Diaphragmatic Paresis Research Articles

Influence of location of paresis on site of pneumonia in stroke

Abstract

Bilateral Superficial Cervical Plexus Block in Combination with General Anesthesia Has a Low Efficacy in Thyroid Surgery: A Meta-Analysis of Randomized Controlled Trials

A combination of bilateral superficial cervical plexus block (BSCPB) and general anesthesia is recommended for thyroid surgery. Proof of the efficacy of this combination remains weak. Furthermore, data on the safety of this regimen are lacking. Therefore, a meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy and safety of BSCPB as an adjunct to general anesthesia in patients receiving thyroid surgery was performed. A meta-analysis of RCT was performed that included interventional groups evaluating the efficacy of BSCPB 6 and 24 hours after thyroid surgery. Eight RCT, including a total of 799 patients (463 who underwent BSCPB and 336 controls), were analyzed. A meta-analysis demonstrated a reduction in pain scores 6 hours (Hedges' g: -0.46 [95% CI: -0.74 to -0.19]; p=0.001) and 24 hours postoperatively (Hedges' g: -0.49 [95% CI: -0.71 to -0.27]; p<0.001) in patients who had undergone BSCPB. The relative risk for postoperative nausea and vomiting (PONV) was 0.80 (95% CI: 0.58 to 1.09, p=0.159) in patients receiving BSCPB. Procedure-related adverse events were reported in three of the 476 patients who had undergone BSCPB (0.6%; 95% CI: 0.1% to 2.0%). These three patients had transient paresis of the brachial plexus, combined with a diaphragmatic paresis in one case, and all spontaneously resolved. The combination of BSCPB and general anesthesia has a significant benefit in reducing pain 6 and 24 hours after thyroid surgery. However, the effect on pain reduction is too small to be of clinical relevance. Although it is a safe procedure, the existing evidence allows for no recommendation concerning the application of BSCPB in thyroid surgery. Further trials should evaluate a dose-response relationship and the incidence of PONV with this regimen.

Ipsilateral reversible diaphragmatic paralysis after pons stroke

Neurological disease may present with respiratory dysfunction. This presentation is also well recognized for stroke although the precise mechanisms responsible for respiratory problems are poorly understood. Diagnosis of respiratory dysfunction resulting from diaphragmatic paresis after stroke has been reported but few data are available about the effects of stroke on the diaphragmatic function. It is commonly thought that respiratory muscles are under bilateral hemispheric control although diaphragmatic excursion reduction and cases of diaphragmatic paralysis on the hemiplegic side have been reported in stroke patients [1, 2]. We report a case of a patient with unilateral diaphragmatic palsy contralateral to the hemiparetic side. A 65-year-old woman awoke with vomiting, dizziness and left hemiparesis. There was no history of recent trauma of the neck or the chest or recent surgery. On admission, her pulse rate was 80 beats/min, blood pressure was 110/60 mm Hg, and respirations were 15/min and regular. The patient denied dyspnea. The neurological examination showed a normal mental status. Her speech was dysarthric. The visual fields were intact; pupils were equal, with a normal light reflex; and ocular movements were full and smooth, without nystagmus. A mild left hemiparesis was present involving the face. There were no sensory deficits to touch, pain, temperature, vibration, or position sense. There was no ataxia on either side. No abnormality was demonstrated on brain computed tomography performed in the acute stage. Extensive laboratory investigations including hematological and biochemical parameters were unremarkable. Electrocardiogram, echocardiogram and carotid Doppler studies were normal. Chest radiograph revealed an elevated right hemidiaphragm (Fig. 1a). The brain magnetic resonance imaging (MRI) showed an area of increased signal intensity on T2 weighted or FLAIR images involving the paramedian region of the right pons (Fig. 2). The lesion showed focal restricted diffusion by using MRI diffusion-weighted imaging. The disturbance of neurological symptoms gradually improved. Complete resolution of diaphragmatic elevation and no hemiparesis were detected on day 60 of follow-up (Fig. 1b). The diaphragm is considered to contribute up to 60–70% of the total ventilation at rest, in both sitting and supine positions. Hemidiaphragmatic paralysis results in a vital capacity decrement of 10–30%, with the most substantial decrements seen in the supine position [3]. Breathing can be activated either automatically or volitionally [4]. The exactly cortical motor representation of respiratory muscles is not completely understood and there is no clear evidence of cerebral dominance for diaphragm function [5]. The descending pathways of the voluntary system are associated with the corticospinal tracts in the brainstem and upper cervical cord [6]. G. Moris M. Arias J. M. Terrero Neurology Service, Hospital San Agustin, Aviles, Asturias, Spain

