Management of diaphragmatic paralysis in infants with special emphasis on selection of patients for operative plication

Abstract

Paralysis of the diaphragm may cause life threatening respiratory distress in infants. Paradoxical movement of the diaphragm may result from congenital eventration or may occur from traction injuries to the phrenic nerve and brachial plexus during traumatic deliveries. Phrenic nerve injury occurs most frequently from technical accidents during various operative procedures for congenital heart disease. This complication greatly increases the postoperative morbidity in association with the underlying congenital heart abnormality. Plication of the diaphragm in all these circumstances may be life saving in selected patients; however, which patients require operative intervention is often a perplexing question. We have found that a trial of continuous positive airway pressure breathing is the best form of management. It is also a critical differential test to identify those infants who will benefit from plication of the diaphragm. Each symptomatic infant undergoes endotracheal intubation and is supported with 8 to 10 cm of H2O continuous airway pressure breathing. This system appears to stabilize the diaphragm with better expansion of the lung and prevents continuing paradox of the diaphragm. If the system of continuous positive airway pressure breathing with FiO2 of 40% or greater will not correct the respiratory problem, then parenchymal disease or a residual heart defect rather than diaphragmatic dysfunction is the main problem and plication will not be curative. On the other hand, if this system corrects the respiratory problem and blood gases are satisfactory, the airway pressures are lowered and the FiO2 is adjusted toward room air. If respiratory insufficiency recurs with gradual cessation of continuous positive airway pressure breathing, then such patients will be benefited or cured by operative plication. Paralysis of the diaphragm may cause life threatening respiratory distress in infants. Paradoxical movement of the diaphragm may result from congenital eventration or may occur from traction injuries to the phrenic nerve and brachial plexus during traumatic deliveries. Phrenic nerve injury occurs most frequently from technical accidents during various operative procedures for congenital heart disease. This complication greatly increases the postoperative morbidity in association with the underlying congenital heart abnormality. Plication of the diaphragm in all these circumstances may be life saving in selected patients; however, which patients require operative intervention is often a perplexing question. We have found that a trial of continuous positive airway pressure breathing is the best form of management. It is also a critical differential test to identify those infants who will benefit from plication of the diaphragm. Each symptomatic infant undergoes endotracheal intubation and is supported with 8 to 10 cm of H2O continuous airway pressure breathing. This system appears to stabilize the diaphragm with better expansion of the lung and prevents continuing paradox of the diaphragm. If the system of continuous positive airway pressure breathing with FiO2 of 40% or greater will not correct the respiratory problem, then parenchymal disease or a residual heart defect rather than diaphragmatic dysfunction is the main problem and plication will not be curative. On the other hand, if this system corrects the respiratory problem and blood gases are satisfactory, the airway pressures are lowered and the FiO2 is adjusted toward room air. If respiratory insufficiency recurs with gradual cessation of continuous positive airway pressure breathing, then such patients will be benefited or cured by operative plication.