Aggressive treatment of acquired phrenic nerve paralysis in infants and small children

Plication for diaphragm paralysis after paediatric cardiac surgery: a single-centre experience

OBJECTIVE

Diaphragm paralysis is a well-known complication following surgery for CHDs, which increases morbidity, mortality, and length of hospital stay as well as costs. Herein, we present our experience with diaphragm plication following paralysis of the phrenic nerve encountered after paediatric cardiac surgery.

METHODS

This study retrospectively reviewed the medical records of 23 diaphragm plications in 20 patients who underwent paediatric cardiac surgery between January 2012 and January 2022. The patients were carefully selected based on aetiology and a combination of clinical manifestation and chest imaging characteristics including chest X-ray, ultrasonography, and fluoroscopy.

RESULTS

Twenty-three successful plications were performed in 20 patients (15 males and 5 females) out of a total of 1938 operations performed in our centre. Mean age and body weight were 18.2 ± 17.1 months and 8.3 ± 3.7 kg, respectively. The period between the cardiac surgery and diaphragmatic plication was 18.7 ± 15.1 days. The highest incidence of diaphragm paralysis was encountered in systemic to pulmonary artery shunt patients with 7 out of 152 patients (4.6%). Any mortality was not encountered during a mean follow-up period of 4.3 ± 2.6 years.

CONCLUSIONS

Early results of plication of the diaphragm following phrenic nerve palsy in symptomatic patients who underwent paediatric cardiac surgery are encouraging. Evaluation of the diaphragmatic function should be a routine part of post-operative echocardiography. Diaphragm paralysis may be a consequence of dissection, contusion, stretching, and thermal injury both in terms of hypothermia and hyperthermia.

Management of phrenic nerve palsy following cardiac surgery

Phrenic nerve palsy (PNP) is a potential complication of cardiac surgery. It may prolong ventilation and hospitalization and result in significant morbidity and mortality. The diagnosis and management of PNP following cardiac surgery is reviewed.

Ultrasonography and Lung Mechanics Can Diagnose Diaphragmatic Paralysis Quickly

Diaphragmatic paralysis after cardiovascular surgery requires early diagnosis prior to extubation. The effectiveness of ultrasonography and a lung mechanics assessment was evaluated. Paralysis of the diaphragm was diagnosed when the diaphragm failed to move or moved in a cephalad direction during inspiration. It was diagnosed in 3 of 40 patients (7.5%) who underwent cardiovascular surgery from 1998 to 1999. Patients were extubated when all parameters met the extubation criteria, irrespective of the presence or absence of diaphragmatic paralysis. One patient required prolonged assisted ventilation and died from mediastinitis on the 35th postoperative day. The other 2 patients required assisted ventilation for an additional 1–3 days. Ultrasonography and a lung mechanics assessment are effective tools for the early diagnosis of diaphragmatic paralysis and assessment of respiratory function after cardiovascular surgery.

Airway Management following Pediatric Cardiothoracic Surgery

Objectives

(1) Review airway management in pediatric patients undergoing cardiothoracic surgery (CTS); (2) determine the incidence of airway-related complications of CTS in this population.

Design

Case series with chart review.

Setting

Tertiary care children’s hospital.

Patients

Children undergoing CTS over a 4-year period.

Methods

Patients who underwent CTS at a single, tertiary care, children’s hospital between June 1, 2007, and May 31, 2011, were retrospectively reviewed; those <18 years who had open CTS were included. Statistical analysis examined relationships of intubation duration, complications, and need for tracheotomy while comparing patient characteristics, comorbidities, and types of surgery.

Results

Eight hundred seventy-five primary surgeries in 745 patients met inclusion criteria. Mean postoperative intubation duration was 7.2 days and median 3 days. On univariate analysis, significantly longer postoperative intubation requirements were found in patients younger in age, with congenital comorbidities or prematurity, with preoperative ventilation requirements, and those with early postoperative complications. Multivariate analysis found younger age, presence of congenital comorbidities, preoperative intubation requirements, and early postoperative complications each lengthen ventilation requirements. Four patients developed vocal cord paralysis and 5 developed phrenic nerve palsy. Nineteen patients required tracheotomy.

Conclusions

In this large cohort, CTS in the pediatric population is associated with few long-term or permanent airway-related complications. Patients who are younger in age and those with congenital comorbidities, preoperative ventilation requirements, or early postoperative complications required longer periods of postoperative intubation.

