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Long LE, Alhayo ST, Talbot M. Iatrogenic eventration of the hemidiaphragm in a post-bariatric surgery patient. J Surg Case Rep 2024; 2024:rjae117. [PMID: 38487395 PMCID: PMC10937257 DOI: 10.1093/jscr/rjae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
The aim of this report is to describe the management of an iatrogenic diaphragmatic eventration following surgery to relieve neurogenic symptoms of thoracic outlet syndrome in a patient with a prior history of sleeve gastrectomy. We discuss the case of a 46-year-old woman with a 6-month history of gastro-oesophageal reflux and dyspnoea. Imaging demonstrated a left hemidiaphragm eventration and hiatus hernia. The patient underwent laparoscopic plication of the left hemidiaphragm, repair of the hiatus hernia, and an omega loop gastric bypass, with satisfactory resolution of her symptoms. This demonstrates that surgical diaphragmatic plication has good outcomes in cases where the abdominal anatomy is already altered as a result of previous bariatric surgery, and that concurrent hiatus hernia repair, plication of iatrogenic diaphragm eventration, and sleeve to gastric bypass conversion satisfactorily relieve reflux and dyspnoea in a morbidly obese patient.
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Affiliation(s)
- Leonora E Long
- Department of Surgery, St George Hospital, Grey St, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2217, Australia
| | - Sam Tharwat Alhayo
- Department of Surgery, St George Hospital, Grey St, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2217, Australia
| | - Michael Talbot
- Department of Surgery, St George Hospital, Grey St, Kogarah, NSW 2217, Australia
- St George and Sutherland Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW 2217, Australia
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2
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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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Fitzgerald DB, Muruganandan S, Peddle-McIntyre CJ, Lee YCG, Singh B. Ipsilateral and contralateral hemidiaphragm dynamics in symptomatic pleural effusion: The 2nd PLeural Effusion And Symptom Evaluation (PLEASE-2) Study. Respirology 2022; 27:882-889. [PMID: 35672271 DOI: 10.1111/resp.14307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/05/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The pathophysiology of breathlessness in pleural effusion is unclear. In the PLEASE-1 study, abnormal ipsilateral hemidiaphragm shape and movement, assessed qualitatively, were independently associated with breathlessness relief after pleural drainage. Effects of pleural effusion on contralateral hemidiaphragm function are unknown. PLEASE-2, a prospective exploratory pilot study, assessed the effects of unilateral effusion and drainage on both hemidiaphragms using advanced quantitative bedside ultrasonography. METHODS Individuals with symptomatic unilateral pleural effusion undergoing therapeutic drainage were included. Measurements pre- and post-drainage included severity of breathlessness (visual analogue scale) and ultrasound measurements of diaphragm excursion and thickness, in addition to shape and movement. Diaphragm measurements were compared to published reference values. RESULTS Twenty participants were recruited (mean age 68.9 [SD 12.8] years, 12 females). During tidal breathing, contralateral hemidiaphragm excursion exceeded ipsilateral excursion and reference values (all p ≤ 0.001). Contralateral excursion was greatest in participants with abnormal ipsilateral hemidiaphragm movement and was inversely correlated with ipsilateral tidal excursion (r = -0.676, p = 0.001). Following drainage (mean volume 2121 [SD = 1206] ml), abnormal shape (n = 12) and paradoxical movement (n = 9) of the ipsilateral hemidiaphragm resolved in all participants, and tidal excursion of the contralateral hemidiaphragm normalized. Relief of breathlessness post-drainage correlated with improvement in ipsilateral hemidiaphragm excursion (r = 0.556, p = 0.031). CONCLUSION This pilot study suggests, for the first time, that unilateral pleural effusion not only impairs ipsilateral hemidiaphragm function but also causes compensatory hyperactivity of the contralateral hemidiaphragm, which resolves post-drainage. These findings provide a basis for detailed studies of diaphragmatic function and ventilatory drive in patients with symptomatic pleural effusion.
