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Lamb CD, Schupper AJ, Quinones A, Zhang JY, Steinberger J, Margetis K. Cervical Spine Stenosis Causing Diaphragmatic Paralysis: A Case Study and Narrative Review of Clinical Presentations and Outcomes. Clin Spine Surg 2024; 37:245-251. [PMID: 38419161 DOI: 10.1097/bsd.0000000000001588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
STUDY DESIGN Case report and narrative review. OBJECTIVE To explore the therapeutic role of surgical and nonsurgical treatment of diaphragmatic paralysis secondary to spinal cord and nerve root compression. SUMMARY OF BACKGROUND DATA Phrenic nerve dysfunction due to central or neuroforaminal stenosis is a rare yet unappreciated etiology of diaphragmatic paralysis and chronic dyspnea. Surgical spine decompression, diaphragmatic pacing, and intensive physiotherapy are potential treatment options with varying degrees of evidence. METHODS The case of a 70-year-old male with progressive dyspnea, reduced hemi-diaphragmatic excursion, and C3-C7 stenosis, who underwent a microscopic foraminotomy is discussed. Literature review (MEDLINE, PubMed, Google Scholar) identified 19 similar reports and discussed alternative treatments and outcomes. RESULTS AND CONCLUSIONS Phrenic nerve root decompression and improvement in neuromonitoring signals were observed intraoperatively. The patient's postoperative course was uncomplicated, and after 15 months, he experienced significant symptomatic improvement and minor improvement in hemi-diaphragmatic paralysis and pulmonary function tests. All case reports of patients treated with spinal decompression showed symptomatic and/or functional improvement, while one of the 2 patients treated with physiotherapy showed improvement. More studies are needed to further describe the course and outcomes of these interventions, but early identification and spinal decompression can be an effective treatment. OCEBM LEVEL OF EVIDENCE Level-4.
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Affiliation(s)
- Colin D Lamb
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
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Joseph KR, Wong TS, Singh J, Orde S, Oborska Y, Mayorchak Y. Single port thoracoscopic diaphragm plication: A novel treatment approach to bilateral phrenic nerve palsy and diaphragm paralysis. Int J Surg Case Rep 2023; 108:108387. [PMID: 37329609 PMCID: PMC10382738 DOI: 10.1016/j.ijscr.2023.108387] [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: 04/17/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/19/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The diaphragm is the primary muscle of respiration. Bilateral paralysis of the diaphragm due to phrenic nerve palsy causes severe dyspnoea and is life threatening. Diaphragmatic Plication has shown great promise in treating diaphragm paralysis and has evolved as operative treatment from an open thoracotomy to multiport and robotic video assisted thoracoscopic surgery. CASE PRESENTATION Here we present a case of idiopathic bilateral diaphragm paralysis resulting significant deterioration in lung function tests, supplemental oxygen, and ventilator dependence. The patient was treated with a 2-stage operative plication of each hemidiaphragm through a 2.5 cm single incision thoracoscopic technique, which resulted in normalization of lung function tests, elimination of oxygen dependence and negligible analgesia requirements. CASE DISCUSSION This is the first case reported in the literature of a single port VATS plication of the diaphragm for the treatment of bilateral phrenic nerve palsy. Surgery, specifically diaphragm plication, is indicated for patients with significant symptoms and persistent paralysis. Video-assisted thoracoscopic surgery (VATS) has evolved from open operations to smaller incisions, offering improved lung function, postoperative pain, hospital stay, morbidity, and mortality. CONCLUSION Single port diaphragmatic plication is a novel approach to the treatment of bilateral phrenic nerve palsy. We make the case for indication of the technique for treatment of diaphragmatic paralysis.