Early hemi-diaphragmatic plication through a video assisted mini-thoracotomy in postcardiotomy phrenic nerve paresis

New symptom onset of respiratory distress without other cause, and new hemi-diaphragmatic elevation on chest radiography postcardiotomy, are usually adequate for the diagnosis of phrenic nerve paresis. The symptom severity varies (asymptomatic state to severe respiratory failure) depending on the degree of the lesion (paresis vs. paralysis), the laterality (unilateral or bilateral), the age, and the co-morbidity (respiratory, cardiac disease, morbid obesity, etc). Surgical treatment (hemi-diaphragmatic plication) is indicated only in the presence of symptoms. The established surgical treatment is plication of the affected hemidiaphragm which is generally considered safe and effective. Several techniques and approaches are employed for diaphragmatic plication (thoracotomy, video-assisted thoracoscopic surgery, video-assisted mini-thoracotomy, laparoscopic surgery). The timing of surgery depends on the severity and the progression of symptoms. In infants and young children with postcardiotomy phrenic nerve paresis the clinical status is usually severe (failure to wean from mechanical ventilation), and early plication is indicated. Adults with postcardiotomy phrenic nerve paresis usually suffer from chronic dyspnoea, and, in the absence of respiratory distress, conservative treatment is recommended for 6 months -2 years, since improvement is often observed. Nevertheless, earlier surgical treatment may be indicated in non-resolving respiratory failure. We present early (25(th) day postcardiotomy) right hemi-diaphragm plication, through a video assisted mini-thoracotomy in a high risk patient with postcardiotomy phrenic nerve paresis and respiratory distress. Early surgery with minimal surgical trauma, short operative time, minimal blood loss and postoperative pain, led to fast rehabilitation and avoidance of prolonged hospitalization complications. The relevant literature is discussed.

Diaphragmatic paralysis among very low birth weight infants following ligation for patent ductus arteriosus

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.

Diaphragmatic paralysis after pediatric heart surgery: usefulness of non-invasive ventilation

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.

PHRENIC NERVE TRANSFER IN THE RESTORATION OF ELBOW FLEXION IN BRACHIAL PLEXUS AVULSION INJURIES

OBJECTIVE

Phrenic nerve transfer has been used for treating lesions of the brachial plexus since 1970. Although, today, surgeons are more experienced with the technique, there are still widespread concerns about its effects on pulmonary function. This study was undertaken to evaluate the effectiveness and safety of this procedure.

METHODS

Fourteen patients with complete palsy of the upper limb were submitted to phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. Two patients were lost to follow-up, and 2 patients were followed for less than 2 years. Of the remaining 10 patients, 9 (90%) were male. The lesions affected both sides equally. The mean age of the patients was 24.8 years (range, 14–43 years), and the mean interval from injury to surgery was 6 months (range, 3–9 months). The phrenic nerve was always transferred to the musculocutaneous nerve, and a nerve graft (mean length, 8 cm; range, 4.5–12 cm) was necessary in all cases.

RESULTS

There was no major complication related to the surgery. Seven patients (70%) recovered functional level biceps strength (Medical Research Council grade ≥3). All of the patients exhibited a transient decrease in pulmonary function tests, but without clinical respiratory problems.

CONCLUSION

On the basis of our small series and data from the literature, we conclude that phrenic nerve transfer in well-selected patients is a safe and effective procedure for recovering biceps function.

Subdiaphragmatic venous hemodynamics in patients with biventricular and Fontan circulation after diaphragm plication

OBJECTIVE

Diaphragm paralysis owing to phrenic nerve injury can result in significant morbidity in children undergoing surgical management of congenital cardiac defects. Diaphragm plication is the accepted therapy for diaphragm paralysis. We have investigated subdiaphragmatic venous hemodynamics in patients with biventricular and Fontan circulation after diaphragm plication.

METHODS

Doppler ultrasound was used to evaluate flows in the hepatic vein, portal vein, and subhepatic inferior vena cava under respiratory monitoring and with a tilt table. Twenty-nine patients with biventricular circulation were studied: 19 with normal diaphragms and 10 after diaphragm plication. Twenty-eight patients with total cavopulmonary connections after the Fontan procedure were also studied: 19 with normal diaphragms and 9 with plicated diaphragms. Inspiratory/expiratory flow ratios in supine and upright positions were calculated to investigate respiratory effects, and upright/supine flow ratios were calculated to assess gravity effects.

RESULTS

In patients with biventricular circulation and normal diaphragms, hepatic venous flow was augmented by inspiration; this effect was reduced in patients with a plicated diaphragm (upright inspiratory/expiratory flow ratios: 2.4 vs 1.4, respectively; P = .01). Portal venous flow was higher during expiration; this effect was lost in patients with a plicated diaphragm (supine inspiratory/expiratory flow ratios: 0.8 and 1.0; P < .05). In Fontan patients with normal diaphragms, hepatic venous flow depended heavily on inspiration. This effect was blunted in patients with a plicated diaphragm (supine inspiratory/expiratory flow ratios: 3.2 vs 2.3; P < .05). Expiratory augmentation of portal flow was absent in Fontan patients with normal diaphragms and reversed in patients a plicated diaphragm (supine inspiratory/expiratory flow ratios: 1.0 vs 1.6; P = .02). Gravity reduced Fontan portal venous flow; having a plicated diaphragm did not alter this effect (upright/supine flow ratios: 0.7 vs 0.7).