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Affiliation(s)
- Deirdre B Fitzgerald
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| | | | - Carolyn J Peddle-McIntyre
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia.,West Australian Sleep Disorders Research Institute, Perth, Western Australia, Australia
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5
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Liu X, Qu Q, Deng P, Zhao Y, Liu C, Fu C, Jia J. Assessment of Diaphragm in Hemiplegic Patients after Stroke with Ultrasound and Its Correlation of Extremity Motor and Balance Function. Brain Sci 2022; 12:brainsci12070882. [PMID: 35884689 PMCID: PMC9313444 DOI: 10.3390/brainsci12070882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 12/07/2022] Open
Abstract
Background: A variety of functional disorders can be caused after stroke, among which impairment of respiratory function is a frequent and serious complication of stroke patients. The aim of this study was to examine diaphragmatic function after stroke by diaphragm ultrasonography and then to apply to explore its correlation with extremity motor function and balance function of the hemiplegia patients. Methods: This cross-sectional observational study recruited 48 hemiplegic patients after stroke and 20 matched healthy participants. The data of demographic and ultrasonographic assessment of all healthy subjects were recorded, and 45 patients successfully underwent baseline data assessment in the first 48 h following admission, including post-stroke duration, stroke type, hemiplegia side, pipeline feeding, pulmonary infection, ultrasonographic assessment for diaphragm, Fugl−Meyer Motor Function Assessment Scale (FMA Scale), and Berg Balance Scale assessment. Ultrasonographic assessment parameters included diaphragm mobility under quiet and deep breathing, diaphragm thickness at end-inspiratory and end-expiratory, and calculated thickening fraction of the diaphragm. The aim was to analyze the diaphragm function of hemiplegic patients after stroke and to explore its correlation with extremity motor function and balance function. Results: The incidence of diaphragmatic dysfunction under deep breath was 46.67% in 45 hemiplegia patients after stroke at the convalescent phase. The paralyzed hemidiaphragm had major impairments, and the mobility of the hemiplegic diaphragm was significantly reduced during deep breathing (p < 0.05). Moreover, the thickness fraction of hemiplegic side was extremely diminished when contrasted with the healthy control and non-hemiplegic side (p < 0.05). We respectively compared the diaphragm mobility under deep breath on the hemiplegic and non-hemiplegic side of patients with left and right hemiplegia and found there was no significant difference between the hemiplegic side of right and left hemiplegia (p > 0.05), but the non-hemiplegic side of right hemiplegia was significantly weaker than that of left hemiplegia patients (p < 0.05). The diaphragm mobility of stroke patients under quiet breath was positively correlated with age and FMA Scale score (R2 = 0.296, p < 0.05), and significant positive correlations were found between the diaphragm mobility under deep breath and Berg Balance Scale score (R2 = 0.11, p < 0.05), diaphragm thickness at end-inspiratory and FMA Scale score (R2 = 0.152, p < 0.05), and end-expiratory thickness and FMA Scale score (R2 = 0.204, p < 0.05). Conclusions: The mobility and thickness fraction of the hemiplegic diaphragm after stroke by diaphragm ultrasonography were significantly reduced during deep breathing. Diaphragm mobility on bilateral sides of the right hemiplegia patients were reduced during deep breathing. Moreover, the hemiplegic diaphragmatic function was positively correlated with extremity motor and balance function of the hemiplegia patients.
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Affiliation(s)
- Xiaoman Liu
- Department of Rehabilitation Medicine, Fudan University Huashan Hospital, Shanghai 200031, China; (X.L.); (Q.Q.)
- National Clinical Research Center for Aging and Medicine, Fudan University Huashan Hospital, Shanghai 200031, China
| | - Qingming Qu
- Department of Rehabilitation Medicine, Fudan University Huashan Hospital, Shanghai 200031, China; (X.L.); (Q.Q.)
- National Clinical Research Center for Aging and Medicine, Fudan University Huashan Hospital, Shanghai 200031, China
| | - Panmo Deng
- Department of Rehabilitation Medicine, Jing’an District Central Hospital of Shanghai, Shanghai 200040, China; (P.D.); (Y.Z.); (C.L.)
| | - Yuehua Zhao
- Department of Rehabilitation Medicine, Jing’an District Central Hospital of Shanghai, Shanghai 200040, China; (P.D.); (Y.Z.); (C.L.)
| | - Chenghong Liu
- Department of Rehabilitation Medicine, Jing’an District Central Hospital of Shanghai, Shanghai 200040, China; (P.D.); (Y.Z.); (C.L.)
| | - Conghui Fu
- Shanghai Jinshan Zhongren Aged Care Hospital, Shanghai 201502, China;
| | - Jie Jia
- Department of Rehabilitation Medicine, Fudan University Huashan Hospital, Shanghai 200031, China; (X.L.); (Q.Q.)
