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Diaphragmatic Paralysis Workup

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

Laboratory Studies

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

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Imaging Studies

Chest radiography

This study reveals elevated hemidiaphragms, small lung volumes, and atelectasis.

In contrast to bilateral disease, physicians can usually diagnose unilateral paralysis with only radiographic studies.[8] (see the image below).

Acute unilateral left diaphragmatic paralysis in a 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 the image below).

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

In fluoroscopic sniff testing, paradoxical elevation of the paralyzed diaphragm is observed with inspiration and confirms diaphragmatic paralysis (see the image below).[9] However, the sniff test is not very specific; 6% of normal persons exhibit paradoxical motion on fluoroscopy.[4] Due to compensatory respiratory strategies, apparently normal decent of diaphragms may also be seen with sniff test in bilateral diaphragmatic paralysis.[3]

Fluoroscopy of elevated left hemidiaphragm in a pa 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

Computerized tomography may be indicated in certain patients to evaluate for potential causes of diaphragmatic paralysis that are due to mediastinal pathology and malignancy.

Magnetic resonance imaging of the neck

Magnetic resonance imaging 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 a relatively simple and accurate test for diagnosing paralysis of the diaphragm in the adult population and it can be performed at the bedside.

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.

Patients can be scanned in the anterior axillary line with a curved linear transducer probe angled cranially at a 90° angle to the diaphragm. In this view, the liver is used as a window on the right, while the spleen is used on the left.[10]

B-mode ultrasonography of diaphragm thickness in the zone of apposition of the diaphragm to the rib cage can also provide a sensitive and specific noninvasive assessment of diaphragmatic paralysis. Less than 20% thickening of the diaphragm muscle during inspiration is diagnostic of diaphragmatic paralysis.[3, 11]

Ultrasonography can also be used to serially monitor patients with diaphragmatic paralysis for recovery.[3]

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Other Tests

Pulmonary function testing and arterial blood gas analysis

Measuring the vital capacity in the upright and supine positions is the most important part of the pulmonary function test.

Diaphragmatic paralysis reduces the measured compliance of the lungs and a restrictive pattern can develop.

Normally, vital capacity in recumbency decreases by 10%. 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.

Pulmonary function test results, however, are not always consistent and do not always correlate with the severity of dyspnea from diaphragmatic paralysis.[4]

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.

Electromyography

Electromyography may reveal a neuropathic versus myopathic pattern, depending on the etiology. This can be accomplished by stimulation of the phrenic nerve at the neck.

Technical issues with electromyography include proper electrode placement to avoid “cross-talk” from adjacent muscles and variable results due to variable subcutaneous fat among individuals.[3]

Measurement of transdiaphragmatic pressure

This is the criterion standard for diagnosis.

The transdiaphragmatic pressure is measured 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 measure changes in intra-abdominal pressure. Gastric pressure should become more positive during inspiration. Esophageal pressure should become more negative during inspiration, demonstrating an increased in gradient during normal inspiration. In cases in which the sniff test is negative and clinical suspicion for diaphragmatic paralysis is still high, transdiaphragmatic pressure should be considered.

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.

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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.

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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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