Treatment of diaphragmatic paralysis

INTRODUCTION

Unilateral and bilateral diaphragm paralysis may be caused by motor neuron disease, myopathy, inflammatory myositis, phrenic nerve injury, viral infection, cervical spondylosis, malignancy, or may be idiopathic. Unilateral diaphragm paralysis is more common than bilateral disease and may be discovered incidentally on a chest radiograph. Bilateral diaphragmatic paralysis is usually seen in the context of severe generalized muscle weakness. In some cases, however, the diaphragm is the initial or only muscle involved.

An overview of the different therapies available for the treatment of diaphragmatic paralysis will be presented here. The etiology, assessment, and physiologic effects of unilateral and bilateral diaphragmatic paralysis are discussed separately. (See "Causes and diagnosis of bilateral diaphragmatic paralysis".)

UNILATERAL PARALYSIS

Most patients with unilateral diaphragmatic paralysis are asymptomatic and require no treatment (image 1). The prognosis is good in this setting, and the paralysis is of little clinical relevance in the absence of new or underlying pulmonary disease [1-3].

Some patients with unilateral diaphragmatic paralysis complain of dyspnea. This is most likely to occur with the increased ventilatory demands of intense physical activity or the presence of superimposed pulmonary disease. Treatment of the diaphragmatic paralysis may be considered when the dyspnea is disproportionate to the degree of physical activity or to the severity of the lung disease.

Surgical plication — Surgical plication of the affected hemidiaphragm has provided excellent results in carefully selected patients [4-12]. This operation is performed using an open, thoracoscopic, or laparoscopic approach and involves creating folds in the diaphragm and suturing them in place to reduce mobility of the paralyzed hemidiaphragm (figure 1) [5,13,14]. Plication usually results in improvement in lung function, exercise endurance, and dyspnea [10,14]. The likely mechanism is improved function of the healthy hemidiaphragm and of the accessory muscles of inspiration [15].

      

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Literature review current through: Sep 2014. | This topic last updated: Jan 8, 2014.
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References
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  1. Piehler JM, Pairolero PC, Gracey DR, Bernatz PE. Unexplained diaphragmatic paralysis: a harbinger of malignant disease? J Thorac Cardiovasc Surg 1982; 84:861.
  2. Lisboa C, Paré PD, Pertuzé J, et al. Inspiratory muscle function in unilateral diaphragmatic paralysis. Am Rev Respir Dis 1986; 134:488.
  3. Easton PA, Fleetham JA, de la Rocha A, Anthonisen NR. Respiratory function after paralysis of the right hemidiaphragm. Am Rev Respir Dis 1983; 127:125.
  4. Kuniyoshi Y, Yamashiro S, Miyagi K, et al. Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery. Ann Thorac Cardiovasc Surg 2004; 10:160.
  5. Hüttl TP, Wichmann MW, Reichart B, et al. Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy. Surg Endosc 2004; 18:547.
  6. Alkofer B, Le Roux Y, Coffin O, Samama G. Thoracoscopic plication of the diaphragm for postoperative phrenic paralysis: a report of two cases. Surg Endosc 2004; 18:868.
  7. Wright CD, Williams JG, Ogilvie CM, Donnelly RJ. Results of diaphragmatic plication for unilateral diaphragmatic paralysis. J Thorac Cardiovasc Surg 1985; 90:195.
  8. Graham DR, Kaplan D, Evans CC, et al. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10-year experience. Ann Thorac Surg 1990; 49:248.
  9. Haller JA Jr, Pickard LR, Tepas JJ, et al. Management of diaphragmatic paralysis in infants with special emphasis on selection of patients for operative plication. J Pediatr Surg 1979; 14:779.
  10. Ciccolella DE, Daly BD, Celli BR. Improved diaphragmatic function after surgical plication for unilateral diaphragmatic paralysis. Am Rev Respir Dis 1992; 146:797.
  11. Versteegh MI, Braun J, Voigt PG, et al. Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea. Eur J Cardiothorac Surg 2007; 32:449.
  12. Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. Long-term follow-up of the functional and physiologic results of diaphragm plication in adults with unilateral diaphragm paralysis. Ann Thorac Surg 2009; 88:1112.
  13. Groth SS, Andrade RS. Diaphragm plication for eventration or paralysis: a review of the literature. Ann Thorac Surg 2010; 89:S2146.
  14. Groth SS, Rueth NM, Kast T, et al. Laparoscopic diaphragmatic plication for diaphragmatic paralysis and eventration: an objective evaluation of short-term and midterm results. J Thorac Cardiovasc Surg 2010; 139:1452.
  15. Freeman RK, Wozniak TC, Fitzgerald EB. Functional and physiologic results of video-assisted thoracoscopic diaphragm plication in adult patients with unilateral diaphragm paralysis. Ann Thorac Surg 2006; 81:1853.
  16. Davis J, Goldman M, Loh L, Casson M. Diaphragm function and alveolar hypoventilation. Q J Med 1976; 45:87.
  17. Gibson GJ. Diaphragmatic paresis: pathophysiology, clinical features, and investigation. Thorax 1989; 44:960.
  18. Sandham JD, Shaw DT, Guenter CA. Acute supine respiratory failure due to bilateral diaphragmatic paralysis. Chest 1977; 72:96.
  19. Kreitzer SM, Feldman NT, Saunders NA, Ingram RH Jr. Bilateral diaphragmatic paralysis with hypercapnic respiratory failure. A physiologic assessment. Am J Med 1978; 65:89.
  20. Celli BR, Rassulo J, Corral R. Ventilatory muscle dysfunction in patients with bilateral idiopathic diaphragmatic paralysis: reversal by intermittent external negative pressure ventilation. Am Rev Respir Dis 1987; 136:1276.
  21. Kleopa KA, Sherman M, Neal B, et al. Bipap improves survival and rate of pulmonary function decline in patients with ALS. J Neurol Sci 1999; 164:82.
  22. Carratù P, Spicuzza L, Cassano A, et al. Early treatment with noninvasive positive pressure ventilation prolongs survival in Amyotrophic Lateral Sclerosis patients with nocturnal respiratory insufficiency. Orphanet J Rare Dis 2009; 4:10.
  23. Hill NS. Noninvasive ventilation. Does it work, for whom, and how? Am Rev Respir Dis 1993; 147:1050.
  24. Crausman RS, Summerhill EM, McCool FD. Idiopathic diaphragmatic paralysis: Bell's palsy of the diaphragm? Lung 2009; 187:153.