Semin Respir Crit Care Med 2009; 30(3): 315-320
DOI: 10.1055/s-0029-1222445
© Thieme Medical Publishers

Diaphragm Paralysis

Asher Qureshi1
  • 1Department of Medicine, St. Francis Hospital and Medical Center, Hartford, Connecticut
Further Information

Publication History

Publication Date:
18 May 2009 (online)

ABSTRACT

The diaphragm is a chief muscle of inspiration. Its paralysis can lead to dyspnea and can affect ventilatory function. Diaphragmatic paralysis can be unilateral or bilateral. The clinical symptoms are more prominent in bilateral diaphragm paralysis. Ventilatory failure and cor pulmonale are usually seen in severe cases. Although an uncommon cause of dyspnea it still remains an underdiagnosed condition. A restrictive process is seen on pulmonary function tests in diaphragm paralysis. The symptoms, oxygenation and vital capacity, usually worsen in supine posture. The diagnoses is usually suspected on chest x-ray and clinical exam and confirmed with sniff test or phrenic nerve stimulation/diaphragm electromyography. In most unilateral cases no treatment is needed, especially in the absence of underlying lung disease. In more severe cases modalities such as diaphragmatic pacing or plication of the diaphragm can be used. In bilateral diaphragm paralysis or in patients with ventilatory failure continuous positive airway pressure or mechanical ventilation and tracheostomy are generally needed. Prognosis is good in unilateral paralysis, especially in the absence of underlying neurological or pulmonary process. Prognosis is usually poor in patients with advanced lung disease, bilateral paralysis, and chronic demyelinating conditions.

