fbpx

Diaphragmatic Paralysis

Updated : February 23, 2024





Background

The medical illness known as diaphragmatic paralysis is characterized by the partial or total paralysis of one or both sides of the diaphragm. These are primary breathing muscles which reduces the lung function and breathing difficulties may result from this paralysis. 

This can occur from illnesses in the form of Guillain-Barré syndrome and amyotrophic lateral sclerosis that damage nerves or spinal cord. 

Paralysis can result from tumors in the chest or neck area that harm the nerves that control the diaphragm. It is caused due to neck or chest injuries, such as in car accidents or during surgery. 

Epidemiology

Frequency of incidence is unknown. Diaphragm paralysis is more common among males. 

Anatomy

Pathophysiology

The most frequent cause of diaphragmatic paralysis is injury to the diaphragm’s innervating phrenic nerve. Trauma, surgery, neurological conditions, or tumor compression can all cause this harm. Impaired diaphragmatic contraction results from damage of the phrenic nerve, which disrupts brain to diaphragm impulses. 

The diaphragm muscle’s strength and contractility can be impacted by diseases such muscular dystrophy compromise respiratory function. 

Etiology

Traumatic injuries to the chest or neck can harm the diaphragm directly or damage the phrenic nerve can cause paralysis.  

Diaphragmatic paralysis due to trauma can happen right after the injury or take time to develop. If malignancy is not the cause, many times the etiology cannot be determined. 

Genetics

Prognostic Factors

The underlying cause of diaphragmatic paralysis may have an impact on the prognosis.  

The prognosis may be affected by the extent of diaphragmatic paralysis, whether partial or whole. Those who are partially paralyzed may be able to breathe and do better than those who are completely paralyzed. 

Clinical History

Age Group:  

Trauma-related diaphragmatic paralysis can affect individuals of any age group, depending on the nature and severity of the injury. 

Diaphragmatic paralysis are present from birth and may be associated with congenital abnormalities. These conditions typically affect infants and are often diagnosed shortly after birth. 

 

Associated Comorbidity or Activity:   

Individuals with diaphragmatic paralysis are at increased risk of developing respiratory complications, such as pneumonia, atelectasis, or respiratory failure. These conditions can arise due to impaired lung function and ventilation-perfusion mismatch secondary to diaphragmatic paralysis. 

Diaphragmatic paralysis may occur secondary to underlying neuromuscular disorders such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, multiple sclerosis, muscular dystrophy, or myasthenia gravis. 

Cardiovascular conditions such as congestive heart failure or coronary artery disease may coexist with diaphragmatic paralysis. Reduced respiratory function due to diaphragmatic paralysis can exacerbate cardiovascular symptoms and increase the risk of cardiovascular complications. 

Obesity is associated with impaired respiratory mechanics and decreased lung volumes, which can exacerbate respiratory symptoms in individuals with diaphragmatic paralysis.  

 

Acuity of Presentation:  

In cases of traumatic injury to the chest or neck, diaphragmatic paralysis may present acutely following the traumatic event. 

Diaphragmatic paralysis may also present sub-acutely, with symptoms developing gradually over days to weeks following an inciting event. 

In some cases, diaphragmatic paralysis may present chronically, with symptoms developing over a longer period. This may occur with underlying neurological disorders such as ALS or progressive neuromuscular diseases, where diaphragmatic weakness and respiratory symptoms gradually worsen over months to years. 

Physical Examination

  • Inspection: Observing the patient’s respiratory effort at rest can provide initial clues. Look for signs of increased work of breathing, such as the use of accessory muscles or paradoxical chest wall movement.
  • Check for signs of respiratory distress, such as increased respiratory rate, nasal flaring, or intercostal and supraclavicular retractions. 
  • Palpation: Palpate the chest wall during inspiration to assess for symmetric chest expansion. Diminished expansion on one side may indicate diaphragmatic paralysis on that side. 
  • Percussion: Percuss the chest wall bilaterally to assess for dullness or hyperresonance, which may indicate underlying lung pathology or pleural effusion. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

  • Pneumonia: Infection of the lungs causing inflammation and impaired gas exchange, presenting with fever, cough, dyspnea, and abnormal breath sounds on auscultation. 
  • Pleural Effusion: Accumulation of fluid in the pleural space, causing dyspnea, decreased breath sounds, and dullness to percussion on the affected side. 
  • Pneumothorax: Collection of air in the pleural space, leading to lung collapse and sudden-onset dyspnea, chest pain, and hyperresonance on percussion. 
  • Chronic Obstructive Pulmonary Disease (COPD): Chronic lung diseases such as emphysema or chronic bronchitis can cause dyspnea, cough, wheezing, and reduced breath sounds. 
  • Congestive Heart Failure (CHF): Heart failure can present with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and signs of fluid overload such as peripheral edema and pulmonary crackles. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