- National Clinical Research Center for Aging and Medicine, Fudan University Huashan Hospital, Shanghai 200031, China
- National Center for Neurological Disorders, Shanghai 200031, China
- Correspondence:
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Nafisa S, Messer B, Downie B, Ehilawa P, Kinnear W, Algendy S, Sovani M. A retrospective cohort study of idiopathic diaphragmatic palsy: a diagnostic triad, natural history and prognosis. ERJ Open Res 2021; 7:00953-2020. [PMID: 34527723 PMCID: PMC8435796 DOI: 10.1183/23120541.00953-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background Isolated diaphragmatic palsy in the absence of progressive neuromuscular disease is uncommon. It poses diagnostic challenges and limited data are available regarding prognosis. We present retrospective cohort data from two large teaching hospitals in the United Kingdom. Method 60 patients who were assessed either as inpatients or outpatients were included in this study. Patients with progressive neuromuscular disease were excluded. Clinical presentation, tests of respiratory muscle function (sitting/supine vital capacity, maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP) and sniff nasal inspiratory pressure (SNIP)) and outcomes were recorded. Results For patients with diaphragmatic palsy, mean±sd seated and supine vital capacity pre-noninvasive ventilation (NIV) were reduced at 1.7±1.2 L and 1.1±0.9 L, respectively, with a mean±sd postural fall in vital capacity of 42±0.16%. The mean MEP/MIP and MEP/SNIP ratios for diaphragmatic palsy were 3 and 3.5, respectively. After a year of treatment with NIV, mean±sd upright and supine vital capacity had increased to 2.1±0.9 L and 1.8±1 L, respectively, and the mean±sd fall in vital capacity from sitting to supine reduced to 29±0.17%. MEP/MIP and MEP/SNIP ratios reduced to 2.6 and 2.9, respectively, from the pre-NIV values. The values of postural fall in vital capacity correlated (p<0.05) with MEP/MIP and MEP/SNIP ratio (r2=0.86 and r2=0.7, respectively). Conclusion Tests of respiratory muscle strength are valuable in the diagnostic workup of patients with unexplained dyspnoea. A triad of 1) orthopnoea, with 2) normal lung imaging and 3) MEP/MIP and/or MEP/SNIP ratio ≥2.7 points towards isolated diaphragmatic palsy. This needs to be confirmed by prospective studies. Tests of respiratory muscle strength are valuable in the diagnostic workup of patients with unexplained dyspnoea. A triad of 1) orthopnoea with 2) normal lung imaging and 3) MEP/MIP and/or MEP/SNIP ratios ≥2.7 points towards isolated diaphragmatic palsy.https://bit.ly/2SpOXW2
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Affiliation(s)
- Syeda Nafisa
- Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK.,Dept of Respiratory Medicine, Sherwood Forest Hospital NHS Foundation Trust, Mansfield, UK
| | - Ben Messer
- North East Assisted Ventilation Service, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Beatrice Downie
- Dept of Respiratory Medicine, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Patience Ehilawa
- Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK.,Dept of Respiratory Medicine, Sherwood Forest Hospital NHS Foundation Trust, Mansfield, UK
| | - William Kinnear
- Dept of Sport Science, Nottingham Trent University, Nottingham, UK
| | - Sherif Algendy
- Dept of Respiratory Medicine, Sherwood Forest Hospital NHS Foundation Trust, Mansfield, UK
| | - Milind Sovani
- Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
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Wang L, Liu T, Liu Z. Chronic respiratory dysfunction due to diaphragmatic paralysis following penetrating neck trauma: A case report. Medicine (Baltimore) 2021; 100:e24043. [PMID: 33530199 PMCID: PMC7850730 DOI: 10.1097/md.0000000000024043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/27/2020] [Accepted: 12/07/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Respiratory dysfunction resulting from unilateral diaphragmatic paralysis during neck trauma is very rare in adults. We describe the symptoms, diagnosis and treatment of 1 patient with chronic respiratory insufficiency, in whom the diaphragmatic paralysis was associated with phrenic nerve injury due to penetrating neck trauma. PATIENT CONCERNS A 50-year-old worker was admitted because of left penetrating neck trauma. Imaging investigations demonstrated elevation of the left hemidiaphragm and the C5 and C6 roots avulsion. He complained of gradually worsening dyspnea on exertion 2 months later. DIAGNOSES The patient was diagnosed with chronic respiratory dysfunction secondary to diaphragmatic paralysis, which caused by phrenic nerve injury. INTERVENTIONS A conventional video-assisted thoracoscopic diaphragm plication was performed after failed conservative management. OUTCOMES The respiratory status improved markedly, and he did well without recurrence until 2 years' follow-up. LESSONS The possibilities of phrenic nerve palsy and diaphragmatic paralysis should not be overlooked during the evaluation of neck trauma.
