Diaphragmatic paralysis overview

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Diaphragmatic Paralysis Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Diaphragmatic Paralysis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

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Treatment

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Primary Prevention

Secondary Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Historical Perspective

Diaphragmatic paralysis was first suggested by Steurtz, in 1911 during simple phrenicotomy for treatment of lung disease. In 1946, a case of poliomyelitiswith respiratory paralysis was explained in Rumania.

Classification

Diaphragmatic paralysis may be classified according to involvement of leaflets into unilateral or bilateral. Bilateral diaphragmatic paralysis is a medical emergency. Unilateral diaphragmatic paralysis is often discovered incidentally on chest x-ray for other reasons.

Pathophysiology

It is thought that diaphragmatic paralysis is the result of paralysis of cervical nerve roots( C3-C5 ). Diaphragmatic paralyses can be unilateral or bilateral according to involvemnet of one or two leaflets of diaphragm. In the case of unilateral diaphragm paralysis, it is compensated by other hemidiaphragm or accessory muscles of respiration. In bilateral diaphragmatic paralysis, accessory muscles do all of the work of breathing and finally it may lead to ventilatory failure. Early diaphragmatic paralysis may be one of the manifestations of genetic neuromuscular disorders such as spinal muscular atrophy (Werdnig-Hoffmann disease) and acid maltase deficiency. On gross and microscopic pathology, there are no characteristic findings of diaphragmatic paralysis.

Causes

Common causes of unilateral diphragmatic paralysis include idiopathicphrenic nerve injury in cardiac surgery and viral infection and less common causes of it include cervical spondylosis, cervical compressive tumors and blunt neck trauma. Common causes of bilateral diphragmatic paralysis include idiopathic, cervical spinal cord disease and motor neuron disease. Less common causes of bilateral diphragmatic paralysis include parsonage turner syndrome and malnutrition.

Differentiating Hereditary pancreatitis from Other Diseases

Unilateral diaphragmatic paralysis must be differentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm. Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as pleural adhesions, subpulmonic effusions, obesityascites, abdominal organomegaly and ileus. Diaphragmatic paralysis must be differentiated from other disease that cause dyspnea such as dermatomyositispolymyositisrib fracturepleural effusionsamyotrophic lateral sclerosis.

Epidemiology and Demographics

The incidence of diaphragmatic paralysis is unknown, but incidence of diaphragmatic paralysis after cardiac surgery is approximately 30000 to 75000 per 100,000 individuals. Prevalence of diaphragmatic paralysis after cardiac surgery is 1600 per 100,000 in children.The morbidity and mortality of the unilateral diaphragmatic paralysis is related to underlying pulmonary function and etiology. Most of the bilateral diaphragmatic paralysis are symptomatic and may develop ventilatory failure. Patients of all age groups may develop diaphragmatic paralysis. There is no racial predilection to diaphragmatic paralysis. Men are more commonly affected.

Risk Factors

The most potent risk factor in the development of diaphragmatic paralysis is cooling or streching in cardiac surgery. Other risk factors include viruses, spinal cord transection and malnutrition.

Screening

There is insufficient evidence to recommend routine screening for diaphragmatic paralysis.

Natural History, Complications, and Prognosis

 left untreated, patients with unilateral diaphragmatic paralysis may recover fully or partially. Common complication of diaphragmatic paralysis includes severe pulmonary dysfunction in bilateral diaphragmatic paralysis. Prognosis is generally excellent in unilateral diaphragmatic paralysis. Bilateral diaphragmatic paralysis is a medical emergency.


Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

References


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