Causes and diagnosis of bilateral diaphragmatic paralysis
- Bartolome R Celli, MD
Bartolome R Celli, MD
- Professor of Medicine
- Harvard University School of Medicine
Ventilation depends upon the ability of the respiratory pump to move air in and out of the gas exchanging portion of the lungs. The dome-shaped diaphragm is the chief muscle of inspiration and the most powerful of the respiratory muscles [1-3]. The other main muscles of inspiration are the scalenes, external intercostals, and sternomastoids. The muscles of expiration are the internal intercostals and the muscles of the abdominal wall (including the rectus abdominus, internal and external obliques, and transversus abdominus).
In addition to its role in the respiratory pump, the diaphragm also serves as a mechanical barrier between the abdominal and thoracic cavities and maintains the pressure gradient between the cavities.
The causes and diagnostic evaluation of bilateral diaphragmatic paralysis in adults will be reviewed here. The clinical manifestations and evaluation of respiratory muscle weakness due to neuromuscular disease, the disorders of control of ventilation, the evaluation of unilateral diaphragmatic paralysis, the evaluation and management of diaphragm paralysis in the newborn, and the management of diaphragmatic paralysis in adults are reviewed separately. (See "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation" and "Disorders of ventilatory control" and "Diaphragmatic paralysis in the newborn" and "Treatment of diaphragmatic paralysis" and "Causes and diagnosis of unilateral diaphragmatic paralysis and eventration in adults".)
NORMAL DIAPHRAGM FUNCTION
The diaphragm has two components: the non-contractile central tendon that separates the right and left sides and extends to the dome of each hemidiaphragm and the contracting muscle fibers [1-3]. The diaphragmatic muscle fibers radiate centrifugally and insert peripherally onto the inner surface of the lower six ribs laterally, the costal cartilages and sternum anteriorly, and the arcuate ligaments that extend from the upper lumbar vertebrae to the 12th ribs posteriorly . The crura are posterior muscle bundles that run from the medial central tendon to the upper lumbar vertebral bodies posteriorly (L1 to L3 on the right, and L1 to L2 on the left).
The left and right sides of diaphragm are innervated by the ipsilateral phrenic nerves, which derive from cervical nerve roots three, four, and five . Each nerve divides into four trunks that innervate the anterolateral, posterolateral, sternal, and crural portions of the diaphragm on that side.
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- NORMAL DIAPHRAGM FUNCTION
- ALTERED FUNCTION WITH DIAPHRAGMATIC PARALYSIS
- BILATERAL DIAPHRAGMATIC PARALYSIS
- - Spinal cord disease
- - Motor neuron disease
- - Neuropathy
- - Neuromuscular junction disease
- - Muscle disease
- Clinical manifestations
- Evaluation and diagnosis
- - Laboratory testing
- - Imaging studies
- - Pulmonary function tests and arterial blood gases
- - Diaphragmatic electromyography
- - Measurement of transdiaphragmatic pressure
- - Polysomnography
- SUMMARY AND RECOMMENDATIONS