Bilateral phrenic neuropathies in a diabetic patient responsive to intravenous immunoglobulin: A case report

Introduction Bilateral phrenic neuropathy is an uncommon complication of diabetes mellitus. Case presentation We present a patient with diabetes mellitus who developed dyspnea from diaphragmatic paresis secondary to bilateral phrenic neuropathies on the background of subclinical generalized polyneuropathy documented by electrodiagnostic studies. The patient was treated with intravenous immunoglobulin with improved diaphragmatic function. Conclusion Phrenic neuropathy is a rare but important complication of diabetes mellitus. We report the first case of the beneficial use of intravenous immunoglobulin in diabetic phrenic neuropathy.

Decreasing the Local Anesthetic Volume From 20 to 10 mL for Ultrasound-Guided Interscalene Block at the Cricoid Level Does Not Reduce the Incidence of Hemidiaphragmatic Paresis

This prospective, randomized, double blind study was designed to determine whether reduction in volume from 20 to 10 mL of ropivacaine 0.5% for ultrasound-guided interscalene block might decrease the incidence of diaphragmatic paresis and preserve pulmonary function. Thirty patients scheduled for arthroscopic shoulder surgery were randomized to receive either 10 or 20 mL of ropivacaine 0.5% for interscalene block at the level of the cricoid cartilage. General anesthesia was administered for surgery, and the surgeon infiltrated lidocaine at the port sites. Hemidiaphragmatic excursion and pulmonary function tests were measured before block, 15 mins after block, and at the time of discharge from recovery room. Onset and duration of sensory dermatomal spread, motor block, pain scores, and analgesic consumption were recorded. Hemidiaphragmatic paresis occurred 15 mins after block performance in 14 of 15 patients in each group. At postanesthesia care unit discharge, 13 of 15 patients in each group continued to demonstrate hemidiaphragmatic paresis. Significant reduction of spirometric values(forced vital capacity, forced expiratory volume at 1 sec, and peak expiratory flow) occurred to a similar degree in both groups after block.Sensory dermatomal spread, motor block, pain scores, and analgesic consumption were not significantly different between groups. Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.

166th ENMC International Workshop on Collagen type VI-related Myopathies, 22–24 May 2009, Naarden, The Netherlands

Twenty-four clinicians, basic scientists and representatives of a patient advocacy organisation and pharmaceutical companies from 8 countries (Australia, England, France, Germany, Italy, Switzerland, Turkey, USA) gathered in Naarden, The Netherlands, to discuss the group of neuromuscular disorders caused by the deficiency of collagen type VI (ColVI), collectively termed ColVI-related myopathies. This meeting focused on three main areas: (1) the great heterogeneity observed at the genetic and clinical levels and the resulting complexity of the molecular diagnosis; (2) the pathophysiological mechanisms linking mutations in the COL6A genes to muscle pathology; (3) the current strategies for therapeutic interventions which have led to the design of upcoming clinical trials. Two sessions were also dedicated to existing and future databases, and to outcome measures.

Traumatic Delivery, Diaphragmatic Paresis, and “Dextrocardia”

A term male infant weighing 4170 g was delivered vaginally, by forceps extraction. Apgar scores and cord blood pHs were normal. He was noted to have a left-sided Erb's palsy, tachypnea, and mild chest recession. Oxygen saturations were 87% in room air, and the initial chest radiograph showed an elevated left hemi-diaphragm with mediastinal shift to the right (Figure). Fluoroscopy screening of the diaphragm demonstrated paradoxical movement of the left hemi-diaphragm consistent with left diaphragmatic paresis.

