Management of Diaphragm Paralysis and Eventration

An elevated diaphragm may be due to eventration or paralysis. Diaphragm elevation is often asymptomatic and found incidentally on imaging. Fluoroscopic testing can be used to differentiate eventration (no paradoxic motion) from paralysis (paradoxic motion). Regardless of etiology, a diaphragm plication is indicated in all symptomatic patients with an elevated diaphragm. Plication can be approached either from a thoracic or abdominal approach, though most thoracic surgeons perform minimally invasive thoracoscopic plication. The goal of plication is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm. Diaphragm plication is safe, has excellent outcomes, and is associated with symptom improvement.

Orthopnea secondary to brachial plexitis with bilateral diaphragmatic paralysis

BACKGROUND

Diaphragmatic paralysis can present with orthopnea. We report a unique presentation of bilateral diaphragmatic paralysis, an uncommon diagnosis secondary to an unusual cause, brachial plexitis. This report thoroughly describes the patient's presentation, workup, management, and outcome. It also reviews the literature on diaphragmatic paralysis and Parsonage-Turner syndrome.

CASE PRESENTATION

A 50-year-old male patient developed insidious orthopnea associated with left shoulder and neck pain over three months with no associated symptoms. On examination, marked dyspnea was observed when the patient was asked to lie down; breath sounds were present and symmetrical, and the neurological examination was normal. The chest radiograph showed an elevated right hemidiaphragm. Echocardiogram was normal. There was a 63% positional reduction in Forced Vital Capacity and maximal inspiratory and expiratory pressures on pulmonary function testing. The electromyogram was consistent with neuromuscular weakness involving both brachial plexus and diaphragmatic muscle (Parsonage and Turner syndrome).

CONCLUSIONS

Compared to unilateral, bilateral diaphragmatic paralysis may be more challenging to diagnose. On PFT, reduced maximal respiratory pressures, especially the maximal inspiratory pressure, are suggestive. Parsonage-Turner syndrome is rare, usually with unilateral diaphragmatic paralysis, but bilateral cases have been reported.

Persistent unilateral diaphragmatic paralysis in the course of Coronavirus Disease 2019 pneumonia: a case report

Coronavirus Disease 2019 infections can cause a wide range of symptoms, particularly in the respiratory system. Diaphragmatic paralysis is a rare condition that is poorly documented in the literature. We present the case of a 38-year-old Caucasian male adult who developed unilateral diaphragmatic paralysis during the course of the disease. The patient presented to the Emergency Department with fever, cough, and dyspnea, was admitted, and was immediately fitted with a high flow nasal cannula. When his condition worsened eight days later, he was admitted to the Intensive Care Unit and a tracheostomy was performed. A CT scan of the chest revealed significant left diaphragm elevation. On the 48th day, the patient gradually improved and was discharged. The paralysis of the diaphragm persisted three months later in the follow-up examination. This case illustrates a possible neuromuscular virus invasion that may have an impact on the patient's health after discharge.

High-flow nasal cannula oxygen therapy was effective for dysphagia associated with respiratory muscle paralysis due to cervical spinal cord injury: A case report

RATIONALE

Respiratory muscle paralysis due to low cervical spinal cord injury (CSCI) can lead to dysphagia. Noninvasive positive airway pressure (PAP) therapy can effectively treat this type of dysphagia. High-flow nasal cannula (HFNC) oxygen therapy can generate a low level of positive airway pressure resembling PAP therapy, it may improve the dysphagia.

PATIENT CONCERNS

The patient was an 87-year-old man without preexisting dysphagia. He suffered a CSCI due to a dislocated C5/6 fracture, without brain injury, and underwent emergency surgery. Postoperatively (day 2), he complained of dysphagia, and the intervention was initiated.

DIAGNOSIS

Based on clinical findings, dysphagia in this case, may have arisen due to impaired coordination between breathing and swallowing, which typically occurs in patients with CSCI who have reduced forced vital capacity.

