Semin Respir Crit Care Med 2002; 23(3): 275-282
DOI: 10.1055/s-2002-33036
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Respiratory Management of Diaphragm Paralysis

Bartolome R. Celli
  • Division of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Boston, Massachusetts, and Tufts University School of Medicine, Boston, Massachusetts
Further Information

Publication History

Publication Date:
02 August 2002 (online)

ABSTRACT

The diaphragm is the most important muscle of ventilation. Its contraction is key to the development of intrathoracic pressures. Diseases that affect diaphragmatic function result in decreased pressure-generating capacity by the respiratory muscles. If the involvement is severe or if there is underlying respiratory pathology, diaphragmatic paralysis can lead to overt ventilatory failure. Diaphragmatic involvement can occur unilaterally or bilaterally from systemic diseases or from diseases primarily affecting the diaphragm. Whatever the cause, unilateral diaphragmatic paralysis is usually well tolerated if there is no underlying lung or ribcage pathology. However, under conditions of increased loads, unilateral diaphragmatic paralysis can cause dyspnea and hypoxemia and require treatment. Bilateral diaphragmatic paralysis of any etiology is usually symptomatic and may result in ventilatory failure when severe, or when associated with underlying lung pathology. In some patients unilateral or bilateral paralysis can improve spontaneously but usually over prolonged periods of time. In patients with significant symptoms or development of ventilatory failure, symptoms and outcomes are improved by treatment with noninvasive ventilation or, in selected cases of unilateral paralysis, surgical plication of the diaphragm.