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Affiliation(s)
- Lian Wang
- Department of Thoracic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Tianshu Liu
- Department of Thoracic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Zhihai Liu
- Department of Critical Care Medicine, the First Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
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8
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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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Caleffi-Pereira M, Pletsch-Assunção R, Cardenas LZ, Santana PV, Ferreira JG, Iamonti VC, Caruso P, Fernandez A, de Carvalho CRR, Albuquerque ALP. Unilateral diaphragm paralysis: a dysfunction restricted not just to one hemidiaphragm. BMC Pulm Med 2018; 18:126. [PMID: 30068327 PMCID: PMC6090915 DOI: 10.1186/s12890-018-0698-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/24/2018] [Indexed: 01/07/2023] Open
Abstract
Background Most patients with unilateral diaphragm paralysis (UDP) have unexplained dyspnea, exercise limitations, and reduction in inspiratory muscle capacity. We aimed to evaluate the generation of pressure in each hemidiaphragm separately and its contribution to overall inspiratory strength. Methods Twenty-seven patients, 9 in right paralysis group (RP) and 18 in left paralysis group (LP), with forced vital capacity (FVC) < 80% pred, and 20 healthy controls (CG), with forced expiratory volume in 1 s (FEV1) > 80% pred and FVC > 80% pred, were evaluated for lung function, maximal inspiratory (MIP) and expiratory (MEP) pressure measurements, diaphragm ultrasound, and transdiaphragmatic pressure during magnetic phrenic nerve stimulation (PdiTw). Results RP and LP had significant inspiratory muscle weakness compared to controls, detected by MIP (− 57.4 ± 16.9 for RP; − 67.1 ± 28.5 for LP and − 103.1 ± 30.4 cmH2O for CG) and also by PdiTW (5.7 ± 4 for RP; 4.8 ± 2.3 for LP and 15.3 ± 5.7 cmH2O for CG). The PdiTw was reduced even when the non-paralyzed hemidiaphragm was stimulated, mainly due to the low contribution of gastric pressure (around 30%), regardless of whether the paralysis was in the right or left hemidiaphragm. On the other hand, in CG, esophagic and gastric pressures had similar contribution to the overall Pdi (around 50%). Comparing both paralyzed and non-paralyzed hemidiaphragms, the mobility during quiet and deep breathing, and thickness at functional residual capacity (FRC) and total lung capacity (TLC), were significantly reduced in paralyzed hemidiaphragm. In addition, thickness fraction was extremely diminished when contrasted with the non-paralyzed hemidiaphragm. Conclusions In symptomatic patients with UDP, global inspiratory strength is reduced not only due to weakness in the paralyzed hemidiaphragm but also to impairment in the pressure generated by the non-paralyzed hemidiaphragm.
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Affiliation(s)
- Mayra Caleffi-Pereira
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Renata Pletsch-Assunção
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Letícia Zumpano Cardenas
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Pauliane Vieira Santana
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Jeferson George Ferreira
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Vinícius Carlos Iamonti
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Pedro Caruso
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - Angelo Fernandez
- Thoracic Surgery Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Roberto Ribeiro de Carvalho
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil
| | - André Luís Pereira Albuquerque
- Pulmonary Division, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas Carvalho Aguiar, n°44. Cerqueira Cesar., São Paulo, 05403-900, Brazil. .,Sírio-Libanês Teaching and Research Institute, São Paulo, Brazil.
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10
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Türk M, Weber I, Vogt-Ladner G, Schröder R, Winterholler M. Diaphragmatic dysfunction as the presenting symptom in neuromuscular disorders: A retrospective longitudinal study of etiology and outcome in 30 German patients. Neuromuscul Disord 2018; 28:484-490. [DOI: 10.1016/j.nmd.2018.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/16/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
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Verin E, Morelot-Panzini C, Gonzalez-Bermejo J, Veber B, Perrouin Verbe B, Soudrie B, Leroi AM, Marie JP, Similowski T. Reinnervation of the diaphragm by the inferior laryngeal nerve to the phrenic nerve in ventilator-dependent tetraplegic patients with C3-5 damage. ERJ Open Res 2017; 3:00052-2017. [PMID: 29181382 PMCID: PMC5699880 DOI: 10.1183/23120541.00052-2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/11/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18-24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications.
