Unilateral Phrenic Nerve Palsy Research Articles

Severe respiratory failure secondary to unilateral phrenic nerve injury: A case report

AbstractPatients with unilateral phrenic nerve paralysis are usually asymptomatic at rest. We present a 77‐year‐old woman with a chest wall osteoarthropathy associated with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome that developed severe hypercapnic respiratory failure following cryoballoon ablation for the management of atrial fibrillation. Her right phrenic nerve injury (PNI) was confirmed by chest radiography, phrenic nerve conduction studies, and diaphragmatic ultrasonography. We conclude that unilateral PNI during ablation invalidated the diaphragmatic compensation for pre‐existing reduced thoracic expansion, resulted in severe hypoventilation. Clinicians should be careful of the fact even unilateral PNI could cause catastrophic respiratory failure in patients with restricted thoracic expansion.

17. Ultrasound-guided Supraclavicular Block (USGB) by Surgeon for ORIF of Distal Radius Fractures (DRF): A 6-year Experience with 1830 Consecutive Cases

PURPOSE: Anesthesiologist need for preoperative testing for distal radius (DRF) ORIF delays care and increases costs. Familiar with ultrasound and anatomy, surgeons are well poised to deliver ultrasound guided supraclavicular block (UGSB.) We reviewed our experience with surgeon delivered UGSB without anesthesiologists to assess its safety and efficacy. METHODS: We retrospectively reviewed all DRFsORIF performed at our ASC by 3 surgeons over a 6-year period. Operative data, complications, demographics, clinical characteristics, fracture patterns, and functional outcomes were evaluated. RESULTS: 1,830 consecutive patients underwent ORIF without anesthesiologists; 1123 females, 707 males, age 62years (27-97). Six bilateral fractures. Fracture types: 783(A), 244(B) and 704(C); with 9 Gustilo(I), 4 Gustilo(II), and 92 malunions. Thirty-two distal ulnar fractures also required ORIF. 1,410 patients were ASA2, and 420 ASA3. Average time to administer block was 5.5min, tourniquet time 24.5min, and 63min total time patient spent in facility. Patients received no IV’s, self-ambulated to and from the OR table pain free, and conversed with the sitter nurse thru the procedure. 82 patients had partial UGSB failure requiring local lidocaine supplementation. No block related complications occurred except two transient unilateral phrenic nerve palsy. There were no infections, no hematomas and postoperatively required only 15 narcotic pills on the average (50% of historical). Upon discharge, 1,551 patients achieved normal range-of-motion, and 5 developed CRPS. Patient easily tolerated surgery without anesthesiologists and were highly satisfied with the expedited care and outcome. CONCLUSION: ORIF of DRFs can be safely, expeditiously, successfully, and cost-effectively treated by surgeon delivered UGSB without anesthesiologists and extensive preoperative testing.

333 Phrenic nerve neuropathy discovered with cardiopulmonary exercise test in long-COVID-19 syndrome

Corona virus disease of 2019 (COVID19) is an ongoing global pandemic caused by SARS-CoV-2 virus. COVID-19 typically involves the respiratory tract with a wide spectrum of disease severity. Long-Covid19 syndrome refers to a series of symptoms that sometimes persist after COVID-19 infection. We describe a case of unilateral phrenic nerve palsy in a young woman with Long-COVID-19 syndrome. a 28-year-old woman admitted for COVID-19 presented persistent exertional dyspnoea. All the examinations performed were normal. At Cardiopulmonary exercise test (CPET) however, the ventilation plot was characterized by a lack of increase of the tidal volume compensated with a premature and continuous rise in respiratory frequency. Suspecting a ventilation abnormality, an electroneurography of the diaphragmatic nerves was conducted showing a right phrenic nerve palsy. Long-COVID-19 syndrome is a growing entity in clinical practice and dyspnoea is one of the most common symptoms. In this setting, phrenic nerve palsy should be ruled out, especially in patients with unexplained dyspnoea. CPET is a complete technique that assesses both pulmonary and cardiac performance. Since it might give important clues in the recognition of the cause of persistent symptoms after COVID-19 it should be extensively performed in these patients.

