressure cuirass, pulmonary wrap, rocking bed, positive-pressure pneumobelt).

Tracheostomy with positive-pressure intermittent or permanent ventilation is reserved for patients who are not candidates for less invasive methods or in whom less invasive methods fail.

Nerve reconstruction techniques

In a select group of patients, nerve surgery may be used to restore function to the paralyzed hemidiaphragm.[18, 19] Neurolysis, nerve grafting, and neurotization have demonstrated promise in returning function to unilateral phrenic nerve injury that occurred as a result of anesthetic procedures and operative and nonoperative trauma to the neck. With microscopic neurolysis, fibrous tissue from the compressed portion of the phrenic nerve is removed.

Inspiratory muscle strength and endurance training

Daily inspiratory muscle strength and endurance training can lead to increased nondiaphragmatic inspiratory muscle recruitment and help those with mild symptoms from diaphragmatic paralysis.[20]

 
 
Contributor Information and Disclosures
Author

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Coauthor(s)

Shahriar Pirouz, MD Resident Physician, Department of Internal Medicine, Olive View-UCLA Medical Center

Disclosure: Nothing to disclose.

Payam Rohani, MD Resident Physician, Department of Internal Medicine, Olive View-UCLA Medical Center

Payam Rohani, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Chair of the Clinical Competency Committee, Pulmonary and Critical Care Fellowship Program, Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System; Chair, Guideline Oversight Committee, American College of Chest Physicians

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society

Disclosure: Nothing to disclose.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

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

  11. Gottesman E, McCool FD. Ultrasound evaluation of the paralyzed diaphragm. Am J Respir Crit Care Med. 1997 May. 155(5):1570-4. [Medline].

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

  13. Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis. Ann Thorac Surg. 2009 Oct. 88(4):1112-7. [Medline].

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  19. Kaufman MR, Elkwood AI, Colicchio AR, CeCe J, Jarrahy R, Willekes LJ, et al. Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. Ann Thorac Surg. 2014 Jan. 97(1):260-6. [Medline].

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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 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 patient with unilateral diaphragmatic paralysis. The diaphragm does not move during expiration. For confirmation, a sniff test is required.
 
 
 
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