Anesthetic Management of a Patient With Bilateral Diaphragmatic Paralysis Secondary to Neuralgic Amyotrophy Undergoing Open Aortic Valve Replacement

Abstract

BILATERAL DIAPHRAGMATIC PARALYSIS (BDP) is a rare clinical condition that often results from damage to the phrenic nerves. Underlying causes have included but are not limited to traumatic injury, infection, myopathy, and neuropathy. A rare, idiopathic neuropathy, known as neuralgic amyotrophy (NA), uncommonly can cause BDP as well. Without diaphragmatic function, muscles, such as the sternocleidomastoids, scalenes, and intercostals (accessory muscles), are used to generate the negative intrathoracic pressure necessary for inspiration. 1 Ricoy J Rodriguez-Nunez N Alvarez-Dobano J et al. Diaphragmatic dysfunction. Pulmonology. 2019; 25: 223-235 Google Scholar This may result in rapid and inefficient breathing leading to hypoventilation, atelectasis, and cyanosis. Pulmonary function testing often demonstrates a restrictive pathology, with a decrease in functional residual and vital capacities with preservation of the forced expiratory volume in one second (FEV1)-to-forced vital capacity (FVC) ratio. 2 Steier J Jolley C Seymour J et al. Sleep-disordered breathing in unilateral diaphragm paralysis or severe weakness. Eur Respir J. 2008; 32: 1479-1487 Google Scholar Supplemental oxygen and noninvasive positive-pressure ventilation are recommended for those patients with an oxygen saturation <88%. 3 Kokatnur L Rudrappa M. Diaphragmatic palsy. Diseases. 2018; 6: 16 Google Scholar Although resolution of BDP is possible over months-to-years, most patients will remain symptomatic or experience minimal improvement in their symptoms. 1 Ricoy J Rodriguez-Nunez N Alvarez-Dobano J et al. Diaphragmatic dysfunction. Pulmonology. 2019; 25: 223-235 Google Scholar