CONCLUSIONS

In patients with biventricular and those with Fontan circulation with a paralyzed diaphragm, plication does not completely restore normal subdiaphragmatic venous hemodynamics. In Fontan patients with a plicated diaphragm, important inspiration-derived hepatic venous flow is suppressed, and portal venous flow loses its normal expiratory augmentation. These flow dynamics share similarities with those observed in patients with failing Fontan circulation. This suboptimal splanchnic circulation may contribute to early problems of prolonged pleural effusions and ascites and potentially may promote late Fontan failure. Phrenic nerve injury should consequently be avoided at all costs before or at the time of the Fontan operation.

Mid-term follow-up in patients with diaphragmatic plication after surgery for congenital heart disease

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.

Postoperative phrenic nerve palsy: early clinical implications and management

OBJECTIVE

We examined the clinical impact of diaphragmatic palsy (DP) as a result of phrenic nerve injury following cardiothoracic surgery, specifically its effects on morbidity and mortality, early regeneration capacity of the phrenic nerve, and role of surgical diaphragmatic plication.

METHODS

A retrospective case control study was performed in 74 children with DP and 74 matched controls after cardiothoracic surgery within the past 14 years.

RESULTS

Following 5,128 surgical procedures in children (aged under 18 years) we found an incidence of DP of 1.4%. There were no differences in mortality between the groups, and the cause of death was not related to DP or plication in any of the patients. However, patients with diaphragm impairment had significantly longer duration of mechanical ventilation (median 3 days vs. 1), ICU stay (7 days vs. 3.5), duration of hospital stay (16 days vs. 12), and for antibiotic treatment (16 days vs. 7). Because of prolonged respiratory problems 40 children (54%) underwent surgical diaphragmatic plication to flatten the diaphragm in its inspiratory position. In children with DP younger age was a strong predictor for plication (median 3.8 months vs. 12.1).

CONCLUSIONS

Especially in newborns and young infants with DP the length of mechanical ventilation, ICU stay, and hospital stay are prolonged. Early spontaneous recovery of the phrenic nerve is rare. In cases of respiratory impairment early transthoracic diaphragmatic plication is an effective means of treatment.

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management

Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc-Taussig (B-T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B-T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8 +/- 3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n = 22), failure to wean from ventilator (n = 12), recurrent lung infections (n = 5) and persistent respiratory distress (n = 3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P < 0.05). Phrenic nerve injury is a serious complication of cardiac surgery. It is more common after some special procedures. Spontaneous recovery is very rare. Being under 1 year of age, plication after 10 days from the surgery and pneumonia are major risk factors for mortality even in plicated patients. Transthoracic plication is helpful if performed early.

M-mode sonography of diaphragmatic motion: description of technique and experience in 278 pediatric patients

BACKGROUND

The use of M-mode sonography for evaluation of diaphragmatic motion has only been previously reported in small series of children, and its use is not widespread among pediatric radiologists.

OBJECTIVES

To present our experience with M-mode sonography in the evaluation of diaphragmatic motion in a large number of children with suspected diaphragmatic paralysis, to describe the technique used and to correlate sonographic findings with chest radiographs and clinical outcome.

MATERIALS AND METHODS

Retrospective analysis of all M-mode sonograms performed in children from September 1999 to December 2003. The available chest radiographs and the clinical findings were reviewed and correlated with the sonographic findings.

RESULTS

A total of 742 hemidiaphragms were evaluated in 278 children. There was no visualization of the left hemidiaphragm in 2 children (0.71%). Movement of the right hemidiaphragm was normal in 238 and abnormal in 131. Movement of the left hemidiaphragm was normal in 232 and abnormal in 135. Abnormal diaphragmatic movement was present in 118 (63%) of 187 children in whom chest radiographs had shown normal position of the hemidiaphragms. Follow-up examinations were obtained in 56 children, revealing improvement in diaphragmatic motion in 26, no change in 23 and deterioration of motion in seven.

SUMMARY

M-mode sonography should be the modality of choice to assess diaphragmatic motion, as it can easily depict diaphragmatic dysfunction and allows comparison of changes in follow-up studies. Normal chest radiographs are poor predictors of normal diaphragmatic motion.