INTERVENTIONS

HFNC oxygen therapy was started immediately after the surgery, and swallowing rehabilitation was started on Day 2. Indirect therapy (without food) and direct therapy (with food) were applied in stages. HFNC oxygen therapy appeared to be effective because swallowing function temporarily decreased when the HFNC oxygen therapy was changed to nasal canula oxygen therapy.

OUTCOMES

Swallowing function of the patient improved and he did not develop aspiration pneumonia.

LESSONS

HFNC oxygen therapy improved swallowing function in a patient with dysphagia associated with respiratory-muscle paralysis following a CSCI. It may have prolonged the apnea tolerance time during swallowing and may have improved the timing of swallowing. HFNC oxygen therapy can facilitate both indirect and direct early swallowing therapy to restore both swallowing and respiratory function.

[DIAPHRAGMATIC PARALYSIS]

One-sided diaphragmatic paralysis is a common phenomenon which is usually a-symptomatic. In case of acute onset or if there is an underlying lung disease, the phenomenon may be symptomatic and even limiting. In this article, we present a patient who arrived with subacute shortness of breath when lying down. She underwent thorough investigations but, as happens in most cases, the cause of the paralysis was not identified and it remains idiopathic. The authors present an overview of the etiology, differential diagnosis and treatment of diaphragmatic paralysis.

Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis

OBJECTIVE

Awareness with paralysis is a devastating complication for mechanically ventilated patients and can carry long-term psychologic sequelae. Hundreds of thousands of patients require mechanical ventilation in the emergency department and ICU annually, yet awareness has only been rigorously examined in the operating room (incidence ~0.1%). This report collates the global literature regarding the incidence of awareness with paralysis outside of the operating room.

DATA SOURCES

We searched OvidMedline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, conference proceedings, and reference lists.

STUDY SELECTION

Randomized or nonrandomized studies (except single case studies) reporting on awareness with paralysis in the emergency department or ICU were eligible.

DATA EXTRACTION

Two independent reviewers screened abstracts for eligibility.

DATA SYNTHESIS

The search identified 4,454 potentially eligible studies. Seven studies (n = 941 patients) were included for analysis. A random effects meta-analysis of proportions along with multiple subgroup analyses was performed. Significant between-study heterogeneity in reporting of awareness with paralysis was noted, and the quality of the evidence was low. Analyses stratified by: 1) good-quality studies and 2) use of the modified Brice questionnaire to detect awareness revealed estimates of 3.4% (95% CI, 0-10.2%) and 1.9% (95% CI, 1.0-3.0%), respectively.

CONCLUSIONS

The incidence of awareness with paralysis in mechanically ventilated patients in the emergency department and ICU, as evaluated in a small number of qualifying studies from this comprehensive systematic review, appears much higher than that reported from the operating room. Given the clinical and statistical heterogeneity, caution is warranted in the interpretation of these findings. Further high-quality studies are needed to both define the true incidence and to target the prevention of awareness with paralysis in this vulnerable patient cohort.

Bilateral diaphragmatic paralysis and Lyme neuroborreliosis. Ten years of follow-up

Borrelia burgdorferi infection (Lyme disease) is one of the few identifiable causes of neuralgic amyotrophy. Bilateral diaphragmatic paralysis is considered rare in borreliosis, and the pattern of long-term recovery of diaphragm function is also uncertain. Transdiaphragmatic pressure is the gold standard for diagnosis of bilateral diaphragmatic paralysis, a study that has been reported on few occasions. We present a case of neuralgic amyotrophy associated with Borrelia infection and bilateral diaphragmatic paralysis that provides a detailed follow-up of the spirometric evolution, of the maximum static pressures in the mouth and of transdiaphragmatic pressure from the onset of symptoms and the long term. This case allows us to know one of the possible evolutionary profiles of diaphragmatic dysfunction in neuralgic amyotrophy due to borreliosis.