  • Respiratory Therapy: Pulmonary rehabilitation and respiratory therapy techniques, such as deep breathing exercises, coughing techniques, and incentive spirometry, can help improve lung function and respiratory muscle strength. 
  • Positioning: Advising patients to adopt positions that optimize ventilation, such as sitting upright or leaning forward, may help alleviate dyspnea and improve respiratory mechanics. 
  • Non-Invasive Ventilation (NIV): Non-invasive ventilation modalities may be used to support respiratory function in individuals with diaphragmatic paralysis, particularly during sleep or periods of respiratory distress. 
  • Invasive Mechanical Ventilation: Invasive mechanical ventilation may be necessary for individuals with severe respiratory compromise or respiratory failure due to diaphragmatic paralysis. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of non-pharmacological approach for Diaphragmatic Paralysis

  • Home Environment: Ensure adequate ventilation and air quality in the home to minimize exposure to allergens, pollutants, and respiratory irritants. 
  • Sleep Environment: Optimize the sleep environment to promote restful sleep and alleviate respiratory symptoms during sleep.
  • Use supportive pillows or positional aids to help maintain optimal sleep posture and prevent airway obstruction. 
  • Mobility Aids and Assistive Devices: Provide mobility aids and assistive devices as needed to help individuals with diaphragmatic paralysis maintain independence and mobility. 
  • Physical Environment: Modify the physical environment to reduce the risk of falls and injuries, particularly for individuals with mobility limitations or weakness. 

Role of Bronchodilators

Bronchodilators act on the smooth muscle lining the airways, causing relaxation and dilation of the bronchial tubes. This helps to alleviate bronchospasm and improve airflow in individuals with obstructive respiratory conditions. 

  • Albuterol: It is a short-acting beta-agonist that acts rapidly to relax bronchial smooth muscle and improve airflow in the lungs. It is available in various formulations, including metered-dose inhalers (MDIs), nebulized solutions, and oral tablets. 

Role of Mucolytic agents

  • Acetylcysteine: It works by breaking down disulfide bonds in mucus, reducing its viscosity and making it easier to clear from the airways. 
  • This property is particularly useful in conditions associated with excessive mucus production or impaired mucociliary clearance, such as chronic bronchitis or cystic fibrosis. 

Role of Proton pump inhibitors

  • PPIs: They work by irreversibly inhibiting the proton pump in the gastric parietal cells thus reduced the secretion of gastric acid into the stomach lumen. 
  • This leads to a decrease in gastric acidity and helps alleviate symptoms associated with conditions such as GERD and peptic ulcer disease. 

Use of Intervention with a procedure in treating Diaphragmatic Paralysis

  • Diaphragmatic plication can be performed through an open surgical approach or minimally invasive techniques such as thoracoscopy or laparoscopy.
  • During the procedure, the elevated portion of the paralyzed diaphragm is folded or gathered and sutured in place, reducing its elevation, and restoring a more optimal position for respiratory function.
  • Diaphragmatic plication can be performed unilaterally or bilaterally depending on the extent of diaphragmatic paralysis and the individual’s clinical presentation. 

Use of phases in managing Diaphragmatic Paralysis

  • Assessment and Diagnosis: This phase begins with a thorough medical history, physical examination, and diagnostic tests to assess respiratory function and identify potential causes of diaphragmatic paralysis.  
  • Acute Management Phase: For individuals presenting with acute respiratory distress due to diaphragmatic paralysis (e.g., following trauma or surgery), immediate interventions may be necessary to stabilize respiratory function. This may involve supplemental oxygen, non-invasive ventilation, or, in severe cases, invasive mechanical ventilation in an intensive care setting. 
  • Multidisciplinary approach: Treatment planning involves collaboration among a multidisciplinary team of healthcare professionals, including pulmonologists, neurologists, surgeons, respiratory therapists, and physical therapists.  
  • Interventional Phase: For individuals with symptomatic diaphragmatic paralysis and significant respiratory impairment, surgical interventions such as diaphragmatic plication or phrenic nerve repair may be considered to improve respiratory mechanics and alleviate symptoms. 
  • Rehabilitation and Long-Term Management: Rehabilitation programs focus on improving respiratory muscle strength, exercise tolerance, and activities of daily living.  