The Phrenic Nerve And Atrial Fibrillation Ablation Procedures.

Radiofrequency ablation is increasingly used as an option to optimally manage patients with symptomatic atrial fibrillation. Presently, ablationists strive to improve success rates, particularly with persistent atrial fibrillation, while simultaneously attempting to reduce complications. A well-recognized complication with atrial fibrillation ablation is injury to the phrenic nerve giving rise to diaphragmatic paresis and patient discomfort.Phrenic nerve damage may occur when performing common components of atrial fibrillation ablation including pulmonary and superior vena caval isolation. The challenge for ablationists is to successfully target the arrhythmogenic substrate while avoiding this complication. In order to do this, a thorough knowledge of phrenic nerve anatomy, points in the ablation procedure where nerve damage is more likely, and an understanding of the presently utilized techniques to avoid this complication is required. In addition, when this complication does arise, prompt recognition of its occurrence, knowledge of the natural history, and available methods for management are needed.In this review, we discuss the underlying anatomic principles, techniques of avoiding phrenic nerve damage, and presently available methods of diagnosing and managing this complication.

G.P.1.11 Mitofusin gene mutations (MFN 2) cause a severe CMT2A with diaphragm paresis involvement

G.P.1.11 Mitofusin gene mutations (MFN 2) cause a severe CMT2A with diaphragm paresis involvement

Postoperative course in the cardiac intensive care unit following the first stage of Norwood reconstruction

The medical records of all patients born between 1 September, 2000, and 31 August, 2002, and undergoing the first stage of Norwood reconstruction, were retrospectively reviewed for details of the perioperative course. We found 99 consecutive patients who met the criterions for inclusion. Hospital mortality for the entire cohort was 15.2%, but was 7.3%, with 4 of 55 dying, in the setting of a "standard" risk profile, as opposed to 25.0% for those with a "high" risk profile, 11 of 44 patients dying in this group. Extracorporeal membrane oxygenation was utilized in 7 patients, with 6 deaths. Median postoperative length of stay in the hospital was 14 days, with a range from 2 to 85 days, and stay in the cardiac intensive care unit was 11 days, with a range from 2 to 85 days. Delayed sternal closure was performed in 18.2%, with a median of 1 day until closure, with a range from zero to 5 days. Excluding isolated delayed sternal closure, and cannulation and decannulation for extracorporeal support, 24 patients underwent 33 cardiothoracic reoperations, including exploration for bleeding in 12, diaphragmatic plication in 4; shunt revision in 4, and other procedures in 13. The median duration of total mechanical ventilation was 4.0 days, with a range from 0.7 to 80.5 days. Excluding those who died, the median total duration of mechanical ventilation was 3.8 days, with a range from 0.9 to 46.3 days. Reintubation for cardiorespiratory failure or upper airway obstruction was performed in 31 patients. Postoperative electroencephalographic and/or clinical seizures occurred in 13 patients, with 7 discharged on anti-convulsant medications. Postoperative renal failure, defined as a level of creatinine greater than 1.5 mg/dl, was present in 13 patients. Eleven had significant thrombocytopenia, with fewer than 20,000 platelets per microl, and injury to the vocal cords was identified in eight patients. Risk factors for longer length of stay included lower Apgar scores, preoperative intubation, early reoperations, reintubation and sepsis, but not weight at birth, genetic syndromes, the specific surgeon, or the duration of surgery. Although mortality rates after the first stage of reconstruction continue to fall, the course in the intensive care unit is remarkable for significant morbidity, especially involving the cardiac, pulmonary and central nervous systems. These patients utilize significant resources during the first hospitalization. Further studies are necessary to stratify the risks faced by patients with hypoplasia of the left heart in whom the first stage of Norwood reconstruction is planned, to determine methods to reduce perioperative morbidity, and to determine the long-term implications of short-term complications, such as diaphragmatic paresis, injury to the vocal cords, prolonged mechanical ventilation, and postoperative seizures.

