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Palleschi A, Mattioni G, LoMauro A, Privitera E, Musso V, Morlacchi L, Vergari M, Velardo D, Grasselli G. Diaphragm and Lung Transplantation. Transpl Int 2024; 37:12897. [PMID: 38979122 PMCID: PMC11228173 DOI: 10.3389/ti.2024.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/05/2024] [Indexed: 07/10/2024]
Abstract
Mutual interactions between the diaphragm and lung transplantation (LTx) are known to exist. Before LTx, many factors can exert notable impact on the diaphragmatic function, such as the underlying respiratory disease, the comorbidities, and the chronic treatments of the patient. In the post-LTx setting, even the surgical procedure itself can cause a stressful trauma to the diaphragm, potentially leading to morphological and functional alterations. Conversely, the diaphragm can significantly influence various aspects of the LTx process, ranging from graft-to-chest cavity size matching to the long-term postoperative respiratory performance of the recipient. Despite this, there are still no standard criteria for evaluating, defining, and managing diaphragmatic dysfunction in the context of LTx to date. This deficiency hampers the accurate assessment of those factors which affect the diaphragm and its reciprocal influence on LTx outcomes. The objective of this narrative review is to delve into the complex role the diaphragm plays in the different stages of LTx and into the modifications of this muscle following surgery.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Mattioni
- Thoracic Surgery and Lung Transplantation Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- School of Thoracic Surgery, University of Milan, Milan, Italy
| | - Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Emilia Privitera
- Department of Healthcare Professions, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Musso
- Thoracic Surgery and Lung Transplantation Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Morlacchi
- Pneumology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Vergari
- Neuropathophysiology Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Velardo
- Neuromuscular and Rare Diseases Unit, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergencies, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Fang Y, Wu J, Zhang M, Yang Y, Yao L, Liu L, Luo J, Li L, Zhang C, Qin Z. Conservative rehabilitation therapy for respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor: A case series study. Medicine (Baltimore) 2023; 102:e35117. [PMID: 37682133 PMCID: PMC10489249 DOI: 10.1097/md.0000000000035117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023] Open
Abstract
RATIONALE Cases of respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor have rarely been studied in detail. Diaphragmatic dysfunction in such cases can lead to potentially fatal respiratory and circulatory disturbances. Therefore, timely diagnosis and intervention are important. Conservative rehabilitation therapy is the first choice for respiratory dysfunction due to diaphragmatic dysfunction. PATIENT CONCERNS, DIAGNOSES AND INTERVENTIONS We present 3 patients with respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor. The diagnostic methods and therapeutic procedures for diaphragmatic dysfunction for each patient are described in detail. This study highlights the role of ventilator support combined with physical therapy in the treatment of respiratory dysfunction in such cases. The diagnosis of diaphragmatic dysfunction as well as the risk assessment of phrenic nerve involvement are also discussed. The modalities of ventilator support, including modes and parameters, are listed. OUTCOMES AND LESSONS This study provides experiences of diagnosis and treatment of respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor. Timely diagnosis of diaphragmatic dysfunction primarily relies on clinical manifestations and radiography. Conservative rehabilitation therapy can improve or restore diaphragmatic function in majority of patients, and avert or delay the need for surgical intervention. Preoperative assessment of the risk of phrenic nerve involvement is important in such cases.
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Affiliation(s)
- Yu Fang
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Wu
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Maolin Zhang
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Yang
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lijun Yao
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lu Liu
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Luo
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Linjun Li
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Zhang
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiming Qin
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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3
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Fang Y, Wu J, Zhang M, Yang Y, Yao L, Liu L, Luo J, Li L, Zhang C, Qin Z. Conservative rehabilitation therapy for respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor.. [DOI: 10.21203/rs.3.rs-2423006/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Abstract
Background: Cases of respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor have rarely been studied in detail. Diaphragmatic dysfunction in such cases can lead to potentially fatal respiratory and circulatory disturbances. Therefore, timely diagnosis and intervention are important. Conservative rehabilitation therapy is the first choice for respiratory dysfunction due to diaphragmatic dysfunction.