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Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Fluorographic findings of diaphragmatic paralysis with spontaneous recovery. Pediatr Int 2021; 63:895-902. [PMID: 33205590 DOI: 10.1111/ped.14548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/31/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Postoperative diaphragmatic paralysis is an unavoidable complication of cardiovascular surgery. Although diaphragmatic plication, as a surgical treatment, can be performed, spontaneous recovery is possible. We aimed to identify differences in fluorographic findings of diaphragmatic paralysis between pediatric patients with and without spontaneous recovery within 1 year of intrathoracic surgery. METHODS Ten children, who had been followed-up for at least 1 year post-surgery and who had not received diaphragmatic plication were included and classified into those with or without spontaneous recovery. The presence or absence of the paradoxical movement of the diaphragm and mediastinum was evaluated based on fluorographic findings. Fisher's exact test was used to compare the presence or absence of paradoxical movement between the groups. RESULTS Eight patients experienced spontaneous recovery. The mean ± standard deviation time to spontaneous recovery was 150 ± 114 days (range, 18-338 days). In the spontaneous recovery group, no patient had paradoxical movement of the mediastinum, and a significant between-group difference was observed in the presence of the paradoxical movement of the mediastinum (present/absent in patients with vs. without spontaneous recovery: 0/8 vs. 2/0, P = 0.02). There was no significant between-group difference in paradoxical movement of the diaphragm (present/absent in patients with vs. without spontaneous recovery: 1/7 vs. 2/0, P = 0.07). Pediatric patients without paradoxical movement of the mediastinum spontaneously recovered within 1 year of intrathoracic surgery. CONCLUSIONS Pediatric patients without paradoxical movement of the mediastinum, based on fluorography findings, spontaneously recovered within 1 year of surgery. The timing of spontaneous recovery varied between cases.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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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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Baird JS, Spiegelman JB, Prianti R, Frudak S, Schleien CL. Noninvasive ventilation during pediatric interhospital ground transport. PREHOSP EMERG CARE 2010; 13:198-202. [PMID: 19291557 DOI: 10.1080/10903120802706112] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We report our use of noninvasive ventilation (NIV) during pediatric interhospital ground transport. METHODS We retrospectively reviewed transport and hospital records for nonneonatal patients <or= 18 years old transferred into or out of our children's hospital between January 2005 and June 2006 while receiving continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). Transport paramedics have extensive experience and supplemental training in NIV and advanced pediatric airway skills. RESULTS NIV was used during 31 transports of 25 patients (CPAP: 18 transports for 16 patients; BiPAP: 13 transports for nine patients). Nine patients (36%) were NIV-dependent prior to transport. Diagnoses included neurologic disease (n = 10), pulmonary disease (n = 10), congenital heart disease (n = 4), and other (n = 1). Oxygen saturation (SpO(2)) improved to or remained greater than 93% during all transports. Neither tracheal intubation nor cardiopulmonary resuscitation was required during or for one hour following any transport-though airway suctioning and/or bag-valve-mask ventilation was required during eight of 31 (26%) transports. Six of 17 patients transferred into our hospital while receiving NIV required tracheal intubation at three to 84 hours after transport; none of these patients developed aspiration pneumonia. CONCLUSIONS Though the use of NIV during pediatric interhospital ground transports was not associated with serious out-of-hospital complications, advanced pediatric airway skills were frequently required.
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Affiliation(s)
- J Scott Baird
- College of Physicians and Surgeons, Children's Hospital of New York-Presbyterian, Columbia University, New York, New York 10032, USA.
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Oktem S, Cakir E, Uyan ZS, Karadag B, Hamutcu RE, Kiyan G, Akalin F, Karakoc F, Dagli E. Diaphragmatic paralysis after pediatric heart surgery: usefulness of non-invasive ventilation. Int J Pediatr Otorhinolaryngol 2010; 74:430-1. [PMID: 20096939 DOI: 10.1016/j.ijporl.2010.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 12/22/2009] [Accepted: 01/05/2010] [Indexed: 11/19/2022]
Abstract
Diaphragmatic paralysis after cardiac surgery is an important complication especially in infants. We report a child who developed diaphragmatic paralysis, atelectasis, bronchomalasia and respiratory failure following cardiac surgery. Ventilatory support alleviated respiratory distress in this child. This report illustrates the usefulness of invasive and non-invasive ventilatory support for a pediatric patient with diaphragmatic paralysis.