Thoracoscopic diaphragmatic procedures under artificial pneumothorax

Diaphragmatic plication is technically simple using a conventional operative technique, but it requires a large skin incision and rib injury. We present an alternative technique for thoracoscopic plication of the diaphragm and evaluate the advantages of the procedure. Six patients (five with diaphragmatic eventration and one with diaphragmatic hernia with a sac) ranging in age from 8 to 20 months were treated by this method. Three of the six cases were right-sided, and three were left-sided. The operation was performed under artificial pneumothorax using carbon dioxide gas at 4 mmHg. Three trocars for laparoscopy were inserted at the 4th and 5th intercostal spaces. An adequate operative view was obtained by pressing the diaphragm throughout the operation. The eventrated diaphragm was plicated with several rows of nonabsorbable sutures in the anterolateral-to-posterolateral direction to prevent injury to the main phrenic nerve. A tight diaphragm was confirmed by decompressing the artificial pneumothorax. The technique was successfully performed in all cases, and the patients' postoperative courses were uneventful. During the operation, the hemodynamic effects of carbon dioxide gas at 4 mmHg were minimal. Over a mean follow-up period of 3.1 years (range, 1-6 years), no recurrence of diaphragmatic eventration was seen. Judging from the satisfactory postoperative course, this procedure is suitable for children with all forms of diaphragmatic eventration.

Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy

BACKGROUND

Paralysis of the diaphragm is a severe complication of cardiothoracic surgery carrying significant morbidity and mortality. This study demonstrates a novel minimally invasive technique for treatment of phrenic nerve injuries presenting with symptomatic eventration of the diaphragm. It also presents long-term results of three patients treated with this operation.

METHODS

Chest x-ray proved eventration of the left diaphragm in all patients. Two patients required treatment due to prolonged respirator therapy/assisted ventilation for 4 weeks after cardiac surgery. One patient suffered from progressive dyspnea caused by increasing left-sided diaphragmatic elevation and underwent surgery 2 years after cardiac surgery. In all cases, a minimally invasive abdominal approach was chosen. During surgery the dome of the diaphragm was pulled down via three percutaneously inserted retention stitches. This resulted in two or three folds of the diaphragm located within the abdomen. These diaphragmatic folds were subsequently tightened using 12 to 15 unresorbable sutures with extracorporally prepared knots. Surgical as well as long-term follow-up results are presented of all patients and a review of the current literature is provided.

RESULTS

Mean operating time was 203 min; mean intraoperative blood loss was 130 ml. No major complications occurred during surgery or the postoperative period. At a median follow-up of 72 months no recurrence was observed.

CONCLUSIONS

Laparoscopic diaphragmatic plication provides excellent relief of symptoms caused by diaphragmatic paralysis. There is no perioperative morbidity, and hospital stay is short. The laparoscopic approach, therefore, is an attractive surgical alternative for the treatment of phrenic nerve palsy and should be considered in all suitable patients.

Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients

BACKGROUND

A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury.

METHODS

A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated.

RESULTS

One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication.

CONCLUSIONS

Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.

Diaphragmatic plication in the extremely low birth weight infant

A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed.

Pulmonary risk factors compromising postoperative recovery after surgical repair for congenital heart disease

STUDY OBJECTIVES

To identify pulmonary risk factors associated with prolonged ICU stay in young children (< or = 2 years) undergoing surgical repair for congenital heart disease (CHD).

DESIGN

Retrospective case series analysis.

SETTING

Tertiary-care facility.

PATIENTS

Clinical records of 134 consecutive patients aged < or = 2 years undergoing cardiac surgery for CHD were reviewed, and 37 were excluded according to inclusion criteria. Thus, 97 patients were allocated to two groups based on the duration of ICU stay: < or = 7 days (group 1, n = 57), and > 7 days (group 2, n = 40).

RESULTS

Mean ICU duration for groups 1 and 2 was 3.0 +/- 0.4 days and 28.1 +/- 4.4 days, respectively (p < 0.001). In group 1, there were three extubation failures, whereas 41 extubation failures occurred in group 2 (p < 0.0001). A total of 22 patients (4 in group 1 and 18 in group 2) developed noninfectious pulmonary complications, such as airway problems, including extrinsic airway compression and tracheobronchomalacia (n = 6); pulmonary hypertension (n = 5); phrenic nerve palsy (n = 7); and pleural effusion (n = 8). These 22 patients (23%) contributed to the majority of total ventilator days (67%) as well as ICU stay (61%).

CONCLUSIONS

Pulmonary complications in general, and central airway problems in particular, are a frequent cause for delayed recovery following cardiac surgery in young children.

Impact of diaphragmatic paralysis after cardiothoracic surgery in children

OBJECTIVES

We sought to determine the prevalence and clinical impact of diaphragmatic paralysis caused by phrenic nerve injury after cardiothoracic surgery in children.