Unilateral Phrenic Nerve Palsy in Infants with Congenital Zika Syndrome

Abstract Since the first identification of neonatal microcephaly cases associated with congenital Zika virus infection in Brazil in 2015, a distinctive constellation of clinical features of congenital Zika syndrome has been described. Fetal brain disruption sequence is hypothesized to underlie the devastating effects of the virus on the central nervous system. However, little is known about the effects of congenital Zika virus infection on the peripheral nervous system. We describe a series of 4 cases of right unilateral diaphragmatic paralysis in infants with congenital Zika syndrome suggesting peripheral nervous system involvement and Zika virus as a unique congenital infectious cause of this finding. All the patients described also had arthrogryposis (including talipes equinovarus) and died from complications related to progressive respiratory failure.

Unilateral Phrenic Nerve Palsy in a Patient with Traumatic Brachial Plexus Injury Contributing to Early Pulmonary Complications: A Case Report

Unilateral Phrenic Nerve Palsy in a Patient with Traumatic Brachial Plexus Injury Contributing to Early Pulmonary Complications: A Case Report

Postoperative Phrenic Nerve Palsy, A Cause Of Prolonged Mechanical Ventilation In Trans-Sternal Thymectomy

Post trans-sternal thymectomy, the patient may develop respiratory failure, usually due to myasthenic crisis or cholinergic crisis. These crises may prolong mechanical ventilation and impede on-table extubation. We report a case of respiratory failure due to unilateral phrenic nerve palsy in a case of myasthenia gravis. A 35 year old female, known case of myasthenia gravis was posted for trans-sternal thymectomy. Anaesthesia was induced with Propofol, Fentanyl and low dose of Atracurium. Thymoma was incasing right subclavian vein and was adherent with the pericardium, Masaoka Grade III. Blood loss was approximately 200ml. Immediate post operative period showed low tidal volume, tachypnea and tachycardia in spite of train of four ratio >0.9. Patient was kept intubated with suspicion of myasthenic crisis and the dose of Pyridostigmine was increased, but this lead to increased cholinergic symptoms. Pain was addressed with thoracic epidural analgesia. Chest radiograph done later in the evening showed elevated right hemi diaphragm, thereby, confirming the diagnosis of phrenic nerve palsy. Difficult dissection in this case has resulted in right phrenic nerve palsy. Phrenic nerve palsy has to be considered as a cause of respiratory failure post sternotomy thymectomy, especially in case of Masaoka grade III and IV.DOI: http://dx.doi.org/10.3126/jkmc.v3i3.12249Journal of Kathmandu Medical CollegeVol. 3, No. 3, Issue 9, Jul.-Sep., 2014, Page: 122-125

Phrenic nerve paralysis from recurrence of stage I thymoma with myasthenia gravis 10 years after complete resection

A 34-year-old woman underwent thymo-thymectomy for myasthenia gravis (MG) and was diagnosed with type B3 Masaoka stage I thymoma. Phrenic nerve paralysis developed 8 years after surgery, and a left-sided mediastinal mass was seen on a chest radiograph 10 years after surgery. Chest computed tomography revealed a tumor measuring 57 × 21 × 28 mm beside the aortic arch. Surgical resection of the tumor with partial resection of phrenic and recurrent nerve, the left upper lobe, and the pericardium was performed through a left thoracotomy. Histological examination confirmed recurrent thymoma invading the resected surrounding organs. The patient received radiation therapy postoperatively and was alive with stable symptoms of MG at the 2-year follow-up. Symptomatic relapse of thymoma is very rare and an occult recurrent thymoma should be considered in patients with unilateral phrenic nerve paralysis even after complete resection of thymoma. Detailed examination with careful follow-up should be considered.