Medication

Media Gallary

Diaphragmatic Paralysis

Updated : February 23, 2024




The medical illness known as diaphragmatic paralysis is characterized by the partial or total paralysis of one or both sides of the diaphragm. These are primary breathing muscles which reduces the lung function and breathing difficulties may result from this paralysis. 

This can occur from illnesses in the form of Guillain-Barré syndrome and amyotrophic lateral sclerosis that damage nerves or spinal cord. 

Paralysis can result from tumors in the chest or neck area that harm the nerves that control the diaphragm. It is caused due to neck or chest injuries, such as in car accidents or during surgery. 

Frequency of incidence is unknown. Diaphragm paralysis is more common among males. 

The most frequent cause of diaphragmatic paralysis is injury to the diaphragm’s innervating phrenic nerve. Trauma, surgery, neurological conditions, or tumor compression can all cause this harm. Impaired diaphragmatic contraction results from damage of the phrenic nerve, which disrupts brain to diaphragm impulses. 

The diaphragm muscle’s strength and contractility can be impacted by diseases such muscular dystrophy compromise respiratory function. 

Traumatic injuries to the chest or neck can harm the diaphragm directly or damage the phrenic nerve can cause paralysis.  

Diaphragmatic paralysis due to trauma can happen right after the injury or take time to develop. If malignancy is not the cause, many times the etiology cannot be determined. 

The underlying cause of diaphragmatic paralysis may have an impact on the prognosis.  

The prognosis may be affected by the extent of diaphragmatic paralysis, whether partial or whole. Those who are partially paralyzed may be able to breathe and do better than those who are completely paralyzed. 

Age Group:  

Trauma-related diaphragmatic paralysis can affect individuals of any age group, depending on the nature and severity of the injury. 

Diaphragmatic paralysis are present from birth and may be associated with congenital abnormalities. These conditions typically affect infants and are often diagnosed shortly after birth. 

 

Associated Comorbidity or Activity:   

Individuals with diaphragmatic paralysis are at increased risk of developing respiratory complications, such as pneumonia, atelectasis, or respiratory failure. These conditions can arise due to impaired lung function and ventilation-perfusion mismatch secondary to diaphragmatic paralysis. 

Diaphragmatic paralysis may occur secondary to underlying neuromuscular disorders such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, multiple sclerosis, muscular dystrophy, or myasthenia gravis. 

Cardiovascular conditions such as congestive heart failure or coronary artery disease may coexist with diaphragmatic paralysis. Reduced respiratory function due to diaphragmatic paralysis can exacerbate cardiovascular symptoms and increase the risk of cardiovascular complications. 

Obesity is associated with impaired respiratory mechanics and decreased lung volumes, which can exacerbate respiratory symptoms in individuals with diaphragmatic paralysis.  

 

Acuity of Presentation:  

In cases of traumatic injury to the chest or neck, diaphragmatic paralysis may present acutely following the traumatic event. 

Diaphragmatic paralysis may also present sub-acutely, with symptoms developing gradually over days to weeks following an inciting event. 

In some cases, diaphragmatic paralysis may present chronically, with symptoms developing over a longer period. This may occur with underlying neurological disorders such as ALS or progressive neuromuscular diseases, where diaphragmatic weakness and respiratory symptoms gradually worsen over months to years. 