Case presentation: We present three patients with respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor. The diagnostic methods and therapeutic procedures for diaphragmatic dysfunction for each patient are described in detail. This study highlights the role of ventilator support combined with physical therapy in the treatment of respiratory dysfunction in such cases. The diagnosis of diaphragmatic dysfunction as well as the risk assessment of phrenic nerve involvement are also discussed. The modalities of ventilator support, including modes and parameters, are listed.
Conclusions: This study provides experiences of diagnosis and treatment of respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor. Timely diagnosis of diaphragmatic dysfunction primarily relies on clinical manifestations and radiography. Conservative rehabilitation therapy can improve or restore diaphragmatic function in majority of patients, and avert or delay the need for surgical intervention. Preoperative assessment of the risk of phrenic nerve involvement is important in such cases.
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Affiliation(s)
- Yu Fang
- The First Affiliated Hospital of Chongqing Medical University
| | - Jun Wu
- The First Affiliated Hospital of Chongqing Medical University
| | - Maolin Zhang
- The First Affiliated Hospital of Chongqing Medical University
| | - Yang Yang
- The First Affiliated Hospital of Chongqing Medical University
| | - Lijun Yao
- The First Affiliated Hospital of Chongqing Medical University
| | - Lu Liu
- The First Affiliated Hospital of Chongqing Medical University
| | - Jun Luo
- The First Affiliated Hospital of Chongqing Medical University
| | - Linjun Li
- The First Affiliated Hospital of Chongqing Medical University
| | - Cheng Zhang
- The First Affiliated Hospital of Chongqing Medical University
| | - Zhiming Qin
- The First Affiliated Hospital of Chongqing Medical University
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Kaufman MR, Ferro N, Paulin E. Phrenic nerve paralysis and phrenic nerve reconstruction surgery. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:271-292. [PMID: 36031309 DOI: 10.1016/b978-0-323-91532-8.00003-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Phrenic nerve injury results in paralysis of the diaphragm muscle, the primary generator of an inspiratory effort, as well as a stabilizing muscle involved in postural control and spinal alignment. Unilateral deficits often result in exertional dyspnea, orthopnea, and sleep-disordered breathing, whereas oxygen or ventilator dependency can occur with bilateral paralysis. Common etiologies of phrenic injuries include cervical trauma, iatrogenic injury in the neck or chest, and neuralgic amyotrophy. Many patients have no identifiable etiology and are considered to have idiopathic paralysis. Diagnostic evaluation requires radiographic and pulmonary function testing, as well as electrodiagnostic assessment to quantitate the nerve deficit and determine the extent of denervation atrophy. Treatment for symptomatic diaphragm paralysis has traditionally been limited. Medical therapies and nocturnal positive airway pressure may provide some benefit. Surgical repair of the nerve injury to restore functional diaphragmatic activity, termed phrenic nerve reconstruction, is a safe and effective alternative to static repositioning of the diaphragm (diaphragm plication), in properly selected patients. Phrenic nerve reconstruction has increasingly become a standard surgical treatment for diaphragm paralysis due to phrenic nerve injury. A multidisciplinary approach at specialty referral centers combining diagnostic evaluation, surgical treatment, and rehabilitation is required to achieve optimal long-term outcomes.
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Affiliation(s)
- Matthew R Kaufman
- Institute for Advanced Reconstruction, Shrewsbury, NJ, United States; Division of Plastic and Reconstructive Surgery, UCLA Medical Center, Los Angeles, CA, United States.