Fontan Failure Secondary to Charcot-Marie-Tooth-Induced Phrenic Neuropathy

Charcot-Marie-Tooth disease comprises a vast array of defects in myelin integrity that causes progressive peripheral sensorimotor neuropathy. It is the most prevalent inherited peripheral neuropathy, and it can affect the management of coexisting medical conditions. We report the case of a 25-year-old woman who had undergone successful Fontan surgery during childhood, but her Fontan circulation failed as a result of diaphragmatic paresis caused by Charcot-Marie-Tooth disease type 1A. This diagnosis precluded cardiac transplantation.

[An unrecognized cause of dyspnoea]

BACKGROUND

Neuralgic amyotrophy is characterised by pain in the neck or shoulder region, followed by neuropathy of both motor and sensory nerves of the brachial plexus. The incidence of this condition is estimated at 1/1000 per year. In a rare variant of the syndrome, involvement of both phrenic nerves can occur, leading to diaphragmatic paralysis and severe orthopnoea.

CASE DESCRIPTION

A 67-year-old woman was referred to us with acute orthopnoea. Imaging studies showed bilateral diaphragmatic paralysis, and electromyography (EMG) confirmed neuropathy of both phrenic nerves. The diagnosis was bilateral neuralgic amyotrophy. The patient received nocturnal ventilation support via nasal high flow oxygen therapy. This symptomatic treatment had a positive effect.

CONCLUSION

Isolated phrenic nerve neuropathy is a rare variant of neuralgic amyotrophy, leading to orthopnoea. Recovery is slow and frequently incomplete. Supportive treatment with non-invasive ventilation support is necessary to improve the patient's quality of life.

[Progressive paralysis of the diaphragm following intra-abdominal chemotherapy]

INTRODUCTION

In patients presenting with intra-abdominal tumor and peritoneal carcinomatosis, cytoreductive surgery associated with hyperthermic chemotherapy may offer improved survival. We describe a case of diaphragmatic paralysis following that kind of procedure.

CASE REPORT

A 60-year-old woman presented with respiratory insufficiency following cytoreductive surgery and intra-abdominal hyperthermic chemotherapy performed for pseudomyxoma intraperitonei. Pulmonary function assessment demonstrated a restrictive pattern. Three successive chest CT-scans demonstrated a thinning diaphragm muscle. Respiratory insufficiency eventually led to the death of our patient.

CONCLUSION

We conclude in favor of a muscular degeneration of the diaphragm consecutive to the combined effect of cytoreductive surgery and intraperitoneal chemotherapy. Owing to the unusual nature of this complication, we did not consider it as a hypothesis at an early point in this patient's management. We think physicians should be aware of such a complication in order to consider it in a timely way. We recommend performing a biopsy of the diaphragm for pathology examination to assess muscular degeneration.

Is polysomnographic examination necessary for subjects with diaphragm pathologies?

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.

Acute Neuromuscular Respiratory Failure

PURPOSE OF REVIEW

Neurologists working in the hospital are often called to evaluate patients with severe muscle weakness. Some of these patients can develop ventilatory compromise and require admission to the intensive care unit (ICU). This article reviews the general evaluation of neuromuscular respiratory failure, discusses its differential diagnosis, and provides practical advice on the management of its most common causes.

RECENT FINDINGS

Determining the cause of acute neuromuscular respiratory failure is crucial because functional prognosis is poor in patients for whom the cause cannot be defined. The differential diagnosis is extensive, but the first step is to discriminate between cases related to a primary neurologic disease (primary neuromuscular respiratory failure) and those provoked by systemic disease, most often critical illness from sepsis and multiorgan failure (secondary neuromuscular respiratory failure). Guillain-Barré syndrome (GBS) and myasthenic crisis are the two most frequent causes of primary neuromuscular respiratory failure. Although they are both autoimmune conditions that benefit from the administration of plasma exchange or IV immunoglobulin (IVIg), they are otherwise very different disorders with unique features and distinct complications. Optimal strategies for mechanical ventilation also differ between these two conditions; while myasthenic crisis is ideally managed with noninvasive bilevel positive airway pressure (BiPAP) ventilation, GBS demands early intubation.

