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Bhende VV, Sharma TS, Krishnakumar M, Kumar A, Panesar G, Soni KA, Dhami KB, Patel MR, Sharma AS, Pathan SR, Majmudar HP. Hemi-Diaphragm Plication and/or Tracheostomy Are Valuable Adjunctive Procedures After Repair of Congenital Heart Defects in Children: A Systematic Review. Cureus 2023; 15:e48648. [PMID: 37954631 PMCID: PMC10638678 DOI: 10.7759/cureus.48648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 11/14/2023] Open
Abstract
Diaphragmatic paralysis (DP), whether unilateral or bilateral, often leads to extended recovery and more severe complications, particularly in neonates and infants undergoing congenital heart surgery. This condition's impact is most pronounced after single-ventricle palliative procedures. Tracheostomy prevalence is rising in pediatric patients with congenital heart disease (CHD) despite its association with high resource utilization and in-hospital mortality. This study examines the reported incidence of diaphragmatic paralysis and timing of tracheostomy in pediatric patients undergoing surgery for congenital heart disease in the literature and a retrospective analysis of cases in our institution between 2018 and 2023, offering insights for prospective management. An electronic search of PubMed databases retrieved 10 studies on pediatric tracheostomy and 11 studies on DP. Our retrospective analysis included 15 patients, of whom 10 underwent tracheostomy, four underwent diaphragmatic plication, and one underwent both. Postoperative tracheostomy had an 11.8% mortality rate in our systematic review, rising to 40% in our observational study. Diaphragm repair and early diagnosis can reduce morbidity, prevent complications, and improve patients' quality of life.
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Affiliation(s)
- Vishal V Bhende
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Tanishq S Sharma
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
- Community Medicine, SAL Institute of Medical Sciences, Ahmedabad, IND
| | | | - Amit Kumar
- Pediatric Cardiac Intensive Care, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Gurpreet Panesar
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Kunal A Soni
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Kartik B Dhami
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Mamta R Patel
- Central Research Services, Bhaikaka University, Karamsad, IND
| | - Ashwin S Sharma
- Internal Medicine, Gujarat Cancer Society Medical College, Hospital and Research Centre, Ahmedabad, IND
| | - Sohilkhan R Pathan
- Clinical Research Services, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Hardil P Majmudar
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
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Parmar D, Panchal J, Parmar N, Garg P, Mishra A, Surti J, Patel K. Early diagnosis of diaphragm palsy after pediatric cardiac surgery and outcome after diaphragm plication - A single-center experience. Ann Pediatr Cardiol 2021; 14:178-186. [PMID: 34103857 PMCID: PMC8174623 DOI: 10.4103/apc.apc_171_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/17/2020] [Accepted: 11/27/2020] [Indexed: 11/24/2022] Open
Abstract
Objective : The aims of our prospective observational study were to evaluate the (1) reliability of clinical signs in the early detection of diaphragm palsy (DP); (2) reliability of ultrasonography using echo machine as a bedside tool for the diagnosis of DP; and (3) does early diaphragm plication result in the improved outcome? We also sought to determine the incidence and predominant risk factors for DP and diaphragm plication at our center. Materials and Methods : This prospective observational study included patients with suspected DP from January 2015 to December 2018. Patients with suspected DP were initially evaluated by bedside ultrasonography using echo machine and confirmed by fluoroscopy. Diaphragm plication was considered for patients having respiratory distress, difficult weaning, or failed extubation attempt without any obvious cardiac or pulmonary etiology. Patients were followed for 3 months after discharge to assess diaphragm function. Results: A total of 87 patients were suspected of DP based on clinical signs. DP was diagnosed in 61 patients on fluoroscopy. The median time from index operation to diagnosis was 10 (1–59) days. Diaphragm plication was done among 52 patients and not done in nine patients. Bedside ultrasonography using echo machine was 96.7% sensitive and 96.15% specific in diagnosing DP. Early plication (<14 days) significantly reduced the need for nasal continuous positive airway pressure (65% vs. 96%, P = 0.02), duration of mechanical ventilation (12 vs. 25 days, P = 0.018), intensive care unit (ICU) stay (25 days vs. 39 days, P = 0.019), and hospital stay (30 days vs. 46 days, P = 0.036). Conclusion : Hoover's sign and raised hemidiaphragm on chest X-ray are the most specific clinical signs to suspect unilateral DP. Bedside ultrasonography using an echo machine is a good diagnostic investigation comparable to fluoroscopy. Early plication facilitates weaning from the ventilator and thereby decreases the ICU stay and hospital stay.