A Prospective, Randomized Comparison Between Combined (Deep and Superficial) and Superficial Cervical Plexus Block with Levobupivacaine for Minimally Invasive Parathyroidectomy

Minimally invasive parathyroidectomy (MIP) can be performed under cervical plexus block (CPB). Superficial CPB has been reported to be easier to perform with similar efficacy and less anesthesia-related complications than combined deep and superficial CPB. In this study, we compared the efficacy of superficial and combined (deep and superficial) CPB in patients undergoing MIP. Forty-two patients with primary hyperparathyroidism due to a solitary adenoma were randomized to receive either a superficial (group superficial, n = 20) or a combined deep and superficial CPB (group combined, n = 22) using 0.35 mL/kg of 0.5% levobupivacaine. The primary end-point was the amount of supplemental fentanyl required to complete surgery. There were no differences in onset of block, pain scores during surgery, or time to first analgesic request between groups. Fentanyl consumption was similar in both groups, i.e., 50 (0-200) microg in group superficial and 50 (0-100) microg in group combined (P = 0.60). Six patients [1 in group superficial (5%) and 5 in group combined (22.7%)] were converted to general anesthesia for surgically required bilateral neck dissection (P = 0.18). General anesthesia for block failure was reported in three superficial (15%) and two combined group patients (9%) (P = 0.99). In group combined, only one patient (4.5%) showed diaphragmatic paresis after the block (P = 0.99). Superficial CPB is an alternative to combined block for MIP.

Étirement du nerf phrénique droit avec parésie diaphragmatique au décours d'une décélération chez un patient de 54 ans

Traumatic interruption or stretch of the phrenic nerve is a well-recognized complication of blunt thoracic trauma and may involve dysfunction of the main respiratory muscle, with respiratory insufficiency and consequent ventilation problems. Althougt symptoms often occur shortly after the injury, patients without clinical symptoms or the presence of concomitant thoraco-abdominal lesion may pose a diagnostic quandary and lead to a delayed presentation. Diaphragm's palsy generally heals spontaneously in six to twelve months, with a concomitant gradual return of diaphragm function, provided that it doesn't result from permanent damage to the phrenic nerve. The indication of surgical implication are becoming rarer but patients who remain symptomatic or the imbrication of a diaphragmatic hernia may require a surgical treatment. We report the case of a right sided diaphragmatic paresis after a blunt thoracic trauma in a 54-year-old patient. The elevation of the right diaphragm, showed by the initial chest x-ray, led to a thoracoabdominal CT scan, despite the absence of suggestive clinical symptoms and pose the diagnosis of diaphragmatic hernia. The delayed respiratory degradation involved an explorer thoracotomy, finding a diaphragmatic paresis induced by phrenic nerve stretch who was sticked by the deceleration during the car accident.

Paresia diafragmática bilateral idiopática

We report the case of a patient with severe dyspnea upon reclining. Lung disease, neuromuscular disorders and heart disease were ruled out. However, during the course of the investigation, bilateral diaphragmatic paresis was discovered. A key sign leading to the diagnosis was evidence of paradoxical respiration in the dorsal decubitus position. When the patient was moved from the orthostatic position to the dorsal decubitus position, oxygenation and forced vital capacity worsened. The orthostatic fluoroscopy was normal. Maximal inspiratory pressure was severely reduced. The responses to transcutaneous electric stimulation of the diaphragm were normal. However, electric stimulation of the phrenic nerve produced no response, leading to the diagnosis of bilateral diaphragmatic paresis.

Diaphragmatic Hernia After Radiofrequency Ablation Therapy for Hepatocellular Carcinoma