SUMMARY

Prompt recognition of neuromuscular respiratory failure can be lifesaving, and identification of its cause has substantial prognostic implications. Adequate management of these patients requires a multidisciplinary team with the neurologist at its center, not only to guide the diagnostic evaluation but often also to prescribe the optimal management.

Failing phrenics: an obscure cause of exertional dyspnea: Case report and literature review

INTRODUCTION

Idiopathic phrenic nerve palsy is a rare cause of exertional dyspnea. We present a case of a patient presenting with worsening dyspnea of an unknown etiology found to be related to bilateral phrenic nerve palsy.

DISCUSSION

Forty-two-year-old man presented to our emergency department with exertional dyspnea, orthopnea, and a left lower lobe consolidation treated initially as bronchitis by his primary physician as an outpatient, then subsequently as pneumonia at another institution, with no improvement in symptomatology. After admission to our hospital, CT chest demonstrated only supradiaphragmatic atelectatic changes. Echocardiography was normal. Bronchoscopy was contemplated however the patient could not lie flat. A fluoroscopic sniff test demonstrated diaphragmatic dysfunction and pulmonary function tests revealed restrictive pulmonary disease with evidence of neuromuscular etiology. Nerve conduction studies confirmed bilateral phrenic neuropathy. He was referred to a specialized neuromuscular disease center where subsequent workup did not demonstrate any specific etiology. A sleep study confirmed sleep disordered breathing suggestive of diaphragmatic paralysis and he was discharged on bi-level positive pressure ventilation.

CONCLUSION

This is a unique case of exertional dyspnea and orthopnea from diaphragmatic paresis caused by bilateral phrenic nerve palsy where the initial workup for pulmonary and cardiovascular etiologies was essentially unremarkable. Shortness of breath and orthopnea caused by phrenic neuropathy is a rare condition, yet has a variety of etiologies. Our case suggests a template to the diagnostic approach, management, and follow up of bilateral phrenic nerve palsy.

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.

Prolonged hemidiaphragmatic paresis following continuous interscalene brachial plexus block: A case report

Interscalene brachial plexus block provides effective anesthesia and analgesia for shoulder surgery. One of the disadvantages of this technique is the risk of hemidiaphragmatic paresis, which can occur as a result of phrenic nerve block and can cause a decrease in the pulmonary function, limiting the use of the block in patients with reduced functional residual capacity or a preexisting pulmonary disease. However, it is generally transient and is resolved over the duration of the local anesthetic's action.We present a case of a patient who experienced prolonged hemidiaphragmatic paresis following a continuous interscalene brachial plexus block for the postoperative pain management of shoulder surgery, and suggest a mechanism that may have led to this adverse effect.Nerve injuries associated with peripheral nerve blocks may be caused by several mechanisms. Our findings suggest that perioperative nerve injuries can occur as a result of combined mechanical and chemical injuries.

Bilateral Diaphragmatic Paralysis in a Patient With Critical Illness Polyneuropathy: A Case Report

Bilateral diaphragmatic paralysis (BDP) manifests as respiratory muscle weakness, and its association with critical illness polyneuropathy (CIP) was rarely reported. Here, we present a patient with BDP related to CIP, who successfully avoided tracheostomy after diagnosis and management.A 71-year-old male presented with acute respiratory failure after sepsis adequately treated. Repeated intubation occurred because of carbon dioxide retention after each extubation. After eliminating possible factors, septic shock-induced respiratory muscle weakness was suspected. Physical examination, a nerve conduction study, and chest ultrasound confirmed our impression.Pulmonary rehabilitation and reconditioning exercises were arranged, and the patient was discharged with a diagnosis of BDP.The diagnosis of BDP is usually delayed, and there are only sporadic reports on its association with polyneuropathy, especially in patients with preserved limb muscle function. Therefore, when physicians encounter patients that are difficult to wean from mechanical ventilation, CIP associated with BDP should be considered in the differential diagnosis.