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Affiliation(s)
- Divyakant Parmar
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Panchal
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Neha Parmar
- Department of Physiotherapy, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Amit Mishra
- Department of Pediatric Cardiac Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Surti
- Department Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Kartik Patel
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
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Gerard-Castaing N, Perrin T, Ohlmann C, Mainguy C, Coutier L, Buchs C, Reix P. Diaphragmatic paralysis in young children: A literature review. Pediatr Pulmonol 2019; 54:1367-1373. [PMID: 31211516 DOI: 10.1002/ppul.24383] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 04/18/2019] [Accepted: 05/10/2019] [Indexed: 11/11/2022]
Abstract
Diaphragmatic paralysis (DP) is a rare cause of respiratory distress in young children. In the first years of life, the main cause is phrenic nerve injury after cardiothoracic surgery or obstetrical trauma. DP usually presents as respiratory distress. Asymmetrical thorax elevation, difficulty weaning from mechanical ventilation, pulmonary atelectasis, and repeated pulmonary infections are other suggestive signs or complications. DP is usually suspected on chest X-ray showing abnormal hemidiaphragm elevation. Although fluoroscopy was considered the gold standard for DP confirmation, it has gradually been replaced by ultrasound, which can be done at the bedside. Some electrophysiological tools may be useful for a better characterization of phrenic nerve injury and chance of recovery. The management of DP is mainly based on clinical severity. In mild asymptomatic cases, DP may only require close monitoring. In more severe cases, adequate ventilatory support and/or surgical diaphragmatic plication may be needed. Electrophysiological tools may help clinicians assess the ideal timing for diaphragmatic plication.
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Affiliation(s)
- Nathalie Gerard-Castaing
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Thomas Perrin
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Camille Ohlmann
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Catherine Mainguy
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Laurianne Coutier
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Clelia Buchs
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Philippe Reix
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.,UMR 5558 (EMET), CNRS, LBBE Université Claude Bernard Lyon 1, Université de Lyon, Villeurbanne, France
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4
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Al-Hanshi SAM, Al-Ghafri MHR. Bilateral Diaphragmatic Paralysis Following Paediatric Cardiac Surgery: Experience of four cases at the Royal Hospital, Muscat, Oman. Sultan Qaboos Univ Med J 2017; 17:e334-e338. [PMID: 29062558 DOI: 10.18295/squmj.2017.17.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/19/2017] [Accepted: 04/17/2017] [Indexed: 11/16/2022] Open
Abstract
Bilateral diaphragmatic paralysis (BDP) is a rare complication of paediatric cardiac surgery. We report four children who developed BDP following cardiac surgery who were managed at the Royal Hospital, Muscat, Oman, between 2009 and 2014. All four children suffered severe respiratory distress soon after extubation and required re-intubation within two hours. In addition, all of the children underwent a tracheostomy as an interim method for ventilation. The four children were successfully weaned from positive pressure ventilation following the functional recovery of at least one side of the diaphragm.