3Department of Radiology, Kitasato University School of Medicine, Sagamihara, Kanagawa 228-8555, Japan. ercutaneous radiofrequency ablation is a novel thermal ablation technique for achieving coagulative necrosis of liver tumors with fewer treatment sessions than percutaneous ethanol injection therapy requires [1, 2]. Several recent developments in radiofrequency ablation technology, such as a high-power (150–200 W) radiofrequency generator, a method for conducting radiofrequency ablation during occlusion of hepatic blood flow, and saline-enhanced radiofrequency ablation techniques, have made it possible to necrotize a larger volume of tissue—3 cm or more in diameter—during a single ablation procedure [3]. Most of the complications after radiofrequency ablation have been minor, but some severe and fatal complications have been reported [4, 5]. In a multicenter study in 2,320 patients with 3,554 lesions [4], six patients (0.3%) died after radiofrequency ablation, including two caused by multiorgan failure following intestinal perforation; one case each of septic shock, tumor rupture, liver failure after bile duct stenosis; and sudden death of unknown cause. Fifty cases (2.2%) of additional major complications were also reported, including 12 (0.5%) of peritoneal bleeding, 12 of tumor seeding, six of hepatic abscess, five of gastrointestinal wall perforation, three of hemothorax, two of rapid hepatic decompensation, and one case each of diaphragmatic paresis, common bile duct stenosis, cardiac arrest, pulmonary embolism, pneumothorax, large biloma, multisegmental hepatic infarction, acute cholestasis, and septicemia. Thermal damage has been documented as a specific complication of radiofrequency ablation. We recently encountered a patient with a diaphragmatic hernia due to thermal damage of the diaphragm. A defect of the diaphragm occurred after radiofrequency ablation for hepatocellular carcinoma (HCC) and remained quiescent for 18 months until bowel herniated through it. To our knowledge, this is the first case in the literature to report diaphragmatic hernia as a complication of radiofrequency ablation. The clinical presentation was acute abdominal pain, whereas MDCT clearly indicated a diaphragmatic defect.

Interscalene Brachial Plexus Block with Bupivacaine and Ropivacaine in Patients with Chronic Renal Failure: Diaphragmatic Excursion and Pulmonary Function Changes

In this randomized, double-blind study, we compared the anesthetic characteristics and pulmonary function changes of 0.33% bupivacaine and 0.33% ropivacaine used for interscalene brachial plexus (IBP) anesthesia in patients with chronic renal failure. Forty-two patients undergoing IBP anesthesia for creation of arteriovenous fistulas were randomly allocated to receive either 30 mL of 0.33% bupivacaine (Group B) or 0.33% ropivacaine (Group R). Block onset time, diaphragmatic excursion (ultrasonographic evaluation), and free plasma concentrations of bupivacaine and ropivacaine were evaluated. Negative motion or immobility of the ipsilateral hemidiaphragm and a decrease of >10 mm in positive motion were defined as diaphragmatic paresis. The pulmonary function variables were measured by bedside spirometry equipment. Seven patients needed supplemental local anesthetic, one with total spinal block; these patients were excluded from the study. The success rate was 80.9%. Block quality was similar in the two groups. Ipsilateral hemidiaphragmatic excursion was decreased in both groups compared with baseline values (P < 0.05). Diaphragmatic paresis was identified in 10 of 16 patients and 8 of 18 patients in Groups B and R, respectively (P > 0.05). Pulmonary function significantly decreased from baseline in both groups (forced vital capacity (FVC) 30%, forced expiratory volume at 1 second (FEV(1)) 32%, and peak expiratory flow (PEF) 31% in Group B and FVC 17%, FEV(1) 17%, and PEF 5% in Group R) (P < 0.001). The decreases in Group B were larger than those in Group R (P < 0.05). Three patients in Group B and one in Group R had mild respiratory problems (P > 0.05). Concentrations of bupivacaine and ropivacaine were below toxic levels rather than "normal range." We conclude that pulmonary function decreased more after IBP with 0.33% bupivacaine than with 0.33% ropivacaine.

Lower lobe collapse during continuous interscalene brachial plexus local anesthesia at home

Objectives We report a case of pulmonary left lower lobe collapse following an interscalene local anesthetic infusion administered at home. This case highlights the need for patient education and postoperative communication. Case report A 52-year-old male patient presented for a rotator cuff repair. He was a chronic tobacco abuser with a history of occasional chest pain of unexplained cause. An interscalene catheter was placed preoperatively and surgery was performed under a combination of an interscalene block and a general anesthetic. An infusion of 0.2% ropivacaine was started via the interscalene catheter postoperatively and continued at home following his discharge from the hospital on the third postoperative day. Within 24 hours of discharge, he was readmitted to the hospital after complaining of chest pain and dyspnea. The patient was seen in the emergency department by nonanesthesiologists who were not familiar with the potential for interscalene blocks to cause diaphragmatic paresis. Conclusions Good communication must be maintained with the patient at all times. Doctors from other specialties may be unaware of the potential complications of an interscalene block.