Patient with spinal muscular atrophy with respiratory distress type 1 presenting initially with hypertonia

Spinal muscular atrophy with respiratory distress type 1 (SMARD1) is a rare autosomal recessive neuromuscular disorder caused by mutations in the IGHMBP2 gene and characterized by life-threatening respiratory distress due to irreversible diaphragmatic paralysis between 6weeks and 6months of age. In this study, we describe a two-month-old boy who presented with hypertonia at first and developed to hypotonia progressively, which was in contrast to the manifestations reported previously. Bone tissue compromise was also observed as one of the unique symptoms. Muscle biopsy indicated mild myogenic changes. He was misdiagnosed until genetic screening to be confirmed as SMARD1. SMARD1 is a clinical heterogeneous disease and this case broadens our perception of its phenotypes.

Bedside sonographic evaluation of the diaphragm in ventilator dependent patients with amyotrophic lateral sclerosis. A report of two cases

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with progressive and inexorable loss of bulbar and limb functions. Respiratory muscle weakness and failure is a common complication late in the course of disease. Bedside ultrasonography of the diaphragm was done in two ventilator dependent patients with ALS. Thickness of the diaphragm was markedly reduced during both end expiration and end of deep inspiration. The degree of diaphragmatic thickening was also significantly reduced. The diaphragmatic excursion during deep inspiration was sub-optimal. The findings were consistent with diaphragmatic atrophy and paralysis. Sonography of the diaphragm can be a useful non-invasive bedside tool for the diagnosis and follow up of diaphragmatic involvement in patients with amyotrophic lateral sclerosis.

Isolierte, unilaterale Parese des N. phrenicus nach Pneumonie und Pleuritis

Unilateral diaphragmatic paralysis has many causes. Tumor and trauma are the two most frequent identifiable causes. Infectious processes involving the lung and/or mediastinum may result in temporary or permanent diaphragmatic paralysis. We report the case of an 81-year old man who suffered from right-sided pneumonia followed by a period of several months with exertion dyspnea. Radiological examinations showed an elevated right diaphragm, abnormal restrictive lung function, and impaired diaphragmatic muscle strength. The neurophysiological studies provided evidence of a partial phrenic nerve lesion. We discuss the differential diagnosis of isolated phrenic nerve lesions with particular regard to infections.

Myasthenia gravis: a rare cause of orthopnoea due to bilateral diaphragmatic paralysis

A case of a 68-year-old patient with bronchial asthma who presented with orthopnoea and respiratory failure in supine position is presented.

An important cause of dyspnea after coronary artery bypass grafting: phrenic nerve paralysis

Diaphragmatic paralysis (DP) due to phrenic nerve paralysis is a rare complication after cardiac surgery. A 48-year-old male patient developed respiratory insufficiency, tachypnea, sinus tachycardia, chest pain, pneumonia, and fever immediately after coronary artery bypass grafting. Paradoxical movement of the epigastrium was noted during spontaneous ventilation and the chest X-ray showed elevation of the left hemidiaphragm. The diagnosis of DP was confirmed by ultrasonographic assessment. Antibiotherapy and intermittent positive airway pressure ventilation by a nasal mask resulted in significant improvement in the general condition of the patient. Respiratory problems were observed only on exertion. Spontaneous recovery of DP was considered and the patient was discharged 10 days after surgery with grade 1 dyspnea. However, after six months of follow-up, increased elevation of the left hemidiaphragm was noted on the chest X-ray with worsening respiratory discomfort even at rest. Thoracoscopic diaphragmatic plication was performed. After the operation, dyspnea disappeared, the chest X-ray showed the left hemidiaphragm in its normal position, and there was marked improvement in spirometric values.