Phrenic Nerve Palsy Associated With Brachial Plexus Avulsion in a Pediatric Patient With Multitrauma

Although brachial plexus injury occurring during multitrauma is frequent in adults, it is rarely observed in childhood. The most common cause of pediatric traumatic brachial palsy is motor vehicle accidents followed by pedestrian struck. Generally, phrenic nerve palsy accompanying brachial plexus trauma is observed in 10% to 20% of cases, but it is overlooked because unilateral injuries are frequently asymptomatic. Severe unilateral phrenic nerve palsy accompanying brachial plexus avulsion is very rare. Here, we present a pediatric case of unilateral phrenic nerve palsy associated with respiratory distress and brachial plexus avulsion due to multitrauma.

Unilateral phrenic nerve lesion in Lyme neuroborreliosis

BackgroundAmong a variety of more common differential diagnoses, the aetiology of acute respiratory failure includes Lyme neuroborreliosis.Case presentationWe report an 87-years old huntsman with unilateral phrenic nerve palsy as a consequence of Lyme neuroborreliosis.ConclusionAlthough Lyme neuroborreliosis is a rare cause of diaphragmatic weakness, it should be considered in the differential workup because of its potentially treatable nature.

Can bilateral bronchospasm be a sign of unilateral phrenic nerve palsy after supraclavicular brachial plexus block?

Ultrasound-guided peripheral nerve blocks facilitate ambulatory anesthesia for upper limb surgeries. Unilateral phrenic nerve blockade is a common complication after interscalene brachial plexus block, rather than the supraclavicular block. We report a case of severe respiratory distress and bilateral bronchospasm following ultrasound-guided supraclavicular brachial plexus block. Patient did not have clinical features of pneumothorax or drug allergy and was managed with oxygen therapy and salbutamol nebulization. Chest X-ray revealed elevated right hemidiaphragm confirming unilateral phrenic nerve paresis.

Poster 69 Waiting to Inhale: Electrodiagnosis of A Left Phrenic Nerve Palsy After Chiropractic Cervical Manipulation: A Case Report

Disclosures: C. M. Roque-Dang, none. Patients or Programs: A 50-year-old man. Program Description: The patient had presented with the chief complaint of dyspnea for several months. He reported that he had chiropractic treatment for cervicalgia and, on the day after cervical manipulation, developed unexplained dyspnea with mild exertional activities. Due to his worsening symptoms, he terminated his chiropractic visits and was evaluated by his primary care physician and a neurologist. Pertinent radiographic imaging included a SNIFF fluoroscopic examination, which revealed left hemidiaphragmatic paralysis and a chest radiograph that demonstrated an elevated left hemidiaphragm. Based on the patient’s history and radiographic imaging a electrodiagnostic testing was then performed to rule out a left phrenic nerve palsy. Setting: Outpatient private practice office. Results: On motor nerve conduction studies, he was found to have delayed distal latencies of the left phrenic nerve. Electromyography revealed reduced recruitment throughout the left hemidiaphragm, rare spontaneous denervation potentials in the left lateral diaphragm, and complex and nascent polyphasic single motor unit potentials in the left anterior diaphragm. The electrodiagnostic findings were consistent a left phrenic nerve segmental demyelinated injury. We referred the patient to a plastic surgeon, who performed a left phrenic nerve reconstruction. After surgery, the patient had improved respiratory function and activity tolerance. Discussion: A phrenic nerve injury that resulted in symptomatic diaphragmatic paralysis is most commonly associated with cardiothoracic surgery or malignancy. There are only a few cases that report phrenic nerve palsies sustained from chiropractic cervical manipulation. In these isolated reports, electrodiagnosis was not routinely used to detect these lesions. Conclusions: Reported is an unusual case of unilateral phrenic nerve palsy sustained after chiropractic manipulation. Before receiving cervical spine manipulation, patients should be counseled of this possible and serious complication. Electrodiagnostic studies are useful in phrenic nerve injury diagnosis and treatment determination.

PONM03 Neuralgic amyotrophy and viral infections are important causes for phrenic nerve palsy and surgery is effective treatment

Phrenic nerve palsy is a rare condition but it can lead to disabling dyspnoea. The following are reports of four patients who developed unilateral nerve palsy due to neuralgic amyotrophy...