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Affiliation(s)
- Sedat Oktem
- Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
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Aplicación de ventilación no invasiva en pacientes postoperados cardíacos. Estudio retrospectivo. An Pediatr (Barc) 2009; 71:13-9. [DOI: 10.1016/j.anpedi.2009.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 03/29/2009] [Accepted: 04/01/2009] [Indexed: 11/20/2022] Open
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López-Herce Cid J, Leyton Avilés P, Urbano Villaescusa J, Cidoncha Escobar E, Del Castillo Peral J, Carrillo Alvarez A, Bellón Cano JM. [Risk factors for prolonged mechanical ventilation after cardiac surgery in children]. Med Intensiva 2009; 32:369-77. [PMID: 19055929 DOI: 10.1016/s0210-5691(08)75707-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To study the postoperative factors associated with prolonged mechanical ventilation after cardiac surgery in children. DESIGN Prospective observational study. SETTING Pediatric intensive care unit (PICU). PATIENTS 59 children aged between 2 months and 14 years after cardiac surgery. VARIABLES OF INTEREST We analyzed postoperative parameters associated to mechanical ventilation lasting more than 3 and more than 7 days. We performed a stepwise multiple logistic regression analysis to study the influence of each factor on prolonged mechanical ventilation. RESULTS Mechanical ventilation lasted more than 3 days in 19 (32%) children and more than 7 days in 12 (20%). Predictive factors at PICU admission and 24 hours after admission associated with mechanical ventilation at 3 and 7 days were age less than 12 months, weight less than 7 kg, extrapulmonary complications (hypotension, arrhythmias, postoperative bleeding, delayed sternal closure, and airway complications), nitric oxide treatment, midazolam perfusion more than 4 microg/kg/min or fentanyl perfusion more than 4 microg/kg/h, and continuous muscle relaxant treatment. In the logistic multiple regression study, weight less than 7 kg and extrapulmonary complications predicted 82.8% of children with mechanical ventilation more than 3 days and 87.9% with mechanical ventilation more than 7 days. CONCLUSIONS Weight less than 7 kg and extrapulmonary complications are the most important factors associated with prolonged mechanical ventilation after cardiac surgery in children.
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Affiliation(s)
- Jesús López-Herce Cid
- Sección de Cuidados Intensivos Pediátricos. Hospital General Universitario Gregorio Marañón. Madrid. España.
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Joshi G, Tobias JD. A five-year experience with the use of BiPAP in a pediatric intensive care unit population. J Intensive Care Med 2007; 22:38-43. [PMID: 17259567 DOI: 10.1177/0885066606295221] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The authors retrospectively reviewed their experience with bilevel positive airway pressure (BiPAP) to treat respiratory insufficiency in pediatric patients over a 5-year period. After excluding patients on chronic home BiPAP and those in whom BiPAP was used to facilitate tracheal extubation (because there were no pre-BiPAP values on which to judge its efficacy), the study cohort included 45 patients (1.5 to 22 years) in whom BiPAP was used for acute respiratory insufficiency. The primary indication for BiPAP was a primary pulmonary parenchymal process in 29 patients and postoperative atelectasis with respiratory insufficiency following cardiac or upper abdominal surgery in 16 patients. There were no differences in the pre-BiPAP values of oxygen requirement, PCO2, oxygen saturation, and respiratory rate between the 2 groups. With the application of BiPAP in patients with primary pulmonary parenchymal disease, there was a decreased oxygen requirement, PCO2, and respiratory rate. No change in oxygen saturation was noted. In patients with postoperative respiratory insufficiency, there was an improvement in all 4 parameters. There was no difference in post-BiPAP values of oxygen requirement, respiratory rate, or PCO2 between the 2 groups. The post-BiPAP oxygen saturation was greater in patients with postoperative respiratory insufficiency (96% +/- 4%) than in patients with primary pulmonary parenchymal disease (92% +/- 6%, P = .02). Endotracheal intubation was required in 11 of 29 patients with primary pulmonary parenchymal pathology versus 1 of 16 patients with postoperative atelectasis and/or respiratory insufficiency (P = .03). The chances of requiring intubation were greater in patients < or = 6 years of age (relative risk 1.9), if the oxygen requirement did not decrease to less than 60% within the first 24 hours of BiPAP use (relative risk 3.3) and if there were any PCO2 values > or = 55 mmHg during the first 24 hours of BiPAP use (relative risk 9.8). No severe complications to BiPAP were noted. BiPAP safely and effectively improves the respiratory status of and might decrease the need for endotracheal intubation in pediatric patients with acute respiratory insufficiency of various etiologies.
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Affiliation(s)
- Gayatri Joshi
- University of Missouri School of Medicine, Columbia, MO, USA
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