An unusual complication of dengue infection

We present an unusual complication of dengue infection resulting in postviral phrenic neuropathy and diaphragmatic paralysis in a 34-year-old man. There is a paucity of literature on this condition, with postviral neuropathies previously reported to be associated commonly with herpes zoster, poliovirus, and rarely, West Nile virus and human immunodeficiency virus infections. To our knowledge, this is the first reported case of flavivirus causing isolated postviral phrenic neuropathy and diaphragmatic paralysis.

Diaphragmatic paralysis: a clinical imitator of cardiorespiratory diseases

Diaphragmatic paralysis has a predictable effect on lung function. However, the symptoms depend on the preexisting heart-lung diseases and may mimic various cardiorespiratory processes. We describe the presentation in six patients. In a fit man, unilateral diaphragmatic paralysis caused dyspnea only at strenuous exercise. In a patient with emphysema it caused dyspnea mainly when carrying light weights. In another patient with emphysema it caused life-threatening hypoxemia simulating parenchymal lung disease. A patient with mild chronic obstructive lung disease and nocturnal wheezing following the onset of ULDP was believed for 15 years to have asthma. A patient with bilateral diaphragmatic weakness had severe choking sensation only in the supine position, simulating upper airway obstruction or heart failure. Afemale patient suffered nocturnal sweating due to ULDP. The clinical manifestations of diaphragmatic paralysis vary and can mimic a wide range of cardiorespiratory diseases.

Diaphragmatic paralysis following minor cervical trauma

Two asthmatic patients developed unilateral diaphragmatic paralysis from phrenic nerve injury, in one case following cervical chiropractic manipulation and in the other after a motorcycle accident. Both presented with increased dyspnea and orthopnea. Diagnosis, severity, and level of the lesion were established by neurophysiological methods, which are preferred to chest radiography and diaphragmatic ultrasonography. In spite of only partial electrophysiological recovery of the nerve, both patients were asymptomatic 1 year later.

Diaphragm paralysis definitively diagnosed by ultrasonography and postural dependence of dynamic lung volumes after seven decades of dysfunction

Unilateral diaphragm paralysis is an important and often unrecognized cause of dyspnea. In patients with appropriate risk factors, such as prior head and neck surgery and presentation of positional dyspnea or dyspnea on submersion, unilateral diaphragmatic paralysis should be considered. We present our approach to the diagnosis of diaphragm paralysis and demonstrate the utility of upright/supine spirometry and M-mode ultrasonography in these patients' evaluation.

Evaluation and management of respiratory muscle dysfunction in ALS

Neuromuscular respiratory failure is the cause of death in the majority of patients with ALS. Respiratory muscle dysfunction impacts on quality of life and survival. Attentive management of respiratory muscle weakness is an important aspect of the management of the ALS patient. The respiratory muscles may be thought of as four functional groups: the inspiratory muscles, the expiratory muscles, the accessory muscles of respiration, and the upper airway muscles. This paper will review the structure and function of the neuromuscular respiratory system, and the evaluation and management of respiratory muscle dysfunction in ALS patients.

Spontaneous recovery of diaphragmatic strength in unilateral diaphragmatic paralysis

The aim of the present study was to evaluate diaphragmatic strength in patients with unilateral diaphragmatic paralysis and to determine whether patients with recent diaphragm paralysis develop lower inspiratory pressure than patients with longstanding diaphragmatic paralysis. Twenty patients (16 men and 4 women, 62+/-12 years) and six control subjects were included (4 men and 2 women, 53+/-15 years) in the study. Esophageal pressure during sharp sniff (Pes,sniff), bilateral cervical phrenic nerve magnetic stimulation (Pes,cms) and unilateral phrenic nerve stimulation (Pes,ums) (in nine patients) were measured. Sixteen patients presented right diaphragmatic paralysis and four, left diaphragmatic paralysis. Pes,sniff was higher in control subjects than in patients with diaphragmatic paralysis (respectively 110+/-22 cmH2O and 82+/-24 cmH2O, P<0.05). There was no difference in Pes,cms between patients with diaphragmatic paralysis and control subjects (14+/-7 cmH2O vs. 16+/-4 cmH2O; ns). Pes,ums after stimulation of the affected phrenic nerve was less than 4 cmH2O, was 8+/-2 cmH2O after stimulation of the intact phrenic nerve and was correlated to Pes,cms (R=0.87, P<0.01). There was a positive correlation between Pes,cms, Pes,ums of the intact hemidiaphragm, Pes,sniff and the time from the onset of symptoms and the diaphragmatic explorations (respectively R=0.86, P<0.0001; R=0.72, P<0.05; R=0.48, P<0.05). In conclusion, diaphragmatic strength after unilateral diaphragmatic paralysis seems to improve with time.