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Affiliation(s)
- Eric Verin
- EA 3830, Normandy University, Groupe de recherche sur le handicap ventilatoire (GRHV), Université de Rouen, Rouen, France.,Service de physiologie, CHU de Rouen, Rouen, France.,CRMPR les herbiers, Bois Guillaume, France
| | - Capucine Morelot-Panzini
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Jesus Gonzalez-Bermejo
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Benoit Veber
- Service de réanimation chirurgicale, CHU de Rouen, Rouen, France
| | | | | | | | - Jean Paul Marie
- EA 3830, Normandy University, Groupe de recherche sur le handicap ventilatoire (GRHV), Université de Rouen, Rouen, France.,Service d'ORL et Chirurgie Cervicofaciale CHU de Rouen, Rouen, France
| | - Thomas Similowski
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
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Exercise testing in patients with diaphragm paresis. Respir Physiol Neurobiol 2017; 248:31-35. [PMID: 29155335 DOI: 10.1016/j.resp.2017.11.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Diaphragm paresis (DP) is characterized by abnormalities of respiratory muscle function. However, the impact of DP on exercise capacity is not well known. This study was performed to assess exercise tolerance in patients with DP and to determine whether inspiratory muscle function was related to exercise capacity, ventilatory pattern and cardiovascular function during exercise. METHODS This retrospective study included patients with DP who underwent both diaphragmatic force measurements, and cardiopulmonary exercise testing (CPET). RESULTS Fourteen patients were included. Dyspnea was the main symptom limiting exertion (86%). Exercise capacity was slightly reduced (median VO2peak: 80% [74.5%-90.5%]), mostly due to ventilatory limitation. Diaphragm and overall inspiratory muscle function were correlated with exercise ventilation. Moreover, overall inspiratory muscle function was related with oxygen consumption (r=0.61) and maximal workload (r=0.68). CONCLUSIONS DP decreases aerobic capacity due to ventilatory limitation. Diaphragm function is correlated with exercise ventilation whereas overall inspiratory muscle function is correlated with both exercise capacity and ventilation suggesting the importance of the accessory inspiratory muscles during exercise for patients with DP. Further larger prospective studies are needed to confirm these results.
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13
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Diaphragm plication: When and why to do it. J Thorac Cardiovasc Surg 2017; 154:1712-1713. [PMID: 28867382 DOI: 10.1016/j.jtcvs.2017.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/25/2017] [Indexed: 11/21/2022]
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14
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Xu Y, Rui J, Zhao X, Xiao C, Bao Q, Li J, Lao J. Effect of isolated unilateral diaphragmatic paralysis on ventilation and exercise performance in rats. Respir Physiol Neurobiol 2014; 196:25-32. [DOI: 10.1016/j.resp.2014.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 02/10/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
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15
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Boudarham J, Pradon D, Prigent H, Falaize L, Durand MC, Meric H, Petitjean M, Lofaso F. Optoelectronic Plethysmography as an Alternative Method for the Diagnosis of Unilateral Diaphragmatic Weakness. Chest 2013; 144:887-895. [DOI: 10.1378/chest.12-2317] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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16
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Prognosis of phrenic nerve injury following thoracic interventions: Four new cases and a review. Clin Neurol Neurosurg 2012; 114:199-204. [DOI: 10.1016/j.clineuro.2011.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 11/20/2011] [Accepted: 12/11/2011] [Indexed: 11/19/2022]
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17
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Le Pimpec-Barthes F, Brian E, Vlas C, Gonzalez-Bermejo J, Bagan P, Badia A, Riquet M, Similowski T. [Surgical treatment of diaphragmatic eventrations and paralyses]. Rev Mal Respir 2010; 27:565-78. [PMID: 20610072 DOI: 10.1016/j.rmr.2010.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 01/03/2010] [Indexed: 11/26/2022]
Abstract
Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.
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Affiliation(s)
- F Le Pimpec-Barthes
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75908 Paris cedex 15, France
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Jammes Y, Budin-Poirier C, Brégeon F. Electromyographic tools to assess hemidiaphragm paralysis. Clin Physiol Funct Imaging 2010; 30:107-15. [DOI: 10.1111/j.1475-097x.2009.00911.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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