METHODS

A search of cardiology, radiology, and hospital databases identified 170 episodes of diaphragmatic paralysis after cardiothoracic surgery in 168 children operated on from 1985 to 1997. Medical records were reviewed to determine demographics, details of the operation and postoperative course, diagnostic features and management of diaphragmatic paralysis, and follow-up status.

RESULTS

The prevalence of diaphragmatic paralysis was 1.6% (95% confidence interval 1.4%-1.8%). Median age at operation was 6 months (range <1 day-14.4 years). Median time from the operation to the initial investigation was 5 days (range <1 day-61 days), with 57% of patients receiving mechanical ventilation at diagnosis. Diaphragmatic plication was performed in 40% of the patients at a median interval from the initial investigation of 15 days (range 3 days-11.1 months). Significant independent factors associated with increased postoperative hospital stay were lower patient weight at operation, previous cardiothoracic operations, bilateral diaphragmatic paralysis, increased interval from operation to investigation, mechanical ventilation at the time of investigation, and diaphragmatic plication. Confirmed recovery of diaphragmatic function was noted before hospital discharge in only 15 episodes.

CONCLUSIONS

Diaphragmatic paralysis complicating cardiothoracic surgery continues to occur in the current era, with a significant impact on morbidity. Smaller patients with bilateral hemidiaphragmatic paralysis, requiring mechanical ventilation, may represent a higher risk subgroup to target for increased diagnostic suspicion and more aggressive management; early spontaneous recovery is rare.

Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery

OBJECTIVES

Evaluation of an aggressive policy for the treatment of phrenic nerve palsy (PNP), following cardiac operations, with emphasis on early diaphragmatic plication. Attention was given to the incidence and predisposing factors for PNP and the potential for recovery following plication.

METHODS

From 1 June 1991 to 1 January 1996 we prospectively screened patients for PNP following cardiac surgery. The diagnosis was suspected if difficulty was experienced in weaning the child from the ventilator. If abnormal elevation of the hemidiaphragm was present diaphragmatic plication was performed. Echocardiography was used to assess subsequent return of diaphragmatic function.

RESULTS

Seventeen children (nine boys, eight girls), out of 867 (1.9%) children younger than 16 years of age, undergoing cardiac operations were found to have PNP. The mean age was 66 days (range 1-17 months) with 16 patients below 1 year out of a total of 285 patients (incidence 5.6%) and one patient 17 months old. The incidence following open procedures was 11/190, following closed procedures 2/95 and following reoperation 4/83. PNP was diagnosed from 2 to 44 days (mean 14 days) following surgery. It was present on the right side in seven cases, the left in nine and was bilateral in one patient. Two patients were extubated at the time of diagnosis, one patient could be extubated shortly thereafter. Fourteen children underwent diaphragmatic plication, at a median 5 days post diagnosis. Extubation was possible 1-60 days (mean 4 days) after plication. Mean follow-up was 19 +/- 5 months. Subsequent recovery of diaphragmatic movement was documented in seven (41%) children. Time to recovery following plication was 16 months, without plication 38 months.

CONCLUSION

Prospective screening for PNP revealed an incidence in children younger than 1 year of 6%. Early plication substantially reduces the duration of ventilation, with its associated reduced morbidity and ICU stay.

Phrenic nerve injury following cardiac surgery: a review

Phrenic nerve injury following cardiac surgery is variable in its incidence depending on the diligence with which it is sought. Definitive studies have shown this complication to be related to cold-induced injury during myocardial protection strategies and possibly to mechanical injury during internal mammary artery harvesting. The consequences are also variable and depend to a large extent on the underlying condition of the patient, particularly with regard to pulmonary function. The response of the patient may range from an asymptomatic radiographic abnormality to severe pulmonary dysfunction requiring prolonged mechanical ventilation and other associated morbidities and even mortality. Two cases are presented to demonstrate the variability in clinical responses to diaphragmatic dysfunction secondary to phrenic nerve injury from cardiac surgery. In addition, treatment strategies are reviewed including early tracheostomy and diaphragmatic plication, which appear to be the most effective options for patients who are compromised by phrenic injuries.

Surgical treatment of diaphragmatic eventration caused by phrenic nerve injury in the newborn

BACKGROUND

Phrenic nerve palsy in infants and young children usually results from birth injury or iatrogenic damage. The newborn almost invariably presents with severe respiratory distress, diaphragmatic elevation, and paradoxical movement at the affected side.