5,10-Methylenetetrahydrofolate reductase deficiency with progressive polyneuropathy in an infant

5,10-Methylenetetrahydrofolate reductase (MTHFR) deficiency is the most prevalent inborn error of folate metabolism, and has variable clinical manifestations from asymptomatic to severe psychomotor retardation, microcephalus and seizure. In untreated infantile cases, it predominantly affects the central nervous system, which is sometimes fatal. On the other hand, peripheral nerve involvement is uncommon. We present a severe infantile case of MTHFR deficiency that manifested unilateral phrenic nerve palsy with communicating hydrocephalus, developmental delay and died at 11 months of age. An enzymatic study confirmed MTHFR deficiency with residual activity of 0.75% of mean control values in cultured fibroblasts. Mutation analysis of the MTHFR gene revealed homozygous, tandem missense mutations c.[446G>T; 447C>T] in exon 3 of the MTHFR gene converting glycine to valine (Gly149Val). In MTHFR deficiency, betaine may improve the symptoms if started immediately after birth by reducing the level of serum homocysteine and increasing that of methionine. Our results show that we should be aware of possible inborn errors of folate metabolism such as MTHFR deficiency, in infants with unexplained developmental delay manifesting rapidly progressive polyneuropathy.

Transient phrenic nerve paralysis after carotid endarterectomy in a patient with asthma

To the Editor: Transient phrenic nerve paralysis occurred in a patient with asthma after carotid endarterectomy (CEA). The patient, a 64-year-old male with a height of 164 cm and weight of 69 kg, had been suffering from asthma for 15 years for which he was taking 400 mg of theophylline daily. A respiratory examination showed a reduced percentage forced expiratory volume in 1 second (%FEV1.0: 61.2%), and he was assigned to class II in Hugh–Jone’s classification. The patient was scheduled for CEA due to cerebral infarction with left lower extremity paralysis and transient dizziness 1 year earlier. With respect to the patient’s positioning during surgery, the anterior edge of the skin on the sternocleidomastoid muscle was located at the highest point by placing a shoulder pillow under the right shoulder in the supine position and rotating the head 30 to the left side; the jaw was tracted in the cephalic direction and the right shoulder was also tracted in the caudal direction. Anesthetic management was performed without difficulty for 4 h and 2 min, and surgery was completed without complications in 2 h and 43 min. Since the neurosurgeons were concerned about possible respiratory disorders, such as atelectasis, due to the patient’s asthma and wanted to ensure that there was no problem, they requested an X-ray before extubation. The post-operative X-ray revealed right diaphragm elevation at the end-inspiratory phase during spontaneous breathing (Fig. 1). Since there were no problems in emergence from anesthesia or in respiratory functions, such as blood gas data or respiratory pattern or tidal volume, extubation was attempted in the sitting position. There was also no respiratory disorder after extubation. Diaphragm elevation was improved the next day. Post-operative transient phrenic nerve paralyses mainly occur after cardiac surgery due to direct injury or hypothermia, mainly on the left side, and can be caused after other surgery due to traction or compression caused by the patient’s position [1, 2]. Unilateral diaphragmatic paralysis in adults generally has minimal symptoms or no symptoms, but bilateral or unilateral diaphragmatic paralysis in children can cause serious medical problems [1, 3]. The cause in the patient described here is thought to be traction by the head position. Although extubation was performed in the sitting position because of the possibility of respiratory disorder caused by unilateral phrenic nerve paralysis with asthma, there was no problem in the respiratory system after extubation. In the present case, a post-operative X-ray, which was taken because the patient had asthma, revealed, by chance, transient phrenic nerve paralysis. However, X-rays are not standard procedures following CEA in many institutions. Presented at the Annual Meeting of the Japan Society for Clinical Anesthesia, Osaka, October 24, 2004.