| | - Nicole Ferro
- Institute for Advanced Reconstruction, Shrewsbury, NJ, United States
| | - Ethan Paulin
- Institute for Advanced Reconstruction, Shrewsbury, NJ, United States
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5
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Kaufman MR, Chang EI, Bauer T, Rossi K, Elkwood AI, Paulin E, Jarrahy R. Phrenic Nerve Reconstruction for Effective Surgical Treatment of Diaphragmatic Paralysis. Ann Plast Surg 2021; 87:310-315. [PMID: 34397519 DOI: 10.1097/sap.0000000000002896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Diaphragmatic paralysis due to phrenic nerve injury may cause orthopnea, exertional dyspnea, and sleep-disordered breathing. Phrenic nerve reconstruction may relieve symptoms and improve respiratory function. A retrospective review of 400 consecutive patients undergoing phrenic nerve reconstruction for diaphragmatic paralysis at 2 tertiary treatment centers was performed between 2007 and 2019. Symptomatic patients were identified, and the diagnosis was confirmed on radiographic evaluations. Assessment parameters included pulmonary spirometry (forced expiratory volume in 1 second and FVC), maximal inspiratory pressure, compound muscle action potentials, diaphragm thickness, chest fluoroscopy, and Short Form 36 Health Survey Questionnaire (SF-36) survey. There were 81 females and 319 males with an average age of 54 years (range, 19-79 years). The mean duration from diagnosis to surgery was 29 months (range, 1-320 months). The most common etiologies were acute or chronic injury (29%), interscalene nerve block (17%), and cardiothoracic surgery (15%). The mean improvements in forced expiratory volume in 1 second and FVC at 1 year were 10% (P < 0.01) and 8% (P < 0.05), respectively. At 2-year follow-up, the corresponding values were 22% (P < 0.05) and 18% (P < 0.05), respectively. Improvement on chest fluoroscopy was demonstrated in 63% and 71% of patients at 1 and 2-year follow-up, respectively. There was a 20% (P < 0.01) improvement in maximal inspiratory pressure, and compound muscle action potentials increased by 82% (P < 0.001). Diaphragm thickness demonstrated a 27% (P < 0.01) increase, and SF-36 revealed a 59% (P < 0.001) improvement in physical functioning. Symptomatic diaphragmatic paralysis should be considered for surgical treatment. Phrenic nerve reconstruction can achieve symptomatic relief and improve respiratory function. Increasing spirometry and improvements on Sniff from 1 to 2 years support incremental recovery with longer follow-up.
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Affiliation(s)
| | - Eric I Chang
- From the Institute for Advanced Reconstruction, Shrewsbury, NJ
| | - Thomas Bauer
- Department of Thoracic Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune City, NJ
| | - Kristie Rossi
- From the Institute for Advanced Reconstruction, Shrewsbury, NJ
| | | | - Ethan Paulin
- Department of Thoracic Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune City, NJ
| | - Reza Jarrahy
- Division of Plastic and Reconstructive Surgery, UCLA Medical Center, Los Angeles, CA
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Hannan LM, De Losa R, Romeo N, Muruganandan S. Diaphragm dysfunction: A comprehensive review from diagnosis to management. Intern Med J 2021; 52:2034-2045. [PMID: 34402156 DOI: 10.1111/imj.15491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 06/08/2021] [Accepted: 06/27/2021] [Indexed: 11/29/2022]
Abstract
Although the diaphragm represents a critical component of the respiratory pump, the clinical presentations of diaphragm dysfunction are often non-specific and can be mistaken for other more common causes of dyspnoea. While acute bilateral diaphragm dysfunction typically presents dramatically, progressive diaphragm dysfunction associated with neuromuscular disorders and unilateral hemidiaphragm dysfunction may be identified incidentally or by recognising subtle associated symptoms. Diaphragm dysfunction should be considered in individuals with unexplained dyspnoea, restrictive respiratory function tests or abnormal diaphragm position on plain chest imaging. A higher index of suspicion should occur for individuals with profound orthopnoea, those who have undergone procedures in proximity to the phrenic nerve(s) or those with co-morbid conditions that are associated with diaphragm dysfunction, particularly neuromuscular disorders. A systematic approach to the evaluation of diaphragm function using non-invasive diagnostic techniques such as respiratory function testing and diaphragm imaging can often confirm a diagnosis. Neurophysiological assessment may confirm diaphragm dysfunction and assist in identifying an underlying cause. Identifying those with or at risk of respiratory failure can allow institution of respiratory support, while specific cases may also benefit from surgical plication or phrenic nerve pacing techniques. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Liam M Hannan
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne Medicine
| | - Rebekah De Losa
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia
| | - Nicholas Romeo
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia
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Singh M, Mejia JM, Auckley D, Abdallah F, Li C, Kumar V, Englesakis M, Brull R. [The impact of unilateral diaphragmatic paralysis on sleep-disordered breathing: a scoping review]. Can J Anaesth 2021; 68:1064-1076. [PMID: 33725316 DOI: 10.1007/s12630-021-01970-y] [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: 07/05/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Unilateral diaphragm paralysis (UDP) may potentially worsen sleep-disordered breathing (SDB). Unilateral diaphragm paralysis has been associated with proximal brachial plexus blockade, such as interscalene and supraclavicular block. The impact of UDP in patients with SDB is not known in this context. The objectives of this scoping review were to explore the associations between UDP and worsening SDB severity, oxygenation, and pulmonary function. METHODS A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to include studies involving adult patients (≥ 18 yr) with SDB, where the effects of UDP on SDB severity, oxygenation, and pulmonary function were examined. RESULTS Six studies (n = 100 patients) with UDP and SDB were included. The sample population was derived exclusively from respirology-sleep clinics, and none were surgical patients. Compared with control (no UDP), UDP was associated with an increased respiratory disturbance index, most pronounced during rapid eye movement (REM) sleep and supine sleep. Supine and REM sleep were associated with obstructive and mixed (both obstructive and central) events, respectively. Compared with control, UDP was associated with a lower mean and minimum oxygen saturation and arterial oxygen tension during all sleep stages and in all body positions. The majority of UDP patients were found to have clinically significant reductions in mean forced expiratory volume in one second and forced vital capacity values, consistent with restrictive ventilatory pattern. CONCLUSION We observed an association between UDP and increasing SDB severity, particularly during REM sleep and while sleeping in the supine position. Although we identified weaknesses in study design and lack of perioperative data, anesthesiologists should be aware of this association when considering proximal brachial plexus blockade in patients with SDB.
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Affiliation(s)
- Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada. .,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Jorge M Mejia
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Faraj Abdallah
- Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Li
- Department of Respirology, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Vivek Kumar
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Marina Englesakis
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
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8
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Wang YG, Lin C, Ye SN, Xu YT, Lin XH, Ke XY, Zheng JX, Chen Y, Chen GH. Study on the correlation between OSAS and thoracic deformity in children: A retrospective single-center study in China. Int J Pediatr Otorhinolaryngol 2020; 137:110226. [PMID: 32658806 DOI: 10.1016/j.ijporl.2020.110226] [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: 05/17/2020] [Revised: 06/20/2020] [Accepted: 06/20/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the correlation between obstructive sleep apnea syndrome (OSAS) and the development of thoracic deformity in Children. METHODS A retrospective analysis was performed with the medical records of 39 pediatric OSAS patients with thoracic deformity and matching 39 without thoracic deformity as control group between January 2015 and June 2019. The contrast was performed with age, gender, height, weight, body mass index (BMI), apnea/hypopnea index (AHI), the lowest oxyhemoglobin saturation (loSpO2)at night, tonsil and adenoid size, Alkaline phosphatase (ALP)and trace elements and metals between two groups. RESULTS BMI, AHI, the lowest SpO2, Phosphorus and Zinc were the risk factors of thoracic deformity. Age, gender, disease history, the size of tonsil and adenoid, ALP and other trace elements were no significant difference occurred between two groups. CONCLUSION OSAS characterized by apnea and hypoxia which are caused by narrow upper airway may be one cause of thoracic deformity in children. Pediatricians, thoracic and otolaryngologic surgeons should be alert to OSAS when thoracic deformities are diagnosed in children.
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Affiliation(s)
- Ying-Ge Wang
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Chang Lin
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Sheng-Nan Ye
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Yuan-Teng Xu
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Xiao-Hong Lin
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Xiao-Ying Ke
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Jin-Xing Zheng
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Ying Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
| | - Guo-Hao Chen
- Department of Otorhinolaryngology, The First Affiliated Hospital of Fujian Medical University, Fujian Otorhinolaryngology Institute, Fuzhou, 350000, Fujian, China.
