History

Background information is of prime importance when considering dysfunction of the diaphragm. An adequate history is essential to help identify potential causes. Even so, an etiology for diaphragmatic dysfunction is not ascertained in 50%-60% of patients. Note the conditions discussed below.

Congenital hernias

Respiratory distress and/or cyanosis may occur within the first 24 hours of life. If the defect is small enough, patients often remain asymptomatic for years or even decades.

Traumatic rupture

The acute phase of a traumatic diaphragmatic rupture manifests with abdominal pain, concurrent intra-abdominal and intrathoracic injuries, respiratory distress, and cardiac dysfunction. Latent-phase symptoms include gastrointestinal complaints, pain in the left upper quadrant or chest, pain in the left shoulder, dyspnea, and orthopnea. The gastrointestinal obstructive phase manifests with nausea and vomiting with unrelenting abdominal pain, prostration, and respiratory distress.

The development of a ventral hernia is a relatively common complication of abdominal surgery. If large enough, a ventral abdominal hernia may lead to diaphragm dysfunction accompanied by complaints of dyspnea and platypnea. Because diaphragm dysfunction is more commonly associated with orthopnea and not platypnea, these symptoms can be misattributed to deconditioning or atelectasis.^[38]

Neurologic causes

Most patients with unilateral diaphragm dysfunction are asymptomatic, and they are generally found with incidental unilateral elevation of a hemidiaphragm on chest imaging.^[5]When symptoms are present, they include mild exertional dyspnea, generalized muscle fatigue, chest wall pain, and resting dyspnea while lying with the paralyzed side down or when the abdomen is submerged under water. Symptoms are generally more severe in patients with concomitant lung disease.

Bilateral dysfunction is more severe and manifests with shortness of breath, severe exertional dyspnea, poor sleep quality, and marked orthopnea.^[39]The orthopnea of bilateral diaphragmatic dysfunction is dramatic and occurs within minutes after assuming the recumbent position; it is caused by cephalad movement of the abdominal viscera against the weakened diaphragm. Orthopnea is associated with tachypnea and rapid, shallow breathing. Chest radiographs in patient with bilateral diaphragmatic disorder may be interpreted as “small lung volumes” or “poor inspiratory effort.”

Physical Examination

Physical findings upon examination in patients with diaphragm disorders vary depending on the etiology.

Congenital hernia findings include the following:

Right-sided heart
Decreased breath sounds on the affected side
Scaphoid abdomen
Auscultation of bowel sounds in the thorax

Traumatic diaphragmatic rupture findings include the following:

Marked respiratory distress
Decreased breath sounds on the affected side
Palpation of abdominal contents in the chest when inserting a chest tube
Auscultation of bowel sounds in the chest
Paradoxical movement of the abdomen with breathing

Neurologic findings include the following:

Decreased breath sounds
Generalized or focal neurologic deficits
Dullness on the lower chest upon percussion on the involved side
Decreased excursion of the involved hemithorax compared to the healthy side
Paralysis
Paradoxical abdominal wall retraction during inspiration (this is best appreciated in the supine position)
Hypoxemia, secondary to atelectasis-induced ventilation-perfusion mismatch, exacerbated in the supine position
Signs of cor pulmonale (occasionally present)

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Media Gallery

Diaphragm Disorders (Diaphragmatic dysfunction). Radiograph of a man who fell 45 ft from scaffolding, through plate glass windows, and onto the ground. Intraoperatively, he had a completely avulsed diaphragm on the left side. The patient subsequently recovered after a 45-day hospital course of treatment.
Diaphragm Disorders (Diaphragmatic dysfunction). Congenital diaphragmatic hernia is shown in this coronal obstetric ultrasound (the patient's head is to the right of the image; the thorax is center, and the abdomen is left). The stomach (st) and heart (hrt) are both within the thorax. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/File:Cdh0002.jpg), author Dr Laughlin Dawes.
Diaphragm Disorders (Diaphragmatic dysfunction). Sagittal computed tomography scan of the chest with intravenous contrast demonstrates a Morgagni hernia (red arrow) containing abdominal fat. Courtesy of Wikipedia (https://en.wikipedia.org/wiki/File:Morgagni_Hernia.PNG), author Jason Robert Young, MD.

of 3

Author

Garrett L Rampon, MD Fellow in Pulmonary and Critical Care Medicine, University of Kansas Health System

Garrett L Rampon, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Ravi P Nayak, MD, FCCP Professor of Internal Medicine, St Louis University School of Medicine; Interim Chairman, Department of Internal Medicine, James B and Ethel D Miller Endowed Chair in Internal Medicine, Director, Adult Cystic Fibrosis Program, Director, Division of Pulmonary, Critical Care and Sleep Medicine, Director, Pulmonary Disease and Critical Care Medicine Fellowship, Division of Pulmonary, Critical Care and Sleep Medicine, St Louis University Hospital

Ravi P Nayak, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Association of Physicians of India, Association of Pulmonary and Critical Care Medicine Program Directors, Pulmonary Hypertension Association, Society of Critical Care Medicine

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.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Anne T Saladyga, MD, Jason M Johnson, DO, Sidney R Steinberg, MD, FACS, and Abhijit A Raval, MD,to the development and writing of this article.