REFERENCES

  • 1 Aldrich T K, Tso R. The lungs and neuromuscular disease. In: Mason RJ, Broaddus VC, Murray JF, Nadel JA Murray and Nadel's Textbook of Respiratory Medicine. 4th ed. Philadelphia; Elsevier Saunders 2005: 2287-2290
  • 2 Moore K L, Dalley A F. Clinically Oriented Anatomy. 5th ed. Philadelphia; Lippincott Williams and Wilkins 2006: 325-330
  • 3 Dimopoulou I, Daganou M, Dafni U et al.. Phrenic nerve dysfunction after cardiac operations: electrophysiologic evaluation of risk factors.  Chest. 1998;  113 8-14
  • 4 Olopade C O, Staats B A. Time course of recovery from frostbitten phrenics after coronary artery bypass graft surgery.  Chest. 1991;  99 1112-1115
  • 5 Dorffner R, Eibenberger K, Youssefzadeh S. Diaphragmatic dysfunction after heart or lung transplantation.  J Heart Lung Transplant. 1997;  16 566-569
  • 6 Akay T H, Ozkan S, Gultekin B et al.. Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management.  Pediatr Surg Int. 2006;  22 341-346
  • 7 Schram D J, Vosik W, Cantral D. Diaphragmatic paralysis following cervical chiropractic manipulation: case report and review.  Chest. 2001;  119 638-640
  • 8 McCaul J A, Hislop W S. Transient hemi-diaphragmatic paralysis following neck surgery: report of a case and review of the literature.  J R Coll Surg Edinb. 2001;  46 186-188
  • 9 Vest J V, Pereira M B, Senior R M. Phrenic nerve injury associated with venipuncture of the internal jugular vein.  Chest. 1980;  78 777-779
  • 10 Aldrich T K, Herman J H, Rochester D F. Bilateral diaphragmatic paralysis in the newborn infant.  J Pediatr. 1980;  97 988-991
  • 11 Swallow E B, Dayer M J, Oldfield W L, Moxham J, Polkey M I. Right hemi-diaphragm paralysis following cardiac radiofrequency ablation.  Respir Med. 2006;  100 1657-1659
  • 12 Hayashi H, Kihara S, Hoshimaru M, Hashimoto N. Diaphragmatic paralysis caused by cervical spondylosis: case report.  J Neurosurg Spine. 2005;  2 604-607
  • 13 Hassoun P M, Celli B R. Bilateral diaphragm paralysis secondary to central von Recklinghausen's disease.  Chest. 2000;  117 1196-1200
  • 14 Teixeira A, Cherin P, Demoule A et al.. Diaphragmatic dysfunction in patients with idiopathic inflammatory myopathies.  Neuromuscul Disord. 2005;  15 32-39
  • 15 Abbott R A, Hammans S, Margarson M, Aji B M. Diaphragmatic paralysis and respiratory failure as a complication of Lyme disease.  J Neurol Neurosurg Psychiatry. 2005;  76 1306-1307
  • 16 Berk J L, Wiesman J F, Skinner M, Sanchorawala V. Diaphragm paralysis in primary systemic amyloidosis.  Amyloid. 2005;  12 193-196
  • 17 Panda N B, Yaddanapudi S, Bharadwaj N, Das C, Chari P. Phrenic nerve palsy in severe tetanus.  Anaesth Intensive Care. 2004;  32 271-274
  • 18 Betensley A D, Jaffery S H, Collins H, Sripathi N, Alabi F. Bilateral diaphragmatic paralysis and related respiratory complications in a patient with West Nile virus infection.  Thorax. 2004;  59 268-269
  • 19 Piliero P J, Estanislao L, Simpson D. Diaphragmatic paralysis due to isolated phrenic neuropathy in an HIV-infected man.  Neurology. 2004;  62 154-155
  • 20 Sivak E D, Salanga V D, Wilbourn A J et al.. Adult onset acid maltase deficiency presenting as diaphragmatic paralysis.  Ann Neurol. 1981;  9 613-615
  • 21 Piehler J M, Pairolero P C, Gracey D R, Bernatz P E. Unexplained diaphragmatic paralysis: a harbinger of malignant disease?.  J Thorac Cardiovasc Surg. 1982;  84 861-864
  • 22 Hart N, Nickol A H, Cramer D et al.. Effect of severe isolated unilateral and bilateral diaphragm weakness on exercise performance.  Am J Respir Crit Care Med. 2002;  165 1265-1270
  • 23 Elefteriades J, Singh M, Tang P et al.. Unilateral diaphragm paralysis: etiology, impact, and natural history.  J Cardiovasc Surg (Torino). 2008;  49 289-295
  • 24 Kumar N, Folger W N, Bolton C F. Dyspnea as the predominant manifestation of bilateral phrenic neuropathy.  Mayo Clin Proc. 2004;  79 1563-1565
  • 25 Skatrud J, Iber C, McHugh W, Rasmussen H, Nichols D. Determinants of hypoventilation during wakefulness and sleep in diaphragmatic paralysis.  Am Rev Respir Dis. 1980;  121 587-593
  • 26 Allen S M, Hunt B, Green M. Fall in vital capacity with posture.  Br J Dis Chest. 1985;  79 267-271