Respiratory failure in a patient with antecedent poliomyelitis: Amyotrophic lateral sclerosis or post-polio syndrome?

We report a 69-year-old man who developed paralytic poliomyelitis in childhood and then decades later suffered from fatal respiratory failure. Six months before this event, he had progressive weight loss and shortness of breath. He had severe muscular atrophy of the entire right leg as a sequela of the paralytic poliomyelitis. He showed mild weakness of the facial muscle and tongue, dysarthria, and severe muscle atrophy from the neck to proximal upper extremities and trunk, but no obvious pyramidal signs. Electromyogram revealed neurogenic changes in the right leg, and in the paraspinal, sternocleidomastoid, and lingual muscles. There was a slight increase in central motor conduction time from the motor cortex to the lumbar anterior horn. Pulmonary function showed restrictive ventilation dysfunction, which was the eventual cause of death. Some neuropathological features were suggestive of amyotrophic lateral sclerosis (ALS), namely Bunina bodies. In patients with a history of paralytic poliomyelitis who present after a long stable period with advanced fatal respiratory failure, one may consider not only respiratory impairment from post-polio syndrome but also the onset of ALS.

Respiratory failure in infants due to spinal muscular atrophy with respiratory distress type 1

BACKGROUND

Spinal muscular atrophy with respiratory distress type 1 (SMARD1) is a rare autosomal recessive neuromuscular disease of unknown prevalence characterized by degeneration of anterior horn alpha-motoneurons and manifesting in the first 6months of life as life-threatening irreversible diaphragmatic paralysis associated with progressive symmetrical muscular weakness (distal lower limbs mainly involved), muscle atrophy, and peripheral sensory neuropathy.

SETTING

Pediatric intensive care unit of tertiary care hospital.

PATIENTS

We present two new cases of SMARD1 and report two new mutations in the gene IGHMBP2 which encodes immunoglobulin mu-binding protein 2 on chromosome 11q13.

CONCLUSIONS

SMARD1 is a poor-prognosis disease that should be considered when acute respiratory insufficiency, of suspected neuromuscular or unclear cause, develops during the first 6months of life. Diaphragmatic paralysis, manifesting as dyspnea and paradoxical respiration, is the most prominent presenting sign and diaphragmatic motility should be investigated early by fluoroscopy or ultrasound. Electromyography and nerve conduction studies revealing peripheral motor and sensory neuropathy then suggest the diagnosis which should be confirmed by genetic analysis.

Idiopathic bilateral diaphragmatic paresis

We report the case of a patient with severe dyspnea upon reclining. Lung disease, neuromuscular disorders and heart disease were ruled out. However, during the course of the investigation, bilateral diaphragmatic paresis was discovered. A key sign leading to the diagnosis was evidence of paradoxical respiration in the dorsal decubitus position. When the patient was moved from the orthostatic position to the dorsal decubitus position, oxygenation and forced vital capacity worsened. The orthostatic fluoroscopy was normal. Maximal inspiratory pressure was severely reduced. The responses to transcutaneous electric stimulation of the diaphragm were normal. However, electric stimulation of the phrenic nerve produced no response, leading to the diagnosis of bilateral diaphragmatic paresis.

Reliability of two-dimensional echocardiography in the assessment of clinically significant abnormal hemidiaphragm motion in pediatric cardiothoracic patients: Comparison with fluoroscopy

OBJECTIVE

To assess the utility and reliability of echocardiographic assessment of hemidiaphragm motion abnormalities in pediatric cardiothoracic patients.

