eMedicine Specialties > Pulmonology > Diaphragmatic Disorders

Diaphragmatic Paralysis: Treatment & Medication

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

Treatment

Medical Care

Unilateral diaphragmatic paralysis

Most patients are asymptomatic and do not require treatment. In these patients, the long-term prognosis is usually good if an underlying cause is diagnosed and treated. In a select group of patients 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.
  • Improvements in lung mechanics and exercise performance follow this procedure.6,7 In a select group of patients, diaphragmatic plication decreases breathlessness, improves vital capacity by 10-20%, and improves 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.8 Diaphragmatic plication is a useful procedure for the treatment of diaphragmatic paralysis in adults and children.9
  • Plication of the diaphragm through a thoracotomy is known to provide excellent long-term results. Plication can also be performed via video-assisted thoracoscopic surgery (VATS). Case reports have described patients with postoperative left phrenic nerve paralysis who underwent plication of the diaphragm using VATS and achieved total relief of all symptoms.10
Bilateral diaphragmatic paralysis

The treatment of bilateral diaphragmatic paralysis mainly depends on the etiology and severity of the paralysis. The main differentiation for treatment of these patients is based on the patency of the phrenic nerves. Patients whose phrenic nerves are intact may be considered for diaphragmatic pacing. The main treatment for all other patients is ventilatory support.

 Ventilatory support
  • Patients with bilateral diaphragmatic paralysis have progressive ventilatory failure. The therapeutic tool of choice for symptomatic patients is noninvasive positive-pressure ventilation. Overtime, as the symptoms worsen, patients with bilateral diaphragmatic paralysis have increased carbon dioxide retention leading to hypercapnic ventilatory failure.
  • 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.11 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 can identify this condition.
  • 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 with life-threatening disease or a diagnosis of high quadriplegia.
Diaphragmatic pacing
  • The phrenic nerve may be electrically stimulated to cause diaphragmatic contraction. Phrenic nerve pacing may be considered in patients who have intact phrenic nerve function and no evidence of myopathy. The ideal patient is one with high quadriplegia without intrinsic lung disease.
  • Data from centers with experience in this procedure show that approximately 50% of patients improve enough to discontinue ventilatory support.
  • Diaphragm pacing has historically been accomplished through placement of phrenic nerve electrodes via thoracotomy, which is an invasive and high-risk procedure in this subset of patients. Case reports have shown a shift to laparoscopic placement of intramuscular electrode at a lower cost and with less risk of injury to the phrenic nerve.12
  • Pacing can provide an alternative to intermittent positive-pressure ventilation (IPPV), but it has limited application based on (1) the need for tracheostomy as a result of the invariable development of upper airway obstruction and (2) the high cost. Its value is in freeing the individual from the encumbrance of a mechanical ventilator, thus increasing mobility.

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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  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].

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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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