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Olmscheid J, Molero H, Gershan W, Demirel N. Bilateral diaphragmatic paresis following pediatric liver transplantation. SAGE Open Med Case Rep 2017; 5:2050313X17719214. [PMID: 28781878 PMCID: PMC5521332 DOI: 10.1177/2050313x17719214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 06/02/2017] [Indexed: 12/04/2022] Open
Abstract
Background: Although diaphragm paresis or paralysis is fairly common following cardiac procedures; it is a less common complication following liver transplantation. Unilateral diaphragm paresis, usually right sided, has been described following liver transplantation in adults and has been rarely described in children. Purpose: Diaphragmatic injury following LT is often unrecognized and is typically unilateral, involving the right hemidiaphragm. Bilateral diaphragm dysfunction following liver transplantation in children is a rare complication. Methods: This is a case report of bilateral diaphragm paresis in a young child following a repeat liver transplantation. Conclusion: Bilateral diaphragm paresis following liver transplantation in children is rare and spontaneous resolution is possible. A conservative approach with noninvasive ventilation as a first line treatment to allow the diaphragm to regain function should be considered.
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Affiliation(s)
- Jillian Olmscheid
- Midwestern University, Glendale, AZ, USA.,Arizona College of Osteopathic Medicine, Glendale, AZ, USA
| | - Helena Molero
- Division of Pediatric Pulmonology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - William Gershan
- Division of Pediatric Pulmonology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Nadir Demirel
- Division of Pediatric Pulmonology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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6
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Abstract
Diaphragmatic paralysis following phrenic nerve injury is a major complication following congenital cardiac surgery. In contrast to unilateral paralysis, patients with bilateral diaphragmatic paralysis present a higher risk group, require different management methods, and have poorer prognosis. We retrospectively analysed seven patients who had bilateral diaphragmatic paralysis following congenital heart surgery during the period from July, 2006 to July, 2014. Considerations were given to the time to diagnosis of diaphragm paralysis, total ventilator days, interval after plication, and lengths of ICU and hospital stays. The incidence of bilateral diaphragmatic paralysis was 0.68% with a median age of 2 months (0.6-12 months). There was one neonate and six infants with a median weight of 4 kg (3-7 kg); five patients underwent unilateral plication of the paradoxical diaphragm following recovery of the other side, whereas the remaining two patients who did not demonstrate a paradoxical movement were successfully weaned from the ventilator following recovery of function in one of the diaphragms. The median ventilation time for the whole group was 48 days (20-90 days). The median length of ICU stay was 46 days (24-110 days), and the median length of hospital stay was 50 days (30-116 days). None of the patients required tracheostomy for respiratory support and there were no mortalities, although all the patients except one developed ventilator-associated pneumonia. The outcome of different management options for bilateral diaphragmatic paralysis following surgery for CHD is discussed.
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7
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Tabata Y, Matsui H, Sakamoto T, Noguchi M. Bilateral diaphragm paralysis after simultaneous cardiac surgery and Nuss procedure in the infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2014.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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8
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Rombolá CA, Genovés Crespo M, Tárraga López PJ, García Jiménez MD, Honguero Martínez AF, León Atance P, Rodríguez Ortega CR, Triviño Ramírez A, Rodríguez Montes JA. Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey. Cir Esp 2014; 92:453-62. [PMID: 24602484 DOI: 10.1016/j.ciresp.2013.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 12/04/2013] [Accepted: 12/05/2013] [Indexed: 02/01/2023]
Abstract
Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field. To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases. Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach. We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.
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Affiliation(s)
- Carlos A Rombolá
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España.
| | - Marta Genovés Crespo
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | | | | | - Pablo León Atance
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | | | - Ana Triviño Ramírez
- Servicio de Cirugía Torácica, Complejo Hospitalario Universitario de Albacete, Albacete, España
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9
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Mead AF, Petrov M, Malik AS, Mitchell MA, Childers MK, Bogan JR, Seidner G, Kornegay JN, Stedman HH. Diaphragm remodeling and compensatory respiratory mechanics in a canine model of Duchenne muscular dystrophy. J Appl Physiol (1985) 2014; 116:807-15. [PMID: 24408990 DOI: 10.1152/japplphysiol.00833.2013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ventilatory insufficiency remains the leading cause of death and late stage morbidity in Duchenne muscular dystrophy (DMD). To address critical gaps in our knowledge of the pathobiology of respiratory functional decline, we used an integrative approach to study respiratory mechanics in a translational model of DMD. In studies of individual dogs with the Golden Retriever muscular dystrophy (GRMD) mutation, we found evidence of rapidly progressive loss of ventilatory capacity in association with dramatic morphometric remodeling of the diaphragm. Within the first year of life, the mechanics of breathing at rest, and especially during pharmacological stimulation of respiratory control pathways in the carotid bodies, shift such that the primary role of the diaphragm becomes the passive elastic storage of energy transferred from abdominal wall muscles, thereby permitting the expiratory musculature to share in the generation of inspiratory pressure and flow. In the diaphragm, this physiological shift is associated with the loss of sarcomeres in series (∼ 60%) and an increase in muscle stiffness (∼ 900%) compared with those of the nondystrophic diaphragm, as studied during perfusion ex vivo. In addition to providing much needed endpoint measures for assessing the efficacy of therapeutics, we expect these findings to be a starting point for a more precise understanding of respiratory failure in DMD.
