Preprocedural Planning
Patients with diaphragmatic paralysis are typically referred to a pulmonologist for complete workup and evaluation. All patients suspected of having diaphragmatic paralysis should undergo a chest radiograph and a Sniff test (a fluoroscopic chest radiograph taken during both inspiration and expiration). The Sniff test can assess whether or not the diaphragm is moving appropriately.
Computed tomography or magnetic resonance imaging is necessary to look for abnormalities in the cervical spinal cord, neck, and/or chest cavity, especially to eliminate the possibility of a neoplasm in proximity to the nerve in any of these anatomical locations.
Pulmonary function testing or lung spirometry should be performed when considering diaphragmatic plication. Diaphragmatic paralysis is usually associated with a mild-to-moderate restrictive deficit on spirometry testing, with a reduction in forced expiratory volume, forced vital capacity, and maximum voluntary ventilation.
Electrical studies of the phrenic nerve and diaphragm muscle function are helpful to determine the severity of the injury and likelihood of spontaneous recovery. A phrenic nerve conduction study and diaphragm electromyography assess both nerve and muscle function, respectively. Unfortunately, because of the rarity of the condition, there are few physicians that perform these tests regularly, so it may be difficult to get accurate results.
Monitoring & Follow-up
After diaphragm plication, patients remain in the hospital for wound and chest tube management. Postoperative chest radiographs are performed to confirm reexpansion of the lung and to evaluate the repositioned diaphragm. Patients are discharged from the hospital when their pain can be managed comfortably with oral narcotics and usually after the chest tubes have been removed.
Patients are followed on a regular basis for the first 6-8 weeks, or until full healing has occurred. Regular chest radiographs are obtained as needed. Most patients will follow up with their pulmonologist in the first 3-6 months postoperatively for repeat pulmonary function testing to assess for improvements in lung function.