Risk factors for long intensive care unit stay after cardiopulmonary bypass in children.

To determine whether children who experience longer intensive care unit (ICU) stays after open heart surgery may be identified at admission by clinical criteria. To identify factors associated with longer ICU stays that are potential targets for quality improvement. Tertiary pediatric cardiac surgical center. A retrospective review was performed of pre-, intra-, and postoperative factors for children undergoing open heart surgery. All factors were evaluated for strength of association with length of ICU stay (LOS) using a negative binomial model. After multiple analysis, factors were deemed significant if associated with a LOS with p < .02. A total of 355 pediatric patients who had cardiac surgery with cardiopulmonary bypass in a 1-yr period from April 1999 until March 2000. Children who fell above the 95th percentile for LOS in our institution occupied 30% of bed days and had a three-fold greater mortality. Of all clinical factors considered, those significantly associated with LOS were as follows: preoperative--mechanical ventilation, neonatal status, medical problems, and transfer from abroad; intraoperative--higher operative complexity, increased cardiopulmonary bypass time or ischemic time, and circulatory arrest; and postoperative--delayed sternal closure, sepsis, renal failure, pulmonary hypertension, chylothorax, diaphragm paresis, and arrhythmia. A model combining all factors identified preoperative mechanical ventilation, neonatal status, major medical problems, operative complexity, cardiopulmonary bypass time, and a postoperative complication score as independently associated with LOS (p < .01). At the time of ICU admission after open heart surgery, clinical criteria are evident that highlight a child's risk of longer ICU stay. These pre- and intraoperative factors relate to LOS independent of subsequent postoperative events. Those postoperative complications that are most strongly associated with increased LOS are identified and, therefore, made accessible to quality control.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Tracheotomy tube placement in children following cardiothoracic surgery: Indications and outcomes

Purpose: To review the indications for and outcomes of children requiring tracheotomy tube placement following cardiothoracic surgery, charts were reviewed retrospectively at a tertiary care center for fifteen children who had undergone tracheotomy tube placement following cardiothoracic surgery between 1994 and 2000. Outcomes Measure: Morbidity and/or mortality associated with tracheotomy tube placement in this patient population, duration of tracheotomy tube, and rate of decannulation. Results: Fifteen out of approximately 3000 children undergoing cardiothoracic surgery required tracheotomy tube placement over a 6-year period. Indications included diaphragmatic paresis (DP) (7 patients), vocal cord paresis (VP) alone (3 patients), DP and VP (2 patients), subglottic stenosis (SS) and DP (1 patient), VP and SS (2 patients), and cerebrovascular infarct (1 patient). The mean age at the time of tracheotomy tube placement was 36.5 months (range, 0.75-108 months). The mean duration of intubation between cardiothoracic procedure and tracheotomy was 31.6 days (range, 0-72 days). Six patients were successfully decannulated following a mean of 7.4 months of tracheotomy tube dependence. All 6 decannulated patients had DP necessitating tracheotomy and ventilatory support. Eight patients continue to be tracheotomy tube–dependent, and one patient died of unrelated causes. There was no short-term or long-term morbidity or mortality associated with tracheotomy tube placement. Conclusion: Tracheotomy tube placement is rarely indicated following cardiothoracic surgery in children. The most common indication is DP, which is usually transient. Most children will eventually be candidates for decannulation. (Am J Otolaryngol 2002;23:337-340. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention.

Neuropathies involving the brachial plexus, phrenic, recurrent laryngeal, and saphenous nerves, as well as the sympathetic chain are complications of cardiac surgery. The reported frequency of nerve injuries varies from 1.5% to 24% for the brachial plexus and 10% to 60",,6 for the phrenic nerve (1-5). Neuropathies of the recurrent laryngeal, lower limb (saphenous) nerves, and the sympathetic chain are less frequent.