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Affiliation(s)
- A F Mead
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Hsu KH, Chiang MC, Lien R, Chu JJ, Chang YS, Chu SM, Wong KS, Yang PH. Diaphragmatic paralysis among very low birth weight infants following ligation for patent ductus arteriosus. Eur J Pediatr 2012; 171:1639-44. [PMID: 22763604 DOI: 10.1007/s00431-012-1787-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Accepted: 06/19/2012] [Indexed: 11/30/2022]
Abstract
Management of diaphragmatic paralysis (DP) among newborn infants remains controversial, especially for very low birth weight (VLBW) infants following ligation for patent ductus arteriosus (PDA). This study aimed to characterize the impact of DP after PDA ligation among VLBW infants. Clinical characteristics of DP cases treated with either diaphragmatic plication or conservative methods were described as well. The medical records of VLBW infants who underwent PDA ligation in Chang Gung Memorial Hospital between January 2000 and December 2011 were retrospectively reviewed, and DP was suspected if postligation chest X-rays showed an elevation of the left diaphragm as confirmed by a chest ultrasonograph. For each DP case, three other infants that received PDA ligation with proximate birth dates and who were closely matched in terms of gestational age (±1 week) and birth weight (±10 %) were selected as the control group. A total of eight preterm infants were diagnosed as having DP and 24 infants were selected as the control group. The affected infants usually presented with respiratory distress and extubation failure. The study demonstrated that, among our patient population, DP was associated with a significantly longer duration of ventilator dependency (56.1 ± 16.0 vs. 29.8 ± 17.7 days, p = 0.001) and a higher incidence of severe bronchopulmonary dysplasia (87.5 vs. 23 %, p = 0.002). For selective infants with DP-related ventilatory failure after PDA ligation, surgical plication may facilitate extubation. Diaphragmatic paralysis should be evaluated carefully among VLBW infants receiving PDA ligation because of its adverse impact on ventilator dependency and correlation to a higher incidence of severe bronchopulmonary dysplasia.
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Affiliation(s)
- Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, 12th Fl., Bldg. L, 5-7 Fu-Shin Street, Gueishan, Taoyuan 33305, Taiwan
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11
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Liet JM, Dejode JM, Joram N, Gaillard Le Roux B, Péréon Y. Bedside diagnosis of bilateral diaphragmatic paralysis. Intensive Care Med 2012; 39:335. [DOI: 10.1007/s00134-012-2729-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
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12
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Talwar S, Agarwala S, Mittal CM, Choudhary SK, Airan B. Diaphragmatic palsy after cardiac surgical procedures in patients with congenital heart. Ann Pediatr Cardiol 2011; 3:50-7. [PMID: 20814476 PMCID: PMC2921518 DOI: 10.4103/0974-2069.64370] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Paralysis of diaphragm on one or, exceptionally, both sides is a common cause of delayed recovery and excessive morbidity following pediatric cardiac surgery. The consequences of this complication after all forms of congenital heart surgery in newborns and young infants can be potentially serious. The impact of diaphragmatic palsy on the physiology after single ventricle palliations is particularly significant. It is necessary for all professionals taking care of children with heart disease to be familiar with the etiology, diagnosis, and management of this condition. Early recognition and prompt management of diaphragmatic palsy can potentially reduce the duration of mechanical ventilation and intensive care in those who develop this complication. This review summarizes the anatomy of the phrenic nerves, reasons behind the occurrence of diaphragmatic palsy, and suggests practical guidelines for management.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre and Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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13
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Le Pimpec-Barthes F, Brian E, Vlas C, Gonzalez-Bermejo J, Bagan P, Badia A, Riquet M, Similowski T. [Surgical treatment of diaphragmatic eventrations and paralyses]. Rev Mal Respir 2010; 27:565-78. [PMID: 20610072 DOI: 10.1016/j.rmr.2010.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 01/03/2010] [Indexed: 11/26/2022]
Abstract
Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.