REFERENCES

  • 1 Roussos C, Macklem P T. The respiratory muscles.  N Engl J Med . 1982;  307 786-797
  • 2 Rochester D F. The diaphragm: contractile properties and fatigue.  J Clin Invest . 1985;  75 1397-1402
  • 3 Newsom-Davis J, Goldman M, Loh L, Casson M. Diaphragm function and alveolar hypoventilation.  Quat J Med . 1976;  45 87-100
  • 4 Gibson G. Diaphragmatic paresis: pathophysiology, clinical features and investigation.  Thorax . 1989;  44 960-970
  • 5 Laroche C, Carroll N, Moxham J, Green M. Clinical significance of severe isolated diaphragm weakness.  Am Rev Respir Dis . 1988;  138 862-866
  • 6 Lisboa C, Pare P, Pertuze J. Inspiratory muscle function in unilateral diaphragmatic paralysis.  Am Rev Respir Dis . 1986;  134 488-492
  • 7 Piehler J, Pairolero P, Gracey D, Bernatz P. Unexplained diaphragmatic paralysis.  J Thorac Cardiovasc Surg . 1982;  84 861-864
  • 8 Piehler J, Pairolero P, Gracey D, Bernatz P. Unexplained diaphragmatic paralysis: a harbinger of malignant disease?.  J Thorac Cardiov Surg . 1982;  84 861-864
  • 9 Lisboa C, Pare P, Pertuze J. Inspiratory muscle function in unilateral diaphragmatic paralysis.  Am Rev Respir Dis . 1986;  134 488-492
  • 10 Easton P, Fleetham J, de la Rocha A, Anthonisen N. Respiratory function after paralysis of the right hemidiaphragm.  Am Rev Respir Dis . 1983;  127 125-128
  • 11 Hughes P, Polkey M, Moxham J, Green M. Long-term recovery of diaphragm strength in neuralgic amyotrophy.  Eur Respir J . 1999;  13 379-384
  • 12 Celli B R, Grassino A. Respiratory muscles: functional evaluation.  Sem Respir Med . 1998;  19 367-381
  • 13 Mills G, Kyroussis D, Hamnegard C. Cervical magnetic stimulation of the phrenic nerves in bilateral diaphragmatic paralysis.  Am J Respir Crit Care Med . 1997;  155 1565-1569
  • 14 Takeda S, Miyoshi S, Maida H. Ventilatory muscle weakness and work of breathing in patients with respiratory failure after thoracic srugery.  Eur J Cardiothorac Surg . 1999;  15 449-455
  • 15 Martinez F J, Bermudez M, Celli B R. Hypothyroidism: a reversible cause of diaphragmatic dysfunction.  Chest . 1989;  96 1059-1063
  • 16 Murciano D, Rigaud D, Pingleton S, Armengaud H, Melchio J, Aubier M. Diaphragmatic function in severely malnourished patients with anorexia nervosa.  Am J Respir Crit Care Med . 1994;  150 1569-1574
  • 17 Sanham J, Shaw D, Guenter C. Acute supine respiratory failure due to bilateral diaphragmatic paralysis.  Chest . 1977;  72 96-98
  • 18 Celli B, Rassulo J, Corral R. Ventilatory muscle dyfunction in patients with bilateral idiopathic diaphragmatic paralysis: reversal by intermittent external negative pressure ventilation.  Am Rev Respir Dis . 1987;  136 1276-1278
  • 19 Alexander C. Diaphragm movement and the diagnosis of diaphragm paralysis.  Clin Radiol . 1966;  17 79-83
  • 20 Gottesman E, McCool D. Ultrasound evaluation of the paralyzed diaphragm.  Am J Respir Crit Care Med . 1997;  155 1570-1574
  • 21 Mier A, Brophy C, Moxham J, Green M. Assessment of diaphragmatic weakness.  Am Rev Respir Dis . 1988;  137 877-883
  • 22 Newson Davis J. Phrenic nerve conduction in man.  J Neurol Neurosurg Psychiatry . 1967;  30 420-426
  • 23 Bellemare F, Bigland-Ritchie B. Assessment of human diaphragmatic strength and activation using phrenic nerve stimulation.  Respir Physiol . 1984;  58 263-267
  • 24 Laporta D, Grassino A. Assessment of transdiaphragmatic pressure in humans.  J Appl Physio . 1985;  58 1469-1476
  • 25 Miller J, Moxham J, Green M. The maximal sniff in the assessment of diaphragm function in man.  Clin Sci . 1985;  69 91-96
  • 26 Aubier M, Murciano D, Lecocguic Y, Pariente R. Bilateral phrenic stimulation: a simple technique to assess diaphragmatic fatigue in humans.  J Appl Physiol . 1985;  58 58-64
  • 27 Wright C, Williams J, Ogilvie C, Donnelly R. Results of diaphragmatic plication for unilateral diaphragmatic paralysis.  J Thorac Cardiov Surg . 1985;  90 195-198
  • 28 Graham D, Kaplan D, Evans C, Hind C, Donnelly R. Diaphragmatic plication for unilateral diaphragmatic paralysis: a 10 year experience.  Ann Thor Surg . 1990;  49 248-252
  • 29 Haller J, Pickard L, Tepas J. Management of diaphragmatic paralysis in infants with special emphasis on selection of patients for operative plication.  J Pediatr Surg . 1979;  14 779-785
  • 30 Ciccollella D, Daly B, Celli B. Improved diaphragmatic function after surgical plication for unilateral diaphragmatic paralysis.  Am Rev Respir Dis . 1992;  146 797-799
  • 31 Kreitzer S, Feldman N, Saunders N, Ingram R. Bilateral diaphragmatic paralysis with hypercapnic respiratory failure.  Am J Med . 1978;  65 89-95
  • 32 Hill N. Noninvasive ventilation.  Am Rev Respir Dis . 1993;  147 1050-1065
  • 33 Stolk J, Vesteegh M. Long-term effect of bilateral plication of the diaphragm.  Chest . 2000;  117 786-789
  • 34 Glenn W. The treatment of respiratory paralysis by diaphragm pacing.  Ann Thor Surg . 1980;  30 106-109
  • 35 Glenn W. Ventilatory support of the conditioned diaphragm in quadriplegia.  N Eng J Med . 1984;  310 1150-1155
  • 36 Nochomovitz M, Schmit B, Mortimer J. Electrical activation of the diaphragm. In: Tobin M, ed. Problems in Respiratory Care Philadelphia, Pa: JB Lippincott 1990: 507-533
  • 37 Krieger A J, Gropper M R, Adler R J. Electrophrenic respiration after intercostal to phrenic nerve anastomosis in a patient with anterior spinal artery syndrome: technical case report.  Neurosurgery . 1994;  35 760-764
    >