  • Inspection: Observing the patient’s respiratory effort at rest can provide initial clues. Look for signs of increased work of breathing, such as the use of accessory muscles or paradoxical chest wall movement.
  • Check for signs of respiratory distress, such as increased respiratory rate, nasal flaring, or intercostal and supraclavicular retractions. 
  • Palpation: Palpate the chest wall during inspiration to assess for symmetric chest expansion. Diminished expansion on one side may indicate diaphragmatic paralysis on that side. 
  • Percussion: Percuss the chest wall bilaterally to assess for dullness or hyperresonance, which may indicate underlying lung pathology or pleural effusion. 
  • Pneumonia: Infection of the lungs causing inflammation and impaired gas exchange, presenting with fever, cough, dyspnea, and abnormal breath sounds on auscultation. 
  • Pleural Effusion: Accumulation of fluid in the pleural space, causing dyspnea, decreased breath sounds, and dullness to percussion on the affected side. 
  • Pneumothorax: Collection of air in the pleural space, leading to lung collapse and sudden-onset dyspnea, chest pain, and hyperresonance on percussion. 
  • Chronic Obstructive Pulmonary Disease (COPD): Chronic lung diseases such as emphysema or chronic bronchitis can cause dyspnea, cough, wheezing, and reduced breath sounds. 
  • Congestive Heart Failure (CHF): Heart failure can present with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and signs of fluid overload such as peripheral edema and pulmonary crackles. 
  • Respiratory Therapy: Pulmonary rehabilitation and respiratory therapy techniques, such as deep breathing exercises, coughing techniques, and incentive spirometry, can help improve lung function and respiratory muscle strength. 
  • Positioning: Advising patients to adopt positions that optimize ventilation, such as sitting upright or leaning forward, may help alleviate dyspnea and improve respiratory mechanics. 
  • Non-Invasive Ventilation (NIV): Non-invasive ventilation modalities may be used to support respiratory function in individuals with diaphragmatic paralysis, particularly during sleep or periods of respiratory distress. 
  • Invasive Mechanical Ventilation: Invasive mechanical ventilation may be necessary for individuals with severe respiratory compromise or respiratory failure due to diaphragmatic paralysis. 

  • Home Environment: Ensure adequate ventilation and air quality in the home to minimize exposure to allergens, pollutants, and respiratory irritants. 
  • Sleep Environment: Optimize the sleep environment to promote restful sleep and alleviate respiratory symptoms during sleep.
  • Use supportive pillows or positional aids to help maintain optimal sleep posture and prevent airway obstruction. 
  • Mobility Aids and Assistive Devices: Provide mobility aids and assistive devices as needed to help individuals with diaphragmatic paralysis maintain independence and mobility. 
  • Physical Environment: Modify the physical environment to reduce the risk of falls and injuries, particularly for individuals with mobility limitations or weakness. 

Bronchodilators act on the smooth muscle lining the airways, causing relaxation and dilation of the bronchial tubes. This helps to alleviate bronchospasm and improve airflow in individuals with obstructive respiratory conditions. 

  • Albuterol: It is a short-acting beta-agonist that acts rapidly to relax bronchial smooth muscle and improve airflow in the lungs. It is available in various formulations, including metered-dose inhalers (MDIs), nebulized solutions, and oral tablets. 

  • Acetylcysteine: It works by breaking down disulfide bonds in mucus, reducing its viscosity and making it easier to clear from the airways. 
  • This property is particularly useful in conditions associated with excessive mucus production or impaired mucociliary clearance, such as chronic bronchitis or cystic fibrosis. 

  • PPIs: They work by irreversibly inhibiting the proton pump in the gastric parietal cells thus reduced the secretion of gastric acid into the stomach lumen. 
  • This leads to a decrease in gastric acidity and helps alleviate symptoms associated with conditions such as GERD and peptic ulcer disease. 

  • Diaphragmatic plication can be performed through an open surgical approach or minimally invasive techniques such as thoracoscopy or laparoscopy.
  • During the procedure, the elevated portion of the paralyzed diaphragm is folded or gathered and sutured in place, reducing its elevation, and restoring a more optimal position for respiratory function.
  • Diaphragmatic plication can be performed unilaterally or bilaterally depending on the extent of diaphragmatic paralysis and the individual’s clinical presentation. 

  • Assessment and Diagnosis: This phase begins with a thorough medical history, physical examination, and diagnostic tests to assess respiratory function and identify potential causes of diaphragmatic paralysis.  
  • Acute Management Phase: For individuals presenting with acute respiratory distress due to diaphragmatic paralysis (e.g., following trauma or surgery), immediate interventions may be necessary to stabilize respiratory function. This may involve supplemental oxygen, non-invasive ventilation, or, in severe cases, invasive mechanical ventilation in an intensive care setting. 
  • Multidisciplinary approach: Treatment planning involves collaboration among a multidisciplinary team of healthcare professionals, including pulmonologists, neurologists, surgeons, respiratory therapists, and physical therapists.  
  • Interventional Phase: For individuals with symptomatic diaphragmatic paralysis and significant respiratory impairment, surgical interventions such as diaphragmatic plication or phrenic nerve repair may be considered to improve respiratory mechanics and alleviate symptoms. 
  • Rehabilitation and Long-Term Management: Rehabilitation programs focus on improving respiratory muscle strength, exercise tolerance, and activities of daily living.