METHODS/RESULTS

In this retrospective analysis a group of 23 patients below the age of 1 year with an obstetric or postoperative phrenic nerve injury was studied and compared with cases in the literature. All patients were admitted between 1986 and 1997 to the Pediatric Surgical Center, Amsterdam. Thirteen of 18 patients with an obstetric phrenic nerve injury underwent plication of the diaphragm after an average observation period of 100 days. In the remaining five children with an obstetric phrenic nerve injury, spontaneous recovery appeared within 1 month. Only one of five patients with a phrenic nerve palsy after a cardiac surgical procedure underwent plication of the diaphragm. Fifteen of the 34 patients described in the literature underwent plication of the diaphragm after an average of 54 days.

CONCLUSIONS

If after 1 month no spontaneous recovery of the diaphragmatic paralysis caused by a phrenic nerve injury occurs, plication of the diaphragm is indicated. This operation proved to be successful for relief of symptomatic phrenic nerve injury in all cases. If the condition of the patient clinically deteriorates during this first month of life, the patient should be operated on immediately.

Minimally invasive diaphragm plication in an infant

We report the use of video-assisted thoracic surgery to plicate the diaphragm after phrenic nerve injury associated with an operation for congenital heart disease. Right diaphragm paresis developed in a cyanotic newborn girl with pulmonary atresia and intact ventricular septum after a right modified Blalock-Taussig shunt. Diaphragm plication was performed endoscopically and the patient recovered. Refinement of technique and instrumentation may allow wider application of video-assisted thoracoscopic plication of the diaphragm in neonatal and pediatric patients.

Diaphragmatic eventration in infants and children: is conservative treatment justified?

PURPOSE

The purpose of this study is to examine the justification of diaphragmatic plication to treat diaphragmatic eventration. A retrospective review of 50 patients who underwent diaphragmatic plication for phrenic nerve injury (PNI) or congenital muscular deficiency (CMD) of the diaphragm was conducted.

METHODS

During the last 26 years, 50 patients, aged 4 days to 7 years, were surgically treated for diaphragmatic eventration. Twenty-five patients had iatrogenic PNI and another 25 had CMD. Respiratory distress developed in all patients who had PNI and 10 required mechanical ventilatory support for 13 to 78 days (mean, 41 days) before operation. Respiratory symptoms developed in 17 of 25 patients who had CMD, and four required ventilatory support. In those who were asymptomatic, we justified surgical repair to optimize future lung growth. All patients underwent diaphragmatic plication by a thoracic approach. Reefing mattress sutures on pledgets were used for the plication.

RESULTS

In patients who had PNI, ventilatory support could be discontinued within 0 to 6 days (mean, 3 days) after operation, with a dramatic improvement in their respiratory status. Two patients required reoperation because the plication was not tight enough. Seven patients died in this series, but none because of the diaphragmatic plication.

CONCLUSION

This study suggests that symptomatic patients who have diaphragmatic eventration should be operated on immediately with an expected dramatic resolution of their respiratory problems.

Clinical implications of phrenic nerve injury after pediatric cardiac surgery

Phrenic nerve injury with resulting diaphragm paralysis occurred in 25 (1.5%) of 1,656 cardiac surgical procedures in children during a 10-year period. Phrenic nerve injury was most commonly noted in patients who had undergone previous cardiac surgery (16 of 165, 10%; P < .0001), typically after a previous Blalock-Taussig shunt (10 of 53, 19%; P = .007). Plication of the diaphragm (7 thoracic, 4 abdominal) was performed in 11 patients (44%). Indications for plication were inability to wean from mechanical ventilation (5 patients) and persistent or recurrent respiratory distress (6 patients). The patients who needed diaphragm plication were significantly younger than those who were managed conservatively (median, 11 months [4 days to 23 months] versus 20 months [4 months to 16 years]; P = .01). All patients older than 2 years were extubated within 3 days (mean, 1.5 days) and did not need any surgical intervention. The median follow-up period was 3.2 years, and no patient has had recurrent respiratory problems. There were no deaths as a direct result of phrenic nerve injury. Phrenic nerve injury after cardiac surgery is a serious complication that often leads to respiratory insufficiency in patients under than 2 years of age. For such patients, early diaphragm plication is a simple and effective procedure that prevents the complications of prolonged mechanical ventilation.

Phrenic nerve injury following scalenectomy in a patient with thoracic outlet obstruction

We present a case in which a patient with normal pulmonary reserve experienced orthopnea and hypoxia secondary to unilateral diaphragmatic paralysis following right scalenectomy. This operation was performed in an attempt to relieve neurovascular compromise at the thoracic outlet. To our knowledge, this association has not been previously described in the literature.