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9
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Coexisting central and obstructive sleep apnea and mild diurnal hypoventilation associated with unilateral diaphragmatic dysfunction and brainstem lesion. Neurophysiol Clin 2020; 50:375-381. [PMID: 32650962 DOI: 10.1016/j.neucli.2020.06.003] [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: 03/07/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 11/23/2022] Open
Abstract
A 63-year old man was diagnosed with coexisting central (CSA) and obstructive (OSA) sleep apnea, crescendo-decrescendo (CD) periodic breathing (PB), frequent sustained desaturation hypoxemia events related to prolonged hypopnea and mild diurnal hypoventilation. Unilateral diaphragmatic dysfunction (DD) related to diabetic phrenic neuropathy was identified. Magnetic resonance imaging (MRI) scans of the head disclosed frontal-subcortical white matter (WM) lesions, while brainstem MRI found a small punctiform defect in the median area of the pons. Continuous positive airway pressure (CPAP) therapy was ineffective, while a one-month bi-level positive airway pressure (BIPAP) trial provided better outcomes.
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10
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Physical Activity Intolerance and Cardiorespiratory Dysfunction in Patients with Moderate-to-Severe Traumatic Brain Injury. Sports Med 2020; 49:1183-1198. [PMID: 31098990 DOI: 10.1007/s40279-019-01122-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Moderate-to-severe traumatic brain injury (TBI) is a chronic health condition with multi-systemic effects. Survivors face significant long-term functional limitations, including physical activity intolerance and disordered sleep. Persistent cardiorespiratory dysfunction is a potentially modifiable yet often overlooked major contributor to the alarmingly high long-term morbidity and mortality rates in these patients. This narrative review was developed through systematic and non-systematic searches for research relating cardiorespiratory function to moderate-to-severe TBI. The literature reveals patients who have survived moderate-to-severe TBI have ~ 25-35% reduction in maximal aerobic capacity 6-18 months post-injury, resting pulmonary capacity parameters that are reduced 25-40% for weeks to years post-injury, increased sedentary behavior, and elevated risk of cardiorespiratory-related morbidity and mortality. Synthesis of data from other patient populations reveals that cardiorespiratory dysfunction is likely a consequence of ventilator-induced diaphragmatic dysfunction (VIDD), which is not currently addressed in TBI management. Thus, cardiopulmonary exercise testing should be routinely performed in this patient population and those with cardiorespiratory deficits should be further evaluated for diaphragmatic dysfunction. Lack of targeted treatment for underlying cardiorespiratory dysfunction, including VIDD, likely contributes to physical activity intolerance and poor functional outcomes in these patients. Interventional studies have demonstrated that short-term exercise training programs are effective in patients with moderate-to-severe TBI, though improvement is variable. Inspiratory muscle training is beneficial in other patient populations with diaphragmatic dysfunction, and may be valuable for patients with TBI who have been mechanically ventilated. Thus, clinicians with expertise in cardiorespiratory fitness assessment and exercise training interventions should be included in patient management for individuals with moderate-to-severe TBI.
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11
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Diaphragmatic dysfunction. Pulmonology 2019; 25:223-235. [DOI: 10.1016/j.pulmoe.2018.10.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 10/16/2018] [Accepted: 10/28/2018] [Indexed: 12/13/2022] Open
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Abstract
Gas exchange between the atmosphere and the human body depends on the lungs and the function of the respiratory pump. The respiratory pump consists of the respiratory control center located in the brain, bony rib cage, diaphragm, and intercostal, accessory, and abdominal muscles. A variety of muscles serve to fine-tune adjustments of ventilation to metabolic demands. Appropriate evaluation and interventions can prevent respiratory complications and prolong life in individuals with neuromuscular diseases. This article discusses normal function of the respiratory pump, general pathophysiologic issues, and abnormalities in more common neuromuscular diseases.
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Affiliation(s)
- Joshua O Benditt
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98119, USA.