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Affiliation(s)
- F Le Pimpec-Barthes
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75908 Paris cedex 15, France
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14
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Ross Russell RI, Helms PJ, Elliott MJ. A prospective study of phrenic nerve damage after cardiac surgery in children. Intensive Care Med 2008; 34:728-34. [DOI: 10.1007/s00134-007-0977-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2007] [Accepted: 09/02/2007] [Indexed: 09/29/2022]
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15
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Bibliography. Current world literature. Cardiovascular medicine. Curr Opin Pediatr 2007; 19:601-6. [PMID: 17885483 DOI: 10.1097/mop.0b013e3282f12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Lemmer J, Stiller B, Heise G, Alexi-Meskishvili V, Hübler M, Weng Y, Berger F. Mid-term follow-up in patients with diaphragmatic plication after surgery for congenital heart disease. Intensive Care Med 2007; 33:1985-92. [PMID: 17554521 DOI: 10.1007/s00134-007-0717-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Accepted: 04/06/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Diaphragmatic palsy (DP) is a rare but severe complication after surgery for congenital heart disease. Transthoracic diaphragmatic plication is an effective means of treatment for those with respiratory impairment due to DP, but little is known about the mid-term effects of diaphragmatic plication. DESIGN We performed a study in 24 patients with history of DP. Diaphragm movement was assessed using ultrasound. Patients with DP who were old enough were additionally followed-up with lung function and exercise testing. A group of patients with similar age, diagnoses and operations served as controls. RESULTS Ultrasound showed that in the majority of cases with history of DP the paralysed diaphragm was static, independently of whether it was plicated or not. Patients with DP had a more restrictive lung function pattern (VC: 54.3 vs. 76.4% predicted, p<0.001; FEV(1): 58.4 vs. 86.2% predicted, p<0.001) and a lower exercise capacity compared with the control group (peak VO2: 24.5 vs. 31.3 ml/kg/min, p=0.03). Comparing patients with and without plication for DP, only a tendency towards lower lung function values in patients after diaphragmatic plication, but no differences regarding exercise capacity, could be found. CONCLUSIONS Our results provide evidence that DP is a serious surgical complication with a reduction in lung function and exercise capacity, even at mid-term follow-up; however, diaphragmatic plication, a useful tool in treating post-surgical DP in children with respiratory impairment, seems to be without mid-term risk in terms of recovery of phrenic nerve function, lung function values, and exercise capacity.
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Affiliation(s)
- Julia Lemmer
- Department of Congenital Heart Disease, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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17
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, De Backer D, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Macrae D, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C. Year in Review in Intensive Care Medicine, 2006. III. Circulation, ethics, cancer, outcome, education, nutrition, and pediatric and neonatal critical care. Intensive Care Med 2007; 33:414-22. [PMID: 17325834 DOI: 10.1007/s00134-007-0553-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 01/08/2023]
Affiliation(s)
- Peter Andrews
- Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK
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Ross Russell RI. C 3, 4 and 5, keep the diaphragm alive. Intensive Care Med 2006; 32:1109-11. [PMID: 16741695 DOI: 10.1007/s00134-006-0209-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2006] [Accepted: 04/26/2006] [Indexed: 11/26/2022]
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