DESIGN

Retrospective observational study, with post hoc blinded assessment of echocardiographic and fluoroscopic results.

SETTING

Tertiary care center.

PATIENTS

Thirty-six consecutive pediatric cardiothoracic patients with suspected hemidiaphragm paralysis were identified and included in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The results of both echocardiographic and fluoroscopic studies on all patients were included. In addition, blinded review of study results were performed. The sensitivity and specificity of fluoroscopy in identifying hemidiaphragms that needed plication were 100% and 74%, respectively. The positive predictive value was 55%; negative predictive value was 100%. Comparing reported diagnoses with blinded review of the studies showed poor agreement; reviewers agreed with 89% diagnosed as normal, 44% of paralyzed, and 76% of paradoxical hemidiaphragms. The sensitivity and specificity of echo in identifying hemidiaphragms that needed plication were 100% and 81%, respectively. The positive predictive value and negative predictive value were 66% and 100%. Comparing reported diagnoses with blinded review, reviewers agreed with 97% diagnosed as normal, 81% of paralyzed, and 100% of paradoxical hemidiaphragms. Echocardiography was less accurate in discriminating between paralyzed and paradoxical diaphragm motion. Echocardiography was specific for paradoxical motion, since both patients identified by echocardiography were confirmed by fluoroscopy, but it was not sensitive. In nine patients, echo showed paralyzed motion that was identified by fluoroscopy as paradoxical.

CONCLUSIONS

This study supports the use of echocardiography in the assessment of diaphragm function. When the diaphragms are clearly visualized by echo, as they are in the majority of cases, the addition of an additional fluoroscopic study adds no clinical value. The differentiation between paralyzed and paradoxical motion is unreliable by both imaging modalities.

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.

Motor neurone disease presenting as postoperative respiratory failure

We present the case of a woman who developed respiratory failure in the postoperative period secondary to previously unsuspected motor neurone disease. This case highlights the difficulty in detecting subtle neuromuscular weakness during anaesthetic pre-assessment.

Co-existince of sickle cell disease and hemidiaphragm paralysis

Sickle cell anemia is a disease caused by production of abnormal hemoglobin. Infection, acute splenic sequestration crisis, aplastic crises, acute chest syndrome, stroke, cholelithiasis, renal disease and pain are the major complications. Unilateral or bilateral diaphragm paralysis maybe seen following phrenic nerve injury and with a variety of motor-neuron diseases, myelopathies, neuropathies, and myopathies. Prominent right hemi-diaphragma elevation was observed on chest radiograph of a 14 years' old female patient with sickle cell disease. Her medical history yielded neither trauma nor intra-thoracic surgery. She didn't have either motor deficit or sensation disorder on any region of her body. Thorax CT yielded no lesion except the significantly elevated right diaphragm. Her cranial CT showed no lesion, too. Diagnosis of right hemidiaphragm paralysis was confirmed by positive Hitzenberg Sniff test on fluoroscopy. Although several pathophysiologic mechanisms are known to be involved and lead to central neurologic complications in sickle cell disease, involvement of peripheric nerves have not been reported. Here we present a 14 years' old female patient with sickle cell anemia and unilateral diaphragm paralysis, co-existence of which have not been reported so far.

[Unilateral diaphragmatic paralysis in a diabetes patient]

Bilateral or unilateral diaphragmatic paralysis may be caused by motor neuron or muscle disease. Diabetic neuropathy, which is a common complication in diabetic patients, has a wide range of clinical manifestations. This is a case history of a 52 year old diabetic woman hospitalized with new paralysis of the right diaphragm. A thorough evaluation revealed no reason for diaphragmatic paralysis, other than diabetic neuropathy. A six month follow-up revealed significant clinical improvement. This article includes a summary of the literature, discussing the relationship between diabetes mellitus and diaphragmatic paralysis.