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13
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Abstract
Neuromuscular and chest wall diseases include a diverse group of conditions that share common risk factors for sleep-disordered breathing, including respiratory muscle weakness and/or thoracic restriction. Sleep-disordered breathing results from both the effects of normal sleep on ventilation and the additional challenges imposed by the underlying disorders. Patterns of sleep- disordered breathing vary with the specific diagnosis and stage of disease. Sleep hypoventilation precedes diurnal respiratory failure and may be difficult to recognize clinically because symptoms are nonspecific. Polysomnography has a role in both the diagnosis of sleep-disordered breathing and in the titration of effective noninvasive positive-pressure ventilation.
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Affiliation(s)
- Janet Hilbert
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA.
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Shahshahani A, Laverdiere C, Bhadra S, Zilic Z. Ultrasound Sensors for Diaphragm Motion Tracking: An Application in Non-Invasive Respiratory Monitoring. SENSORS (BASEL, SWITZERLAND) 2018; 18:E2617. [PMID: 30096945 PMCID: PMC6111564 DOI: 10.3390/s18082617] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 12/30/2022]
Abstract
This paper introduces a novel respiratory detection system based on diaphragm wall motion tracking using an embedded ultrasound sensory system. We assess the utility and accuracy of this method in evaluating the function of the diaphragm and its contribution to respiratory workload. The developed system is able to monitor the diaphragm wall activity when the sensor is placed in the zone of apposition (ZOA). This system allows for direct measurements with only one ultrasound PZT5 piezo transducer. The system generates pulsed ultrasound waves at 2.2 MHz and amplifies reflected echoes. An added benefit of this system is that due to its design, the respiratory signal is less subject to motion artefacts. Promising results were obtained from six subjects performing six tests per subject with an average respiration detection sensitivity and specificity of 84% and 93%, respectively. Measurements were compared to a gold standard commercial spirometer. In this study, we also compared our measurements to other conventional methods such as inertial and photoplethysmography (PPG) sensors.
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Affiliation(s)
- Amirhossein Shahshahani
- Department of Electrical and Computer Engineering, McGill university, Montreal, QC H3A 0E9, Canada.
| | - Carl Laverdiere
- Faculty of Medicine, McGill University, Montreal, QC H3A 0E9, Canada.
| | - Sharmistha Bhadra
- Department of Electrical and Computer Engineering, McGill university, Montreal, QC H3A 0E9, Canada.
| | - Zeljko Zilic
- Department of Electrical and Computer Engineering, McGill university, Montreal, QC H3A 0E9, Canada.
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Koopman M, Vanfleteren LEGW, Steijns S, Wouters EFM, Sprooten R. Increased exercise tolerance using daytime mouthpiece ventilation for patients with diaphragm paralysis. Breathe (Sheff) 2017; 13:225-229. [PMID: 28894483 PMCID: PMC5584713 DOI: 10.1183/20734735.005817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Diaphragmatic paralysis can be either unilateral or bilateral. It is a rare condition and can have several causes [1]. As the diaphragm is the most important muscle of inspiration, diaphragmatic paralysis commonly complicates ventilation. Mouthpiece ventilation can improve exercise tolerance in patients with unilateral or bilateral diaphragm paralysishttp://ow.ly/X2Pd30dCT7n
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Affiliation(s)
- Maud Koopman
- Dept of Research and Education, CIRO+ (Center of Expertise for Chronic Organ Failure), Horn, the Netherlands
| | - Lowie E G W Vanfleteren
- Dept of Research and Education, CIRO+ (Center of Expertise for Chronic Organ Failure), Horn, the Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Sander Steijns
- Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands.,Centre of Home Mechanical Ventilation, MUMC+, Maastricht, the Netherlands
| | - Emiel F M Wouters
- Dept of Research and Education, CIRO+ (Center of Expertise for Chronic Organ Failure), Horn, the Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Roy Sprooten
- Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands.,Centre of Home Mechanical Ventilation, MUMC+, Maastricht, the Netherlands
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16
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Abstract
Bilateral diaphragmatic paralysis is a known cause of respiratory failure. Diagnosis can be difficult, particularly in the acute setting. We present the case of a gentleman diagnosed with bilateral diaphragmatic paralysis secondary to phrenic neuropathy in the setting of cervical spondylosis.