Phrenic nerve damage via a right thoracotomy in older children with secundum ASD

Phrenic nerve damage (PND) in children after cardiac operations is now recognized as being more frequent than previously thought. In a prospective study on 400 children, we previously demonstrated electrophysiologic evidence of postoperative PND in approximately 16% of patients, with one third of cases occurring in children under 18 months. In the past 18 months, 30 children have had atrial septal defect (ASD) repairs as their only operative procedure. Fourteen children had ASD repairs via a midline incision, and 16 ASD repairs were via a right thoracotomy. No PND (assessed by phrenic nerve latency) was found after a midline approach. In the right thoracotomy group, 5 children had evidence of PND (31%; p = 0.05). Four of these 5 patients were female and more than 14 years of age. The incidence of damage in this pubescent group was 80% (p < 0.05). In the older age group the duration of ventilation was not prolonged, but affected patients had symptoms of fatigue and breathlessness postoperatively. These data suggest a strong association between right thoracotomies for ASD repairs and PND, especially in the female pubescent group when a low submammary skin incision (seventh to eighth space) is used with a fifth to sixth space entry into the thoracic cavity. In conclusion, the right thoracotomy approach for ASD repair appears to be a significant risk factor for PND in older children.

Phrenic Nerve Injury Following Cardiac Surgery, with Emphasis on the Role of Topical Hypothermia

Phrenic nerve dysfunction that develops after cardiac surgery has generally been attributed to the topical hypothermia used for myocardial preservation and protection. Although studies relying on postoperative radiographic findings to establish the diagnosis reveal an incidence as high as 73%, investigations employing electrophysiological assessment indicate a 10% incidence. Most patients who sustain phrenic injury during cardiac surgery do not suffer major respiratory morbidity; those who do generally recover. In addition to the role of topical hypothermia as a major etiological factor, physical trauma or compromise of the vascular supply to the phrenic nerve and diaphragm may also be important factors. Although a number of measures have been advocated to lower the incidence of the problem, none have been evaluated in a prospective, randomized study using electrophysiological techniques. This review focuses on the incidence, underlying mechanisms, and clinical and electrophysiological recognition of phrenic nerve dysfunction following cardiac surgery.

Unusual varieties of diaphragmatic herniae

Unusual varieties of diaphragmatic herniae can be classified into two major groups, congenital and acquired. The late-presenting Bochdalek herniae often present difficulties in diagnosis which may lead to inappropriate treatment. The prime example is the herniated stomach, which is mistaken for a tension pneumothorax. Strangulation is a rare, but an important, complication of Bochdalek herniae. A number of techniques for closure of large diaphragmatic defects are described with recommendation of those procedures which can be performed rapidly and effectively in a critically ill infant. The literature concerning eventration is confusing due to different definitions of the condition by different authors. It may be difficult to distinguish preoperatively between this condition and congenital diaphragmatic hernia with a sac. Such distinction is often not important as the decision for intervention is based on evaluation of clinical and radiological considerations. The majority of Morgagni herniae are asymptomatic and only rarely does strangulation supervene. There is a small group of infants with Morgagni hernias who present in early infancy with respiratory symptoms. Paralysis of the diaphragm due to phrenic nerve palsy recovers spontaneously in the majority of patients. The selective use of diaphragmatic plication for this condition is widely accepted, but the decision and appropriate timing for surgical intervention is often difficult. The results of surgery are very good both in the early postoperative period and also on long-term follow-up. The diagnosis of traumatic diaphragmatic hernia is often overlooked in the presence of other major injuries. The danger of strangulation of contents of this hernia is ever present and repair should be undertaken without delay once the diagnosis is made.

Plication of the diaphragm for infants and young children with phrenic nerve palsy

Phrenic nerve palsy (PNP) is seen in infants and young children usually resulting from operative trauma or birth injury. Spontaneous recovery usually occurs, but occasionally surgical plication is necessary. Twenty-three cases of PNP over a 10-year period were managed surgically. Patient ages ranged from 1 day to 30 months (median, 4 months), 18 were male and five female. Cause was operative trauma in 18 (17 cardiac surgery, one neuroblastoma), birth trauma in two, and idiopathic in three. The right side was involved in 14, the left in eight, and both in one. Indications for plication were inability to wean from the ventilator (group 1, 16 patients), recurrent pneumonia (group 2, four patients), and respiratory distress (group 3, three patients). The 16 patients in group 1 were intubated for a median of 18.5 days from onset of PNP to plication. Postoperatively, three had continuing congestive heart failure (one died at 16 days of age, one was still chronically ventilated at 22 months, one was extubated at nine days); the other 13 were extubated at a median of two days postoperatively. All the patients in groups 2 and 3 were extubated within two days of surgery. Twelve plications were transthoracic and 11 were transabdominal. Postoperative complications included pneumonia (2), wound infection (1), pneumothorax (2), and mucous plug with pulmonary collapse (1). One patient died of cardiac failure at 16 days. One patient in group 3 developed recurrent respiratory distress 4 months postoperatively; he had a recurrent elevated hemidiaphragm requiring a second plication.(ABSTRACT TRUNCATED AT 250 WORDS)