Changes in Neuronal Expression of c-Fos Protein in the Medulla Oblongata after Unilateral Phrenicotomy in Wistar Rats

[Purpose] The purpose of this study was to examine changes in neuronal expression of c-Fos protein in the medulla oblongata after unilateral phrenicotomy in Wistar rats. [Subjects and Methods] After left side phrenicotomy, rats were maintained for 4 weeks (test experiments), then transcardially perfused with fixatives. Brain sections were prepared, and c-Fos protein induced in neurons in the medulla oblongata was immunohistochemically stained by the ABC method. Control rats were maintained for the same period after sham operation, and the brain sections were similarly processed as in the test experiments. [Results] The number of c-Fos immunoreactive (c-Fos-ir) neurons in the medulla oblongata was counted and their spatial distributions were mapped. In both sides of the ventral respiratory group (VRG) and the left side of dorsal respiratory group (DRG), numbers of c-Fos-ir neurons were significantly increased in phrenicotomy rats compared to the control rats (P<0.05). In the right side of the DRG, the number of c-Fos-ir neurons also increased but without statistical significance. Numbers of c-Fos-ir neurons in the VRG were greater than that in the DRG. [Conclusion] The present results suggest that phrenicotomy may result in an increase in the activity of medullary respiratory neurons during the recovery of respiration after the phrenicotomy. The specific activation of the neurons in the VRG and DRG during unilateral phrenic nerve paralysis could underlie the changes in regulation of the respiratory control center following unilateral phrenicotomy.

Bilateral Phrenic Nerve Palsy in a Neonate Following Complex Congenital Cardiac Surgery

UNILATERAL PHRENIC NERVE PALSY is a recognized complication of cardiac surgery. Bilateral phrenic nerve palsy is rare and very few cases have been reported in the literature thus far. Bilateral diaphragmatic palsy occurring in a neonate can cause life threatening respiratory distress. Management of these cases remains controversial. The consequences of this complication on respiratory physiology can lead to prolonged postoperative mechanical ventilation, increased intensive care stay, and even death. This case report highlights the difficulties in establishing the diagnosis of bilateral diaphragmatic paralysis in a neonate undergoing repair of a complex congenital cardiac defect and the management of the case with prolonged ventilatory support. Diaphragm Paralysis in Children After Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 21Issue 1PreviewWe read with great interest the article by Moideen and associates entitled “Bilateral Phrenic Nerve Palsy in a Neonate Following Complex Congenital Cardiac Surgery.”1 Although we appreciate their excellent result and presentation, we have some comments about their diagnosis and treatment strategies. Also, we would like to share our experience about diaphragm paralysis (DP) after cardiac surgery. Full-Text PDF

Neuromuscular disorders associated with failure to wean from the ventilator.

To determine, by retrospective chart analysis, the frequency, type and significance of neuromuscular disorders in patients whose clinical features suggested a neuromuscular cause of failure to wean. Failure to wean is a common and difficult problem in critical care units. While a neuromuscular cause may be suspected in some patients, the frequency and type has not been determined utilizing comprehensive electrophysiological studies of limbs and the respiratory system. Such knowledge may aid in patient management and prognosis. The clinical setting was a critical care/trauma centre that admits 1500 patients per year, approximately 500 being on ventilators for longer than five days. We analyzed the hospital charts of 40 patients admitted to the unit during three years, whose respiratory assessment suggested a neuromuscular cause for failure to wean from the ventilator. To investigate this possibility, we performed electrophysiological studies of the limbs and also of the respiratory system by phrenic nerve conduction and needle electromyography of the chest wall and diaphragm. The results were compared to 25 healthy controls. 38 of 40 patients (95%) had a neuromuscular disorder: 25--critical illness polyneuropathy, 2--Guillain-Barré syndrome, 4--diabetic and critical illness polyneuropathy, 2--uremic and critical illness polyneuropathy, 10--an abnormality of central drive, 5--unilateral phrenic nerve palsy, 3--a neuromuscular transmission defect, and 5--a primary myopathy. Fifteen (38%) had a combination of disorders. Patients with more severe polyneuropathy took longer to wean, a mean of 136 versus 52 days (p = 0.007). The severity of the polyneuropathy had no effect on mortality. Electrophysiological studies of limbs and the respiratory system are together valuable in confirming the presence, and identifying the specific type of neuromuscular cause for difficulty in weaning from the ventilator. This information is important in patient management and prognosis.