  • 27 Fromageot C, Lofaso F, Annane D et al.. Supine fall in lung volumes in the assessment of diaphragmatic weakness in neuromuscular disorders.  Arch Phys Med Rehabil. 2001;  82 123-128
  • 28 Chetta A, Rehman A K, Moxham J, Carr D H, Polkey M I. Chest radiography cannot predict diaphragm function.  Respir Med. 2005;  99 39-44
  • 29 Lloyd T, Tang Y M, Benson M D, King S. Diaphragmatic paralysis: the use of M mode ultrasound for diagnosis in adults.  Spinal Cord. 2006;  44 505-508
  • 30 Epelman M, Navarro O M, Daneman A, Miller S F. M-mode sonography of diaphragmatic motion: description of technique and experience in 278 pediatric patients.  Pediatr Radiol. 2005;  35 661-667
  • 31 Summerhill E M, El-Sameed Y A, Glidden T J, McCool F D. Monitoring recovery from diaphragm paralysis with ultrasound.  Chest. 2008;  133 737-743
  • 32 Taylor A M, Jhooti P, Keegan J, Simonds A K, Pennell D J. Magnetic resonance navigator echo diaphragm monitoring in patients with suspected diaphragm paralysis.  J Magn Reson Imaging. 1999;  9 69-74
  • 33 Strakowski J A, Pease W S, Johnson E W. Phrenic nerve stimulation in the evaluation of ventilator-dependent individuals with C4- and C5-level spinal cord injury.  Am J Phys Med Rehabil. 2007;  86 153-157
  • 34 Luo Y M, Harris M L, Lyall R A, Watson A, Polkey M I, Moxham J. Assessment of diaphragm paralysis with oesophageal electromyography and unilateral magnetic phrenic nerve stimulation.  Eur Respir J. 2000;  15 596-599
  • 35 Versteegh M I, Braun J, Voigt P G et al.. 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;  32 449-456
  • 36 Lemmer J, Stiller B, Heise G et al.. Mid-term follow-up in patients with diaphragmatic plication after surgery for congenital heart disease.  Intensive Care Med. 2007;  33 1985-1992
  • 37 Joho-Arreola A L, Bauersfeld U, Stauffer U G, Baenziger O, Bernet V. Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children.  Eur J Cardiothorac Surg. 2005;  27 53-57
  • 38 Freeman R K, Wozniak T C, Fitzgerald E B. Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis.  Ann Thorac Surg. 2006;  81 1853-1857 discussion 1857
  • 39 Simansky D A, Paley M, Refaely Y, Yellin A. Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients.  Thorax. 2002;  57 613-616
  • 40 DiMarco A F, Onders R P, Ignagni A, Kowalski K E. Inspiratory muscle pacing in spinal cord injury: case report and clinical commentary.  J Spinal Cord Med. 2006;  29 95-108
  • 41 DiMarco A F, Onders R P, Ignagni A, Kowalski K E, Mortimer J T. Phrenic nerve pacing via intramuscular diaphragm electrodes in tetraplegic subjects.  Chest. 2005;  127 671-678
  • 42 Onders R P, Dimarco A F, Ignagni A R, Aiyar H, Mortimer J T. Mapping the phrenic nerve motor point: the key to a successful laparoscopic diaphragm pacing system in the first human series.  Surgery. 2004;  136 819-826
  • 43 Krieger L M, Krieger A J. The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury.  Plast Reconstr Surg. 2000;  105 1255-1261
  • 44 Hoch B, Zschocke A, Barth H, Leonhardt A. Bilateral diaphragmatic paralysis after cardiac surgery: ventilatory assistance by nasal mask continuous positive airway pressure.  Pediatr Cardiol. 2001;  22 77-79
  • 45 Tokuda Y, Matsumoto M, Sugita T, Nishizawa J. Nasal mask bilevel positive airway pressure ventilation for diaphragmatic paralysis after pediatric open-heart surgery.  Pediatr Cardiol. 2004;  25 552-553
  • 46 Bach J R, Alba A S. Management of chronic alveolar hypoventilation by nasal ventilation.  Chest. 1990;  97 52-57
  • 47 Abd A G, Braun N MT, Baskin M I, O'Sullivan M M, Alkaitis D A. Diaphragmatic dysfunction after open heart surgery: treatment with a rocking bed.  Ann Intern Med. 1989;  111 881-886
  • 48 Dernaika T A, Younis W G, Carlile P V. Spontaneous recovery in idiopathic unilateral diaphragmatic paralysis.  Respir Care. 2008;  53 351-354
  • 49 Gayan-Ramirez G, Gosselin N, Troosters T, Bruyninckx F, Gosselink R, Decramer M. Functional recovery of diaphragm paralysis: a long-term follow-up study.  Respir Med. 2008;  102 690-698

Asher QureshiM.D. 

Department of Medicine, St. Francis Hospital and Medical Center

114 Woodland St., Hartford, CT 06105

Email: aqureshi@stfranciscare.org