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17
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Sleep-Disordered Breathing in Neuromuscular Disease: Diagnostic and Therapeutic Challenges. Chest 2017; 152:880-892. [PMID: 28372949 DOI: 10.1016/j.chest.2017.03.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/23/2017] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Normal sleep-related rapid eye movement sleep atonia, reduced lung volumes, reduced chemosensitivity, and impaired airway dilator activity become significant vulnerabilities in the setting of neuromuscular disease. In that context, the compounding effects of respiratory muscle weakness and disease-specific features that promote upper airway collapse or cause dilated cardiomyopathy contribute to various sleep-disordered breathing events. The reduction in lung volumes with neuromuscular disease is further compromised by sleep and the supine position, exaggerating the tendency for upper airway collapse and desaturation with sleep-disordered breathing events. The most commonly identified events are diaphragmatic/pseudo-central, due to a decrease in the rib cage contribution to the tidal volume during phasic rapid eye movement sleep. Obstructive and central sleep apneas are also common. Noninvasive ventilation can improve survival and quality of sleep but should be used with caution in the context of dilated cardiomyopathy or significant bulbar symptoms. Noninvasive ventilation can also trigger sleep-disordered breathing events, including ineffective triggering, autotriggering, central sleep apnea, and glottic closure, which compromise the potential benefits of the intervention by increasing arousals, reducing adherence, and impairing sleep architecture. Polysomnography plays an important diagnostic and therapeutic role by correctly categorizing sleep-disordered events, identifying sleep-disordered breathing triggered by noninvasive ventilation, and improving noninvasive ventilation settings. Optimal management may require dedicated hypoventilation protocols and a technical staff well versed in the identification and troubleshooting of respiratory events.
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18
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Oruc O, Sarac S, Afsar GC, Topcuoglu OB, Kanbur S, Yalcinkaya I, Tepetam FM, Kirbas G. Is polysomnographic examination necessary for subjects with diaphragm pathologies? Clinics (Sao Paulo) 2016; 71:506-10. [PMID: 27652831 PMCID: PMC5004572 DOI: 10.6061/clinics/2016(09)04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/28/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. METHODS This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. RESULTS Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. CONCLUSION All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented.
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Affiliation(s)
- Ozlem Oruc
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Chest Diseases, Istanbul, Turkey
- E-mail:
| | - Sema Sarac
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Chest Diseases, Istanbul, Turkey
| | - Gulgun Cetintas Afsar
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Chest Diseases, Istanbul, Turkey
| | - Ozgur Bilgin Topcuoglu
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Neurology, Istanbul, Turkey
| | - Serda Kanbur
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Thoracic Surgery, Istanbul, Turkey
| | - Irfan Yalcinkaya
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Thoracic Surgery, Istanbul, Turkey
| | - Fatma Merve Tepetam
- Sureyyapasa Chest & Thoracic Surgery Training and Research Hospital, Allergy and Immunology, Istanbul, Turkey
| | - Gokhan Kirbas
- Faculty of Medicine Dicle University, Chest Diseases, Diyarbakir, Turkey
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Irfan M, Selim B, Rabinstein AA, St. Louis EK. Neuromuscular disorders and sleep in critically ill patients. Crit Care Clin 2015; 31:533-50. [PMID: 26118919 PMCID: PMC5034932 DOI: 10.1016/j.ccc.2015.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sleep-disordered breathing (SDB) is a frequent presenting manifestation of neuromuscular disorders and can lead to significant morbidity and mortality. If not recognized and addressed early in the clinical course, SDB can lead to clinical deterioration with respiratory failure. The pathophysiologic basis of SDB in neuromuscular disorders, clinical features encountered in specific neuromuscular diseases, and diagnostic and management strategies for SDB in neuromuscular patients in the critical care setting are reviewed. Noninvasive positive pressure ventilation has been a crucial advance in critical care management, improving sleep quality and often preventing or delaying mechanical ventilation and improving survival in neuromuscular patients.
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Affiliation(s)
- Muna Irfan
- Street Address: Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Bernardo Selim
- Street Address; Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | | | - Erik K. St. Louis
- Street Address; Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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