Eventration of the diaphragm in infants and children

The study reviews 18 infants and children with eventration of the diaphragm who were treated over a period of eight years. The affected diaphragm and pulmonary tissue were examined by light and electron microscopy. The 18 patients, ranging in age from 10 days to 6 years, were divided according to Thomas' classification into a group with the congenital (10 patients) and a group with the acquired type (8 patients). Fifteen of these patients underwent surgery with diaphragmatic plication. On microscopic examination, biopsies of the lung showed atelectasis and pneumonia. These pathological changes became increasingly diffuse and severe with age. The diaphragm in patients with the congenital type of eventration was occupied by diffuse fibroelastic tissue. In patients with the acquired type, the cross-striated muscles of the diaphragm showed degenerative changes such as fragmentation, and interstitial fibrosis of the diaphragm became prominent with age. The results of this clinical study suggest that, in order to reduce the pathological changes in the lung, early surgical plication should be performed even in patients with the acquired type, if respiratory and digestive symptoms are noted.

Long-term fate of the diaphragm surgically plicated during infancy and early childhood

Favorable early results have been reported utilizing transthoracic diaphragmatic plication in symptomatic children with phrenic nerve injury. However, little has been published about the late functional results of this technique. Since 1976, 10 of 3,000 patients operated on for congenital heart disease have sustained phrenic nerve injury with subsequent respiratory embarrassment. An additional patient sustained phrenic nerve injury as a result of birth trauma. The diagnosis was confirmed by paradoxical diaphragmatic motion on fluoroscopy. All but 2 patients were less than 5 months old at the time of diaphragmatic plication, and the average weight was 5.4 kg. The indication for diaphragmatic plication was inability to wean from the ventilator in 8 of the 11 patients and persistent postoperative tachypnea, stridor, and CO2 retention in the remaining 3 patients. A more aggressive approach to diagnosis and operative treatment since 1980 has resulted in a substantially shorter duration of endotracheal intubation and a shorter stay in the intensive care unit. Diaphragmatic fluoroscopy 1 to 7 years postoperatively has demonstrated return of normal function in 6 of 6 patients studied.

Successful reinnervation of the diaphragm after phrenic nerve transection

A 16-month-old infant presented with bilateral diaphragmatic paralysis and respiratory failure after removal of a thoracic teratoma. Right diaphragmatic function recovered after end-to-end anastomosis of a transected phrenic nerve. We conclude that phrenic nerve repair can restore diaphragmatic function and should be attempted in selected cases of diaphragmatic paralysis due to phrenic nerve injury.

Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease

Phrenic nerve injury (PNI) with resulting hemidiaphragmatic paralysis occurred in 19 (2.1 +/- 0.5%) of 891 closed cardiac surgical procedures during a twenty-three-year period. Diagnosis was confirmed by standard radiographic criteria. Phrenic nerve injury was most commonly noted following systemic-pulmonary artery anastomosis, ligation of persistent ductus arteriosus plus pulmonary artery banding, and atrial septectomy. Most patients were managed conservatively (nasotracheal or orotracheal intubation and positive end-expiratory pressure). Although no deaths were a direct result of PNI, major complications occurred in 15 of the 19 instances of PNI (79% +/- 10%). The serious morbidity and the hospital costs associated with this complication, however, underscore the cardinal importance of prevention. If injury does occur, early surgical intervention (diaphragmatic plication) in very young infants may reduce the attendant morbidity, but the complete role of diaphragmatic plication remains to be defined.

Modification of the technique of radical intrapericardial pneumonectomy

Since radical intrapericardial pneumonectomy was introduced by Allison in 1945, complications of several serious types have been reported secondary to this technique. The authors have seen fatal cardiac herniation, as well as severe paradoxical respiration after sacrifice of the phrenic nerve. Simple technical steps can eliminate these dangers, and after introduction of the required changes we have not seen the former complications. The authors' techniques are described and a small series of animal experiments supporting their use is presented.

A case of neonatal bilateral diaphragmatic paralysis requiring surgery

Diaphragmatic paralysis may cause life threatening respiratory distress especially in infancy. A case is reported of a 32 week gestation infant with bilateral phrenic nerve palsies and associated brachial plexus injury who remained severely compromised despite spontaneous recovery of the right hemidiaphragm after 13 weeks. Operative plication of the left hemidiaphragm produced a marked improvement. Surgery should be considered after an adequate trial of expectant management in symptomatic patients.