Isolated lung transplantation for end-stage lung disease: A viable therapy

Since January 1990, we have performed 29 isolated lung transplantations in 28 patients with end-stage lung disease (12 single, 16 bilateral). Recipient diagnoses were: cystic fibrosis (11), chronic obstructive pulmonary disease (6), pulmonary fibrosis (6), eosinophilic granulomatosis (1), postinfectious lung disease (1), adult respiratory distress syndrome (1), and primary pulmonary hypertension (2). There have been four deaths, two in patients with pulmonary fibrosis and two in patients with primary pulmonary hypertension. Four patients have undergone transplantation while on ventilatory support for respiratory failure (2 with cystic fibrosis, 1 having redo lung transplantation with cystic fibrosis, and 1 with adult respiratory distress syndrome); all of these have survived. Six patients required cardiopulmonary bypass, which was associated with increased transfusion requirement. All patients 2 months after discharge have returned to an active life-style, except for 2 patients who currently await retransplantation. Preoperative pulmonary rehabilitation has resulted in significant improvement in exercise performance in all patients. Immunosuppression consists of cyclosporine, azathioprine, and antilymphoblast globulin (University of Minnesota), withholding systemic steroids in the early postoperative period. We have employed bronchial omentopexy in all but four transplants; there has been one partial bronchial dehiscence, two instances of bronchomalacia requiring internal stenting, and one airway stenosis. Cytomegatovirus disease has been seen frequently (15 cases), but has responded well to treatment with ganciclovir. Other complications have included one drug-related prolonged postoperative ventilation, thrombosis of a left lung after bilateral lung transplantation requiring retransplantation, five episodes of unilateral phrenic nerve palsy after bilateral lung transplantation (4 resolved), and the requirement of massive transfusion (>10 units) in 5 patients. Isolated lung transplantation can be performed with acceptable morbidity and mortality in properly selected patients with a variety of end-stage lung diseases.

Phrenic nerve paralysis following neck dissection

One of the complications of neck dissection to control regional metastatic disease in cancer of the head and neck is phrenic nerve paralysis. The resulting elevation of the ipsilateral diaphragm can be diagnosed on a postoperative chest X-ray and confirmed by fluoroscopy. Symptoms can be respiratory, cardiac or gastrointestinal. In a retrospective study, unilateral phrenic nerve paralysis was observed in 14 (8%) of 176 consecutive neck dissections. None of the patients with postoperative phrenic nerve paralysis displayed severe symptoms, although a significantly higher number sustained atelectasis with or without pulmonary infiltrates to complicate the postoperative course.

Relationship between regional ventilation and aerosol deposition in tidal breathing.

The regional distribution of the deposition of 1.2 micron particles of 99mTc sulfur colloid inhaled by tidal breathing was compared with the distribution of ventilation as measured by a 133Xe washout technique. Twelve subjects were studied, 6 with normal pulmonary function tests, 5 with air-flow limitation, and 1 with unilateral phrenic nerve paralysis. Both xenon and aerosol were inhaled at tidal volume by the subjects while seated upright. A large field gamma camera acquired posterior scans. Thirteen experiments were also done on 7 dogs: 1 with extrathoracic obstruction of the airway to 1 lung, and 12 with bronchoconstriction from the instillation of methacholine chloride into the airways of a lower lobe. Two of these dogs were studied with a gamma camera system, and the others were studied with a Picker multi-probe system. Both in humans and in dogs, an increase in time constant, which indicated a decrease in ventilation, was associated with an increase in peripheral aerosol deposition when normalized for ventilation. It is suggested that the increased residence time is responsible for the increased deposition in regions that received lesser ventilation.